t\Cli MANUAL PHYSICAL DIAGNOSIS. TYSON. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Text-Book for Physicians and Students, with Special Reference to Diagnosis and Treat- ment. Second edition. Thoroughly Re%-ised and Enlarged. ICO Illustrations. Octavo. Cloth, $5.50; Leather, S6.50; Half Russia, S7.50 " This work not only represents the work of a practitioner of great experience, but of a careful culling of the facts set forth in contemporary literature by one who well understands the art of separating the true from the false." — The Jo-ur- nalqfihe American Medical Assoczatzon, Chicag-o. " Represents the outcome of much well-directed labor, and constitutes a reliable and useful text-book." — T/te London Lancet. " Few teachers in the country can claim a longer apprenticeship in the labor- atory- and at the bedside, none a more intimate acquaintance with students, since in one capacity or another he has been associated with the University of Penn- sylvania and the Philadelphia Hospital for nearly thirty years. Moreover, he entered medicine through the portal of pathologj-, a decided advantage in the writer of a text-book. . . . It is a piece of good, honest work, carefully con- ceived and conscientiously carried out." — The University Medical Magazine. GUIDE TO THE EXAMINATION OF URINE. Ninth Edition. For the use of Physicians and Students. With a Colored Plate and 48 other Illustrations. Completely Revised. i2mo. Cloth, 31.25 " It is without exception the best work of its kind in the English language." — Bosto?t Medical and Surgical Jouriial. " The subject-matter of which it treats is complete without being verbose; it is concise, thorough, and up to date. It is a volume that should be in the hands of every medical student, and in the library of every practitioner." — Buffalo Medical and Surgical Joitrnal. THE CELL DOCTRINE: Its History and Present State, together with a copious Bibliography of the Subject. With a Colored Plate and other Illustrations. Second Edition. Cloth, 31.50 " The first edition of Dr. Tyson's work appeared in 1870, and at once received the favorable reception from the profession to which it was entitled by its merits. The present edition shows an increase in size of about fifty pages, and almost every page furnishes evidence of careful revision." — American Journal of the Medical Sciences. These Prices are Xet. P. BLAKISTON'S SON & CO., PHILADELPHIA. MANUAL PHYSICAL DIAGNOSIS FOR THE USE OF STUDENTS AND PHYSICANS. JAMES TYSON, M. D., PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA AND PHYSICIAN TO THE UNIVERSITY HOSPITAL; PHYSICIAN TO THE PHILADELPHIA HOSPITAL; FELLOW OF THE COLLEGE OF PHYSI- CIANS OF PHILADELPHIA ; MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS, ETC. THIRD EDITION, REVISED AND ENLARGED, WITH COLORED AND OTHER ILLUSTRATIONS. PHILADELPHIA : P. BLAKISTON'S SON & CO IOI2 WALNUT STREET, I goo. Copyright, 1898, by James Tyson, M. D. Press of TTickersham Printing Co,, Lancaster, Pa. PREFACE TO THIRD EDITION. Advantage has been taken of the opportunity afforded by the demand for another edition of this manual to improve it and extend it as far as consistent with the original purposes of the book. The section on the examination of blood has been enlarged, so as to meet more completely the requirements of a modern blood examination. The same may be said of the section on the chemical examination of gastric contents. A num- ber of new illustrations have been introduced, together with other additions of a minor character, all intended to add to the accuracy and usefulness of this book. I am indebted to Prof. A. C. Abbott and Dr. Alfred Stengel for assistance in the technique of the blood and bacteriological examinations. 1506 Spruce Street, June I, i8g8. (v) Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/manualofphysicalOOtyso TABLE OF CONTENTS. PAGE General Considerations, 9 Regions or Spaces of the Chest, . . 11 Medical Anatomy of Thorax, 15 Inspection and Mensuration, 26 Palpation, 32 Percussion, 34 Percussion of the Normal Chest, 45 Abnormal Percussion Lung Sounds, 52 Auscultation, 61 Auscultation of the Normal Lung, 65 Abnormal Modifications of Breathing Sounds, .... 68 Auscultation of the Normal Voice, 75 New or Adventitious Sounds, 78 Physical Signs of Abnormal States of the Lungs, ... 83 Acute Bronchitis, 83 Chronic Bronchitis, 84 Emphysema of Lungs, 85 Interlobular Emphysema, 88 Spasmodic Asthma, 88 Pulmonary Tuberculosis, 89 Catarrhal Phthisis, . 94 Fibroid Phthisis, 94 Miliary Tuberculosis, 95 Pneumonia, 96 Croupous, . 96 ( vii ; Vlll TABLE OF CONTENTS. PAGE Pneumonia. Catarrhal, ..... lOO Embolic, • • • lOl Pulmonary CEdema, I02 Collapse of the Lung, 102 Cancer of the Lung, 1O3 Pleurisy . . 103 Chronic Pleurisy, ... 107 Pneumothorax, Ill Physical Examination OF THE Heart, 113 Anatomical Relations of the Heart, 1 13 Percussion and Auscultation of the Normal Heart, . . 116 Abnormal Modification of the Heart Sounds, .... 124 Organic Murmurs, 128 Functional Murmurs, 138 Vascular Murmurs, 141 The Sphygmograph in Diagnosis, 144 The Cardiograph in Diagnosis, 152 Physical Signs OF Different Forms OF Heart Disease, . 156 Mitral Insufficiency, 156 Mitral Stenosis, 159 Mitral Insufficiency and Stenosis, 162 Aortic Stenosis, 162 Aortic Insufficiency, 165 Aortic Stenosis and Insufficiency, 168 Tricuspid Insufficiency, 168 Tricuspid Stenosis, , 171 Pulmonary Stenosis, ... 172 Pulmonary Regurgitation, .... 173 Congenital Defects, 173 Relative Frequency and Danger of Valvular Defects, . 174 Acute Endocarditis, 179 Pericarditis, 180 Diseases of the Myocardium, 181 Thoracic Aneurysm, 188 TABLE OF CONTENTS. IX PACK Physical Examination of the Abdomen, 197 Inspection, 199 Palpation, 201 Percussion, 204 Auscultation, 209 Appendix — Examination of Blood, 212 Estimation of Blood Corpuscles, 212 Estimation of Haemoglobin, 220 Preparation of Stained Films, 222 Widal Test for Typhoid Fever, 224 Examination of Sputum, . 226 Staining of Tubercle Bacilli, 227 The Pneumococcus, 229 Bacillus of Diphtheria, 232 Bacillus of Typhoid, 233 Bacillus of Cholera, 234 Bacillus of Syphilis, 234 Bacillus of Gonorrhcea, 234 Chemical Examination of Gastric Contents, 235 To Test Eate of Absorption from Stomach, 252 To Test Motor Functions of Stomach, . .... 233 To Test Capacity of Stomach, 254 The Roentgen Ray in Diagnosis, 255 The Making of an Autopsy, 258 Order of Examination OF Patient, 271 French Weights and Measures, 273 Index, 275 LIST OF ILLUSTRATIONS. PLATFS PAGE 1. Illustrating different forms of the malarial organism, with their stages of development, 212 2. Differential staining of the blood, 223 1. Regions ot the thorax, anterior aspect, 12 2. Regions of the chest, posterior aspect, 14 3. Anterior view of the organs of the chest and abdominal cavity, 17 4. Posterior view of the organs of the chest and abdominal cavity, 21 5. Transverse section of healthy adult chest at level sterno- xiphoid articulation, . . 28 6. Pigeon-breast, child of seven years, 29 7. Rickety chest, 30 8. Percussion hammer of plexor, 34 9. Ivory pleximeter, 34 10. Sansom's pleximeter, 34 11. The phonendoscope, 37 12. Absolute and relative percussion dulness of liver and heart, 49 13. Gerhardt's change of note, 57 14. Hawksley's stethoscope, 62 15. Sansom's binaural stethoscope, 63 16. Simpler fonn of Sansom's binaural stethoscope, .... 63 17. Valentine's binaural stethoscope, . 64 (xi) XU LIST OF ILLUSTRATIONS. FIG. PAGE 1 8. Bilateral enlargement in emphysema 86 19. Position of heart in relation to ribs and sternum, .... 114 20. Absolute and relative percussion dulness of liver and heart, 117 21 . Diagram showing the location of cardiac valves and points of maximum intensity connected wdth them, 121 22. Mitral sj'stolic murmur, propagated in front, 129 23. Mitral systolic murmur, propagated behind, 130 24. Mitral presystolic murmur (Hutchison and Rainy), . . . 132 25. Aortic systolic murmur and its propagation, 134 26. Aortic diastolic murmur and its seats of propagation J . , 135 27. Normal sph3-gmogram, 146 28. Sphygmogram showing prolonged arterial tension, . . . 148 29. Anacrotic pulse-cur\-es from the radial arterj', 148 30. Tracing of pulse of aortic regurgitation, 149 31. Tracing from case of prolonged arterial tension, showing dicrotic wave, 150 32. Bigeminal pulse, ... 151 33. Trigeminal pulse, 151 34. Normal cardiac apex tracing, 153 35. Tracing pulse of mitral insufficiency, 158 36. Tracing of pulse in mitral stenosis, 160 37. Pulse tracing of aortic stenosis, 163 38. Tracing of pulse of aortic regurgitation, 166 39. Combined aortic and mitral sj-stolic murmurs, 169 • 40. Drawing showing regions of the abdomen, 198 41. Hsemocytometer pipette, 214 42. Thoma-Zeiss counting slide, 215 43. Groups of sixteen small squares, making one large square of the Thoma-Zeiss c}1:ometer, magnified, 216 44. The Thoma-Zeiss ruled shde focused for ten and twelve squares, 217 45. Hsemoglobinometer of Fleischl, 220 46. " Seal Fin " deflexion of the hand in a case of protracted arthritis deformans, 257 MANUAL PHYSICAL DIAGNOSIS GENERAL CONSIDERATIONS. The term physical diagnosis strictly defined would include the diagnosis or investigation of disease by the aid of all the special senses, but practically it is con- fined to eliciting such information as can be furnished by vision, touch, and hearing, whence come the terms inspection., palpation, and nusailtation. The information acquired by hearing is further subdivided into: ist. That gained by listening directly to the various normal sounds and their modifications as produced by morbid states, and to certain new sounds produced by such states. 2d. Information gained by striking or percus- sing the part to be investigated. Hence, too, the words auscultation and percussion are constantly used in asso- ciation. The information furnished by inspection is also ren- dered more accurate by measuring or mensuration, 9 10 PHYSICAL DLA.GXOSIS. when this can be applied. Thus constituted, physical diagnosis is applied to any portion of the body, but it is more especially in the study of diseases of the thoracic and abdominal contents, and particularly the former, that it is useful. The phenomena thus learned are known as physical signs. The use of the term " physical '' is based upon the fact that it is through alterations in the physical properties of the tissue or organ investigated that information is obtained, such as the shape, density, transparency. On the other hand, in its usual application there is a limitation inconsistent with strict accuracy. Thus there is no more accurate means of recognizing physical states than by ther- mometry, yet thermometry is not one of the measures included under physical diagnosis. It is very true that a knowledge of physical signs cannot be acquired from books and must be learned at the bedside; but we may record their import and significance in the recognition of disease and render somewhat easier their study. To this end is indispens- able a familiarity with the physical condition of the organs o£ the body in a state of health. This, too, can only be learned on the living subject by giving the student an opportunity to listen until he is thoioughly familiar with the normal breathing- and heait-sounds, to observe the normal shape and configuration of the body, and to learn the percussion note characteristic of different regions over important organs, as ihe heart, lungs, and various abdominal viscera. Such a study of the situation of internal organs in relation to external REGIONS OR SPACES OF THE CHEST. II parts, for the purposes of the physician, constitutes medical anatomy. The attainment of the objects of physical diagnosis is greatly facilitated by mapping out the body into certain spaces or areas, of which we consider first the REGIONS OR SPACES OF THE CHEST. Starting with the clavicle and sternum as land- marks in physical examination, above each clavicle, in health, is usually a slight depression known as the supraclavicular fossa, and above the sternum another known as the suprasternal notch. Below each clavicle is the infraclavicular space, which is somewhat arbitrarily bounded below by the upper edge of the 3d rib and adjacent cartilage, internally by the edge of the sternum, and externally by the base of the shoulder or a line drawn vertically from the inner end of the outer fourth of the clavicle. Below the clavicle, as well as above, in health, is usually a slight depression. All these depressions or spaces are liable to become deeper in emaciation, and are less conspicu- ous in fat persons. Below the upper edge of the 3d rib is the mammary region, bounded internally by the edge of the sternum, externally by the above described vertical line, and below by the upper margin of the 6th rib. Nearly in the centre of the mammary region is the nipple, which in males and young girls is just below the 4th rib. A line drawn vertically through it is known as the mammillary line. The mid-cla- Fig. I. — Regions of the Thorax, Anterior Aspect. The figure is taken from a photograph of a living subject on which the ribs were made more distinct bs chalk. While the chest is fairly typical, the dis- tance between the end or the ensiform cartilage and the umbilicus, which varies in different individuals, is perhaps longer than the average in this case. REGIONS OR SPACES OF THE CHEST. 1 3 vicular line coincides with the mammillary line when the nipple is in its typical situation, and is therefore a better term. Below the mammary region, as far as the edge of the thorax, is the inframammary region. In the centre of the thorax anteriorly is the sternum, bounded by its notch above and the end of the ensiform cartilage below. It is divided into the upper sternal region, extending as far as a line drawn along the upper edge of the 3d cartilage, and the lower sternal, in- cluding the remainder of -the bone. Laterally are the axillary and the infra-axillary regions, the former above and the latter below a line continuous transversely with the lower border of the mammary region (6th rib) ; bounded in front by the external border of the mam- mary and inframammary regions, and behind by a line drawn vertically downward from the insertion of the posterior fold of the axilla. The infra-axillary region extends downward to the edge of the thorax. Posteriorly are the scapular regions, including the supraspinous fossa and the infraspinous fossa of each scapula, sufficiently indicated by their names; the interscapular region, and the subscapular or infrascapular regions. The interscapular region is in- cluded between the scapulae posteriorly and bounded below, by a line drawn through theangles of these bones m the position assumed by them wheB;-,t|j-e; arms are hanging at the side. Such line usually crosses the 7th rib. The infrascapular regions are bounded above by the line just described, below by the edge of the thorax, 14 PHYSICAL DL4GNOSIS. Fis. 2. — Regions of the Chest, Posterior Aspect. MEDICAL ANATOMY OF THE THORAX. 1 5 and extend from the median line to the posterior axil- lary line on each side. In addition to the mammillary line, are lines drawn vertically down the middle of the axilla and through the angle of the scapula behind, called the mid-axil- lary and mid-scapular lines — also landmarks useful in description. The parasternal line, frequently used, is a vertical line drawn midway between the edge of the sternum and the mammillary line. MEDICAL ANATOMY OF THE THORAX. For the intelligent study of the physical diagnosis of the chest, it is important that the student should know what viscera or parts of viscera are contained in the areas just mapped out. (See Figs. 3 and 4.) 1. In X\\& supraclavicular xtg\Q)\\ is contained the apex of the lung (4, 10, Fig. 3), which rises above the upper border of the clavicle to the extent of ^ inch to i^ inches and even two inches, varying in different per- sons. It is rather toward the inner end of the clavicle. One or the other apex is usually a little higher than its fellow, the left more frequently. The apex of the lung is crossed by the subclavian vessels in the first part of their course. In the subclavicular fossa near the outer border of the sternomastoid muscle, and about one inch above the clavicle, the beating of the subclavian artery can be felt. In this hollow, too, is the termination of the external jugular vein. 2. Behind the clavicle, in the clavicular region, is l6 PHYSICAL DLA.GXOSIS. also found the lung, but the ist and 2d ribs are inter- posed between the clavicle and the lung, so that no typical lung note on percussion can be expected in that situation. Behind the inner end of the clavicle is the commencement of the innominate vein ; behind this, on the left side, the common carotid ; to the outside of , this the left subclavian artery ; and on the right side behind the sternoclavicular joint, the bifurcation of the innominate. 3. The infraclavicular regions are occupied almost purely by lung stmcture. The superior cava extends slightly beyond the right t^g^ of the sternum in this region, the pulmonary artery somewhat more to the left of the left edge of the stemum. The left auricle is in the 2d intercostal space and extends to the left para- sternal line, being covered by the edge of the lung. 4. The structures occupying the mammary regions differ considerably on the two sides. The right side is the simpler. It is occupied mainly by lung. At least Fig. 3. — Anterior View of the Organs of the Chest and Abdominal Cavity with Reference to their Relations to the Skeleton and the Boundaries of the Stomach. I. Larynx. 2. Thyroid gland. , 3. Trachea. 4. Right lung-apex. 5. L^pper lobe. 6. Middle lobe. 7. Lower lobe, of right lung. 8. L^pper, 9. Lower interlobular boundary of the right lung. 10. Apex, 11. Upper lobe, 12. Lingual process of the left lung. 13. Cardiac boundary of the anterior border of the left lung. 14. Portion of the anterior aspect of the pericardium covered by the cardiac pleura. 15. Portion of same uncovered by diaphragm. Site for paracentesis. t6. Anterior border of the right mediastinum. 17. Anterior border of the left mediastinum. 18. L'pper or true border of the liver partially covered by lung. 19. Right lobe of the liver. 20. Quadrate lobe of the liver. 21. Left lobe of the liver. 22. Gall bladder. 23. Cardiac end of the stomach. 24. Stomach cul-de-sac partially covered \>y lung. 25. Pj'loric end of the stomach. 26. Larger curvature of the stomach (right gastro- epiploic artery). 27. Transverse colon. 28. Ascending colon. 29. Descend- ing colon. 30. Vermiform appendix. 31. Small intestine. 32. Bladder. — {After Luschka, slightly modified.) 1 8 PHYSICAL DLA.GNOSIS. lung only reaches the surface in this space. The dome- shaped right lobe of the liver projects into a correspond- ing space in the under surface of the right lung as far as the 4th interspace. To the right of the sternum is the right auricle, behind the 3d costal cartilage, the 3d in- terspace, the 4th costal cartilage, and 4th interspace, and extending almost to the right parasternal line, but covered by lung. The right ventricle extends very slightly, if at all, by the outer inferior angle of its base, from behind the sternum into the 6th interspace. The left mammai-y region is occupied aluiost as far as the mid-cla\acular line b}'^ the heart, including portions of the right and left ventricle. The cardiac line is an oblique one beginning at or near the junction of the left parastemal line with the lower border of the 2d rib and thence downward and outward to the apex formed by the left ventricle in the 5 th interspace an inch below and within the nipple. The upper portion of this area is covered by lung, leaving only a tongue-shaped por- tion of the heart uncovered between the 4th and 6th ribs. Between the 4th and 5th ribs (at 15, Fig. 3), near the sternum, is a spot of the pericardium uncovered by the diaphragm, which is the usual site for paracentesis of the pericardium. The remainder of the left mam- rcary region is occupied by lung. 5. Th^ ififramamfjiary regions d\&eT ev&n more on the two sides in the structures comprehended in them. This region on the 7-ierht side mainly covers the liver separated from the chest-wall by the diaphragm, the dome of which reaches its highest point in the 4th interspace :medical anatomy of the thorax. 19 within the mammillar_y line. The lung extends down to the 6th rib. The lower border of the liver in health just reaches the edge of the ribs at the mid -cla- vicular line, and then extends obliquely upward toward the left, Glossing the median line usually at one-third the distance between the ensiform cartilage and the umbilicus, and reaching the left border of the thorax at or near the left parasternal line. The lower edge of the liver varies somewhat in healthy individuals, and descends below the ribs with deep inspiration. The left inframamma?-y region includes the anterior part of the lower lobe of the left lung, the left lobe of the liver, the cardiac end of the stomach, varying degrees of distension of the latter organ producing considerable variation in the percussion boundaries of these organs. Between the inframammary regions is the epigastrmm in abdominal topography. In the right half of the epigastrium is the quadrate lobe of the liver, the gall bladder, the pyloric end of the stomach at a point mid- way between the ensiform cartilage and the parasternal line, behind the liver and adjacent to the gall bladder. The fundus of the gall bladder can sometimes be felt at the edge of the liver. In the left half of the epigastrium is the left lobe of the liver and lower median part of the stomach. 6. The suprasternal notch is solely occupied by the trachea in health, but is often encroached upon by a dilated aorta, or aoita pushed up by a hypertrophied heart. 20 PHYSICAL DIAGNOSIS. 7. The tipper sternal region under the manubrium is occupied by the trachea, which bifurcates at the junction of the ist and 2d bone, by a part of the superior cava, the arch of the aorta, the left innominate vein, which joins its fellow. to form the superior cava just below the cartilage of the ist rib, close to the right edge of the sternum ; also by a part of the pulmonary artery. The upper and central part of this region is uncovered by lung. 8. The lower sternal region contains a part of the aorta, a portion of the right auricle, much of the right ventricle, beginning opposite the 4th caitilages, and behind this the left ventricle. The edges of the two lungs unite through the upper part of this region in the middle line, the left diverging at the 4th rib where the uncovered tongue-shaped piece of the heart commences. The primary bronchi are found diverging at the upper part of this region, where they penetrate the lung. The right, larger and shorter, passes downward on the level of the 4th dorsal vertebra ; the left, longer and smaller, downward and outward to the level of the 5th dorsal vertebra. 9. The scapular regions cover the lung, the incisure between the upper and lower lobes passing obliquely downward under the bone from the upper edge of the 5 th rib behind, to between the 5th and 6th ribs laterally. 10. The interscapular region in its central portion is occupied by dorsal vertebrae, in front of which is the trachea, bifurcating at the 4th, whence its primary bronchi extend downward and outward surrounded by lung structure. MEDICAL ANATOMY OF THE THORAX. Fig. 4. — Posterior View ok the Organs of the Chest and Abdominal Cavity. T. Upper lobe. 2. Lower lobe of left lung. 3. Interlobular boundary between them. 4. Upper lobe of right lung. 6. Middle lobe of the right lung. 7. Line between upper and middle lobes of the right lung. 9. Stomach demarked by a dark line. 10. Spleen in its relation to the lung in expiration, with the kidney showing behind and below it. 11. Left kidney. 12. Horizontal upper part of the duodenum. 13. Descending portion of the duodenum. 14. Hori- zontal lower part of the duodenum. 15. Duodeno-jejunal flexure. ■i5. Liver, zo Pancreas. 21. First dorsal vertebra. — {After Luschka.) 2 2 PHYSICAL DIAGNOSIS. 11. The infra- or subscapular regions, extending from the angles of the scapulae to the edge of the thorax, in- clude on the right side lung as far as the loth rib in the mid-scapular line. Below this is the complemental pleural space (see p. 24) filled by lung only in deep in- spiration, as far as the nth rib, where the lower border of the liver is met. The thick lumbar muscles separate the integuments to the right of the vertebrae from the upper end of the right kidney, forward of which is the pyloric orifice of the stomach. The upper end of the right kidney is covered by the nth interspace and the short 12th rib. On the left side there is pure lung tissue as far as the loth rib, whence it dips down in deep inspira- tion into the complemental pleural space between the thoracic wall and that part of the diaphragm covering the spleen, which extends from the 9th to the nth ribs inclusive. A small portion of lung tissue is interposed between the posterior edge of the spleen and the loth dorsal vertebra. The cardiac orifice of the stomach is on the left side about opposite to the body of the 9th dorsal vertebra. Beneath the nth rib is the upper end of the kidney, which extends a little higher on the left side than the right. The left end of the pancreas is close to the spinal column in the nth interspace and under the root of the 12th rib. 12. The axillary regions on both sides are occupied with lung structure, a part of the upper lobe of each lung. 13. The infra- axillary regions are again more com- plex in the structures they cover, On the right side MEDICAL ANATOMY OF THE THORAX. 23 there is lung as. far as the 9th rib in the mid-axillary Une; below this is liver to the nth rib, or edge of the thorax in this line. On the left side there is lung as far as the 9th rib in the mid-axillary line. Below this is the spleen, which extends to the nth rib inclusive, or edge of the thorax at this situation. The cardiac end of the stomach, especially when dilated, is apt to protrude into the infra-axillary region and to influence the percussion note. The Borders of the Lungs. — It is to be remem- bered that the anatomical outlines just described are of themselves rather approximate, and, furthermore, that they do not necessarily coincide with the percussion boundaries of the same organ, as in many situations portions of lung protrude between the organs and the surface and produce a modification of the note peculiar to such organs, which modification is the relative or deep-seated dulness of the organs. It is therefore use- ful also to know the correct anatomical boundaries of the lungs as a whole in relation to the landmarks given : In front the lungs extend above the clavicles from Yo inch to 1J-3 inches or more; behind as far as a line drawn through the apex of 1 he spinous process of the 7 th cervical vertebra. Downward and adjacent to the sternum, the right lung extends to the neighbor- hood of the 6th cartilage, the left to the 4th; in the mid-axillary line both extend to the lower border of the 7th rib, in the mid-scapular line to the loth rib, and near the spinal column to the nth rib. On 24 PHYSICAL DLA.GNOSIS. the left side at the inner end of the 4th cartilage the lung diverges from under the breast bone obliquely behind the 4th cartilage through the 4th intercostal space and again turns toward the sternum behind the 5th costal cartilage, but at the 6th cartilage again turns outward. By this divergence is formed the tongue- shaped indentation of the lung border, by which a por- tion of the heart is uncovered. Behind the sternum, from the 2d to the 4th cartilage, the edges of the two lungs approach each other very closely. The summit of the dome of the liver in front reaches as far as the 4th interspace on the right side, but it is covered with a ^^ edge-shaped extension of the lungs as far as the 6th rib, where what is known as the absolute dulness of the liver begins, the lesser impairment of resonance appearing at about the 5th rib being called relative dulness. It is to be remembered that in quiet breathing, during which the boundaries above traced are supposed to be maintained, the anterior edge of the left lung and the inferior edges of both lungs do not reach the extreme limit of the pleural space, so that between the edges of the lungs aird the. limit of the pleural sac there remains a space which is only filled at the time of deep inspiration. At o:her times the costal and diaphragmatic pleurae below the lower edge of both lungs are in contact, as are also the costal and pericardial pleurae toward the niedian line at the anterior order of the left lung. The spaces thus formed ate called complemental spaces. Above the level of the 4th cartilages the anterior MEDICAL ANATOMY OF THE THORAX. 25 edges of the lungs closely approximate and fill the pleural space, but below this the edge of the left lung deviates from the pleural border to form the tongue- shaped cardiac indentation referred to. The inferior border of the left lung extends a little lower than that of the right, more particularly between the parasternal and the mammillary line, where it extends half an inch lower. It is less important to know the interlobular boun- daries of the lung. The two principal fissures begin posteriorly nearly on a line with the spines of the scap- ulas. The left incisure starts under the dorsal end of the 4th rib, passes downward and outward, intersect- ing the 5th rib in the mid-axillary line terminating at the lower edge of the lung at its junction with the right parasternal line and the 6th rib. The right incisure divides at about two or 2j^ inches above the angle of the scapula into two branches, an upper and a lower, which separate the upper lobe from the middle, and the middle from the lower lobe of the lung. The upper branch passes nearly transversely forward to terminate in the edges of the lung at about the level of the 4th cartilage. The inferior branch passes sharply down- ward and slightly forward at the' level of the 6th rib in the neighborhood of the mammillary line, and out at the lower edge of the lung. Hence it is that on the posterior aspect the Idwer lobe on each side makes tip the larger part of the lungs exposed to percussion ; on the left, in front, only the upper lobe, on the right the upper and middle lobes. Laterally, on the left side the upper and 26 PHYSICAL DIAGNOSIS. lower lobe, and on the right side the upper, middle, and lower lobes approach the surface. The bifurcation of the trachea corresponds anteriorly with the lower end of the manubrium, pos- teriorly with the cartilaginous disc between the 4th and 5 th dorsal vertebrae. INSPECTION AND MENSURATION. The appearances of the regions described, during and independent of the motions of breathing, are objects of inspection but these are best described in connection with the conditions which modify them. In inspecting the chest from the front or behind, the patient should stand erect with the hands at his side ; during lateral inspection the hands should be raised alongside of the head, or they may grasp opposite shoulders. Such rela- tions to light should be chosen as will obviate shadows as much as possible. It will be remembered that during breathing a woman exhibits more motion in the upper part of the chest, while in men abdominal motion is marked. Mensuration is for the most part practised by an ordinary tape measure, and thus the circumference of the chest at different situations is determined ; aiso dif- ferences in the circumference at the end of inspiration and of expiration, and differences in the semi-circum- ference as the result of abnormal states. It is to be borne in mind that in right-handed persons the semi- circumference of the right side is often ^ inch to THE SHAPES OF THE CHEST. 27 one inch greater than that of the left, owing to the greater muscular development of that side. The reverse obtains to a less degree in left-handed individuals. The transverse and antero-posteiior diameters of the chest may be determined by a pair of calipers ; any deviations in the shape of the chest by the cyrtometer, a simple form of which may be made out of strips of sheet lead, moulded to the chest-walls, and the outline thus pro- duced is drawn on a large sheet of paper. More perfect appliances for chest measurement are the stethometer of Quain, the stetho-goniometer of Allison, the cyrtometer of Woillez, and others, but they are not needed for the usual measurements. THE SHAPES OF THE CHEST. By inspection and mensuration we learn the shape of the chest. I. The normal shape of the infant's chest at birth is nearly cylindrical, but as development proceeds it asquires an oval shape well established by the time the child has cut its milk teeth. This increases slowly until development is complete, when the outline shown in Fig. 5 is attained. During maturity the chest retains this shape, but with the wane of life and the effect of disease incident to it there come changes which cause the chest again to ap- proach the cylindrical shape of infancy. The effect of various diseases on the shape of the chest will be considered in connection with the diseases 28 PHYSICAL DIAGNOSIS. themselves, but there are several types presented by those in apparent health which are important, in that they favor tendencies to special diseases or are the result of weakness in childhood 2. Thus we have the alar or pterygoid chest, which is one of the forms of the so-called phthisical chest, be- cause supposed to favor the development of this disease. Fig. 5. — Tr.\ksverse Section of Healthy Adult Chest at Level of Sterno-xiphoid Articulation. — {After Gee.) Such a chest is small; the angles of the scapulae project so as to give the appearance of wings. It is narrow, shallow, and long ; but the ratio between the antero- posterior and transverse diameters is not necessarily changed. The ribs droop or are unduly oblique. The throat is prominent, the neck long and the head bent forward. THE SHAPES OF THE CHEST. 29 3. Then there is the flat chest, also phthisical, wherein the antero-posterior diameter is dispioportion- ately short, owing to the loss of convexity in the carti- lages, which are even sometimes turned in so that the sternum is depressed between the cartilages, producing a form of chest which on section is kidney-shaped. In this form of chest there is not the obliquity of the ribs characteristic of the alar chest. Both the flat and alar chests are known 2js, phthinoid c\\fs,i%. 4. The transversely constricted chest is charac- FiG. 6. — Pigeon Breast, Child of Seven Years. (Dotted line indicates natural shape at same age. — {After Gee.) .terized by a depression of varying depth known as Harrison's sulcus. It passes outward and slightly downward on a level with the xiphoid cartilage and as far as the mid axillary line. It is produced in child- hood by some obstruction to the entrance of air, usually a bronchial catarrh, as the result of which the upper part of the chest is not expanded, while the lower part is held upward by the abdominal viscera. It is especially frequent in rickets. 30 PHYSICAL DIAGNOSIS. 5. The pigeon breast is the result of higher degrees of obstruction than are produced by simple catarrhal conditions. Whooping-cough, with its prolonged par- oxysms, is probably the most frequent cause, but any chronic pulmonary catarrh may do it, as may also en- larged tonsils. In it the shape of the transverse section of the chest is more or less triangular, the result of a straightening of the ribs and forward protrusion of the Fig. 7. — Rickety Chest. Dotted line indicates the shape of the chest of an infant about the same age. — {After Gee.') sternum, which takes place while the ribs are plastic and yielding. The pigeon breast is usually associated with the transverse constriction above described, both being the result of different degrees of the same cause. 6. The rickety chest is characterized by a shallow longitudinal groove on each side of the chest, parallel and a little external to the sternum. It is due to exter- nal atmospheric pressure upon soft, rickety ribs before the lungs are sufficiently filled to occupy the space ren- THE SHAPES OF THE CHEST. 3 1 dered vacant by the descent of the diaphragm. The groove takes the position it does because the softest parts of the ribs are about the costo-chondral articula- tions. In addition to the shapes of chest described, inspec- tion recognizes local bulgings, and' shrinking or depression, deficient expansion, the breathing rate, and change of rhythm. Litten's Sign —The Diaphragm Phenomenon. — Inspection also recognizes Litten's sign, a wave-like retraction during inspiration of the intercostal spaces on the frontal, lateral, and dorsal aspects of the thorax. It is ascribed to the peeling off of the diaphragm fiom its thoracic contact, coincident with the descent of the lun-gs, in the act of inspiration. It is seemingly the direct result of external atmos- pheric pressure anticipating the balance of pressure sub- sequently restored by the complete expansion of the lung. It is said to occur in all healthy individuals, but is plainer in those who are thin. Its lower limit in health corresponds with the lower boider of the lung. It is said to be absent in laige pleural effusions and emphysema of the lung, diminished in small effusions. The effect of the latter is to lower the line at which it begins, which is usually the 6th interspace. $2 ?H\'SICAL DLA.GNOSIS. PALPATION. After inspectioD axid mensuration of the chest, palpa- tion is usually practised. This is done by applying the palm of the hand or the fingers, as may best serve the purpose, to the chest-wall. The chief value of palpa- tion lies in the fact that when the hand is thus closely applied, and the person " touched " speaks, a peculiar vibrating or trembling sensation is conveyed to the hand. This is known as vocal fremitus or tactile fremitus. This fremitus or thrill, representing the vibiations communicated to the air by the vocal cords, is conveyed to the walls of the air passages, from the larger to the smaller, until the ultimate structure of the lung is reached, whence it is conveyed to the chest-wall and hands. In health it is felt everywhere over the chest where lung-tissue reaches, but is more distinct where the chest-walls are thinnest, and especially in the infraclavicular spaces. It is further often more plainly felt below the right clavicle than below the left, an im- portant fact to be remembered in recognizing delicate shades of difiference. This is usually explained by the fact that the right bronchus is shorter, larger, and enters the lung higher up and more horizontally than the left, whence a larger volume of air is contained in the right lung, especially in its upper jwrtion, and stronger vibra- tions are produced in speaking. For the same reason vocal fremitus is sometimes slightly more distinct pos- teriorly in the right half of the interscapular space and even below the angle of the right scapula. In the axilla the same difference may exist to a less degree. Tactile PALPATION. 33 fremitus is, of course, more marked in persons with thin chest-walls than in those with thick muscular walls, or walls covered with fat, while it is feebler but still easily appreciable in women. It is also greatly influenced by the pitch or tone of the voice used, being more marked in a deep, low-toned speech than in a high one. It is further influenced by words selected for utterance. My favorites are " ninety nine," as producing a longer vibration than words hke " sixty-six," for instance. But " one, two, three," or " twenty-one," '■' twenty-tAvo," and " twenty-three," and the like, are useful also to bring out vocal fremitus. Vocal fremitus is increased in abnormal states pro- ducing consolidation of the lung, as in pneumonia and tubercular deposit, and is diminished by conditions which separate the lungs from the chest-wall, as pleuritic effusions, plastic pleuritic thickening, and even solid tumors. Fremitus is also produced by the action of coughing, when it is called tussile, as distinguished from vocal; by rales, dry or moist, if the tubes are of sufficient calibre, when it is called rhonchal ; also by pleural and peri- cardial friction. By palpation is also recognized the resistance due to increased density of an organ. Palpation co operates with inspection in recognizing the relative excursion of breathing movement on the two sides of the chest, shght degrees of difference in which being often difficult to discover. Cardiac and vascular thrills are also felt in dis- eases of the heart and blood-vessels. 34 PHYSICAL DL4GNOSIS. PERCUSSION. Percussion naturally succeeds palpation, and consists in striking a part with a view to eliciting sound. In its simplest form it is probably as old as diagnosis itself, but Leopold Auenbrugger, of Vienna, was the first to publish, in 1761, results obtained from its application. Percussion is called immediate or mediate, accord- FiG. 8. — Percussion Hammer or Plexor. Fig. 9. — Ivory Pleximeter. Fig. io. — Sansom's Pleximeter. ing as the blow is struck directly upon the part or upon some interposed medium. Immediate percussion is of limited application, but it is still sometimes very useful, and I much like to percuss the clavicular region by striking directly the bone rather than upon some inter- posed substance. The hammer or agent by which the stroke is practised is the plexor, and the interposed PERCUSSION. 35 material is the pleximeter. By far the most common plexor, and usually the best, is the middle or index finger, or both of these, while one or the other of the same fingers of the other hand becomes tbe pleximeter. It is often useful, however, to have a specialized ham- mer, like that shown in Fig. 8, while more useful and even more indispensable at times becomes a pleximeter (Figs. 9 and lo), in situations which the fingers cannot conveniently reach, or where there is much percussing to do, when the fingers sometimes become sore and tender from the constant pounding. By far the most satisfac- tory pleximeter, in my experience, is the little hard- rubber pleximeter suggested by Sansom. (See Fig. lo.) Either the larger or smaller end may be applied to the chest, and the stroke given to the other, with equal efiiciency. The pleximeter was invented and first used by Piorry, of Paris, in 1828, and the hammer by Wintrich, in 1841. The essential conditions of successful per- cussion are, first, the close application of the plexi- meter, whether it be the finger or an artificial pleximeter, to the chest, so that it will form a part, as it were, of the area to be percussed ; and, as the two sides of the thorax are commonly compared, precisely correspond- ing points should be selected. Then care should be taken to strike with equal force on each side. When the fingers are used as plexors, the stroke should be made from the wrist, and vertically on the pleximeter, while the hand should be raised quickly, and one, 30 PHYSICAL DIAGNOSIS. two, three, or more blows given until the proper sound of the part is elicited. To this end the force of the stroke should be regulated, being made lighter on thin- walled chests and more forcible over thicker walls. When the proper note is brought out it should be re- membered and compared with the sound elicited under the same conditions at the corresponding point on the opposite side. Practice with attention to these condi- tions can alone make perfect. The sound produced by percussing the chest is a mixed one, made up of the vibrations of the pleximeter, those of the thoracic wall, and those of the air in the lungs. The first, when the finger is used as a pleximeter, is scare elv noticeable, but when a pleximeter of ivory or hard rubber is used this element may be recognized, especially when the pleximeter is accidentally struck by the nail of the finger used as a plexor. In like manner the vibrations of the thoracic wall are insignificant and unnoticeable under ordinal}' circumstances, in com- parison with the vibrations of the air in the lungs, which are responsible for most of the sound produced in per- cussing the normal chest. These vibrations are set up by the blow, and it is the sound thus produced, variously modified in health and disease, which we are to study. Where the chest-wall is very thick, however, the note of its percussion becomes more predominant and that of the lungs less. Auscultatory or stethoscopic percussion is a term applied to a method introduced by Cammann and Clark, which consists in listening, A^ith a stethoscope PERCUSSION. 37 applied to the chest- walls, to the sounds obtained by percussion. Such sounds are much intensified when thus conveyed to the ear. The boundaries of organs may, therefore, be thus marked out with greater precision because of the more sudden change of note when they are passed. So long as both plexor and stethoscope are placed over the same organ the intensity continues, but as soon as either passes the limits of the organ the per- cussion note becomes feeble and diffused. This form of percussion is scarcely enough appreciated, as information obtained ])y percussion is rendered more precise, while boundaries may be thus rec- ognized which are not ob- vious to ordinary percussion, as that between the lower border of the heart and the liver, and that between lobes of the lungs. It is not neces- sary to tap with the plexor, — Fig. II. — The Phonendoscope. Designed by Drs. Eazzi and Bmnchi. 38 PHYSICAL DIAGNOSIS. scraping or scratching by the finger or a pencil may be substituted. The phonendoscope is an instrument by which auscultatory percussion as well as auscultation is ren- dered more delicate. It consists of a drum or cylinder (B), one surface of which, covered with a thin sheet of hard rubber, is applied to the part to be examined, while to the other side are attached rubber tubes and ear pieces. Small areas are reached by means of a second disc of hard rubber, into which is screwed a metal cylinder (A). The instrument thus arranged is less delicate but is necessary over small areas. Scraping with the finger is practised, and the same intensity of sound described under stethoscopic percussion is heard until the border of the organ is passed, when the sound suddenly ceases. The instrument is also used in securing greater delicacy in ausculting breath-sounds and cardiac murmurs; but the advantage gained by its use is scarcely sufficient to permit it to replace the ordinary stethoscope. Respiratory percussion is a term proposed by J. M. Da Costa for the study of a note made by per- cussion of the lungs while the breath of the patient is held after a deep inspiration or after a prolonged expira- tion. Constant reference will be made to the effect of the latter on sounds elicited by percussing normal organs. The general effect of a full breath on percus- sion is to increase the lung resonance, make the sound fuller and raise the pitch. The effect is more marked on the right side. The eft'ect of a complete expiration is the opposite. AITRIBUTES OF PERCUSSION SOUNDS. 39 ATTRIBUTES OF PERCUSSION SOUNDS. Percussion sounds have attiibutes of quality, in- tensity or loudness, pitch, and duration. No one of these attributes can, strictly speaking, be so described as to enable it to be recognized by the ear. Practice and illustration must be associated with the description in order that an adequate idea may be obtained. Quality is the easiest indicated of the attributes of sound. Although the late Dr. Austin Flint truly said that " to attempt to describe the quality of sounds to one who has never heard them would be like describing colors to one who is blind," illustration happily comes to OUT assistance and helps greatly. Thus it is not dif- ficult for any one who has heard it to recognize the note of a tuning-fork, violin, or piano, and to name the in- strument producing it. The attribute of sound by which such recognition is made is quality, and each quality is produced by certain conditions peculiar to the instrument producing the sound. It varies there- fore with those conditions. Now, the qualities of sound produced by percussing the normal lung are mainly two : First, the normal 7)es- iciilar resonance or clear sound ; second, the dull sound or dulness. There are modifications of both of these. A third quality, not strictly speaking a normal thoracic sound, but so conspicuous in adjacent organs in health as often to influence the thoracic sounds, will also be de- scribed in this connection. I allude to tympany. Each of these is produced by conditions peculiar to itself. 40 PHYSICAL DIAGNOSIS Vesicular resonance, or lung-clearness, as applied to the healthy chest, is produced by percussion over normal air-distended lung tissue, a structure containing air in minutely divided spaces. Such structure is its condition, and the sound produced is as much siii generis as is the violin's sound. It is of the nature of a rever- beration, and is reverberation modified by minute subdivision of air spaces. It was compared by Auen- brugger to the sound of a drum covered with a thick woolen fabric, and not inaptly by Flint to the sound produced by percussing a loaf of bread over which a towel has been spread, the upper crust of the bread corresponding to the chest-wall ; but it does not do to take this illustration too literally. Normal lung reso- nance differs in different parts of the chest of the same individual and in different individuals. Its typical quality may always be found in the left infraclavicular space or below the angle of eithei scapula in healthy persons with chest-walls of moderate thickness. The chief cause which operates to produce the differ ences alluded to in health is the varying thickness of the chest- walls and the intervention of bone, as a rib, the clavicle, or sternum. But the state of tension of the air in the air vesicles has to do with it, as has also the position of adjacent viscera and the mode of percussion, according as it is forcibly or lightly practised, according as it is well or faultily done. The differences themselves consist in variations in the other three attributes named — intensit5f,^3itch, and duration. Intensity means simply loudness and increases /an ATTRIBUTES OF PERCUSSION SOUNDS. 4 1 passu with the thinness of the chest-wali and the force of the percussion blow. The effects of the attributes of pitch and duration are best studied after the other quah'ties mentioned, dulness and tympany, are con- sidered. Dulness in general may be defined as diminished resonance, but the term is not used by all authors with a single meaning. I do not think Da Costa's description can be improved upon. He says,* " a dull sound denotes the absence of air. It is the sound both of fluids and solids. It is, thus, the sound sent forth by the airless viscera; from the liver, spleen, and heart." The term flatness is essentially synonymous, although also used to indicate a higher degree of dulness. To retain the word flatness for the sound produced by per- cussing an absolutely airless organ or fluid, and dulness for resonance diminished in positive degree, gives a desirable latitude in the use of terms, further increased by the application of the adjective terms slight, moder- ate, considerable, or marked. I shall therefore use the term in this sense. Dulness and flatness are both associated with increased, resistance to the percussing finger, a sign also more or less valuable in diagnosis. Tympany or tympanitic resonance is the sound elicited by percussing over a large cavity filled with air — a cavity whose walls are rather thin, and neither very tense nor very yielding. The stomach and intestines furnish such a cavity, and it is in this region that we * " Medical Diagnosis," 7th ed., 1890, p. 264. 42 PHYSICAL DIAGNOSIS. seek the tympanitic quality of resonance. Tympany also has variations in pitch due to variations in the size of cavities, which will be better understood after this attribute of sound is considered. Pitch and Duration — We are now ready to discuss and illustrate the attributes of pitch and duration, neither of which are so easily described as quality and intensity. They can, indeed, only be learned by prac- tice and with varying facility by different ears, the musical ear having a decided advantage. Perseverance, however, will enable any one to appreciate them suffi- ciently for practical purposes. First as to pitch. VVe speak of it as high or low and of intermediate degre.e Pitch is higher the more rapid is the succession of the vibrations of the sounding body and of the sound waves which emanate from it, while intensity depends on the amplitude of the vibrations.* Shrillness is the acme of pitch, loudness of intensity. The higher the tension of a percussed cavity containiilg air the more numerous the vibrations and the higher the pitch, but the shorter the amplitude of the vibrations and therefore the less the intensity. Vice versa, a high-pitched tympanitic resonance would indicate a smaller cavity with tenser walls than low-pitched tym- pany. The normal vesicular resonance is characterized * Amplitude is the length of the excursion of the particles which at any time form the sonorous wave, and the motion of the particles or their width of swing must not be confounded with the motion of the sonorous wave itself. ATTRIBUTES OF PERCUSSION SOUNDS. 43 oy its low pitch, because the air vesicles are not in a state of high tension. If, however, the lungs be forcibly dilated, the air vesicles are placed in a state of higher tension and of diminished elasticity, a situation akin to that of a distended stomach, and if percussion be now practised over such areas the pitch will be raised, but there will be added not only a higher pitch, but also a tympanitic quality, and a note will be produced which was named by Dr. Flint vesiculo-tympanitic resonance. It is a mixed note, therefore, and its conditions are produced by any cause which over-dis- tends the air vesicles, as prolonged crying in a child. It is also the note of the over-distended air vesicles in emphysema of the lung or of portions of a lung, sup- plementally active in consequence of impairment of function in other parts. Tympanitic sounds, although generally high-pitched, also vary in pitch, the latter increasing inversely as the size of the cavity and directly with the degree of ten- sion. Thus the stomach, being a large cavity, gives to percussion a lower pitch than the small intestine dis- tended to an equal degree. On the other hand, tension may be made so great by forcible distension, say of the stomach, that the tympanitic sound may be destroyed. When a bladder or stomach is so forcibly distended that its percussion produces a dull sound instead of a tympanitic one, — and such distension is only possi- ble when the air space is tightly closed on all sides, — it is as though the air space were surrounded by unyield- ing walls. Percussion under these circumstances — a 44 PHYSICAL DIAGNOSIS. thoroughly closed cavity and firm walls — produces no t3'mpany. The observer hears, for the most part, only the sound produced by the vibrations of the bladder wall, influenced in part by the convex shape of the bladder, and in part by the condensed air witnin it. The pressure of this air resists the inward vibration of the bladder wall, and by shortening the amplitude of the air vibrations diminishes the intensity and resonance of the sound. In a word, it is shorter, duller, non-tym- panitic. If, however, the mass of air thus surrounded by a tense wall communicates with the exteiior by an opening, the tympanitic note responds to percussion. Dull and flat percussion are high pitched in their note, and the pitch increases with the dulness and the area of the dulness, while the first suggestion of im- paired resonance is a slight heightening of pitch which the practised ear readily recognizes, and attaches to it great importance. The suggestion of a higher pitched note just below the right clavicle in health as compared with the note of the corresponding region on the left, is also to be remembered in weighing slight differences in the percussion note of the two sides. It is associated with the tendency to increased vocal fremitus in the same situation, already referred to. The explanations of this tendency to a slightly higher pitched note and slight dulness at the right apex are not uniform, and best considered in a footnote.* * One explanation of this slight impairment of the resonance is based on the different arrangement of the bronchial tubes on the PERCUSSION OF THE NORMAL CHEST. ' 45 Duration is the attribute of least importance, or at least comes little into play in the percussion of the human body. It varies inversely with the pitch, that is, the higher the pitch the shorter the duration, and vice versa. We are now ready to study the percussion sounds as heard in the different regions of the chest as already mapped out. PERCUSSION OF THE NORMAL CHEST— TOPO- GRAPHICAL PERCUSSION. First, in the supraclavicular spaces. Satisfactory percussion here is difficult and results are right side as compared with the left. The former are larger, extend higher up than the latter, and thus give more tubular tissue, in- cluding a larger proportion of connective and muscular tissue to deal with in percussing, which would cause shghtly less resonance. A second explanation, which certainly must be allowed to apply in some instances, is the greater muscular development of the right side of the body, and in consequence greater thickness of the pec- toral muscles of that side. This would also cause a slightly higher pitch. The opposite state of affairs in left-handed persons would go far to confirm this, but I am not aware of any systematic observa- tions intended to settle this question. Still another explanation of this difference is based on the fact that the right lung rests, through the diaphragm, upon the right lobe of the liver, which is a dense organ, and percussion of the lung would be modified, by such relation, toward a slight impairment of resonance. It is not impossible that any one or more of the first three causes might operate to produce the difference on the two sides, the last cause more particularly in explaining any slightly raised pitch in the lower lobe as compared with the left. 46 PH\'5ICAL DLA.GNOSIS. not to be too much relied upon. The nearest approach to normal clear percussion or vesicular resonance is found above the centre of the cla^^cles where the lungs rise from Ji^ inch to 1J2 or even two inches above the clavicle, being usually higher in women than in men. Toward the inner end of the clavicle the percussion may acquire a more tjTiipanitic quality, on account of the proximity of the trachea, while toward the outer end a duller note obtains. On the clavicles themselves the percussion note is clear, almost typically so, over the middle of the bone, but becomes duller as the outer end is approached, while on the inner end it may be higher pitched — osteal. The infraclavicular spaces furnish in health the t}'pical clear lung note or vesicular resonance through- out these spaces. On the right side is to be looked for the shadowy higher pitch, less clearness, and shorter duration, so that the left subclavicular may be selected as affording typically normal lung resonance. This dif- ference is not invariable, but the fact is to be remem- bered in weighing shades of difference with a view to diagnosis. In the mammary region percussing down the right mammillar}- hne, the clearness continues, possibly a trifle less on account of the greater thickness of the pectoral muscle, until the 4th interspace or the 5th rib is reached, when there is a raised pitch and diminished intensit}^, which passes at the 6th rib into a positive dulness which continues in health to the edge of the ribs. This impairment of the resonance on the right PERCUSSION OF THE NOR-MAL CHEST. 47 side is due to the liver, the lesser degree being known as the deep or relative dulness, and below this the absolute dulness. The upper border of the absolute dulness corresponds with the lower edge of the right lung. Close to the sternum on the right side there may be slight impairment of resonance from the 3d to the 5th rib, due to the relative dulness of the right auricle, passing at the 5th rib into the relative dulness of the liver, and at the 6th into the flatness of that organ. On forced inspiration the liver is pushed downward an inch or more, and on forced expiration there is a cor- responding rise. On the left side, close to the sternum, normal vesicular resonance begins to lessen at the 3d interspace, owing to the deep or relative dulness of the heart, and at the 4th costal cartilage is replaced by the absolute dulness of this organ, which continues down along the left edge of the sternum until it passes into the left lobe of the liver, from which it cannot be demarked ; but in gen- eral terms the absolute cardiac dulness may be said to extend from the 4th to the 6th rib along the left edge of the sternum ; and from the sternum to a cur\-ed line extending a short distance along the 4th cartilage and thence down within the nipple line to the seat of the apex- beat, the line of relative dulness being a short distance outside of this. (See Fig. 12.) The cardiac area of dulness is also diminished on deep inspiration, because the organ becomes more fully covered bv the distended lungs. External to the nipple on both sides there is, in health, resonance to the anterior axillary 48 PHYSICAL DL4GN0SIS. line, slightly lessened by the mamman' gland and pec- toral muscle. The inframammary region on the right side is wholly occupied by the liver and furnishes flat percus- sion, beginning in the mammillary line at the 6th rib, rising with this rib as the sternum is approached. In the mammillary line it extends to the edge of the thorax. The extent of the area of absolute dulness of the liver is three to four inches. On the left side the percussion in the inframammary region varies greatly in different persons and in the same person at different times. Near the tip of the sternum and a short distance below, the left lobe of the liver for the most part maintains its dulness, but even this is sometimes replaced by the tympany of a gas-distended stomach, while to the outside of this the stomach as normally distended with gases quite frequently imparts a tympanitic note. On the other hand, the presence of solids and fluids in the stomach contributes dulness in various degrees. A spleen of normal size does not extend into the inframammary region. In this connec- tion it may be mentioned that the lower edge of the liver generally corresponds to a line drawn from the left 6th rib within the mammillar}' line obliquely across the epigastrium to the junction of the right mammillary line with the edge of the thorax. In the suprasternal notch, also difficult to per- cuss, tracheal tympany may be brought out by vertical percussion on a suitably placed pleximeter. Over the upper sternum, as far as the 3d rib, the percussion is Fig. 12. — Showing Absolute and Relative Percussion Dulness of Liver AND Heart. I. Relative dulness of liver. 2. Absolute dulness. 3. Relative dulness of heart. 4. Absolute dulness. 5© Pm.-SICAL DL4GN0SIS. resonant, with a slightly tympanitic note communicated by the trachea. Below this for a short distance there is a purer lung note, though perhaps slightly less resonant than typical lung structure because of the underlying heart. At the 4th rib the heart, though still covered in by the lungs, begins to deaden the note, which is still fairly clear in the median line until the liver is reached opposite the 6th rib, where dulness is absolute and extends one-third to half-way to the umbilicus, although a tympanitic stomach may also influence the note. Toward the left edge of the sternum from the 4th rib down there is decided impairment of resonance caused by the heart immediately under it. In the axillary spaces on both sides there is good pulmonary resonance. In the infra-axillary region of the right side, the relative dulness of the liver is noted at the 8th rib in the mid-axillary line and the absolute dulness at the 9th. On the left side there is also clear- ness until the spleen is reached in the mid-axillary line at the 9th rib, whence it extends to the nth. Laterally the spleen extends upward and backward between these two ribs from two to three inches, and sometimes it is so covered in as to escape recognition by careful percus- sion. The left infra-axillary region is also apt to be encroached upon by the tympany of the stomach. Posteriorly, percussion is best practised with the patient leaning slightly fonvard and folding his arms. The upper border of the lungs behind is on a level with the spinous process of the 7 th cervical vertebra. In the supraspinous fossa the percussion reso- PERCUSSION OF THE NORMAL CHEST, 5 I nance is markedly less than typical, because of the bone and the thick muscles overlying it, and the same may be said of the infraspinous region. At the same time percussion here is important because differences on the two sides are usually easily recognizable. In the interscapular region there is again better resonance than over the scapulse themselves, but still less intense than below the angles of the scapulae, on account of the tolerably thick muscles and the spinal column. In the upper portion the tympany of the trachea may influence the note. In the infrascapular regions we have the nearest approach behind to the typical resonance as represented by the left infraclavicular space. The information ob- tained here by percussion is most valuable, only equaled in importance by that obtained by percussing below the clavicles, and in consequence of this it is important to remember the inferior border of the normal resonance. The lower border of the lung in the line of the angle of the scapula corresponds on both sides to the loth rib, where, on the right side, the absolute dulness of the liver is found, while the relative dulness on strong per- cussion is found a rib higher. On the left side reso- nance extends in the line of the angle of the scapula fully to the loth rib, though sometimes a tympanitic quality may be imparted by a dilated stomach or the colon, or a slightly dull sound if the spleen extends a little further back than usual. Here as elsewhere on the thorax there may be slightly less intensity and slightly higher pitch on the right side, on account of the 52 PHYSICAL DL4 GNOSIS. greater muscular development in right-handed persons; and the effect of a deep inspiration in lowering the line of resonance, and in expiration of raising it an inch or more, is also to be remembered. In ordinary breathing the normal resonance posteriorly passes at the loth rib into the absolute flatness of the lumbar region. The upper border of the kidney below the nth rib, the left being a little higher than the right, cannot ordinarily be separated by percussion from the dulness of the spleen and li\-er, nor can the inner border be separated from the spinal column. The outer edge can, however, be defined by percussion from the colon on the right and the stomach and colon on the left by percussing outward from the median line behind. The outer border of the kidney is three or four inches beyond the median line. The lower border can sometimes be defined by a line of tympany just above the crest of the ilium, produced in the colon. Forcible percussion is required, and it is desirable to place a pillow under the abdomen of the patient lying prone upon his face. ABNORMAL LUNG SOUNDS ELICITED BY PERCUSSION. It goes without saying that a sound which is normal in one situation becomes abnormal when heard in a position unnatural to it in health, as dulness or tympany below the clavicles or below the angles of the scapulas, where vesicular resonance is ordinarily found. But in addition there are certain positive modifications of nor- ABNORMAL PERCUSSION LUNG SOUNDS. 53 mal sounds not heard anywhere in health, or at least under such exceptional conditions as do not permit them to be included among normal sounds. These are vesiculo-tympanitic resonance, am- phoric resonance, and cracked-pot sound. Vesiculo-tympanitic Resonance. — The vesiculo- tympanitic resonance of Flint has already been alluded to, but requires to be further considered because it is not generally recognized by either American, English, or German authors as something distinct and different from tympany, and it requires to be conformed to their treatment of conditions supposed to cause it. In the language of its describer, " the resonance increased in intensity; the quality a combination of the vesicular with a tympanitic, and the pitch higher in proportion as the tympanitic quality predominates over the vesicu- lar." According to him, also, the morbid condition which especially illustrates- this form of resonance is the over dilatation of the air vesicles which constitutes ves- icular emphysema of the lungs, but he includes also in- terstitial or interlobular emphysema. It occurs also over the upper lobe of a lung when the lower lobe is solidified in the second stage of pneumonia, and over the lower lobe when the upper is solidified. So, also, if the lower part of a pleural sac contains fluid, even though the volume of the lung is diminished, the upper part of the same lung may give the same vesiculo-tym- panitic note. Attention was first called to this by Skoda, and it is known as Skoda's resonance. Too much of the intrathoracic space must not be occupied 54 PH\'SICAL DIAGNOSIS. by fluid, because the luug is thus compressed and ren- dered airless. The resonance remains vesiculo-tympan- itic above the liquid \Yhen the latter is suificient to fill a third, a half, or even two-thirds of the intrathoracic space. Xow, these are essentialh' the conditions named by Da Costa, Paul Niemeyer, and Graham Brown as pro- ducing tympanitic resonance of lung tissue. It is well described by Brown * : " Just as when the lung is re- moved from the body and allowed to collapse it gives a tympanitic note, so when a similar retraction and re- laxation of the pulmonic tissue takes place within the thorax, that variety of percussion note may be heard. This is best marked in cases of pleuritic effusion, which, gravitating to the lower portion of the cavity, floats up the lung and causes relaxation of the upper portion. When the effusion is small in amount the tympanitic note can only be detected over that portion of the lung which lies immediately above the upper limit of the fluid, but when the efltusion is considerable the whole upper lobe may be tympanitic on percussion. This is also called tympany by mediate relaxation. Similarly, effusion into the alveoli in pneumonia or oedema may produce a like result." t This is tympany by imme- * " Medical Diagnosis," 3d edition, Edinburgh, 1887, page 207. + This can occur only in the first and third stages of pneumonia when the air vesicles contain air, the second stage being one of absolute airlessness and dulness. ABNORMAL PERCUSSION LUNG SOUNDS. 55 diate relaxation. Nieraeyer* adds, occasionally gan- grene and infarct, also disseminated tubercular infiltra- tion, emphysema, arid nervous asthma, and that portion of the lung not inflamed but immediately adjacent to a hepatized part, — another instance of mediate relaxation. In like manner phthisical consolidations of the apices may also occasion an obscurely tympanitic note over neighboring portions of the lung by mediate relaxation. Finally, Da Costa, who with Flint may be regarded as representing the American School, says : " But gener- ally a tympanitic sound over the seat of the lungs is expressive of emphysema or of pneumothorax, or some- times of a cavity or of oedema of the lungs. Again, as Skoda has taught us, it occurs in moderate pleuritic effusions above the level of the liquid." f It has seemed to me important to contrast these state- ments, both in order to give a better idea of what Flint intends to convey by vesiculo-tympanitic resonance and to avoid confusion in the minds of those who might with reason be confused by statements apparently so diverse. Pure Tympanitic Resonance. — Tympanitic re- sonance is found in normal thoracic states only over the larynx and trachea and in the left infra-axillary region from encroachment of a tympanitic stomach. Else- where it becomes a sign of an abnormal state. * " Grundriss der Percussion uttd Auscultaiiott." Zweite Auf- lage. Erlangen, 1873, pages 38, 39. t " Medical Diagnosis," 7th edition, 1890, page 265. 56 PHYSICAL DIAGNOSIS. The fundamental principle to be remembered in con- nection with .tympanitic sounds is that their pitch depends inversely on the volume "of circumscribed air and the transverse section of an opening communicat- ing with the exterior. In the chest, tympany is pro- duced by percussing over air-containing cavities in the lung tissue, suiSciently near the surface and sufificiently large, and whose wails are not too tense. Bearing in mind the above principle, approximate estimates as to size and shape of cavities may be made even by obser- vations as to pitch. Thus a cavity of small size will give a higher-pitched tympanitic note than one of a large size. As these cavities usually communicate with a bronchus they are further characterized by differences in the pitch when percussed with the mouth open or closed. Thus is produced Wintrich's change of note, according to which percussion over a given cavity gives a higher- pitched tympanitic sound with the mouth open than when it is closed. This may be illustrated by percussing over the thyroid cartilage under the two conditions, when the difference will be very evident. It occurs in connection with the superficially-placed cavities in com- munication with a bronchus. If this change of sound is observed on lying down, but is not on sitting up, or vice versa, it means that the bronchus leading to the cavity is obstructed in the position in which the Win- trich change of note does not occur. This is the interrupted change of note of Wintrich. By what is known as Gerhardt's change of note ABNORMAL PERCUSSION LUNG SOUNDS. 57 we learn something about the shape of cavities. Cavi- ties which have unequal diameters, or are oval in shape and are partially filled with fluid, alter their note on changing the position of the patient from sitting to horizontal. Thus suppose A to represent an oval cavity in the vertical position with the contained fluid at the line c d. If the patient lies down the long diameter Fig. 13. — To Illustrate Gerhardt's Change of Note. will become horizontal, as in B, and the level of the fluid will fall to a b. The percussion note is lower when the longer diameter is horizontal, higher when it is vertical. If, therefore, the percussion note changes in thus altering the position of the patient, the cavity is oval. Every cavity does not, of course, furnish the con- 5 8 PHYSICAL DIAGNOSIS. ditions of tympanitic percussion. Recent experiments also shed some doubt as to the correctness of the law originally announced by Gerhardt, that the pitch of oval cavities partially filled with fluid depends on the direction of the greater diameter, while other conditions, too, have been suggested as capable of explaining the differences of pitch observed in cavities whose relations have been altered by changes in the patients' position. Second, pure tympanitic resonance is also character- istic of pneumothorax if the distension is not too great. There being no free communication of such a space with a bronchial tube, no change of pitch occurs when per- cussing with the mouh open and closed. If there hap- pens to be liquid in the sac, Biermer's change of note may be produced as follows : In the vertical posi- tion of a pneumothorax containing fluid the cavity is larger because the weight of the fluid pushes the dia- phragm downward. Hence in this position the pitch is lower. If the position of the patient is now changed from the vertical to the horizontal, the cavity becomes smaller by reason of the changed position of the fluid and the pitch becomes higher. Third, a pure tympanitic resonance may be produced in pneumonia when the portion of the lung lying between the trachea or primary bronchi and the surface becomes hepatized. This is sometimes called Williavis' s tracheal resonance, and is most frequently found in the first or second intercostal space near the sternum. A pleuritic effusion may compress the lung into a like position, at which a like note may be produced. ABNORMAL PERCUSSION LUNG SOUNDS. 59 Amphoric Resonance. — Amphoric resonance, a variety of tympanitic resonance, is a high-pitched me- tallic' resonance, so called from its resemblance to the sound produced by striking the side of a jar, either empty or containing a small quantity of fluid. It may also be imitated by filliping the cheeks when the mouth is distended with air. It has an echoing sound, the waves being reflected from side to side of the closed vessel, as is speech in a vaulted chamber. A modification or variety of amphoric resonance is the coin-clinking test of Gairdner, or Bell tympany or bell-metal sound, in which a coin of sufiicient size used as a plexi- meter is percussed by another on the anterior surface of the chest, while the auscultator listens posteriorly or vice versa. The sound thus elicited usually resembles that produced by striking with a hammer on an anvil ; more rarely it is softer and more musical. It is especially characteristic of pneumothorax. Amphoric resonance is not very often met ; the con- ditions of its production in the human body are an air- filled cavity of considerable size, with firm and smooth walls, completely closed or communicating with the air by a small opening only. When thus communicating it is louder when the mouth is kept open. These condi- tions are fulfilled by certain phthisical cavities, and especially by pneumothorax or pyopneumothorax, some- times also by a distended stomach. If with a pyopneu- mothorax the body be shaken, a splashing or succus- sion occurs, which will sometimes have the same ringing character. The same conditions are sometimes fulfilled by a distended stomach containing fluid. 6o PHYSICAL DL4GNOSIS. The Cracked-pot Sound. — This sound is well named because it quite resembles that produced bj^ tap- ping a cracked jar, and is therefore one of tbe most distinctive and easily recognized of the abnormal per- cussion sounds. It is, too, a modification of tympanj', and is caused by the explosion of air from a cavity through a small opening by a sudden forcible blow. It is also imitated in mechanism as weU as character by suddenly striking the back of the two palm-apposed hands against the knee, after the method used by boys to imitate the chnking of coins. It may also be made by striking the pleximeter when the latter is not closely apphed to the skin, an accident favored by a hairy skin. The cracked-pot sound may also sometimes be produced in the normal chest by percussing it sharply while the patient is in the act of speaking or crying out, the narrow glottis affording the condition of a small opening. This ma}^ more readily be done under these conditions in children who have thin, elastic chest-walls. The cracked-pot sound is produced in disease by per- cussing over a ca'vity which affords the conditions named, vis., a. somewhat superficial position, sufficiently pelding walls, and communication by a small opening with a bronchial tube and thence with the outside air. It is the most infallible sign of a ca\Tty known. In producing it, the mouth of the patient is kept open and a sudden forcible blow of the plexor given. Often it caiuiot be heard unless the ear is attentively turned near the chest to catch the sound. The same conditions AUSCULTATION. 6 1 exist in a pneumothorax with a thoracic fistula into the lung, and under these circumstances a cracked-pot sound may be produced by percussing such a chest in the manner described. AUSCULTATION. Auscultation is the act of listening to sounds, more particularly those produced in the chest by breathing or speaking, or by the heart's action, or in the blood- vessels ; to these sounds as modified by disease and to certain new sounds produced by disease. In so doing the. ear is applied either directly to the chest or on an instrument known as a stethoscope. According as this instrument is employed or not, the auscultation is mediate or immediate. Both have their advan- tages. When it is desired to isolate or circumscribe a sound, especially in the study of the heart, the stetho- scope helps us greatly, while in the study of more diffuse sounds, as many of those produced in the lungs, the direct application of the ear to the chest is generally to be preferred. The stethoscope becomes also desirable in the examination of patients not especially clean. In inexperienced hands, on the other hand, the patient is often rendered uncomfortable by undue pressure by the head on the instrument. The stethoscope was invented and used by Laennec, of Paris, in 1816, in its single shape. Through the labors of Laennec, by the aid of the stethoscope the diagnosis of diseases of the chest developed in a com- 62 PHYSICAL DLVGXOSIS. paratively short space of time to an accuracy scarcely equaled in the case of any other set of organs. The binaural instrument was devised by Cammann, of New York city, in 1840. There can be no doubt that, with the latter, sounds are more loudly heard. On the other hands, all noises, as that of the rubbing of linen or clothing, are so much exaggerated that the beginner is often confused. The double instrument is becoming more popular of late, but preference depends on training. A man who has been brought up to use the double stethoscope soon grows to prefer it, while he who is trained to the single instrument would not have the dou- ble. When either form of the instru- ment is used, better results are ob- tained when the chest-end is applied directly to the bare skin, whereas in immediate auscultation it is desirable that there should be a thin, soft towel, or some thin garment, inter- posed between the ear and the skin. The ear or stethoscope should also be applied closely to the chest- wall, so as to become a part of it or continuous with it ; and yet, as stated, the stethoscope may be applied too strongly, so as to give pain to the patient. Successful auscultation requires that the attention should be closelv concentrated on the matter in hand. Fig 14. — Hawksley's Stethoscope. AUSCULTATION. 63 The single stethoscope is made of wood or metal. That originally made by Hawksley, of London, out of gun-metal, and provided with a detachable hard rubber Fig. 15. — Sansom's Binaural Stethoscope. Fig. 16. — Simpler Form of Sansom's Binaural Stethoscope. ear piece, shown in Fig. 14, is the most convenient and neatest. A large variety of double stethoscopes has been suggested. The double instrument, Fig. 15 in the 64 PHYSICAL DLA.GN0S1S text, partly metal and partly rubber tubing, was devised by Sansom, and is ver}' conveni- ently carried when folded at the joint. It is especially suitable when the patient is inaccessibly placed in relation to the exam- iner, an advantage possessed in various degrees by all binaural stethoscopes over the single in- strument. A still simpler form is shown in Fig. i6. In selecting this shape, great care should be taken to secure an ear-piece which fits the ear properly ; also, that the rubber tubing embraces closely the metallic chest-portion as well as the ear pieces, and if tubing happen to become split, the spht end can be cut off and the tube reapplied. Recently Dr. H. K. Valentine, of Brooklyn, N. Y., has devised * a binaural stethoscope, which in m)'- experience conducts stetho- scopic sounds more loudly to the ear than any other I have used. The instrument (Fig. 17) is composed of hard rubber, the chest- and ear- pieces Fig. 17. — Valentine's Bin- aural Stethoscope. * A'. V. Med. Record, July 16, 1892. AUSCULTATION OF THE NORMAL LUNG. 65 being united by two pieces of ordinary soft-rubber tubing, each about 3^ inches in length, and being flexible the instrument may be folded and carried in the pocket. The bell consists of two parts, the lower a tube 4^ inches long, having ^ inch at the mouth and ^ inch at the upper end, where it is screwed into the upper section. This top section is ^ inch long and has two canals, each y^ inch in diameter, diverging from it, separated at their origin by a septum of hard rubber. The ear-pieces are straight up to where they are curved to enter the ear, having a bore of }l inch at the lower end, tapering to ^ at the ear ends. These are retained in the ear by a flat steel spring. When the instrument is in use, the waves. of sound pass upward through the long bell, divided at the top by the sharp rubber septum, and thence through the ear-pieces into the ears of the operator. The efficiency of the instrument depends largely on the smooth finish of the interior of the hard-rubber tubing throughout its entire length. It is provided with one or two accessory soft-rubber bells, also figured, which intensify the sounds, but the instrument is, for the most part, best used without them. When the interior of the bell becomes very dusty, it may be easily cleaned by allowing cold water to run through it. AUSCULTATION OF THE NORMAL LUNG. The breathing sounds in health are separable into two distinct orders : first, the bronchial breathing ; 66 PHYSICAL DL4GN0SIS. second, vesicular murmur or respiratory mur- mur. Both are normal sounds, constantly produced in the act of breathing, but in certain parts of the chest one is heard more or less to the exclusion of the other. Thus the vesicular breathing is heard in its most typical character under the left clavicle, where it is best studied by immediate auscultation. Bronchial respiration is the easiest of description. It is blowing or tubal in quality, both in inspiration and expiration, and the two parts are nearly equal in length, the expiratory being often shghtly the longer. It is heard in its purest form over the larynx and trachea, but cflso quite pronouncedly between the scapulee at the root of the lungs, where, however, it is more or less admixed with vesicular breathing. The pitch is high in both in- and out-breathing, and somewhat higher in the latter. It is caused primarily in the glottis by vibra- tions produced in the column of air as it passes the vocal cords in inspiration and expiration. It is con- ducted downward from the larynx partly along the solid walls of the trachea and bronchi and partly by air, the latter being chief conductor. It is modified as the tubes gradually reduce their calibre. Vesicular murmur is the breathing sound heard when listening over the vesicular tissue of the lung. It is also divided into two portions — the inspiratory and expiratory, the in- and out-murmur, the former being much the longer. Perhaps no language can give a correct notion of the vesicular murmur, but it is a soft, low-pitched sound, said to resemble the sighing of ^ AUSCULTATION OF THE NORMAL LUNG. 67 gentle breeze through the leaves of a tree. It is the blowing sound primarily produced in the glottis, sub- dued and muffled by distance and the spongy structure of the lung. When typical the inspiratory murmur is much longer than the expiratory. The ratio is, however, not fixed. The expiration may be one-fourth as long, or it may be a mere whiff, as it were. It represents the recoil of the air vesicles and the back- ward movement of the air. The question why the expiratory murmur is less loud and shorter than the inspiratory is a natural one. It is probably because sound is better conducted in the direction of the movement of the vibrating column from the point at which the vibration is caused, /. e., in this instance at the glottis. During inspiration the sound is conducted toward the periphery and during expiration toward the glottis. The vesicular murmur is not everywhere the same, even in health. As a rule, it is slightly louder, more purely vesicular below the left clavicle, and, assuming it to be typical in this situation, is nearest maintained in the axilla and below the scapulas. Under the right clavicle the slightest rise in pitch and a distinct pro- longation of the- expiratory portion is often noted, and to be remembered as of great importance in diagnosis in doubtful cases. This is usually ascribed to an ad- mixture of the bronchial element due to the larger size of the right bronchus, and of its branches sent up toward the right clavicle. Over the scapular regions posteriorly the vesicular murmur is less intense, because of the thickness of the bone and muscles, but the same differ- 68 PHYSICAL DIAGNOSIS. ence between the two sides may sometimes be noted in the supraspinous fossse, as below the clavicles in front. For the same reason it is less intense in the mammary regions, and in all fat and muscular persons as compared with the thin and emaciated. Between the angles of the scapulae still more of the bronchial element is added than below the right clavicle, and the sound is de- cidedly more blowing and the expiration longer. It is to be remembered that both vesicular and bronchial breathing are being constantly produced in the lungs, but that in certain situations one overshadows the other, partly because of its proximity immediately under the point where the ear is applied, and partly because the normal lung is a poor conductor of sounds. ABNORMAL MODIFICATIONS OF BREATHING SOUNDS. Changes in the Vesicular Murmur. — The vesi- cular murmur is modified by diseased states as follows : 1. It is jerking or interrupted. 2. It is increased in intensity or loudness. 3. It is diminished in intensity, feeble, more indis- tinct. 4. It is altogether absent. 5. It is commingled with bronchial breathing, by which a harsher sound is produced, and of altered rhythm. 6. It is substituted by bronchial breathing. I. Interrupted or jerking or cogwheel breath- ing is the least important of the alterations in the vesicular murmur, being generally of no significance. ABNORMAL BREATHING SOUNDS. 69 Such is its value in persons who are nervous or sHghtly alarmed during examination. The interruption affects most frequently the inspiratory act, but it may occur in either or both, and the act may be broken into two or three parts. More serious is its cause when it occurs in connection with severe pleurisy or pleurodynia, where the pain of the act of breathing causes the latter to be interrupted. Finally, it may be present in incipient tuberculosis or emphysema, but even here its diagnostic value is merely confirmatory, and that only when it persists. 2. Vesicular breathing is exaggerated or supple- mental, or increased in intensity by any cause which compels the lung or a part of it to assume increased function. This happens in one lung or a part when the other or the remainder is deprived of its use by compression or destruction. In this change both the inspiratory and expiratory factors are proportionally increased in loudness and in length. Its pitch is unal- tered. From the resemblance of this exaggerated breath- ing, as it is also called, to the louder, normal breathing in children it is often called puerile breathing. 3. The vesicular murmur is feeble or diminished in intensity by various causes. The quieter the breathing the less loud its sounds, and diminished loudness may be due to feebleness in the inspiratory act from debility, or to obstruction in the bronchus leading to the ausculted area. More commonly, in actual practice, the^feeble- ness is due to the interposition of a liquid or a solid medium between the lungs' [and theyear,^such as 'a d 70 PHYSICAL DL4GN0SIS. pleuritic eflusion or the plastic exudation of a pleurisy. Or it is due to the filling up of the air vesicles hy an exudate, as in pneumonia, or tubercular infiltration in phthisis. More frequentl_v it is obliterated by these causes. 4, The vesicular murmur is absent or altogether re- moved by the higher degrees of the last-named condi- tions, viz., pleuritic effusion, pneumonic and tubercular infiltrations. 5. The vesicular murmur is altered by the addition of a bronchial element, the first effect of which is to lengthen the expiratory factor of the breathing sound, to alter, in a word, its rhythm. Coincidently with, or immediately succeeding upon this, is a roughening of both inspiration and expiration, at first slight and then positive. As long as this degree is maintained there is still a vesicular factor in the breathing, whence it was named by Flint broncho-vesicular breathing. It has also been called indeterminate breathing. Expressive terms are also, harsh respiration, 7-i/de respiration, or rough respiration. Such niodifications of normal breath- ing are brought about by an infiltration of a certain number of air vesicles with solid material, while others still niaintain their function. The effect of this is also to iniprove the conducting power of the portion of the lung involved, so that it becomes a better conductor of the bronchial sounds elsewhere produced, which are thus brought to the ear. It means, therefore, that a certain small extent of consolidation has taken place. How shall we distinguish between puerile breathing ABNORMAL BREATHING SOUNDS. 71 and broncho-vesicular breathing, a most important re- quirement, since they indicate opposite conditions? Yet there is a certain similarity between them which inexperienced observers may mistake for identity, and which even an experienced man may sometimes have occasion to dwell on before deciding. Both are louder and rougher as to inspiration, but vastly different is the manner in which expiration is influenced. In puerile breathing it may be slightly longer and more distinct than in health, but it maintains its ratio to the length of the inspiratory murmur. Not so is it with rude respiration. Here the expiratory sound is roughened and prolonged out of all proportion to the inspiratory. And in catching slight degrees of difference the atten- tion must be concentrated on the expiratory murmur. If it is greatly prolonged in proportion to the inspira- tory, so as to nearly or quite equal it, and at the same time harsher than in health, not simply loud-er, then we have broncho-vesicular breathing and the conditions which produce it. And if to this is added a slight rise of pitch on percussion, a slight dulness, the condition is confirmed. Sometimes, however, these conditions do not go entirely pari passu. Then we must wait and watch. We must not forget, too, the physiological dif- ferences on the two sides, that there is the slightest higher pitch on the right in both percussion note and breathing sound, and that the expiratory murmur is blightly longer on the right. The difficulties are in- creased by the physiological variations in the vesicular murmur, which are not to be overlooked. 72 PHYSICAL DL4.GN0SIS. 6. The expiratory vesicular murmur is prolonged in emphysema because of the loss of elasticity of the air vesicles resulting in a slowing of the expiratory act. 7. Finally, the vesicular murmur may be altogether substituted by bronchial breathing. This means that a considerable area of lung has become obhterated as to its vesicular structure, and has thus also become an excellent conductor of the distant normal bronchial breathing, which is heard with a blowing tubal quality as though produced directly under the ear. Again, it is to be remembered, that there is no more bronchial breathing produced under these circumstances than there was before the consolidation took place. It is simply that the vesicular murmur has altogether vanished for the reason named, and therefore cannot longer mask the bronchial breathing, while the latter also is better con- ducted to the ear. iVcute croupous pneumonia furnishes the most characteristic bronchial breathing. Between this and broncho-vesicular breathing there is every degree, depending upon the degree of destruction of vesicular tissue and the extent of consolidation. When the con- solidation is very intense the bronchial breathing is rendered more intense, more metallic even than the tracheal breathing sound, which may be regarded as the type of bronchial breathing in disease, the latter resem- bling more the tracheal sound as heard in health than the sound heard over the bronchial tubes. ABNORMAL BREATHING SOUNDS, 73 Varieties of Bronchial Breathing. — Bronchial breathing is low pitched or high pitched according as the tubes whence the sound is conveyed by the consoli- dated lung are large or small. Low-pitched bronchial breathing is also heard over cavities of moderate size, when it is called cavernous breathing. The expiration in cavernous breathing is also commonly lower pitched than the inspiration, reversing, in this respect, the bronchial breathing, although this is not constant enough to be made a rule of difference. The conditions of its production are a cavity with yielding and resiUent walls, by the collapse of which the air can be forced out, since the sound de- pends upon the entrance and exit of air. It is also often associated with gurgling, or may alternate with it. It may. disappear to reappear after copious expectoration. Cavities at the apex of the lung in tubercular consump- tion are the most common causes, but whatever produces an excavation of the kind may cause it. A dilated bronchus, an abscess, and even gangrene of the lung may be such a cause. High-pitched bronchial breathing is heard when the lung about smaller bronchial tubes is consolidated, as often occurs in pneumonia, which affords the most frequent site of bronchial breathing. The term tubular breathing is reserved by some for such high-pitched breathing, while others use the terms bronchial and tubular as synonymous. Amphoric Breathing. — Amphoric breathing is more easily recognized from its ringing metallic char- 74 PHYSICAL DIAGNOSIS. acter, like that of the amphoric percussion note, resem- bling also the sound produced by blowing upon the mouth of a bottle. It is produced by the same condi- tions, a cavity with firm walls — a large cavity. It is likewise a blowing sound, of high or low pitch, inspira- tory or expiratory, or both. It is an echoing sound. Clinically its presence most frequently means pneumo- thorax, but a phthisical cavity may rarely furnish the same conditions. Every case of pneumothorax does not, however, produce it, since there must be a perfora- tion of the pleura above the level of the fluid and free communication with a bronchial tube. There are other modifications of bronchial breathing more or less accidental and therefore of less importance. Thus it sometimes happens that either the inspiratory or the expiratoiy portion is absent, when the peculiar breathing may be still recognized by the pitch and quality of the portion remaining cavernous. Again, we may have a vesicular inspiration with a cavernous expira- tion {I'esiculo-caveimoiis respiration) , or there may be an admixture of cavernous and pure bronchial breathing (^broncho-cavernous) . In the latter, the sound of expira- tion is bronchial, high pitched, and is said to indicate a cavity situated near consolidated lung. In the vesiculo- cavernous breathing the cavity is surrounded by a com- paratively intact pulmonary tissue which produces an admixture of sound. Another variety of modification is the Seitz-meta- morphosing respiration, in which the inspiratory AUSCULTATION OF THE NORMAL VOICE. 75 sound is heard for about one-third of its time as harsh tubal and the remainder is of ordinary blowing, cavern- ous, or amphoric quality. It is said to be caused by air entering a cavity through a narrow opening. AUSCULTATION OF THE NORMAL VOICE. Normal Vocal Resonance. — When the ear is ap- plied below the clavicle of a person speaking, a confused monotonous humming sound is produced, of slight in- tensity and low pitch. In the aged, it is apt to be tremulous or somewhat bleating. This is normal vocal resonance. It varies, however, in intensity and pitch in different persons, being almost inaudible in some. It depends also somewhat upon the manner in which the person speaks and the words he utters. It is in- creased not so much by loud speaking as speaking " from the chest." It is better noted also if the patient counts " one, two, three," or speaks the word " ninety- nine." It is also feebler in women than in men. It is accompanied by a fremitus which is the same as that described under palpation. It is a tactile fremitus in M'hich the ear is the touching part instead of the palm of the hand. Vocal resonance varies in different parts of the chest, being more marked where the walls are thin. Hence below the clavicles it is relatively loud, and more so below the right, just as is tactile fremitus, an important fact to be remembered in diagnosis, as well as that everywhere on the right side it may be more marked. Toward the sternal portion of the clavicular region it is 76 PHYSICAL DIAGNOSIS. louder, the tracheal voice influencing it. Below the clavicles it diminishes with the greater thickness of the chest-walls of the mammary region, it is again more marked in the axillae, less intense over the scapulae and louder below them. Between the scapulae it is also in- tense. The whispering voice also requires some allusion. It being borne in mind that whispering in most persons is an act of expiration, if the ear is applied to a thin- walled portion of the chest, as that below the clavicle, and the patient is asked to count in a whisper, there is heard a feeble, low-pitched blowing sound, unaccom- panied by fremitus, with a pitch and quality the same as those of the expiratory vesicular sound in breathing. All that has been said of vocal resonance, as to its audibleness and the degree thereof in different persons and on the different parts of the chest, is true of the " normal bronchial whisper," as it is called by Flint, because " the conduction of the sound produced by the whispered voice must be chiefly by the air contained in the bronchial tubes." Normal Bronchophony. — When the stethoscope is placed over the thyroid cartilage of the larynx of a person speaking, a much louder resounding soimd is heard directly under the ear, accompanied also by a thrill or fremitus conveyed to the ear. But it is still confused and no articulate vrords are heard. It corre- sponds to bronchial respiration, as normal vocal reso- nance accords with vesicular breathing. If the person thus auscultated over the larynx or trachea whispers instead of speaks audibly, a high-pitch AUSCULTATION OF THE VOICE. 77 tubal sound accompanied by feeble fremitus is heard. It is, in fact, the expiratory breathing sound, as heard in these air tubes, interrupted by the act of speech. Abnormal Modifications of the Ausculted Voice. — The association of a corresponding degree of vocal resonance with normal vesicular breathing and of bronchophony at the seat of normal bronchial breathing has been referred to. The same relation exists in pathological conditions. Thus any increase in the intensity of the normal vocal resonance implies a cor- responding condensation of lung tissue, culminating in typical bronchophony when the consolidation is com- plete, just as the normal vesicular breathing passing through bronchovesicular terminates in bronchial breath- ing. Pari passu with increased vocal resonance and bronchovesicular breathing goes increased bronchial whisper. Pectoriloquy. — In addition there are certain special modifications of the normal vocal resonance correspond- ing more or less to certain morbid states. Thus there is the cavernous voice or pectoriloquy, in which articu- late speech is heard as though coming directly from the chest into the ear. While this is commonly the sign of a cavity of some size, it is not always so, the voice being similary transmitted by solidified or collapsed lung, a tumor of the lung, and over the upper lobe of a lung whose lower lobe is compressed by a pleuritic effusion. Whispering pectoriloquy, in which whispered articulate speech is conveyed to the ear, is a much more rehable sign of a cavity. 78 PHYSICAL DLA.GNOSIS. Amphoric voice is ringing and metallic, echoing like the other amphoric sounds, and like them indicates the same conditions — a large cavity with firm walls. ^gophony is another ver}' distinctive modification of bronchophony. It is admirably likened to the bleat- ing of a goat, and is produced during speech when there is a thin layer of liquid between the chest-wall and the lung, in pleuritic effusions, or when there is liquid in the chest cavity from other causes. It is most frequently heard behind at about the angle of the scapula or some- what anterior to this. It is said to be produced in flattened air tubes of moderate size whose calibre is constantly changing in size during speech. It is not confined to the condition just named, but may occur over any superficial area of collapsed lung, whether caused by effusion or false membrane. Diminished Vocal Resonance. — Finally, speech sounds may be diminished in intensity by the same causes which diminish the tactile fremitus ; pleuritic effusions, pleuritic thickening, separation of the lung by fluid or air, and by over-distension of the lung. NEW OR ADVENTITIOUS SOUNDS. These sounds are not a modification of preexisting sounds, but something altogether new or additional. They include rales, or rhonchi, the friction sound, and metallic tinkling. Rales are new sounds produced in the trachea, bron- chial tubes, or in cavities, concurrent with the movement NEW OR ADVENTITIOUS SOUNDS. 79 of air inward or outward in the act of breathing. They are the direct result of some partial obstruction to the onward movement of the air, for the most part within the tube, but the narrowing may also be the result of extra -tubal pressure. They are divided into moist or dry rales, according as the obstructing substance is liquid or the reverse. Both are influenced by coughing and may often be completely removed, for the time being, by this act. When not thus influenced by coughing they are probably due to pressure from without. Dry Rales are sounds engendered in the air of the air passages by any causes which narrow their lumen. These are commonly adherent mucus or the swollen mucous membrane of the bronchi. Sounds produced in the tubes of large lumen, hke the trachea, are musical, low pitched, and are called sonorous rales. Those produced in the small tubes are high pitched and hissing, and therefore cafled sibilant rales. Moist rales are caused by the passage of air through liquid, which may be blood, mucus, or seium. They are therefore of the nature of bubbling sounds and are spoken of as large and small bubbhng sounds, according as the bubbles are large or small, and as large bubbles can only form in tubes of large size or cavities, they indicate these conditions, while the small rales indicate smaller tubes. Moist rales, except the crepitant, are heard in inspiration or expiration, or both. The bub- bhng sounds are further subdivided, according to size, into gurgling, mucous, submucous, subcrepitant, and crepitant rales, and crackling. 8o PHYSICAL DLA.GNOSIS. Gurgling is a term applied to the largest bubbling sounds, and is produced in cavities containing fluid. It is also known as the cavernous rale, and has sometimes a metallic character when it becomes associated with the other metallic physical signs already mentioned as characteristic of a cavity with firm walls. The mucous rale is a bubbling sound smaller than the cavernous, but still of large size, produced in the trachea and larger bronchi. The death-rattle is a tracheal mucous rale. The submucous rale is a smaller bubbling sound produced in tubes of smaller size and the subcrepitant in still smaller. The crepitant rale is formed in tubes of smallest size and in the air vesicles. It may be a true bubbhng sound, or it may be due to the separation of agglutinated air vesi- cles by entering air. From its extreme importance in the diagnosis of pneumonia, although it occurs also in oedema and collapse of the lungs, it requires some further illustration. It is aptly compared to the crackling pro- duced by throwing salt on the fire, or rolling the hair between the fingers alongside of the ear ; also to the noise made by separating near the ear the moistened thumb and index finger. The f^rst appears to me the best imitation. It is heard only in inspiration and is thus distinguished from the subcrepitant rale, which is heard in expiration as well. It is sometimes heard throughout the whole of the inspiratory act, more fre- quently only toward the end of it. Crackling literally means the same as crepitation, and, in fact, the mechanism of the two signs is nearly NEW OR ADVENTITIOUS SOUNDS. «I the same. Both are inspiratory sounds, and both may be small bubbles. The main difference is really in the number of crackles which go to make up the rale, the crepitant consisting of several of these, while the crack- ling consists of but one, two, or three. " Crackling " is heard at the apices of the lungs, and the crepitant rale for the most part at the base. The interpretation of crackling is almost invariably tubercular consumption, and it means that the tubercle is beginning to break down. Yet we may have pneumonia of the apex. What is known as " moist crackling " is a little larger rale than crackling, a pure bubbling sound produced in the smallest bronchial tubes, and is really a subcrepita- tion. It is essentially a subcrepitant rale. Friction sound is a noise produced by the rubbing of two slightly roughened serous surfaces upon each other. The pulmonary and costal pleurae and the cardiac and pericardiac serous membranes move over each other smoothly and noiselessly in health, but let them be roughened in any way by an inflammatory exudate, an eruption of the tubercles, or other morbid growth, and at once the friction sound is produced. In its simplest and most frequent form, representing the first stage of pleurisy, it also resembles somewhat the crepitant rale and it is sometimes not easy to distinguish from it. In addition, however, to being more superficial in situation, the friction sound is not influenced by coughing, while the crepitant rale is. The friction sound is heard more loudly if the stethoscope is pressed closely to the chest wall and is localized, while the 82 PHYSICAL DIAGNOSIS. crepitant rale is heard over a large area of lung. It is also often a to-and-fro sound, being heard with ex- piration as well as with inspiration, while the crepitant rale is confined to inspiration. The friction sound dis- appears with pleuritic or pericardial effusion, to return for a time with the subsidence of the effusion. In addition to its typical crepitant like character, as heard in pleurisy, the friction sound assumes also at times greater roughness, which is more conspicuous in pericardial friction. Where organization has taken place in an exudate there is sometimes a leather like creaking produced under the same circumstances as the friction sound, and it is regarded as a friction sound. It is sometimes so loud as to be heard by the patient himself, and may also be recognized by palpation. Pleural friction may be found anywhere in the chest, but is more frequent in a circumscribed area in one side of the chest, especially below the nipple toward infra- axillar}'- region or below the angle of the scapula. Metallic tinkling is the last of the adventitious sounds to be considered. It is another one of the am- phoric sounds, requiring a space with firm, tense walls as its condition. ,A pneumothorax will furnish such con- dition, as also do certain pulmonan,' cavities. Under these circumstances a drop of liquid falling into such a space will produce metallic tinkling. This sometimes happens in a pneumothorax when a drop of secretion will sometimes fall from a bronchial tube into a cavity. Such resonance also is contributed to rales in a bronchus communicating with a pneumothorax or cavit}\ ACUTE BRONCHITIS. 8^ Allied to the metallic tinkling is the Hippocratic succussion produced in pyopneumothorax, and very rarely in a cavity whea the patient is shaken. PHYSICAL SIGNS OF ABNORMAL STATES OR DISEASES OF THE LUNGS. ACUTE BRONCHITIS. Acute bronchitis of the larger tubes is essen- tially a symmetrical disease, the bronchi of both lungs being generally more or less equally invaded. There may be absolutely no physical signs ; inspection, palpa- tion, percussion, and auscultation being alike negative. In other cases inspection may discover increased fre- quency of respiratory movement, and possibly increased frequency in the cardiac apex-beat if there be fever. Palpation may appreciate a rhonchal fremitus if there be sufficient narrowing of the breathing tubes. It may be found anywhere or on either side and may be very tran- sient. Percussion continues invariably clear so long as the bronchitis is uncomplicated. Auscultation furnishes the most distinctive and con- stant physical sign, the presence of dry rales, the sonor- ous and sibilant, which may invade either or both lungs, and may also be transient. To these may be added harshness of breath sounds. In the resolution of bron- chitis, bubbling rales may substitute the sonorous and sibilant, in consequence of the presence of liquid secre- tion. 84 PHYSICAL DIAGNOSIS. Other symptoms are pain or a sense of oppression behind the sternum, some shortness of breath, and an- noying cough. Capillary bronchitis, catarrhal or broncho- pneumonia, involves the finer and finest tubules and adjacent air vesicles, into whch it generally extends from the larger bronchi. The frequent breathing is more evident and constant ; so is the frequent heart beat with fever. Percussion elicits circumscribed areas of dulness. Auscultation recognizes first the signs of an ordinary acute bronchitis, followed by more or less dis- tinct bronchial breathing, very soon by small bubbling rales, subcrepitant and crepitant, but dry rales are often absent at the outset. These signs are most frequent in ttie bases of the lungs posteriorly, but may be found anywhere all over. CHRONIC BRONCHITIS. Physical signs attend chronic bronchitis more con- stantly than acute, yet they afford no unchanging pic- ture. To inspection there is often nothing apparent, except the corresponding motion of more frequent breathing. Even this is sometimes absent. To palpa- tion there may be rhonchus with normal tactile fremitus, unchanged or slightly increased or as much dimin- ished. To percussiofi there may be no change or, un- less in the vicinity of a superficial dilated bronchus filled with secretion, where there may be impairment of EMPHYSEMA OF THE LUNGS. 85 resonance. If such a dilated bronchus be emptied of its contents by expectoration, the percussion signs of a cavity may be present, but in the middle or lower part of a lung instead of the apex. Vesiculot5'mpanitic or even tympanitic resonance may be present from relaxa- tion of lung tissue, especially in the lower posterior part of the lungs. Auscultation may also be negative, but much more frequently recognizes an alternation or combination of harsh and feeble breathing, sonorous and sibilant rales, with moist rales of all sizes, variously modified by dif- ferent distances from the ear and varying consistence of the secretion. Other symptoms are cough and expectoration, usually copious, of muco-purulent sputum, little or no pain but marked shortness of breath. If the frequently associated complication of emphy- sema of the lungs is present, the signs and symptoms of that condition are superadded as detailed below. EMPHYSEMA OF THE LUNGS. This condition, an over-distension and destruction of air vesicles with a like destruction of their covering of capillaries, is most frequently the result of bronchitis and a complication of it. It may also be produced from forced straining efforts, as in heavy lifting or carrying heavy loads. It also commonly affects both lungs at the same time, but involves different lungs and different parts of the same lung unequally. 86 PHYSICAL DIAGNOSIS. The physical signs are more or less distinctive. Inspection discovers a rounded chest anteriorly and pos- teriorly, with increased circumference and wide inter- costal spaces, the highest degree of which is known as the " barrel-shaped chest " (Fig. i8). But the emphy- sema may be so circumscribed as to produce local bulgings, by preference in the upper lobe of the right Fig. i8. — Bilateral Enlargement in Emphysema — {After Gee.) and lower lobe of the left lung. The excursion of expansion of the chest-walls is diminished, while the scaleni and sterno-cleido-mastoid muscles stand out dis- tinctly. The rate of the movements is increased. The apex of the heart is displaced downward and to the right, but it is often difficult to find, because covered EMPHYSEMA OF THE LUNGS. 87 up by the enlarged lung. To palpation vocal fremitus is diminished, while the natural resiliency of the chest- walls is substituted by increased resistance. Pe7'cussio7i recognizes resonance exaggerated in vari- ous degrees, sometimes amounting almost to tympany, the vesiculotympany of Flint. The cardiac dulness is extended to the right and downward, partly from dis- placement by the distended lungs and partly from hypertrophy of the right ventricle. At the same time the cardiac area is more thoroughly covered by the lungs, and pretty strong percussion is often necessary to bring it out. The hepatic area of dulness is also lowered by reason of the encroachment of the lungs, and often diminished from the same cause. The distinctive auscultatory sign of the emphysema- tous area is the feeble inspiratory murmur due to the fact that the air vesicles are already distended with air, and current conduction is impaired. The prolonged expiratory murmur is the result of the lost elasticity of the air vesicles, in consequence of which they recoil but slowly on their contents. Vocal resonance is diminished because of the diminished motion in the air columns. Crackling is sometimes heard. If bronchitis be present its sounds are associated and often obscure all else. The pulmonary second sound at the second left interspace is accentuated on account of the hypertrophy of the right ventricle, but the heart sounds are usually obscured by the extra covering of the lung. With dilation of the right ventricle, which sooner or later succeeds, the increased accentuation disappears. 80 PHYSICAL DIAGNOSIS. Of Other symptoms the most invariable is short- ness of breath, but there is often a good deal of cough. Interlobular emphysema is a condition in which the connective tissue between the lobules is infiltrated with air as the result of rupture of air vesicles due to violent acts of coughing or to wounds of the lung. The physical signs, except to inspection, are the same as those of vesicular emphysema, except that the crack- ling sound referred to is more common. The configu- ration of the chest in such cases is not usually altered. Suddenness of onset is characteristic of this form of emphysema, and it is apt to be associated with a similar infiltration of the tissues of the neck, which gives rise to a very distinctive crepitation on palpation. BRONCHIAL OR SPASMODIC ASTHMA. The physical signs of this peculiar neurosis reveal themselves to all the methods of physical diagnosis em- ployed. There is a spasm of the muscles of the smaller bronchi. Inspection observes the most labored effort in breathing, while the chest moves but slightly, because the lungs cannot be inflated. The spaces above and below the clavicle and above the sternum, the inter- costal spaces, and the pit of the stomach, are drawn in, for the same cause, — that is, the thoracic cavity not being filled from within, the external atmospheric pres- sure forces the yielding portions inward. Rhonchal fremitus is recognized by palpation, while vocal fremitus, obscured by the rhonchus, is otherwise diminished by a frequently associated emphysema. PULMONARY TUBERCULOSIS, OR CONSUMPTION. 89 Percussion is negative in uncomplicated asthma, but if asthma is associated with emphysema it may produce abnormal resonance. Auscultation discovers the most striking and easiest recognized of the physical signs. All over the chest are heard sonorous and sibilant rales, inspiratory and expiratory, but more commonly the latter. In fact, for the most part they do not require the ear to be placed close to the chest for recognition. The vesicular mur- mur, on the other hand, is inaudible. It is to be remembered that chronic bronchitis, em- physema, and asthma may also complicate each other, and render correspondingly complex the physical signs. Other symptoms include little else than the labored breathing until the spasm breaks up and secretion is established, when there is cough and scanty sputum containing small lumps in which Curschmann's spirals and Charcot-Leyden crystals are found. PULMONARY TUBERCULOSIS, OR CONSUMPTION. Accepting the modern doctrine that all phthisis is tubercular, there are three ways in which it invades the lungs : 1. As catarrhal or bronchopneumatic phthisis. 2. As fibroid phthisis. 3. As miliary tuberculosis of the lungs. Catarrhal Phthisis. — This, the most common form of consumption, presents two varieties, differing mainly in the rapidity of their course, — whence acute and 90 PHYSICAL DL4GN0SIS chronic phthisis. The former is also known diS, phthisis florida or galloping consumption. Perhaps there should be added, as a distinctive feature of the latter, the dif- fuseness as well as the rapidity of the process. Catarrhal phthisis resolves itself, with more or less definiteness, into three separate stages, of which the physical signs, commonly sought at the apices of the lungs, are also more or less distinctive : 1. The incipient stage, or beginning deposit* 2. Stage of complete consolidation. 3. Stage of softening and cavity formation. I. Inspection, in the incipient stage, is as often negative as not. A slight impairment of motion in the infra- clavicular space may be present, and more rarely a slight flattening of the same region. The clavicle becomes correspondingly conspicuous. The body may continue well nourished or slightly emaciated, or the heart beat in the normal position may be somewhat accelerated, while the respirations are likely to be more frequent than in health. Palpation recognizes increased vocal fremitus in the same situation, although this may not always be notice- able in the first stage, while the physiological difference in favor of the right side is to be remembered. Percus- sion in this stage gives slightly higher pitch and impair- * This subdivision does not seem to me as satisfactory nor based on as well-defined clinical features as another which makes the first stage that of cojtsolidation ; the secoiid that of softe7ii7ig ; third, tliat of cavity formation ; but for the sake of uniformity with other writers I retain it for the present. PULMONARY TUBERCULOSIS, OR CONSUMPTION. 91 ment of resonance, which may be noted above, on, or below the clavicle. Dulness may sometimes be brought out by directing the patient to hold his mouth open during percussion, or to hold his breath at expiration. To auscultation above or below the clavicle, we have the first evidence of abnormality in a prolongation of the expiratory murmur and harshness in the inspira- tory sound — the bronchovesicular breathing described. Theoretically, this should be preceded by a diminished intensity in the inspiratory sound, owing to the inter- ference of the newly deposited tubercles with the con- duction of sound into the air vesicles, but practically this is scarcely encountered, and if encountered, is of such indistinctive significance as to be of little value. Increased vocal resonance is a constant accompani- ment of these modifications in the normal breathing sounds, but it, as well as the vocal fremitus, may be masked by a pleuritic thickening, and the physiological difference so often referred to must be remembered. Da Costa also calls attention to the fact that in a certain number of cases, at this stage, there is a blowing sound in the subclavian or pulmonary artery, and that a mur- mur is sometimes present in the subclavian or pulmonary artery before any other physical sign is present. There are frequently concurrent with these signs those of a bronchitis more or less acute. 2. In the second stage the changes discoverable by inspection are more easily recognized. There is evident loss of flesh, depression of surface, and impaired range of respiratory movement on the side affected. The 92 PHYSICAL DIAGNOSIS. hectic flush is intermittingly present. Palpation may also discover an increased warmth of skin. The increased vocal fremitus should be plainly recognized unless obscured by a thickened pleural membrane. Dul- ness on peraission is positive. To aiisctdtatioji there is increased vocal resonance. The bronchial factor in the breathing now becomes conspicuous, showing itself by the harshness and relative shortening of the inspiratory element, with the decid- edly rough and blowing expiration ; also a gradual diminution of the vesicular factor, until the latter dis- appears entirely, when we have the typical bronchial breathing of extended areas of tubercular mfiltration. This sign will now be found in the supraspinous fossa as well. The high degree of vocal resonance, known as bronchophony, is also superadded as a valuable confirma- tion of the presence of complete consolidation. The auscultation signs of a concurrent bronchitis may also be present in this and the next stage. The heart sounds are sometimes conducted with great intensity by an adjacent consolidated area. 3. In the third stage the information furnished by in- spection is still more decided. Emaciation is extreme, and breathing and the pulse are rapid, the face often flushed. There is flattening over the affected area, and the excursion of respiratory movement is still more limited. In this stage the superficial veins over the in- volved area may be prominent, partly from emaciation and partly from obstructed circulation. To palpation the vocal fremitus is still more marked. PULMONARY TUBERCULOSIS, OR CONSUMPTION. 93 and even remains distinct over cavities, because of the consolidation around them, unless there be some ob- struction to the entrance of air in the bronchus leading to the involved area. Rhonchal fremitus may be added if adventitious sounds are present. The skin is hot and dry, unless succeeding one of the sweats which charac- terize this stage, when it may be moist and clammy. Dulness on percussion is always to be found in the third stage, but to it is constantly added some one of the varieties of tympanitic note referred to, viz., pure tympany, the " cracked-pot " sound, or amphoric reso- nance, due to cavities. These require sufficient size and superficial situation on the part of the cavity, and the other conditions described on pages 55, 56, 57, and 58. On the other hand, resonance may even be normal over a cavity some distance from the surface, especially if the percussion be lightly made. Auscultation in this stage may continue to recognize the bronchial breathing of the second, but to it may be superadded the distinctive signs of a cavity, which may also supplant those of the bronchial breathing. These signs are cavernous breathing, cavernous voice, or pec- toriloquy, either when whispering or speaking with the ordinary voice, amphoric breathing, and amphoric voice, the full import and conditions of all of which have been described. To these are often added the large bubbling sounds known as gurgling, caused by the air bubbling through the fluid in a cavity. Metallic tinkling may be added to these phenomena, caused by the bursting of bubbles in a cavity with the amphoric conditions. 94 PHYSICAL DL4GN0SIS. The heart sounds are often heard with great intensity and even with amphoiic note over neighboring cavities. Fibroid Phthisis, or Cirrhosis of the Lung. — Fibroid phthisis does not admit of the same sharp divi- sion into stages which characterizes catarrhal phthisis. Frequently traceable in its initial symptoms to the inha- lation of irritating substances, and much more chronic in its course even than the chronic form of catarrhal phthisis, the general clinical history is of great value in distinguishing it from the latter. It is constantly asso- ciated in its beginning with pleurisy, and it may be a sequel of it. The degree of retraction as noted by inspection is greater and more easily recognized, and not confined to the apices of the lungs. The heart is frequently dislo- cated and its apex correspondingly displaced, sometimes to an extreme degree. If on the left side, owing to the retraction of the lung, there is sometimes noted a dis- tinct cardiac pulsation in the 3d, 4th, and 5 th inter- spaces. The intercostal spaces are often narrowed and the diaphragm may be drawn up. The modifications of vocal fremitus as revealed to palpation are not nearly as constant, being masked by the retraction and pleuritic comphcations, and may be absent. There is usually little or no elevation of temperature. Peraission is more constant in its results, there being marked dulness and a wooden-like resistance. There is sometimes hypertrophy of the right ventricle due to the extra effort of the right heart to propel the blood through the obstructed lung areas. Auscultation most PULMONARY TUBERCULOSIS, OR COiSTSUMPTION. 9 5 frequently notes bronchial breathing and exaggerated voice, but both of these may be lessened in intensity by thickened pleurae. A dilated bronchus is a frequent result, furnishing the signs of a cavity, which may be in the middle or even at the base of the lung, and furnishes a copious expec- toration characterized by a peculiar fetor, in which the microscope sometimes discovers fat-crystals. To the signs of the fibroid state in one part of a lung are frequently added those of emphysema in the re- mainder or in the other lung, or there may be a similar involvement of that lung. The rarity with which the bacillus tuberculosis is found in the sputum in this condition is not regarded as sufficient evidence to exclude it from the category of tubercular diseases. Acute miliary tuberculosis is not accompanied by any distinctive physical signs, and the diagnosis is made from the clinical and hereditary history rather than from such signs. The temperature is high and exceed- ingly fluctuating. A tympanitic or hyperresonant per- cussion note is sometimes present throughout the lung in disseminated miliary tuberculosis due to the relaxed state of the air vesicles which such an infiltration favors. Not every case of tuberculosis of the lungs begins in the apex, nor even when it does thus begin are the physical signs always first discovered anteriorly. Ex- amination of every case should therefore include the posterior portion of the lung, and especially the supra- 96 PHYSICAL DIAGNOSIS. spinous fossae. Tuberculosis not ven' rarety succeeds upon a pneumonia as well as upon a pleuris}', and espe- cially a catarrhal pneumonia, when the signs first make their appearance in the area which has been made vul- nerable by the previous state. Indeed, many cases sup- posed from the physical signs to be pneumonia are tubercular from the beginning. PNEUMONIA. Acute croupous or lobar pneumonia, more common in the right lower lobe, presents three easily separated sets of physical signs corresponding to as many stages in the morbid process itself. The FIRST, or stage of congestion, jn which the air vesicles are still open, is of short duration, terminating within, the first twenty-four hours, and may therefore be overlooked. Inspection notes the face flushed, increased frequency of respiration, with restricted movement upon the involved side and exaggerated motion on the sound side. The patient lies by preference on the affected side because of the greater comfort it gives him. This posture not only diminishes the pain by hindering the motion of the affected side, but also lessens the dyspnoea by permitting unrestrained expansion of the other side which is doing the work. Palpation at first may even find vocal fremitus dimin- ished on account of the relaxation of the air vesicles, but vocal fremitus becomes decidedly increased as the air vesicles fill up. The skin is hot and the pulse is fre- PNEUMONIA. 97 quent. Percussion obtains but slight if any impairment of resonance. In fact, tympany or the vesiculotympany of Flint is frequently present in this stage as the result of the relaxation of the partially filled air vesicles, giving resonance by immediate relaxation. (See p. 54.) Auscultation in the very earliest stage may find the vesicular murmur feeble, but very soon is heard the dis- tinctive physical sign of pneumonia, the crepitant rale at the end of inspiration, or if there be coincident pleurisy — pleuropneumoiiia — the closely simulating fric- tion sound may be added. Morison * calls attention to a jerky expiration over a limited area as the first physical sign, heard soon if not immediately after the rigor, before dulness or crepitation appears. The sign is said to be more distinct in children, but has been noted in adults. Over the normal part of the lung there is exaggerated vesicular breathing. But all of these physical signs, even if carefully sought for, may be wanting if the pneumonia is deep-seated, as is not infrequently the case. They appear as the surface is reached, or they may not be recognized at all if it remains central. The SECOND STAGE,- Or STAGE OF RED HEPATIZATION, or solidification, lasting four or five days, furnishes un- mistakable signs. All the signs pneumonia reveals to inspection in the first stage are intensified in the second, and the breathing is markedly abdominal. To palpa- * Medical News, Dec. 16, 1893, P- 683, from Lancet, No. 3656, p. 746. , 98 PHYSICAL DIAGNOSIS. tion, vocal fremitus is now intense, the skin is hot and dry, and the pulse continues frequent. Percussion gives absolute flatness over the solidified area, with high pitch and short duration, except in those very rare instances alluded to on p. 58, where the extreme consolidation throws the column of air in the trachea and bronchi into vibration, producing tympany. This explanation is perhaps the only one when it occurs in the upper lobe. In a lower lobe, tympany may result in the same way, from the proximity of a dilated stomach. Over the adjacent normal areas, also, resonance is ex- aggerated in consequence of the supplemental action of these parts. Here there may even be tympany or vesi- culotympany due to the relaxation of the adjacent air vesicles, an instance of resonance by mediate relaxation. Even cracked-pot sound may be produced by percussion over the solidified lung as the result of the sudden ex- pulsion of -air from 'a large bronchus leading to the solidified area. Ausadtation discerns high-pitched bronchial breath- ing over the solidified lung. Indeed, these are the cir- cumstances which give the typical bronchial or tubal breathing. The air vesicles are obliterated, and the resulting excellent conducting medium brings the tracheobronchial blowing to the ear. The ausculted voice gives us typical bronchophony and occasionally even pectoriloquy, as well as whispering bronchophony and pectoriloquy. The heart sounds are also heard with great distinctness over the consolidated lung, owing to the improved conduction, while the sounds of a cpr\cur- PNEUMONIA. 99 rent bronchitis are similarly intensified. A lingering crepitant rale may also be heard. The THIRD STAGE, Or STAGE OF GRAY HEPATIZATION or resolution, occupies six to ten days. It repeats largely, to inspection, palpation, and auscultation, the phenomena of the first. Resonance continues impaired for some time. The normal manner of breathing gradually returns, the temperature of the skin is noticeably less, the crepitant rale returns, technically known as the " crepitans redux," and is finally replaced by the normal vesicular breathing sound, by which time the dulness has disappeared. Croupous pneumonia may rarely terminate in abscess or gangrene, when the signs of the second stage con- tinue, the temperature does not fall, in a word, the crisis does not occur. The signs of a cavity which might naturally be expected are rarely present, and it is rather the general symptoms, the failure to recover, the con- tinued high temperature, the expectoration of pus, and, in the case of gangrene, the intensely disagreeable odor, that informs us of the issue. These issues probably represent on a large scale what takes place in every in- stance in minute areas in the third stage of all pneumo- nias which terminate favorably. The occasional termi- nation in tubercular phthisis exhibits a similar arrest of the resolving process in the second stage, and the phe- nomena of the catarrhal or fibroid phthisis supervene. The obscuring effect of a thickened pleura upon all of these signs is to be remembered, and too much stress cannot be laid upon the fact that we may have a central lOO PHYSICAL DL4GN0SIS. deep-seated pneumonia which may give no physical signs, also that in old persons the physical signs of a pneumonia are very apt to be delayed from one to three days. Other symptoms are sudden onset with chills, dull pain, cough with rusty, rather scanty tenacious expectoration, flushed cheeks, frequent breathing, and high continuous fever. The sputum contains pneu- mococci. Catarrhal or Lobular Pneumonia or Broncho- pneumonia. — The phj^sical signs of this form of pneu- monia are not nearly so distinctive as those of croupous. A circumscribed affection involving a few lobules, the physical signs are necessarily more obscure. Occurring most frequently in the course of a bronchitis in children and in old persons, as well as de novo in the former, the physician should be on the watch for it under these cir- cumstances. It also occurs in adults, though more rarely, especially in those suffering from tuberculosis, as the result of insufflation of broken- down tubercular matter, which produces by inoculation and irritation a tubercular bronchopneumonia. When superadded to a bronchitis under any of these conditions, there ensue increase of fever, embarrassed breathing, and associated increased inspiratory effort. Palpation should recognize increased vocal fremitus if the area involved be suffi- ciently large, /i?;r//j'j-/(9;; should reveal dulness and /I'w- panicity of adjacent supplementally acting areas. Aus- cultation will also discover in the inflamed area the crepitant rale, the bronchial breathing, increased vocal PNEUMONIA. lOI resonance, and bronchophony, in addition to the physi- cal signs of the concurrent bronchitis. Embolic Pneumonia and Hemorrhagic In- farct. — Pulmonary Apoplexy. — The effect of the lodgment of an embolus from any source in a branch of the pulmonary artery is to produce an extravasation of blood in the conical area formerly supplied by the vessel. Such an extravasation is called a hemorrhagic infarct. It is, in fact, a circumscribed apoplexy, but the term apoplexy of the lung is better retained for such extrava- sations of blood, circumscribed or diffuse, as are due to rupture of branches of the pulmonary artery from other causes than embolism. Such is over-distension of blood-vessels in valvular disease of the heart, disease of the blood-vessel wall, or traumatism. Small infarcts of the lungs may give rise to no symp- toms whatever. When large enough they cause sudden pain and embarrassed breathing, rusty expectoration, and circumscribed dulness, all of which increase with the size of the infarcted areas. Palpatio7i reveals increased vocal fremitus, and auscultation crepitant and subcrepitant rales, bronchial breathing, and broncho- phony. These are the signs of a croupous pneumonia, which is indeed present, the consequence of the infarct, which acts as an irritant. The circumscribed area covered by these signs would exclude an ordinary croup- ous lobar pneumonia, while the absence of fever, the suddenness of onset, and the presence of cardiac disease aid in the diagnosis. .Similar symptoms may be caused by massive hemor- I02 PHYSICAL DLA. GNOSIS. rhage into the lungs, or pulmonary apoplexy, caused by the rupture of a large branch of the pulmonar}'^ artery, whose wall is weakened by tuberculous infiltration or the engorgement due to vahnilar heart disease. Such a vessel may suffer a further strain in consequence of some transitor}' congestion, and rupture occurs. A great mass of blood is poured out, which, besides entering the bronchial tubes and producing haemoptysis and mucous rales, also infiltrates the lungs, coagulates, and produces consolidation. If the patient lives, the blood in the bronchi may be insufiiated into the vessels and there act as an irritant, producing intense inflammaiion followed by gangrene or abscess. Pulmonary cedema furnishes many of the signs of the first stage of croupous pneumonia, and is sometimes accompanied by a frothy, pinkish expectoration ; but the absence of fever, and the presence of dropsy else- where, or its causes, account for the condition. Collapse of the Lung. — In the course of a capillary bronchitis there sometimes occurs a collapse of a portion of the lung, owing to a valvular plugging of a bronchus, as the result of which air may pass out during expiration but cannot enter with inspiration, or it may occur as the result of a want of strength to fill the air cells. The area of collapse often corresponds in size with that of lobular pneumonia. When such collapse occurs there is sudden difficult breathing noticed on inspection, hnt palpation gives no information. Percussion reveals dulness, but it is much less marked than in lobular pneumonia, while ausculta- PLEURISY. 103 Hon finds no bronchial breathing, or if present it is very feeble ; no bronchophony, but rather diminished inten- sity of breathing sounds and diminished voice. Col- lapse of the lung is apt to be symmetrical. Compressed lung, most frequently due to pleural effusion, generally furnishes flattening, increased vocal fremitus, impaired resonance, increased vocal resonance, and bronchial or bronchovesicular breathing. Cancer of the lung furnishes signs of consolidation very similar to those of the second stage of tubercular consumption. Flattening, increased fremitus, dulness, increased vocal resonance, bronchial breathing, all ex- cept elevation of temperature, may be present, and it is the history of the case and special symptoms that de- termine the diagnosis rather than the physical signs. Plistory of heredity, cancer elsewhere, cachexia, more constant and severe pain, are symptoms of importance In the diagnosis. A peculiar currant-jelly-like sputum is much mentioned as characteristic. PLEURISY. Acute pleurisy is also resolvable into three stages, each of which is characterized by physical signs more or less distinctive. They include a dry stage, a stage of effusion, and a stage of resolution or absorption. The FIRST or dry stage is characterized anatomic- ally by the presence of the so-called lymph or exudate on the pleural surfaces. During this is revealed to in- spection a restrained expansion of the affected side, often I04 PHYSICAL DIAGNOSIS. thrown into jerks or catches because of the pain suffered in a continuous inspiration. The expansion on the opposite side, on the other hand, is full and unham- pered. The patient is apt to lie on the affected side. Very X2iie\y palpation recognizes a fremitus corresponding to the friction of the two pleural surfaces. I-ercussion in this stage is negative as to modified note, but often causes decided pain. Auscultation recognizes the fric- tion sound already described. It may be at a single spot in the inframammary or infra-axillary space, and hence be overlooked. At other times it may be noted over a considerable area. The inflammatory process may stop here and resolu- tion take place, or it may continue into the second or STAGE OF EFFUSION. The signs of this stage vary with the amount of liquid in the sac. With a small amount the lungs are slightly floated up, and there may be no signs unless there be a vesiculotympany above the line of the fluid, a Skodaic resonance by mediate relaxation of the air vesicles. The effusion, however, rarely remains so trifling, but commonly rises to the mid-chest. In the upright posi- tion of the patient, inspection discovers in a spare person shallowness and perhaps obliteration of the lower inter- costal spaces. The motion of the chest-wall is lessened both in the vertical and transverse directions. To palpation vocal fremitus is diminished over the area of effusion, but may be increased in the lung above it. To percussion there is absolute flatness over the area of eft'usion, but the line of demarcation is not every- PLEURISY. 105 where at the same level, being higher behind than in front. The late Dr. Calvin Ellis first called attention to an S-like curve in the line of demarcation which is said to be characteristic. Very important in the diagnosis is the fact that the fluid changes its level, and with it the line of dulness, when the position of the patient is changed. There is also an abnormal sense of resistance to the finger in percussing over the area of effusion. Above the effusion, especially anteriorly, there is again Skodaic resonance by mediate relaxation, and even sometimes a cracked-pot sound. Tympany may also be present, due to the proximity of a distended stomach. To auscultation, the breathing sounds are inaudible or very feeble, as compared to the corresponding por- tion of the opposite side, but vocal resonance, though diminished, is still well heard where the collection of fluid is moderate. Above the line of dulness there is occasionally a friction sound, and close to the root of the lung bronchial breathing may be heard. This is, however, more apt to be the case when the effusion is larger and the lung is further compressed. Qilgophony is also sometimes heard. When the effusion is larger, filling up two-thirds or three-fourths of the pleural sac, the effects described are increased, while new ones are added. Inspectio7i notes that respiratory movement is still more hampered, the intercostal spaces are widened and even bulging, while fluctuation may sometimes be recognized through them. The heart is displaced by the accumulated fluid, and if it be in the left sac, the apex is often found far over to Io6 PH\-SiCAL DIAGNOSIS. the right of the median line, and if on the right, the apex is pushed further to the left. Its sounds are not, however, altered further than to be heard more intensely in the situation where the}' are not usually so heard, be- cause sound is transniitted more readily through a single uniform medium than through two or more of different densities. On the opposite side the breathing move- ments are supplementally increased. There is complete absence of vocal fremitus on the affected side. In pleural effusion the line at which the movement in Litten's sign, or the diaphragm phenomenon, begins, is lowered from the 6th interspace, while if the effusion is large it is entirely obliterated. Perctission is absolutely flat all over the effusion, and Skodaic resonance is not now obtainable, because the lung is too thoroughly compressed up into the apex of the sac. Resistance to pressure is marked. On ans- cultatio7i bronchial breathing may be heard at the upper part of the lung posteriorly, because the large tubes are still pervious to air, and the compressed lung intensifies the sound. Sometimes bronchial breathing is heard in more peripheral parts of the chest, probably conducted hither along a band of adhesion or along a rib. Else- where there is absence of breath sounds. Vocal reso- nance and whispering voice are alike absent, or the former is ver}' feeble. Diminished vocal resonance and diminished tactile fremitus are the distinctive featuj-es which distinguish a bronchial breathing of pleurisy from that of pneumonia. In certain situations, too, high up, where there is but a thin film between the chest-wall PLEURISY. 107 and the lung, there may be oegophony, but this is more apt to be present as the fluid is being absorbed. By massive effusion on the right side the hver is de- pressed. In the THIRD STAGE, if resolution takes place with a gradual retrocession of the fluid and the reexpansion of the lung, we have a return to normal physical signs. There may be, too, a friction redux. A considerable time is, however, required for absorption, and it is often many days before the normal breathing sounds are heard with their usual intensity or the natural fre- mitus is felt. Often resolution is not complete, and there then remain the symptoms and sequelae of chronic pleurisy. Other symptoms of acute pleurisy are sharp pain in the side, short, rapid breathing, and suppressed, dry cough. Chronic Pleurisy. — Its symptoms and sequelse are not uniform. The simplest and most harmless expres- sion is a thickened pleiu-al ?ne77ibraiie. In this there is no adhesion between the opposite pleural surfaces, and the motion of the lung is not interfered with. There is, however, a general interference with the conduction of sound, and all the normal physical signs — including vocal fremitus, vocal resonance, normal percussion sounds, and normal breathing sounds — are diminished in intensity. For the same reason many abnormal physical signs, as already more than once instanced, are also less plainly heard. The serious symptoms of chronic pleurisy are more Io8 PHYSICAL DIAGNOSIS. frequently manifested in the results of delayed absorp- tion of effusion, and in a change of its character from serous to purulent. The resulting accumulation of fluid in the pleural cavity is not always a continuation of acute disease. A chronic pleurisy may originate de nozw, and often without the consciousness of the patient, although a careful analysis of the case will not fail to find symptoms of ill health which are explained by the state of affairs ultimately found. Such pleurisies are known as latent. With the discovery of the effusion, which may depend more or less on the acumen of the physician, the latency disappears. Such fluid furnishes the physical signs detailed on page 104 and following pages. Its further effects vary very much according as it is serum or pus. In either event its speedy removal is desirable, because the longer it remains compressing the lung, the longer will the latter be in returning to its natural state. Hence, it is better done by aspiration than by the slower method of medication. If the fluid be serous, and if it has not been too long retained, the lung gradually resumes its normal state, and a thickened pleura is all that remains, with the physical signs referred to as associated with it. Not infrequently, however, the two pleural surfaces, costal and pulmonary, remain permanently agglutin- ated, and then, although the lung slowly resumes its natural furiction, there still remains some flattening over the lower part of the thorax, while the signs of a com- pressed lung may be found at the apex. If the liquid be pus, we have an empyema, and the PLEURISY, 109 consequences are much more serious. The occurrence of a chill and continued high temperature will suggest a purulent collection. BaccelH's test may be tried. * Medical treatment almost never removes an empyema, and aspiration is as invariably followed by reaccumu- lation. Hence, permanent measures, as the introduction of a drainage tube with or without exsection of a rib, must be used. If the drainage tube be inserted early, the lung may resume its natural office, and there may be no more permanent damage than the agglutination referred to, and subsequently a retracted thorax. More fre- quently, however, we have to do with a lung partly bound by adhesions into its new and unnatural position, while the pleural surface may be looked upon as an ex- tensive ulcer. The restrained lung is unable to expand to refill its naural space, while the huge ulcer referred to must heal slowly with a resulting cicatrix. This cica- trix has the property of all cicatricial tissue. It must contract, and with this contraction drags with irresisti- ble force whatever is attached to it, including the ribs and even the spinal column, which is sometimes drawn out of line. Thus there results distortion, in various degrees, of the shape of the thorax, associated with a * Baccelli, of Rome, in 1875, suggested a method of distinguish- ing purulent accumulations from serous. He found that the whispered voice was often audible over these serous accumulations, while it was inaudible over pus collections. Douglas Powell ("Transactions of International Medical Congress," 1881) failed to confirm this observation. I have sometimes noted the sign under the circumstances described by BaccelH, but not always. no PHYSICAL DLA. GNOSIS. shortness of breath n^hich is permanent, but which may, nevertheless, grow less as time rolls on. A form of empyema which remains to be alluded to is a circumscribed empyema wherein the pus is circumscribed in two or more separate or communi- cating spaces. It is not always easy to recognize such a state of affairs. ]\Iost frequently it is ascertained by the attempt at the removal by tapping, the with- drawal of a certain amount of fluid giving partial relief and leaving other areas with physical signs un- changed.- Da Costa gives us from Jaccoud * some points to assist toward such recognition. Given, in the area of dulness, a zone along which vocal vibrations are preserved, as from the spinal column toward the sternum, a separation between two portions of fluid probably exists along such line. When the diaphragm is adherent to the chest wall the normal movements at the epigas- trium and hypochondrium are reversed, and the inspi- ration is accompanied by depression in the lower intercostal spaces instead of a filling out. One other feature must be pointed out as associated with such collections, and that is pulsation sometimes communicated to them by the heart. Hence the term pulsating empyema. In one such under mv care situated below the left clavicle, the pulsation was so striking that I hesitated to puncture it lest it be a pul- sating auricle or an aneurism. The knowledge that there *Da Costa, op. cit, p. 366, from Bulletin de rAcademie de Midecine, 1879. PNEUMOTHORAX. Ill was pus elsewhere in the pleural sac, the elevation of temperature, and the absence of sound or murmur or thrill, seemed to justif}^ operation, and a large quantity of fetid pus was drawn through a communication made with a pus cavity lower down. The tumor and pulsation and fever disappeared, and the patient, who was a girl, recovered. This situation, the upper prsecordial region, is a favorite one. Other Symptoms of Chronic Pleurisy.— A fever which is septic is almost invariably associated with empyema, causing emaciation. Shortness of breath is also constant. Chronic serous effusions are not com- monly attended by fever, but breathing more frequent than normal is present. PNEUMOTHORAX. This comparatively frequent complication of tuber- cular consumption commonly results from the rupture into the pleural sac of a cavity in the lung, an accident usually brought about by a fit of coughing. Sixty to eighty per cent, of cases are said to be due to tuber- culosis. After this comes emphysema, while other pos- sible causes are gangrene and ruptuie of subpleural abscess. The perforation, is followed by a rapid filling of the pleural cavity with air, which is soon followed by an effusion of liquid, at first seropuiulet, but sooner or later becoming purulent. The result is a distended air sac, occupied to a certain height with liquid, com- pressing somewhat the lung and displacing the heart, 1 1 2 PHYSICAL DIAGNOSIS. while the physical conditions are those of a resounding cavity. The effect on the physical signs is as follows : To inspection a bulging chest, a filling out of the intercostal spaces. The thoracic wall on the affected side dimin- ishes its excursion of respiratory movement, or it ap- pears at a standstill. Palpation appreciates no vocal fremitus. Percussion furnishes over most of the half of the thorax involved the most striking of the percus- sion notes, the ringing, amphoric resonance, which contrasts strongly with the absolute dulness due to the fluid below. When the patient hes on his back, the portion of the lung floated up in front gives good Skodiac resonance, while a striking sign is the marked lowering of the dulness in the recumbent position, a lowering far exceeding that noticed in a simple pleuritic effusion, and amounting to three and four inches. Bell tympany may also be elicited. If the pneumothorax is on the left side the heart may be pushed over to the right, and if on the right the liver may be lowered. To aus- cultation the normal breathing sounds are distant and feeble, the expiratory sound continuing short. Along with this may be heard amphoric breathing at the apex. The voice is ringing, amphoric, and an unmistakable tinkling sound attends the dropping of fluid from the perforation into the fluid below, or a similar metallic character may be given to rales in the adjacent tubes. A sudden shaking of the body produces a splashing sound similarly intensified by the reechoing to which it is subjected, — the Hippocratic succussion splash. PHYSICAL EXAMINATION OF THE HEART. II3 PHYSICAL EXAMINATION OF THE HEART. Anatomical Relations of the Heart. — The actual boundaries of the heart in the chest cavity demand some notice. The base of the heart is held fast by the great vessels coming from it, but the remainder of the organ has a certain freedom of motion, chiefly rotary but slightly also of elongation, but limited by the pericar- dial sac attached to the diaphragm and pleurae. The heart lies with its right ventricle upon the central tendon of the diaphragm. The auricles are nearly transversely placed, on a level with the 2d interspaces and the 3d costal cartilages, both extending slighdy beyond the corresponding borders of the sternum. The ventricles are obliquely placed, the right being in front and directly under the sternum, extending by its lowermost right-hand corner a trifle only to the right of the sternum at the 5th interspace, and considerably to the left. The right ventricle is on a level below with the 6th carti- lage. A much smaller portion of the left ventricle is turned to the front when the heart is in situ, and it is altogether within the line of the nipple, the apex corre- sponding to a point between the 5th and. 6th cartilages and an inch to i^ inches below and within the nipple. The base of the heart corresponds behind with the 5th and 6th dorsal vertebrae, between which and it he the aorta and oesophagus. The heart, surrounded with its pericardial sac, is covered very largely by the lungs, the right extending to the middle of the sternum, the left Th. /'''; '^--P^^'""^' °^ K^-^^'T IN Relation to Ribs and Sternu^ actuaUy rSti'^^vitK"^ ,j^ placed in a position too oblique. The heart Hule, if aLroflL^e^^K'^t.Srst tr^KtSe ^^^^^ ^^ PHYSICAL EXAMINATION OF THE HEART. 1 T 5 also to the middle as low as a line continuous with the lower edge of the 4th cartilage, along which it passes; thence obliquely across the 4th interspace and the 5th rib, the lung covering the whole of the left ventricle except the apex. The size of the heart approximates that of the fist of its owner. I am inclined to think it is commonly a little larger. Its weight in adult males is 311. 6 grams (11 ozs.) ; in females 255 grams (9 ozs.). The Prsecordium. — By the praecordial region or prsecordium is meant that portion of the thoracic wall covering the heart, and it may be said to be bounded above by a line drawn through the junction of the manu- brium with the blade of the sternum, below by a line drawn along the upper edge of the 6th cartilage, and laterally by a vertical line drawn through the seat of the apex-beat, and another 3^ of an inch to the right of the sternum. In this region inspection and palpation rec- ognize the apex-beat between the 5th and 6th ribs, and lY^ inches below and within the nipple. In children it may be found an interspace higher, and in the aged and in persons with long and narrow thoraxes it may be an interspace lower. Occasionally, in the 2d interspace to the left of the sternum in thin persons, a feeble impulse can be seen, produced by the filling of the left auricle. The situation of the apex is slightly altered by changes of position or by distension of the stomach from any cause. The act of breathing, however, influences it most. With a deep breath the heart descends and is pushed inward by the inflated lung, and the apex 1 1 6- Pm-SICAL DL4GN0SIS. approaches the epigastrium. On deep expiration it rises shghtly, and while the breath is held remains higher. The apex-beat is rendered more distinct by exercise or emotion. This is still more the case in pathological states where there is enlargement. Emphysema of the lungs and effusion into the pericardial sac render it more or less indistinct. Its position is also variously changed by morbid conditions, and a thrill or fremitus is often communicated to the hand in valvular diseases. Fremitus is also sometimes noticeable as the result of pericardial friction. The whole pr^ecordial region is sometimes abnormally prominent in hypertrophy and pericardial eft'usion, especially in the young, while re- traction due to adhesion is also seen. In the neighbor- hood of the prsecordium, at the root of the neck, pul- sations, arterial and venous, are noted, also in the epi- gastrium, which will be explained under the head of the conditions that pjroduce them. PERCUSSION AND AUSCULTATION OF THE NORMAL HEART. The percussion boundaries of the heart have been already pointed out on page 47, but it may not be amiss to review them at this point in somewhat further detail. To map out the percussion border of the heart, we begin percussing on a horizontal line at the left edge of the sternum, at about the 2d inteispace, proceeding downward, by moderately strong percussion only, until Fig. 20.-SH0WING Absolute and Relative Percussion Dulness of Liver A^'D Heart. '"livel-^''? ^.1^1"'''°" <^"'".«^°f, •'■^«- ,^- Absolute percussion dubess of niss of heart! ^"^"'"°"^^*''^ ^^''"- 4- Absolute percussion dul- Il8 PEPi'SICAL DIAGNOSIS. positive duliiess is readied. This is usually found to be on the 4th costal cartilage, which is the upper border of the uncovered area of the heart, and where a line should be drawn. Relative or deep dulness is found in the interspace or on the rib above. We then begin to per- cuss on a vertical line at Ihe right edge of the sternum at about the level of the 4th rib, and proceed across the sternum until evident dulness is reached, which is in most cases toward the left edge of the sternum, and this is the right border of the absolute dulness of the heart, and here a vertical line is drawn. Relative dulness is met usually at the right edge of the sternum in this situation. The situation of the apex is then found by pal- pation or bv the stethoscope. Percussion is again com- menced on an oblique line, in the direction of a line from the junction of the 4th cartilage with the sternum toward the apex, but sufificiently beyond to be certain of clear- ness. Then, parallel with such a line, proceed downward until positive dulness is reached. The lower border of the heart cannot be satisfactorily separated by percus- sion from the liver, but such a boundary can be obtained with sufificient accuracy by drawing a line from the apex perpendicular to the sternum. By the phonendoscope, however, the line of demarcation between the two organs can be found. Thus the area of absolute dulness in adults will correspond to a rude triangle, of which the base is 2 to 2j^ inches, the perpendicular 2 inches, and the hyporhenuse 3}^ to 4 inches on a somewhat curved line. The area of relative dulness, elicited by stronger PERCUSSION AND AUSCULTATION OF HEART. II9 percussion, extends a short distance beyond tine bounda- ries indicated in every direction except downward. Ttie exact measure of this must depend somewhat on the delicacy of the ear of the examiner and the mode in which he percusses, but it may be put down approxi- mately as a finger's breadth, and on the left side still within an oblique line draw.n through the nipple in adults. Various causes influence the area of cardiac percussion dulness in health. In children, the area of the cardiac dulness is decidedly reduced on account of the intense resonance of the child's thorax. In old age, on the' other hand, the area of absolute cardiac dulness is increased on account of the shrinkage of the lungs. The upper border of absolute dulness may be at the 3d rib, and the apex may be in the 6th interspace. The effect of a deep inspiration is materially to dimin- ish the area of dulness, while that of expiration en- larges it. Pathologically the normal area is increased downward to the left in hypertrophy of the left ventricle, down- ward toward the epigastrium and to the right in hyper- trophy of the right ventricle. Auscultation of the normal heart is very simple. By it we recognize the normal heart-sounds, known as first and second. Both sounds are audible over he whole praecordial region in health, but the first sound, characterized by its longer, booming character and lower pitch, is heard most loudly at the seat of the apex-beat, where it is the louder of the two. I20 PHYSICAL DLA.GNOSIS. The second — shorter, sharper, higher pitched, and more snapping in character — is most intense at the base of the heart, on the stermnn opposite the 2d interspace. Both sounds are heard at both situations, but each has its situation of greatest loudness. Hence, at the apex the rhythm may be said to be represented by the tro- chaic foot — ^^ , while at the base it is represented by the iambus ^ • — . The two sounds have also been long compared to the word hib-tiip, the fiist syllable corresponding to the first sound and the second to the second part. While this word cannot be said to re- semble the heart sounds very closely, there seems to be no other that resembles them more. As to the mechanism of the sounds, while that of the first is probably somewhat complex, — including the shutting down of the auriculo-ventricular valves, the apex-beat, the rush of blood through the aorta and pulmonary artery, and the noise of muscular con- traction, — it is sufficient for clinical purposes to consider it produced, as it is for the most part, by the shutting down of the auriculo-ventricular valves, the mitral or bicu-spid on the left side and the tricuspid on the right. Both sets of valves shut down sinrultaneously, both contribute to the production of the sound, while the greater muscular power of the left side gives to it a distinct predominance. The second sound is of simpler mechanism, and is caused solely by the shutting down of the semilunar valves of the aorta and pulmonary arter}', with the recoil of the blood upon them. On account of the more PERCUSSION AND AUSCULTATION OF HEART. 121 powerful recoil in the aorta, the aortic is the predomi- nating sound. Fig. 21. — Diagram Showing the Location of Cardiac Valves and Points OF Maximum Intensity CoNNjiCTED with Them. The triangle, a b c,{s the area of superficial or absolute dulness. A corresponds to the anatomical seat of the aortic valves, P to the pulmonary, M to the mitial, T to the tricuspid. The points of greatest intensity of the sounds are ai iox the aortic, /z' for the pulmonary, m for the mitral, t for the tricuspid. — {After Page.) We may isolate the part played by each set of valves by carrying the stethoscope to certain situations, and in 122 PHYSICAL DIAGNOSIS. diagnosis constant advanage is taken of this. Thus, in order to pick out the mitral part of the first sound, the stethoscope is placed at the seat of the apex-beat, while the tricuspid factor is best heard at the left sternal border, between the 5th and 6th cartilages. So with the second sound, the aortic factor is best heard at the 2d interspace to the right edge of the sternum; and the cartilage just above this is known as the aortic cartilage, because this great vessel approaches next to the chest-wall in this situation. The pulmonary part of the sound, on the other hand, is heard at the left edge of the sternum at the 2d interspace, while the cartilage above this, behind which ascends the pulmon- ary artery, is called the pulmonary cartilage. These points, and a circle about an inch in diameter around them, are known as the mitral, tricuspid, aortic, and pulmonary areas. Topography of 'the Valves. — It is to be remem- bered, however, that these are not the precise seats of the valves themselves. These are all situated in won- derfully close proxin:iity to each other — in fact, a por- tion of each is contained within a space of less tlian ^ inch square. The mitral valve is placed behind all the others, at a point toiresponding to the left border of the sternum at the 3d interspace. It lies almost hori- zontally about Y^ inch below the attachment of the aortic valves. The tricuspid valve corresponds to a line drawn obliquely across the sternum from the 3d left interspace to the 5th costal cartilage of the opposite side. The aortic valve lies nearly horizontally be- PERCUSSION AND AUSCULTATION OF HEART. 1 23 hind a line joining the middle of the sternum and the end of the 3d left costal cartilage. The pulmonary valve, a little higher and to the left of the aortic, runs quite horizontally, corresponding to a line drawn along the upper border of the 3d left costal cartilage. Thus all of the valve attachments except the tricuspid are horizontal or very nearly horizontal. The want of iden- tity of the auditory valve area, or place where the sounds are best isolated, with the actual sites of the valves, is due to the fact that the sounds are best heard at points on the chest-walls nearest the cavity or chan- nel in which vibrating blood is flowing. The normal heart-sounds are heard less loudly over the normal areas during deep inspiration, when they are more completely covered by the fully expanded lungs, and the first sound is heard more loudly at a new point toward the median line, to which the apex is pushed by the inflated lungs. On the other hand, forced expiration increases the area over which the sounds are heard. The time of the normal heart- sounds requires some further study, because on a thorough understanding of this depends largely skill in diagnosis. The first sound begins with the systole of the ventricles and is coinci- dent with the apex-beat; the second occurs in the dias- tole, immediately after the first, with a short pause between. The second sound is succeeded by a longer pause occupied with the diastole of the ventricles, during the latter part of which occurs the systole of the auricles, terminating the diastole of the ventricles. Thus, if a 124 PHYSICAL DL4GN0SIS. revolution of the heart's sounds and pauses be repre- sented by a dash and interspaces we will have the fol- lowing: : P^ 2d &- Pi 2d P-i ist sound tJ sound tjo ist sound t; sound M I I I I I I M I I I I I I I I 1234 5 6789 10 123 4 56789 10 of which the first sound will occupy four-tenths, the short pause one-tenth, the second sound two-tenths, and the long pause three-tenths. It is to be remembered that each one of these sounds is double, two systolic, occurring at the ventricular ori- fices, and two diastolic, at the aortic and pulmonary orifices. It may be further conceded that the first sound as heard at the base of the heart and the second sound as heard at the apex are simply conducted from the seat of their production, and that they are in no part produced at the situation where they are less loud. ABNORMAL MODIFICATIONS OF HEART- SOUNDS. It is not impossible, even in health, to have these paired sounds separated, and thus is produced what is known as reduplication of the heart-sounds, a phe- nomenon more common in diseases of the heart. Thus, as the effect of running there may result such an en- gorgement of the lesser circulation and high tension in ABNORMAL MODIFICATIONS OF HEART-SOUNDS. 1 25 the pulmonary artery, that the pulmonary valve closes a little sooner than the aortic, and reduplication of the second sound occurs. In like manner the closure of the tricuspid valve may be retarded, the synchronism de- stroyed, and reduplication of the first sound thus pro- duced. Intermission is an almost constant feature of reduplication, the double sound occurring with certain beats of the heart, with others not. This intermission has a close relation with the movements of respiration. Thus the first sound is reduplicated at the end of expira- tion and beginning of inspiration, the second at the end of inspiration and the beginning of expiration. The same and similar conditions operate to produce redupli- cation of the heart-sounds in disease. In labored breathing the order of reduplication is reversed, the first sound being doubled at the end of inspiration and beginning of expiration, and the second sound at the end of expiration and beginning of inspiration. The intensity of the heart-sounds is greater in per- sons with thin chest-walls and under the influence of excitement. Abnormally the feverish state and general hypertrophy have the same effect, but the latter is more apt to influence the sound of the particular cavity which is hypertrophied. The heart-sounds are often heard with unusual distinctness at points distant from their normal areas because of consolidation of adjacent lung, and sometimes inexplicably. Intensification or accentuation, as it is called, of the aortic or pul- monary element of the second sound is caused by whatever produces increased tension in the arterial or 126 PHYSICAL DIAGNOSIS. pulmonary circulations. Heart-sounds are also some- times made ringing by their proximity to a cavity with firm walls or even a tensely distended stomach. Abnormally, heart-sounds are rendered less intense by general and cardiac weakness, fatty degeneration of the myocardium, pericardial and pleural effusions, and emphysematous lungs, which cover up the heart more completely. Abnormal heart-sounds or murmurs are modi- fications of the normal sounds, either superadded to them or altogether substituting them. These are pro- duced within the cavity of the heart, and are accord- ingly known as endocardial. In addition an altogether new sound is engendered external to the heait, and therefore called exocardial or pericardial. To this the term m.urmur is also applied, although the mechanism of its production is so widely different it does not seem to me desirable to perpetuate the practice. The endocardial abnormal sounds, or heart murmurs, are sounds due to alteration in the con- ditions of normal blood currents, produced either by structural changes in the heart, its valves, or in the composition of the blood. The former are called organic murmurs, the latter functional or accidental.* Both are due to vibra- * The term inorganic is sometimes applied to the fur.ctional mur- murs, but this word has another meaning so definite, that of mineral, that it seems almost misleading to apply it in the sense referred to in the text. ABNORMAL MODIFICATIONS OF HEART-SOUNDS. 1 27 tions or oscillations in the blood stream produced by the causes referred to, and not to a friction between the blood current and the narrowed orifices or inequalities on the valves. Hydraulic laws teach us that when a fluid passes through a tube the inner suiface of which it wets, a thin film of fluid becomes attached to this sur- face, over which the remainder of the fluid moves with- out friction. So it is with the cardiac cavity and its valves over which the blood moves. Further, while a fluid passing along a tube of uniform diameter at a moderate speed, no murmur results, whether the inner wall of the tube te smooth or rough. A murmur is only produced when the tube becomes suddenly narrower and then widens again, and the greater the narrowing the less speed of current required to produce the mur- mur. Thus the vibrations arise, and thus the sound is produced. In the case of functional murmurs, which apparently occur without the intermediation of sudden narrowing, we must suppose such a change in the composition of the blood either as to its density or viscidity, which permits it to be more readily thrown into vibration. In either event there is a derangement of that adaptation of the column of blood to the orifices and cavities through which it has to pass, which ordinarily per- mits the function of the heart to be performed noise- lessly except so far as its normal sounds are concerned. In the case of the organic murmurs the alteration is produced by the various valvular defects to which the heart is subject, in that of the functional murmurs by 126 PHYSICAL DIAGNOSIS. the various anaemias 'which are principally associated with such murmurs. The true valvular murmurs may- be intensified by conditions of the blood. It should be mentioned that Ernest Sansom considers that the vibration of solids is by far the most important in the generation of murmurs, the influence of fluids being intermediate, and not immediate.* ORGANIC MURMURS. An organic murmur may be produced at any one of the four cardiac orifices, mitral, tricuspid, aortic, or pulmonary. They are far more common at the mitral and aortic. Murmurs are also classified as systolic, diastolic, and presystolic. Systolic murmurs occur during the sys- tole of the ventricles, diastolic murmurs during their diastole and alternate with the apex-beat. A diastolic murmur which immediately precedes the systole is called a presystolic murmur. Murmurs are further classified as direct and indirect. Direct murmurs are those which arise in the blood current as it is flowing in the normal direction ; indirect are those which arise in a current flowing opposite to the natural direction. The order in which murmurs are considered is of little importance. Their great frequency seems a sufficient reason for taking up mitral murmurs first. * "Diagnosis of Diseases of Heart and Aorta," Philadelphia, 1892, p. 236. ORGANIC MURMURS. I 29 Mitral Murmurs.— 7%^ Mitral Systolic or Mitral Indirect Murmur. — During the systole of the ventricles the auriculo-ventricular orifices in a perfect heart are closed in order to prevent the return of blood to Fig. 22. — Mitral Systolic Murmur, Propagated in Front. {After Hutchison and Rainy.) the auricles, while the aortic and pulmonary orifices are wide open to permit the blood to enter these great ves- sels, and the ear placed at the apex hears mainly the first sound. If, however, there be a defect in the mitral valve, as the result of which it closes imperfectly, then, during the systole a stream of blood will flow back- I30 PHYSICAL DIAGNOSIS, ward into the left auricle accompanied by a murmur. This is the mitral systolic murmur, and it means incom- petency or insufficiency of the valve with consequent regurgitation of blood. The mitral systolic murmurs are almost invariably best heard in the mitral area at the S.S5/ Fig. 21 -Mitral Systolic Murmur, Propagated Behind. {After H-utchiso7i and Raiiiy.') apex, and are conducted into the left axilla and under the angle of the left scapula. Rarely, however, they are heard just to the left of the pulmonary area, prob- ably because the vibrations are conducted into the ap- pendage of the auricle and are best heard where this ORGANIC MURMURS. 13 X approaches nearest the surface, namely, i>^ inches to the left of the pulmonary area. This occurs more fre- quently, too, with functional murmurs. Mitral Diastolic and Presystolic Murmurs, or Mitrat Direct Murmurs. — During the diastole of the ventricles the aortic orifice is closed and the mitral orifice open, and the blood flows noiselessly into the left ventricle, the filling of which is finally completed by the systole of the auricle. If, however, the mitral orifice be nar- rowed from any cause, the blood column is thrown mto vibration and a murmur results— a diastolic murmur. When, as frequently happens, the narrowing or stenosis is not sufficient to cause a murmur throughout the entire diastole, but only when the additional momentum is given to the blood by the systole of the auricle, a mur- mur occurs only at this time — that is, just before the systole commences. It is then called /;rj;j'^/^/zV. These murmurs mean, therefore, mitral stenosis, which is, however, generally associated with incompetency of the mitral valve. The systolic mitral murmur is, for the most part, soft, but may have every variety of character and be high pitched or low pitched, but the presystolic is always rough, and is variously characterized as rat- tling, rolling, churning, grinding, blubbering, and bubbling, being compared to the vibration in the hps caused by blowing the breath through them. The sound is further characterized by its abrupt termination, although this is not invariable. It may also disappear for a time or even altogether. A presystohc thrill, felt 132 PHYSICAL DL\GNOSIS at the apex of the heart, often accompanies the murmur. The presystolic murmur is best heard in the ■ mitral area, and is not, as a rule, conducted thence in any direc- tion. Sometimes the murmur is heard slightly to the right of the apex. Fig. 24. — Mitral Presystolic Murmur. — (After Htitchiso7L and Rahiy.) A diastolic murmur heard in the mitral area may also be due to aortic regurgitation, the sound being con- ducted from the seat of its production to the apex. This is a frequent matter of niisinterpretatio:i.~ It is often difficult to differentiate the presystolic murmur from a svstoHc mitral murmur Avhen, as is often the ORGANIC MURMURS. 1 33 case, the two are associated, the presystoHc murmur passing indistinguishably into the systolic murniur. The difficulty is further increased because in mitral stenosis the first sound is usually short, resembling the second. The point, therefore, is to get the exact time of the murmur by noting carefully its anticipation of the apex-beat or the carotid pulse. The so-called Flint's murmur also closely resembles the murmur of mitral stenosis, and the infrequency of the latter alone prevents more mistakes. This murmur is heard at the apex, the same site as the presystolic, and may be simi- lar in quality. It is said to occur with high degrees of dilatation of the ventricle, and is due to the fact that in such dilatation the mitral leaflets cannot during diastole be kept back against the ventricle wall, but remain in the blood current, throwing the latter into audible vibration. Mitral diastolic murmurs are not always presystolic. More rarely they follow immediately on the second sound, when they are called simply diastolic. lu other instances they are mid-diastolic, being separated from the second sound by a brief interval; in others still there is a brief interval between the diastolic and pre- systolic murmurs. These are refinements which can only be made by the skilled ear. They are always organic. Aortic Murmurs. — Aortic Systolic or Aortic Direct Murmur. — During the systole of the ventricles in health the aortic orifice is wide open, and the blood flows noiselessly through it. If any interference with the 134 Pm^SICAL DIAGNOSIS. complete opening of the orifice or roughness or in- equalit^v exists, the stream of blood is thrown into vibra- tion, and the aortic systolic murmur results, heard at the base of the heart in the aortic area. Such a mur- mur, therefore, means narrowing or stenosis of the Fig. 25.— Aortic Systolic Murmur and its Propagation. — {After Hutchison and Rainy ^ aortic orifice or roughening at the beginning of the aorta. It is generally loud and harsh, sometimes musical, heard most loudly in the aortic area — second right interspace — but generally all over the praecordium. It is conducted into the great vessels of the neck with great intensit}'. ORGANIC MURMURS. 1 35 Aortic Diastolic o?- Aortic Indirect Alurmur. — During diastole the aortic orifice should be closed and imper- meable to blood. If, however, as the result of disease, perfect closure be impossible, a stream of blood will flow backward into the left ventricle, accompanied by Fig. 26. — Aortic Diastolic Mukmur and its Seats of Propagation. — 'After Hutchison and Rainy.) a murmur at the base of the heart, which is the aortic diastolic murmur, and means always insufficiency or incompetency of the aortic valve. This murmur more or less replaces the second sound of the heart, is generally loud, long, and blowing, though less harsh than the aortic systolic miirmur^ and varies more in the seat of 136 PHYSICAL DLA.GNOSIS. its intensity and condition than any other cardiac mur- mur. It is sometimes loudest in the aortic area, but often over the niidstemum, and it is even well heard as low- as the ensiform cartilage, or at the apex itself. It has been mistaken in this situation for a presystolic mitral murmur. It is also transmitted downward along the sternum and toward the apex, because it is in this direction that the column of regurgitant blood is moving. It is accompanied by a powerful heaving impulse and the striking trip-hammer or Corrigan pulse characterized by its rapid rise and sudden fall. It also occurs alone, but is frequently associated with the aortic systolic murmur, indicating stenosis or roughen- ing or deformity of the valve-segments. Thus is pro- duced the double, sawing, or steam-tug murmur. Murmurs in the Right Side of the Heart. — The same conditions at the valve-oiifices on the right side of the heart produce similar murmurs, but they are very much rarer. Thus tricuspid regurgitation pro- duces the tricuspid systolic murmur, and tricuspid stenosis produces the tricuspid presystolic murmur. These are heard in the tricuspid area at the lower part of the sternum, at its junction with the 5 th and 6th car- tilages. Tricuspid regurgitation is apt to occur sooner or later in connection with mitral disease, but indepen- dent of mitral diseases it is very rare, being generally congenital. (See, however, page 169.) Pulmo nary- stenosis scarcely occurring, except congenitally, pro- duces the pulmonary systolic murmur, and pulmonary regurgitation, the rarest of all, would produce a dias ORGANIC MURMURS. 1 37 tolic murmur. Both are heard in the puhnonary area at the second interspace, at the left edge of the sternum. Impurity of Heart-Sounds. — In addition to the easily recognizable abnormal sounds described^ there occur more or less marked modifications of the normal sounds due to slight defects of the valves, which render them less typical, whence the term impurity of heart- sound. They may be caused by slight thickenings or other changes which modify the normal closure of the valves, and are of uncertain significance. On the other hand, very decided alterations in the valves and orifices are sometimes found at necropsy when no modifications of the normal sounds were detectable during life. The Exocardial or Friction Sound. — The only true exocardial murmur is the pericardial friction sound caused by rubbing of the two surfaces of the peri- cardium upon each other, in health a noiseless act like that of the pleural surfaces. When roughened, however, by disease a to-and-fro sound of varying loudness and harshness is produced. The most frequent cause is peri- carditis, but any cause which roughens the two opposite surfaces, such as tubercular and other morbid growths, will produce a friction sound The friction sound sometimes resembles the intracar- dial murmur, but a little experience enables one to dis- tinguish them. The friction sound is a superficial to- and-fro sound heard directly under the ear, commonly loud and rasping, never blowing, sometimes creaking. It is most loud over the middle of the heart, not syn- chronous with the normal heart-sounds and not con- 138 PHYSICAL DIAGNOSIS. ducted in the direction of the blood current. It is often influenced by changes of position or by breathing, or by pressure with the stethoscope. It may sometimes be felt by the hand placed over the heart. It is gen- erally of short duration and disappears with the filling of the pericardium by effusion. A friction may be pleuropericardial, that is, given a circumscribed pleurisy, the pericardium in its motion over the rough surface of the pleura may produce a fric- tion sound simulating the pericardial friction, but such sound ceases with the compelte holding of the breath. A churning or water-wheel sound is produced when air and water are both present in the pericardium, — a rare event. Cardio-respiratory murmurs are s3stolic mur- murs heard at the end ot a full inspiration, and are caused by the heart's impulse forcing with its contrac- tion the air out of sorne adjacent air-vesicles, or possibly even a cavity. The sound resembles a soft systolic murmur, but ceases when the breath is held in expira- tion. Similarly caused 2st pulsating crepitations. FUNCTIONAL, OR ACCIDENTAL, OR H^EMIC MURMURS. These are murmurs usually supposed to arise indepen- dently of any abnormality in the state of the cardiac valves or orifices. They have certain characters by which they are commonly distinguished from organic murmurs, although such distinction is not always easy. FUNCTIONAL, ACCIDENTAL, OR H^MIC MURMURS. 1 39 I. They are invariably systolic. 2. They are almost always soft and blowing, and greatly influenced by pos- ture, being more pronounced in the recumbent position than in the upright, although this relation is sometimes reversed. 3. They are most frequently basic, and far more common pulmonary than aortic, but occasionally they are heard at the apex. 4. Functional murmurs are unattended by the unequal distribution of blood and the alteration in the size of the heart and its cavities, which always, sooner or later, accompany the organic mur- murs. They have therefore been regarded as due I0 some condition of the blood, as the result of which its parti- cles are thrown into vibration more readily than in health. Hence they are also called hczmic murmurs. Such condition is generally accompanied by a watery state of the blood ; for this reason they are also called anaemic murmurs, being especially frequent in anaemia and chlorosis, and in women immediately after child- birth. Whether it be this thinness of the blood which is repponsible for the murmur, or some accompaniment of such a state is not known. These murmurs also occur in connection with various morbid states of the blood, such as exist in the infec- tious fevers as well as the various anaemias ; also in certain neuroses, especially in Graves' disease and allied affec- tions. In these latter there are also arterial murmurs, which are ascribed to vasomotor influences producing inequalities of calibre of the vessel, which engender murmurs. From these facts Sansom's theory ascribes to 140 PHYSICAL DL4GN0SIS. a similar origin the murmurs in the great vessels in neu- roses and anaemia. The ventricle, weakened by im- paired nerve force, toils to overcome an unusual resist- ance due to tension in the great vessels, and the muscular fibrillse of the conns of the ventricle just below the valves are thrown into tremor. The valves themselves may vibrate, and these vibrations are communicated to the area of the thoiax adjacent to these vessels through the portions of these vessels immediately above the valves. The right ventricle and its conus are moie superficial, its muscular walls are thinner, and in the conditions named it has to contend against relatively greater obstruction, hence murmurs at its site are more frequent.* Natmyifs theory ascribes the so called pulmonary murmur to a regurgitation through the mitral valve into the left auricle, reaching the ear by the auricular appen- dix. Hence the fact that the murmur attains its greatest intensity not in the ' pulmonary area but to its left. Russell's theory ascribes the pulmonary murmui to pressure of a distended auricle on the artery. Certain systolic murmurs at the apex, associated with anaemia and neuroses, but unaccompanied by valve lesions, Sansom ascribes to an actual mitral regurgita- * It will be remembered, as stated on p. 128, that Sansom ascribes murmurs to vibrations in solids rather than in fluids as commonly accepted. To make the statements quoted accord with such view we have only to suppose that the vibrations described are communi- cated to the blood stream and conducted thence to the ear. VASCULAR MURMURS. 141 tion, the result of weakness of the muscles concerned in closure of the mitral orifice. Other explanations than these are assigned by various authors, for information as to which the student is referred to Sansom's recent work on " Diseases of the Heart and Thoracic Aorta." I will only add that Balfour, for one, holds that the pulmo- nary murmur, is not an arterial but an auricular murmur. VASCULAR MURMURS. In the examination of arteries the stethoscope is ap- plied — for the carotid, at the intersection of the steino- cleido-mastoid muscle into the clavicle and sternum, and carried upward along the anterior edge of the muscle ; for the subclavian, behind the clavicular insertion of the sterno-cleido-mastoid muscle, the arm being dependent ; for the brachial, on the inner border of the biceps at the bend of the elbow, with the arm partially flexed, and for the crural, in the popliteal space. Care should be taken to apply the stethoscope very lightly, as pressure itself will engender a sound called the acoustic pressure murmur. This may be made self audible at almost any time with sufficiently quiet surroundings by pressing upon the artery in front of the ear. Normal Arterial Murmurs. — Considering the apparent simplicity of the matter, there is a singular discrepancy in the statements concerning the so-called normal arterial murmurs. I am inclined to agree with W. Russell, who says no murmur originates in the great vessels of the neck in health, unless it be as the 142 PHYSICAL DIAGNOSIS. result of undue pressure with the stethoscope. On the other hand, there can be no doubt that two sounds are commonly heard on such auscultation. My own obser- vations go to show the following : If a stethoscope be thus lightly placed over the caiotid or subclavian arte- ries, so as not to compress the vessels, two sounds are heard with each movement of the heart — one corre- sponding to the systole of the ventricles and the expan- sion of the arteries, the other to the diastole of the heart and the contracting recoil of the arteries. The first is shorter and fainter and is the first sound propagated from its seat of production, the auriculo-ventricular valves. The longer and louder is the second or aortic heart-sound, conducted from the site of its production, the aortic valves. The latter sound is occasionally heard in the abdominal aorta, more rarely in the brachial and femoral. The fainter sound is not con- ducted so far. Abnormal Arterial Murmurs. — Abnormal sounds are conducted into the arteries in valvular disease of the heart, particularly aortic disease, both obstructive and regurgitant, and rarely also in mitral disease. The systolic murmur of aortic stenosis is always conducted at least into the great vessels of the neck. Finally, murmurs may arise in the larger arteries themselves from any causes which produce a change in the diameter of the vessel, such as aneurismal dilatation, congenital narrowing, or narrowing due to thrombi or to compression from any cause, such as adhesions, con- traction of cicatricial tissue, morbid growths or in- VASCULAR MURMURS. 1 43 flammatory infiltration, or the pregnant uterus. Thu a murmur may occur in a branch of the pulmonary artery from pressure by a tubercular deposit or pneu- monic infiltration or enlarged bronchial gland, and a murmur may even be produced in the subclavian artery by a tubercular deposit at the left apex. A murmur in a branch of the pulmonary artery from such cause is intensified during expiration, while a murmur in the left subclavian from the same cause is said to be intensi- fied by holding the breath at inspiration. Thyroid tumors in the neck also produce arterial murmurs by pressure. Sounds also arise in the larger arteries as the result of change of pressure. Such is Traube's sound produced in aortic regurgitation. This is usually a double sound, of which the first element is due to the rapid distension of the artery by a blood-wave which throws its walls into vibration. A second sound occurs with the cessa- tion of the pressure. The placental murmur is a mixed venous and arterial murmur. Venous Murmurs. — These are distinguished from arterial murmurs by their continuousness as contrasted with the intermittent arterial murmur. An acoustic pressure murmur may be produced in any vein which is large enough, as the jugular and femoral, by pressing slightly upon it with the stethoscope, without, however, pressing so hard as to obliterate the blood current. Murmurs independent of such pressure are sometimes heard in these large veins, including the femoral, from 144 PHYSICAL DL4.GNOSIS. tricuspid regurgitation, but the principal pathological venous murmur is the venous hum or bruit de diable. It is compared to the sound heard on placing a sea-shell of moderately large size against the ear. It is frequently heard in chlorotic females over the bulb or dilatation of the internal jugular vein; also sometimes in the large intrathoracic trunks, the superior cava, and the innom- inata. It is best heard on the right side by turning the head as far as possible to the left and then placing the stethoscope above the right clavicle behind the sterno- cleido-mastoid muscle, or over the sterno-clavicular articulation, by which an artificial murmur from pressure is avoided. It is a continuous soft murmur resembling the humming of a top, and by its continuousness can be readily distinguished from an intermittent arterial murmur. This murmur cannot be regarded as ahvays abnormal, since it is often heard in healthy individuals. Thus Winterich found it in So per cent, of the Bavarian cuirassiers whom he examined. It is much more fre- quent in women than men in the proportion of 7 to i, according to Aran. Extreme loudness may be regarded as an indication of abnormality. Its presence may especially be regarded as corroborative. THE SPHYGMOGRAPH IN DIAGNOSIS. Whatever the diagnostic value of the sphygmographic tracing in valvular heart disease, and it is sometimes con- siderable, no study of a case of such disease is complete without it. While the original sphygmograph of Marey THE SPHYGMOGRAPH IN DIAGNOSIS. 1 45 probably furnishes a better tracing than any of the modern instruments, the latter have the advantage of cheapness. That of Dudgeon is the most popular at the present day, especially Richardson's modification with sphygmometric attachment. Directions for its use and the preparation of suitable paper always accompany the instrument. Space need not therefore be occupied by them. By means of the sphygmometer varying degrees of tension may be measured before the tracing is made. In the pulse of low tension the maximum movement of the lever is attained with slight degrees of pressure, and small increase of the same tends to extin- guish the tracing. In pulses of high tension the maxi- mum excursion of the lever is brought only by rather strong pressure, and the strongest pressure will not extinguish the tracing. The Normal Pulse Tracing — This is shown in the drawing on p. 146. It consists, first, of a vertical or almost vertical up-stroke, a b.2. sudden oblique fall, soon interrupted by a notch, c, followed by a short rise to d, another fall, a second notch, e, and another rise to /, followed by an undulating fall to the base line of the sphygmogram. The anacrotic or up-stroke, ox perc2ission stroke, as it is also called, is the effect of the sudden dilatation * of the artery upon the lever, which, having * It is held by Broadbent that no actual increase of the lumen of the artery takes place in the formation of the pulse, but that with the filling of the vessel it simply changes from the oval to the circular shape. This seems, however, to be an error, as an actual increase in diameter is easily demonstrable by suitable instruments. T46 PHYSICAL DL4GN0SIS. reached its maximum height, falls to rise again and form "the ?iO-C'2i\\e.d. tidal OT p7-e dicrotic loave, c d e. This wave is still a part of the effect of the distending force of the vessel on the lever, which through its inertia is carried too high, then falls, and is again caught by the still dilating vessel and carried to d. The vessel now begins to collapse and the lever to fall with it, but soon rises again to form the curve, ^/rt:, called the normal dici-oUc Fig. 27. — Normal Sphygmogram Enlarged. 1^. Percussion up-stroke. a b c. Percussion wave, c d e. Tidal rr predi- crotic wave, ef a. Dicrotic wave, d e f. Aortic notch, /a. Diastolic notch. — Sanso7!z.) wave, while the notch immediately before it is the aortic or predicrotic notch. The dicrotic wave is the result of a second rise of the vessel wall due to the elastic recoil of the over-dilated aorta on the contained blood, which, being prevented from going backward by the closed aortic valve, moves forward, producing the dicrotic wave. The second sound of the heart is found to coin- cide exactly with the predicrotic notch, ^:.\ \°': • , '»' :-i-: ° • = ' = '<>! { \\ ]: ;-; \° - V 'i' / =;■"= ■ »' • ' V :•'. ■ " J '.'o i,'" ' ' ?} ».' ■: .»■!.'.' .',! • .%;. = o % ' ; ' ■ . '. -■U =v." .'" " , ''4-: Fig. 43. — Group of 16 Small Squares, each of a capacity of jtrtct. c. mm. mak- ing one large square of the Thoma-Zeiss cj'tometer, magnified. horizontal lines should be counted in the squares above them, and all corpuscles lying on the vertical hnes should be counted in the squares to the right of them. The calculation is as follows : If by a dilution of the blood in the proportion of i : a, z corpuscles have been counted in ;/ squares, then I c. mm. of undiluted blood ^= 4000 X — — — blood corpuscles. n THE COUNTING OF BLOOD CORPUSCLES. 217 If, for example, by a dilution of the blood in the pro- portion of I : 100, as we supposed above, in 200 squares altogether 2570 red blood corpuscles were found, then the calculation will give for i c. mm. of blood — 4000 X 100 X 2570 _ 5^j4o^ooo blood corpuscles. 200 For counting the white Mood corpuscles a pipette should be used which allows a dilution in the propor- r^ Fig. 44. — Thoma-Zeiss Ruled Slide, focussed for lo and 12 squares to cover exactly the field of view of the microscope. tion of I : lo, or i : 20, and instead of the salt solution an aqueous .5 per cent, solution of acetic acid, to which may be added a little methyl-violet, should be chosen for diluting. The red corpuscles will disappear in this fluid, but the white ones will remain and are easily counted. The easiest method of calculation is to de- termine the cubic contents of the space covered by the field of the microscope and to count the leucocytes in 2l8 PHYSICAL DIAGNOSIS. a large number of such fields. ]\Iove the tube of the microscope up and down until one of the parallel lines of the ruled slide corresponds with the edge of the cir- cular field of vision, as at a, b (Fig. 44). Then, as each square is Jq- mm. wide, the whole diameter of the field equals -^-^^ multiplied by the number of squares included between the parallel lines. Thus if the number be 10, the diameter is \^ or }^ mm., the radius ^4 , and the area of the circle {^%Y X 3-i4i6; the cubic contents iYxY or yL X 3-1416 X y\j- , (yq^ mm., being the depth of the space) ; /. e., ^l^l^ = -V ^- ^^^^^^- ^ ^^^ capacity of the field of vision. A number of fields are counted, say 10, containing in all 200 leucocytes, making the average of each field 20. But as the capacity of one field is Jj- c. mm., an entire c. mm. would contain 10x51 = 51 o- Now, as the blood is supposed to have been diluted 20 times, the actual number of leucocytes per c. nim. would be 10,200. Hence, for a field of to squares, 10 fields being counted, we need simply to multiply the average of one field by 51 and 20, or 1020. Calculations for fields of five, six, or any convenient number of squares may be made. Studies by Thoma and others, with a view to deter- mining possible errors with the instrument whose use has thus been described, go to show the constant errors to be insignificant, less than one per cent., while the accidental and variable errors, which are unavoidable, diminish with the number of corpuscles counted. Thus, by counting 200 red corpuscles they amount to five per cent, of the total result, by counting — THE COUNTING OF BLOOD CORPUSCLES. 219 1,250 corpuscles amount to 2 per cent, of the total. 5,000 " " I " " " " 20,000 " " ^2 " " " " At least four sets of i6, or 64 squares, should be counted in estimating red corpuscles. To count the whole 256 such squares takes about one-half hour, and usually means from 1200 to 1500 corpuscles. Estimating the Corpuscles by the Centrifuge. In 1885, Professor Blix, of Upsala, Sweden, sug- gested the use of centrifugal force in estimating the volume of red blood corpuscles, and Dr. S. G. Heden has devised an instrument called the hcematokrit for this purpose. Dr. Judson Daland has further improved this instrument so that after the blood, diluted with an equal bulk of a 2.5 per cent, solution of bichromate of potash, has received the requisite amount of rotation, the percentage volume of red corpuscles may be read off from the cylindrical tubes in which the blood is placed, and from this deduced the number in each cubic milli- meter by simply adding five ciphers to the reading. Dr. Daland regards the hsematokrit as both more speedy and more accurate than the cytometer, basing his conclusions on a very large number of comparative observations. He used also a great variety of fluids for dilution, and concluded that the 2.5 per cent, solution of bichromate of potash is, for many reasons, the best. The hsematokrit also enables one to measure the volume of colorless blood corpuscles, but no method has yet been devised for calculating their number. 2 20 PHYSICAL DIAGNOSIS. TO MEASURE HEMOGLOBIN. Such estimation is, of course, approximate. The best instrument for this i)urpose is the hi^moglobinometer Fig. 45. — H.BMOGLOBINOMETER OF FlEISCHL. of Fleischl. It consists of a stage perforated by a central opening, below which is a gypsum reflector, .S", by which TO MEASURE HEMOGLOBIN. 221 the light from a candle may be thrown directly into the opening. Into the latter is fitted a cylinder, G, divided by a partition into two equal parts, one-half a, being over the unobstructed opening, the other, a\ over a wedge-shaped piece of glass interposed between it and the opening. The glass is colored with Cassius' gold purple, and presents, of course, a gradually increasing depth of color in passing from the thinner to the thicker end. The wedge of glass is movable by a rack and pinion alongside of a scale graduated in loo equal parts, of which the figure lOO corresponds with the depth of color of a mixture of normal blood, and lower figures correspond with that of thinner blood. The examination should be made in a cool, dark room. To use the instrument each demi-cylinder is filled with water, and into the one a, opposite the tmobstructed opening is put a quantity of blood, measured in the little cylinder shown in the cut. In order to prevent oxidation, the mixing vessel should be covered with the round cover-glass supplied with the hsemometer. It should be applied from that side containing the water. If applied from the other side some of the blood might be carried into the clear water and thus spoil the examination. The wedge of glass is then moved along by the milled head, T, until the color of the blood solution exactly coincides with the color of the opposite half cylinder containing water only, but placed over the colored glass. The figure attained on the scale when the shades are identical indicates the percentage 222 PHYSICAL DIAGNOSIS. of haemoglobin. In point of fact, it rarely happens that a normal blood exceeds ninety per cent., a fact which should be borne in mind. Dr. Daland has suggested covering the entire cylinder when ready for use by a cap containing a central slit % inch (6 mm.) wide over the centre, through which the examination can be made with greater facility than with the entire cylinder exposed. PREPARATION OF STAINED FILMS. The staining of the blood preparations for clinical pui poses may be rapidly performed by the following methods : Blood films are prepared by cleansing the finger or the lobe of the ear carefully with alcohol ; pricking it gently, wiping away'the first few drops that emerge, and then touching the top of a small drop with a clean cover-glass, placing upon another equally clean cover- glass and sliding the two apart. The film dries in the air quickly and may be kept indefinitely. Fixation may be accomplished by immersing the cover-glass in a mixture of equal parts of absolute alcohol and ether, for from three minutes to one-half hour. In rapid clinical work staining with eosin and hgematoxylin gives satisfactory pictures of the morphology of the corpuscles. The cover-glass fixed and dried is stained wnth a one per cent, solution of eosin (soluble in water) in sixty per cent, alcohol for one or two minutes. It is then counter- ^^, /^ CT"^ J^t's:. /.—Normal Blood. Fixed bs' heat- ing, stained with Erlich's triple stain. a. Normal polymorphous leucocytes. b. Lymphocyte. c. Large mononuclear leucocyte. d. Eosinophile. e. Red Corpuscles. Fig. 2. — LiENO Medullary LEUK.E.VIIA. Fixed by heating, stained with Erlich's acid fuchsia, methyl green, orange O mixture. a. Normal polymorphous leucocytes. b. Erlich's myelocyte, neutrophilic. c. Small myelocyte. d. Eosinophile. e. Red Corpuscles. f. Nucleated red corpuscle. FIO. 8. '9 ^*%. ^ , ^ i Fig. J.— NORM.A.L Blood. Fixed in abso- lute alcohol-ether, stained with Eosin and Hematoxylin. a. Polymorphous leucocytes. b. Lymphocyte. c. Large mononuclear leucoc5'te. d. Eosinophile. e. Red Corpuscles. PREPARATION OF STAINED FILMS. 223 stained with Delafield's * hsematoxylin for from one-half to one minute. The specimen is then washed, dried, and mounted. The red corpuscles take the eosin (pink) as do also the eosinophile granules, but nuclei of the white corpuscles are stained blue with the hsema- toxylin. Simultaneous staining and counterstaining may be obtained by Gollasch's mixture : Eosin, • • • 0.5 H£ematoxylin, 2.0 Glycerine, Distilled water, Al)solute alcohol, of each, 100. o Glacial acetic acid, 10. o Alum — slight excess. This solution requires several weeks for ripening. The blood films after, fixation are stained for several minutes and then washed, dried, and mounted. For the demonstration of the eosinophilic and * Delafield''s Hematoxylin is made of hsematoxylin crystals, 4 grams; 95 per cent, alcohol, 25 c. c; saturated aqueous solution of ammonia alum, 400 c. c. Add the hsematoxylin dissolved in the alcohol to the alum solu- tion, and expose the mixture in an unstoppered bottle to the light and air for from three to four days. Filter and add glycerine, 100 c. c; 95 per cent, alcohol, 100 c. c. Allow the solution to stand in the light until sufficiently dark, then filter and keep in a tightly stoppered bottle. It keeps well and maintains a purplish tinge as long as it is good. 2 24 PHYSICAL DIAGNOSIS. neutrophilic granulations as well as the general morph- ology, Ehrlich's triple stain is used. This consists of — Saturated aqueous solution orange G., . . 120 to 135 " " " acid fuchsin, . 80 to 165 " " " methyl-green, 125 Add— Water, 300 Absolute alcohol, 200 Glycerine, 100 Frequently a little more methyl-green is required, and the solution must generally be tested and corrected by the addition of one or other stain after each prepara- tion. - Staining with the triple stain is most satisfactory after previous heating of the blood films for fixation ; they may be baked in a hot oven at 110° or 120° C. for an hour, or with some experience . the heating is readily carried out by passing the specimen through the flame, as in staining sputum. The Widal Test for Typhoid Fever —This depends on the power inherent in the serum of a person who has had typhoid fever a variable but generally short time, of causing living typhoid bacilli to cease their active movements, and to form clumps. These changes take place in from a few minutes to an hour after the contact has been brought about. The test is practised as follows: The finger or ear lobe is thoroughly sterilized and punctured with a sterile lancet, and the blood drawn into a sterilized PREPARATION OF STAINED FILMS. 225 pipette, which is then sealed up. A drop of diltite bouillon culture of typhoid bacilli, not more than twenty- four hours old, is placed on a sterilized slide. To this add a minute quantity of the serum from the pipette, mix rapidly, apply the sterilized cover-glass and press it gently to obtain a uniform film, and examine with a power of 300 to 400 diameters. Uninfluenced by the specific serum the bacilli maintain active movement for a long time — days if the specimen be properly prepared — and exhibit no tendency to form clumps. Under the in- fluence of the typhoid serum the movement promptly ceases and the clump formation takes place. The re- action is more frequent after the first week, but may take place as early as the third or fourth day. Instead of the serum a drop of dried blood may be mixed with distilled water and used instead of serum with the same result. The bacillus culture is commonly obtained from the spleen of one dead of typhoid. 226 PHYSICAL DLAGNOSIS. EXAMINATION OF SPUTUM. The coarse examination of sputum includes the coarser examination for quantity, color, consistence, shape, and odor. The minute examination seeks bacilli, cellular elements, including blood and eosinophile cells, elastic fibres, Curschmann's spirals, and Charcot-Leyden cr}'stals. The eosinophile cells are .large and contain numerous fine granules stainable with eosin. They are often found in asthma, where they may be associated with Charcot-Leyden crystals, minute acicular or spmdle- shaped bodies. Curschmauii's spirals also occur in the sputum of asthma. They are large enough to be seen by the naked eye, looking like sago grains. When unrolled they appear as convoluted threads which may be an inch long. Under the microscope they are found made of a central thread, about which clings a coating of tough mucus containing mucous corpuscles. Previous to the discovery of the tubercle bacillus, elastic fibres were the most distinctive objects found in sputum. They are found where there has been break- ing down of the lung from gangrene, tuberculosis, or abscess. They are best sought by boiling suspected sputum with several times its bulk of liquor sodse, or potassae, by which the former is thinned and the fibres fall to the bottom of the test-tube or conical glass, whence they may be raised with a pipette. Good examples fur- nish circular forms derived from the alveoli of the lungs. STAINING OF TUBERCLE BACILLI. 227 STAINING OF TUBERCLE BACILLI. Of the various methods of staining tubercle bacilli that by the carbol fuchsin solution of Ziehl-Neelsen, with or without Gabbetfs counter-stain of methyl blue, appears to stand the test of time as well, if not better than any other. By this method the bacillus takes a bright red color from the fuchsin, the mordant being carbolic acid. The carbol-fitchsin solution is made as follows : Powdered fuchsin, I part Alcohol, .... 10 parts Five per cent, solution carbolic acid, . . . 100 parts Mix and filter. ^The older the solution the better. Two methods are practised with this staining fluid, a rapid and a slow, the former being more commonly practised for diagnostic purposes. I. The rapid method with carbol-fuchsin ivithotit or with counter-stain by methylene blue. A very small clump of the moist solid part of the sputum mass is selected and brought with forceps or platinum loop on a clean cover-glass. Upon this another cover-glass is superimposed and the two are pressed and rubbed over each other until the specimen is thoroughly smeared over both. They are then separated and two specimens are thus obtained. When dry, one of these covers is passed, specimen side up, three times slowly over the flame of a spirit lamp or Bun sen burner, by which the albumin 2 28 PHYSICAL DIAGNOSIS. is coagulated and the specimen fixed. The specimen is then completely covered with the staining fluid and held over the flame until the solution begins to vaporize, care being taken to keep all parts of the glass thoroughly covered with the stain, but not allowed to boil. This is kept up for one minute, when it is washed in water for two or three seconds. It is then decolorized in acidulated alcohol, eight or ten drops of HCl or five drops HNO3 to a watch cr}'stal of alcohol, and examined in the latter solution, by a one-twelfth oil-immersion and Abba's condenser, although a little experience with a dry lens of 350 diameters or higher will soon lead to the recog- nition of the bacilli, which are stained a handsome red. The preparation is more brilliant and its study rather less tr}dng to the eyes if counter-stained by Gabbe^tt's acid blue, composed of — Methylene blue, 2 parts Twenty-five per cent, solution sulphuric acid, 100 parts After being washed in water, the specimen is immersed for about thirty seconds in the acid blue, washed off in water, dried between filtering paper, and examined in water. 2. Slower method with ca^-bol-fiichsin, and counter- stai7i with Gabbetfs acid blue. This slower rnethod is always more satisfactory if time permits, and should alone be used for permanent preparations. The steps are the same until the staining stage is reached, when the cover-glasses containing the speci- THE PNEUMOCOCCUS. 229 men are placed in the carbol-fuchsin solution, say at five or six o'clock in the evening, and allowed to remain until next morning. They are then washed in water, counter-stained by Gabbett's acid-blue solution, again washed in water, dried between filtering paper, and studied in water, or if it is desired to mount the speci- men permanently, it is passed through alcohol or xylol into Canada balsam. Oil of cloves should not be used for clearing, as it sometimes declorizes the stained specimen. Nor should specimens stained in aniline colors be mounted in glycerin, as this gradually with- draws the stain. The bacillus may be stained by Gram's method. Sections are treated similarly by the slow method and mounted in balsam. Dr. C. W. Purdy has devised a " beater " with which to beat up the sputum mixed in a two-ounce glass graduate with equal parts of a three per cent, salt solution for a moment or two, after which he puts the fluid into the centrifuge. The sediment thus obtained is then stained and studied. THE PNEUMOCOCCUS. The micrococcus lanceolatus or diplococcus pneu- vionice, the true bacillus of pneumonia, was discovered independently by Surgeon General Sternberg, U. S. A., in 1 88 1, and by Pasteur somewhat later. The latter was the first to publish an account of it. Neither appre- ciated its relation to croupous pneumonia. This Tala- 230 PHYSICAL DLV GNOSIS. moil first asserted in 1S83. The subject was first satis- factorily cleared up by Frae'nkel and ^Veichselbaunl in 1886, whence it is also associated with their names. The piiciimococciis is characterized by its lance-shape and capsulation as found in tissues and sputum. In cultures it is without capsule. Found most frequently in the lung in croupous pneumonia, it also occurs in the sputum of pneumonia, in fresh endocardial vegetations, and the pus of cerebro-spinal meningitis. It usually occurs in pairs— diplococci — sometimes in filaments of three or four elements. The simplest extemporaneous stain is the carbol- fuchsin solution (p. 227). An immersion of a few minutes usually suffices, when the coccus itself will have become intensely red, while the capsule has assumed a light reddish tint. The capsule may also be stained in the same way as that of Friedlander's bacillus described below. The diplococcus puci/jiionice may also be stained by Gram's metliod, as follows : I . The cover-glass preparation is i)laced for from two to five minutes in warm Ehrlich- Weigerfs saturated aniline solution of gentian violet.* * Aniline oil, 4 parts Distilled water, 100 parts Shake, filter through moist filter and then add — Saturated alcoholic solution (stain, 10 grams; absolute alcohol, 40 grams), gentian violet, or methyl-blue, 11 parts Filter. THE PNEUMOCOCCUS. 23 I 2. Transfer directly without washing into Gram's solution (iodine, t, iodide of potass. 2, water 300) for from two to three minutes, where it becomes quite black. 3. Wash in absolute alcohol until the primary black color becomes pale gray. All the cellular elements are decolorized except the micro-organism, which has assumed a deep blackish blue. 4. Mount in Canada balsam. This method is particularly valuable in the differential diagnosis between the diplococcus and the — ' Pncunw-bacillus of Friedldnder. — -This bacillus is oval, encapsulated, and occurs, also, in pairs, and is sometimes found in the lung of croupous pneumonia. It is also stainable in aqueous staining solutions as the bacillus of Fraenkel-Weichselbaum, the capsule remain- ing unstained. // cannot be stained by Gramas method. To stain the capsule in cover-glass preparations, Friedlander directs : 1. The prepared cover-glass, drawn three times through the flame, is placed in one per cent, acetic acid solution for two minutes. 2. Remove the acetic acid by blowing on the cover- glass through a pointed glass tube, and allow to dry in the air. 3. Stain for ten seconds in saturated aniline-water- gentian-violet solution. 4. Wash in water, dry between filter paper, mount in balsam. For sections : I. Stain for twenty-four hours in warmth in a solu- 232 PHYSICAL DL4GN0SIS. tion composed of concentrated * alcoholic gentian- violet solution 50, distilled water 100, glacial acetic acid 10. 2. Wash in one per cent, acetic acid solution. 3. In alcohol to dehydrate. 4. Mount in balsam. Bacillus of Diphtheria. — The short curved bacil- lus assigned by Loffler as the cause of diphtheria is well stained by Loffler's alkaline methylene blue solution of — Concentrated alcoholic solution methyl-blue (1:40), . 30 c. c. Caustic potash (i: 10,000), lOO c. c. Another specimen should be stained by Neisser's method, which consists in staining for from one-half to one minute in a solution consisting of one gram of Grlibler's methylene blue dissolved in 20 c. c. of 90 per cent, alcohol and then added to 960 c. c. of distilled water and 50 c. c. glacial acetic acid. After staining in the blue mixture they are washed off in water, and are then stained for from three to five seconds in a solution consisting of two grams of vesuvin (Bismarck brown) dissolved in one litre of boiling dis- tilled water and filtered. They are then again washed off in water and are ready for examination. The object of these duplicate examinations is this : By the ordinary Loffler method of staining there are occasionally encountered micro-organisms that are mor- *Ten grams of the powdered dye, 40 grams absolute alcohol. THE PNEUMOCOCCUS. 233 phologically strikingly suggestive of the diphtheria bacillus. When, however, these micro-organisms are sub- jected to the Neisser stain, the difference between them and the genuine diphtheria bacillus is, in the vast majority of instances, very manifest. This difference consists in the appearance in the true diphtheria bacillus of minute granules or spheres that take on the blue stain very heavily, looking almost black, and show very con- spicuously in the brown counter-stain to which the micro-organisms have been subjected. These granules do not appear in the organisms that are not true diph- theria bacilli, — at 'least when they do, it is so rare as to be extremely exceptional. This method of duplicate preparation is greatly superior to the methods hitherto used, since the Neisser stain controls the ordinary ex- amination with the Lofifler stain. The Lofifler bacillus may also be stained by Gram's method (p. 230). Slides made from the false membrane are seldom satisfactory, because it is seldom that a pure infection exists. Cultures should be made, which should be eight to fifteen hours old, and in order that the Neisser stain may give the best results, the culture should not be older nor younger than about fifteen hours, and should not have been cultivated at a greater temperature than 35° to 36° C. The typhoid bacillus is stained by Lofifler's solu- tion. // is not stainable by Grant's method. It may be obtained from the spleen and from the blood in rose- colored spots. 234 PHYSICAL DLA.GNOSIS. The cholera bacillus is stained in the concen- trated aqueous solutions of fuchsin ; sections by fuchsin solutions or methyl-blue. A flocculent mass from a stool is treated between glass covers and dried and fixed as in the case ot sputum. // is not stained by Gramas method. Bacillus of Syphilis. — DeGiaconus method. The cover-glass preparations made from the pus are warmed for a few minutes in the aniline-water fuchsin solution then washed in water to which a few drops of a chloride of iron solution have been added, and decolorized in a concentrated solution of chloride of iron. They are finally washed and studied in water. The syphilis bacillus remains red, while all other cells are decolorized. If desired to mount, dehydrate rapidly in absolute alcohol, clarify in xylol and mount in Canada balsam. The gonococcus is very well stained by the carbol- fuchsin method already described for the tubercle bacil lus. The true gonococcus is not stained by Gram's method. It is thus distinguished from similar microbes. EXAMINATION OF GASTRIC CONTENTS. 235 CHEMICAL EXAMINATION OF GAS- TRIC CONTENTS. A variety of test-meals has been suggested, the pro- ducts of whose digestion are submitted to examination. The test breakfast of Ewald is usually preferred on account of its simplicity, convenience, comparative cleanliness, and easy manipulation. It consists of an ordinary dry roll,* weighing 35 grams (a little more than an ounce), and 300 c. c. (10 ounces) of either warm water or weak tea without milk or sugar. The Ewald meal contains no lactic acid, or, if any, so small a quantity that it does not respond to the ordi- nary tests. The meal is given after fasting all night, or after washing out the stomach. The stomach should be first washed out under any circumstances if there is reason to believe any residue is left from a previous meal. The Leube meal, which may be regarded as a full meal, the Ewald being a light meal, consists of soup- meat and bread, and contains consideiable lactic acid. One hour after the ingestion of the Ewald meal the product is removed by the flexible stomach tube. The tube is sufficiently lubricated by dipping it into warm water, after which it is introduced by carrying the end well back into the pharynx and directing the patient * Such a roll containing about 35 per cent, of water, 7 per cent, of albumen, 5 per cent, of fat, 4 per cent, of sugar, 52.5 per cent, of non-nitrogenous extractive substances, and i per cent, of ash, includes, therefore, the usual elements of a mixed diet. 236 PHYSICAL DIAGNOSIS, to s^A'allo^v as it is gently pushed downward. The tube should be about 95 centimetres (37^2 inches) long. From the fundus of the stomach to the incisor teeth is 60 to 65 centimetres (23.5 to 25.5 inches), and about this much should be taken up when the tube is well in place. The Ewald tube is usually marked at this place. A long tube allows the stomach to be emptied by siphonage after a little pressure on the abdomen has been exerted to start the motion of the contents ; or they may be removed by aspiration. The amount with- drawn, which should be about 40 c. c, is first examined macropcopically as to quantity, color, and consistence, minutely for blood or other abnormal constituents, then filtered after previous thorough shaking, in order to diffuse uniformly the acid constituents. In healthful conditions the gastric contents are acid in ten or fifteen minutes after food ingestion, the acidity depending on free acids or acid salts. The secretion of hydrochloric acid begins immediately, the first secreted combining with the native proteids and mineral salts, forming acid proteids and acid salts. The latter, chiefly acid phosphates (HjKPO^) form in the gastric contents by the action of HCl upon the phosphates (HK2PO4) contained in the food. As soon as the affinities of these substances are satisfied, free HCl makes its appearance. Free HCl appears in from 15 to 20 minutes after the ingestion of an Ewald meal; in from 25 to 30 minutes after ingestion of twice as much; in from 25 to 35 minutes after the ingestion of 60 gm. meat; 60 to 90 minutes after egg albumen ; 45 minutes EXAMINATION OF GASTRIC CONTENTS. 237 after a mixed meal of bread, meat, and vegetables. Fat and potato delay the appearance of HCl. It gradually increases in amount until at the acme of digestion the free HCl reaches, after a light meal, .05 to .19 per cent., and .2 to .33 per cent, after an abundant meal. The maximum is reached in one and a half to two hours after a light meal, and two to three hours after a full meal. Lactic acid is not secreted by the stomach ; if present, it has either been introduced with food or is the lesult of abnormal fermentation of food ingested. The procedure is as follows with the filtered fluid : 1. Test reaction with litmus or Congo red paper, the former being rendered red, the latter blue by acids. 2. Test for free acid and acid salts qualita- tively. See also p. 246. This may be done roughly by means of the aniline dyes Congo red and tropaoline 00 — r orange Poirier of the French. A saturated watery or alcoholic solution is made, strips of filtered paper dipped into such solution, dried, and thus preserved for use. The paper is, however, less delicate than the solution, which in the case of Congo red, strikes a beautiful sky- blue reaction with a solution containing but 0.02 per 1000 of HCl. A purple color is produced by organic acids, and a dull brown with acid salts. Combined acids do not affect the color. The tropseolin solution is dark yellowish red, and a solution of free acid, as HCl, 0.025 fo 1000, changes it to a deep dark brown. It is slightly less delicate, therefore, than the Congo red. Acid salts, as acid 238 PHYSICAL DIAGNOSIS. sodium phosphate, make if straiu-yellow. In all of these tests it is necessary to use an Excess of the fluid to be tested. This is accomplished by placing five or ten drops of the reagent in. a test glass or porcelain capsule and adding one to two cubic centimetres (15 to 30 d?-ops) of the filtered contents. Tolerably delicate tests can thus be made, though their delicacy is affected by acid salts and albuminoids, especially albumose and peptones. Leo^s carbonate of calciujti test is based upon the fact that CaOCOs in cold solution 7ieutralizes free acids ojily, not reacting with acid salts. A strip of blue litmus paper having been previously moistened with the filtrate as a standard, a few" drops of the latter are thoroughly mixed in a watch-glass with a small amount of chemically pure powdered calcium carbonate. After the complete neutralization of the free acids and dis- appearance of the separated CO2, the reaction is tested with another piece of litmus and the result compared with the standard. If the litmus is no longer reddened the acidity was due to free acids only, while if there is still redness, but less in degree than that of the standard, theie are both free acids and acid salts. 3. Test for free Hydrochoric Acid — Gilnz- burg^s test is commonly used, or if the result is negative or doubtful with it, Boas's test. Giinzburg's solution is made as follows : Phloroglucin, . 2 parts (gr. xxx) Vanillin, i part (gr. xv) Absolute alcohol, 30 parts (fjj) EXAMINATION OF GASTRIC CONTENTS. 239 The solution is pale yellow and has a decided odor of vanilla. On exposure to light it assumes a dark golden yellow, and it must therefore be kept in dark hued bottles or be freshly made as required. A drop or two of the reagent is placed on a porce- lain plate or capsule with an equal quantity of the gastric filtrate, and a gentle heat applied, not to boil, but simply to evaporate. Very soon a beautiful rose- red tinge will appear at the edge of the mixture,or red stripes will be observed. Blowing at the edge will favor the appearance of the red stripes. This test is unmistakable, and surpasses all others in delicacy, being available when HCl is present in the proportion of i to 20,000, or .05 per mille. Filtration of the gastric contents is not necessary. Boasts test is based upon the fact that resorcin strikes a similar reaction with hydrochloric acid. The solution consists of — Resublimed resorcin, 5 parts (gr. Ixxv) ■ White sugar, 3 " (gr. xlv) Dilute alcohol, 100 " (f^iiiss) Three to five drops of the reagent are poured into a porcelain dish and an equal quantity of stomach con- tents added. Heat is applied as in Giinzburg's test, and a purple-red color appears at the edge of the drop. It is said also to detect .05 per mille of HCl. Neither of these tests responds to the organic acids or is interfered with by peptones or acid salts. Topfefs test consists in the addition of one drop of a 240 PHYSICAL DIAGNOSIS. half per cent, alcoholic solution of dimethyl-amido- azo-benzol to a portion of the contents in a test-tube. If HCl is present a carmine-red color results. Free HCl may also be sought by Leo's test after ex- tracting the fatty acids by heat and the lactic acid by ether, when the fre acid remaining will only be HCl, of which, according to Leo, .02 per 1000 may be detected if decided amounts of acid phosphates are not present, and even then .008 per cent. 4. Test for Organic Acids. — These include lactic acid and the true fatty acids, especially butyric. They are not normal secretions, but in the early stage of digestion are not necessarily abnormal constituents, as they may be ingested with food. This is especially true of lactic and acetic. Commonly, if detectable by the ordinary reagents, they are pathological. Abnor- mal lactic acid is formed by fermentation of carbo- hydrate foods by action of bacteria, probably more than one. Butyric acid is also formed from carbohydrate and milk foods by the action of bacilli. Acetic acid has a like origin through the action of the mycoderma aceti. Uffehnanii' s Test. — Lactic acid is recognized by its effect upon a very dilute, almost colorless, solution of neutral ferric chloride, which is converted into a canary- yellow color by its action. This is Uffelmann's test. It is rendered more certain when a few drops of a neutral ferric chloride solution are mixed with one or two drops of pure carbolic acid, and adding water until the solu- tion assumes an amethyst blue color. A few dops of EXAMINATION OF GASTRIC CONTENTS. 24 1 even a .05 per mille solution of lactic acid (i in 20,000) will change the blue to the distinctive yellow color. There are, however, sources of error. The lactates cause the same reaction, but this matters not, because we desire to recognize the lactic acid, whether in com- bination or not. The reaction, however, takes place with alcohol, sugar, and certain salts, especially phos- phates, which are often found in gastric contents. The color produced by phosphates is not identical, but if the filtrate operated with has a yellow tinge the resulting color may approximate very closely. Under these cir- cumstances the lactic acid must be extracted with ether. To five c. c. of the stomach contents add two drops of strong hydrochloric acid. Heat the mixture to a syrupy consistence over a flame or water-bath. Shake the resi- due thoroughly with three or four times the amount of ether. The ether is allowed to rise on top, which it does rapidly, and is then poured off into a glass beaker. More ether is added and the washing repeated, until in all about 30 c. c. (f§j)of ether have been us^d. The ether is then evaporated by placing the beaker, with its con- tents, in a vessel of hot water. The residue is redissolved in a few drops of water and one or two drops of Uffel- mann's reagent allowed to fall from a pipette into the solution. Too much of the solution may mask the reaction. This test is much more delicate than tro- paeoline, which may fail to show a reaction for free acid because of its concealment by acid salts. ■ The fatty acids, especially hityric, strike a tawny yel- low color with a reddish tinge with Uffelmann's chloride 242 Pm^SICAL DIAGNOSIS. of iron solution, but .5 per 1000 or i in 2000 is required before the reaction occurs. Fatty acids may also be detected by heating to the boiling point a few c. c. of the gastric filtrate in a test- tube, over the mouth of which a strip of moistened neutral or blue litmus paper is placed. On this the vaporized acid will produce the usual change. The oily particles of pure fat may be recognized floating in the gastric contents or in the aqueous solu- tion of the residue after evaporating the ethereal extract. Butyric acid may also be separated in the form of drops by adding small pieces of sodium chloride. Acetic acid is easily recognized by its odor, but it may also be detected by neutralizing by sodium car- bonate the water}' residue after the removal of the ethereal extract : then adding a few drops of a ten per cent, neutral ferric chloride solution. A striking blood- red color is struck, also produced by formic acid, but this is never a constituent of gastric contents. Alcohol, which is sometimes formed in the stomach in intense yeast fermentation, may be detected by Lieben's iodoform-test applied to the distillate of the stomach contents, as follows : To a portion of the distillate add a small quantity of liquor potassse, then a few drops of a solution of iodine and iodide of potassium (i, 2, 50). If alcohol is present a yellowish precipitate of iodoform takes place slowly. The same precipitate occurs with acetone, but rapidly. 5. To Determine the Total Acidity, including Free and Combined Acids and Acid Salts.- A Mohr's EXAMINATION OF GASTRIC CONTENTS. 243 burette is filled with a decinormal * solution of caustic soda. Ten c. c. of the filtered solution are placed in a beaker and one or two drops of one per cent, alcoholic solution of phenolphthalein added as an indicator. The decinormal solution is then slowly dropped from the burette until the red color produced in the fluid by the action of the alkali on the phenolphthalein no longer disappears on shaking. As a rule, the total acidity of the gastric contents, an hour after such a meal, requires four to six c. c. of the decinormal solution to neutralize it in normal digestion. Figures above and below this are therefore abnormal. The acidity may be expressed by the number of c. c. required to neutralize one hundred c. c. of gastric contents ; thus, if four c. c. were required to neutralize ten c. c, there would be forty per hundred, which is also spoken of as degrees of acidity ; or, if six c. c, 60 per hundred total acidity. Again one cubic centimeter of the decinormal solution is equivalent to .00365 HCl. If, therefore, the number of cubic centimeters used to neutralize ten c. c. of the solution be multiplied by .00365 and again by ten, the result will be the percentage. Thus, if six c. c. of the decinormal solution be used, the percentage will be 6 X .00365 X 10 ^ .219 per cent., within the nonxial range, which is from .14 to .24 per cent, in the fil- trate; if four c. c. be used the HCl percentage will be * Decinormal solution of soda ^^ NaH0^4 grams NaHO dis- solved in 1000 c. c. distilled water. Each c. c. of this solution exactly neutralizes 0.0036 gram HCl. 244 PHYSICAL DIAGNOSIS. 4 X -00365 X 10 = .146, or less than normal. The range of total acidity in the unfiltered contents is greater than in the filtrate, being .15 to .3 per cent. This is probably because of the large amount of combined acids in the unfiltered contents. 6. To Determine Total Free HCl Quantita- tively. — (^)By Mintz's method : Ten c. c. of the stomach contents are titrated with the decinormal soda solution until a response with Giinzburg's reagent no longer occurs, testing a drop or two of the partly neu- trahzed gastric contents with the addition of each one- tenth c. c, or fraction thereof. Then, as one c. c. decinormal soda solution equals .0036 HCIO, we have simply to multiply .00365 by the number of c. cs. used, this by 10, and the result will be the percentage re- quired. The last reading before the disappearance of the reaction is taken as the measure of the HCl. Thus if the test responds after 5 c. c. of the decinormal solu- tion have been added, and does not respond after 5.1 have been added, the HCl in 10 c. c. will be repre- sented by 5 X -00365 gm. (^) By Topfer's method : To ten c. c. of the filtered contents add a few drops of a 5 per cent, alcoholic solution of dimethyl-amido azo-benzol. The mixture turns a bright red in the presence of free HCl. Titrate with the decinormal sodic solution until the red turns to a clear yellow. Calculate as above. 7. To Determine Free HCl, Organic Acids, and Acid Salts. — To ten c. c. of the gastric filtrate add a few drops of a one per cent, aqueous solution of alizarin EXAMINATION OF GASTRIC CONTENTS. 245 (alizarin monosulphonate of sodium) and titrate with the decinormal sodic solution until the mixture assumes a clear violet color. Combined acids have no effect. Alizarin responds to the alkalinity which succeeds the neutralization of the acidity due to free HCl, organic acids, and acid salts. As the violet tint is more or less difhcult for the unpractised eye to recognize, Topfer recommends the following preliminary tests : (a) To five c. c. of distilled water add two or three drops of the alizarin solution. A clear yellow color results. (/^) To five c. c. of a one per cent, solution of disodium phosphate add the alizarin solution as above. A red- dish color with a slight tinge of violet results. (c) Five c. c. of a one per cent, solution of sodium carbonate when treated with alizarin, as above, gives a clear violet tint, which is the tint to be reached in the titration. It should be used as a guide until the eye becomes sufhcientlv practised. Where there are no free organic acids the result of this test represents free HCl and acid salts. 8. To determine the combined HCl, subtract the acidity found by alizarin from that found by the phenolphthalein, /. e., from (5) subtract (7). 9. To determine the acidity due to organic acids and acid salts, subtract the free HCl from that found by alizarin, t. e., from (7) subtract (6). 10. To determine total HCl, free and combined, to (6) add (8). Where free HCl is present all the com- bined acid is HCl. 246 PHYSICAL DIAGNOSIS. II. To Determine Acid Salts. — See also p. 237. This may also be done by Leo's method, which is based on the fact that -when calcium carbonate is added as a fine powder to gastric contents, the free and combined HCl unite with the calcium carbonate, forming calcium chloride, a neutral salt, the acid salts being unaffected. Moreover, the calcium chloride thus formed reacts with the phosphates to form acid calcium phosphate, which requires twice the amount of sodium carbonate to neu- tralize it as the acid sodium phosphate. Hence it is necessary before each titration to add an excess of calcium chloride solution. Method. — To fifteen c. c. of the gastric contents is added a small quantity of calcium carbonate, as much as will go on the end of a penknife, the mixture stirred and immediately filtered through a dry filter. The liber- ated carbonic acid is expelled from the filtrate by passing a current of air through it by means of a glass tube. Ten c. c. of this filtrate are then treated with five c. c. of a saturated solution of calcium chloride and titrated as before. The result divided by two represents the acid phosphates. Examination of Products of Albumin Digestion. The term //-(^/i'c'/r.f/j- is applied to albumin digestion, in which all proteid substances are converted into peptone. It takes place partly in the stomach, but probably even to a greater degree in the small intestine. In this process the first step is the production of certain substances intermediate between albumin and peptone EXAMINATION OF GASTRIC CONTENTS. 247 which are called albumoses or proteoses. Those which are of chief importance in the study of gastric digestion are syntonin or acid albumin, and propeptone or hemi- albumose. In the ordinary process of digestion with a normal gastric juice some or all of these substances should be present in the stomach at the end of an hour. So far as they are the products of gastric digestion they may, therefore, be studied by the aid of a test-meal and removal of the gastric contents as already described. This digestion is accomplished by the agency of the hydrochloric acid, a proteolytic ferment pepsiii, and a coagulating ferment 7-ennin, all three secreted by the glands of the stomach. The secretion of HCl begins at once after the intro- duction of food. It unites at once with the native proteids of the food, forming acid proteids, and reacts with the neutral phosphates of the food, forming acid salts ; also with the proenzyme pepsinogen, forming pepsin, and with the rennet zymogen, forming rennin. A part of the rennin is formed as such in the glands. The secretion of the gastric juice continues in health until all these affinities are supplied and a certain amount of HCl remains over as free acid. As soon as this appears the pepsin ferment begins to act on the proteids and to convert them into albumoses and peptones, while the rennet acts on the casein of the food, coagulating and converting it also into soluble proteid. Pepsin acts only in the presence of HCl, while rennin is active in acid, neutral, or even feebly alkaline solution. Propeptone and Peptone. — Propeptone at the 248 PHYSICAL DL4GN0SIS. maximum of normal digestion should be present only in traces and must be removed before peptone is tested for, since it responds to the same test, — the biuret test. To remove propeptone treat 2 or 3 c. c. of the stomach filtrate with an equal quantity of a saturated solution of chloride of sodium and then add one or two drops of strong acetic acid. Propeptone if present is thus precipitated and may be filtered out. To the fil- trate add one c. c. of liquor potassae, then a few drops of a one per cent, solution of sulphate of copper. A purple red color indicates the presence of peptone, and we may approximately estimate its amount by the intensity of the biuret reaction, provided we always use the same proportion of stomach contents, solution of potash, and cupric sulphate. Should it happen that a handsome biuret reaction is struck before removing the propep- tone, and but a faint one or none afterward, the pro- portion of propeptone is large and of peptone small. Cahn has shown that in dogs, at least, the quantity of peptone remains at a certain percentage, being probably kept at that figure by constant removal. Hence the only index of the rapidity and amount of albumin trans- formation is the amount of propeptone formed or remaining. Finally, Ewald and Gumlich conclude that the formation of tiue peptone in the human stojtiach is slight, albumoses being mainly produced, the chief transformation of which is effected in the small intes- tine. To Estimate the Activity of Proteolysis, or Albumin Digestion. — By Ewald's method, coagu- EXAMINATION OF GASTRIC CONTENTS. 249 lated white of egg is cut into thin slices, and out of these small discs are cut by a cork-borer or similar in- strument. These may be prepared in quantity and kept for use in glycerin, which should, however, be washed off before using the slices. An equal quantity of the filtered gastric fluid is placed in four small test-tubes and one or two discs of albumin put into each. To the first nothing else is added, to the second enough hydro- chloric acid to make a solution of about * 0.3 to 0.5 per cent. This is accomplished by adding two drops of hydrochloric acid to five c. c. (90 minims) of stomach contents. To the third is added a definite quantity of pepsin, about 0.2 to 0.5 gram [gr. iij to gr. viiss], to the fourth both hydrochloric acid and pepsin. The test-tubes are placed in an incubator at about 100° Fahr., and from time to time examined with a view to learning how far the liquefaction of the discs of albumin has proceeded. The rate of this will inform us whether digestion would have occurred without the addition of anything, or whether acid or pepsin or both were necessary. We will learn, also, whether by adding more hydrochloric acid we have made the acidity excessive. It must be remembered, however, that after the pep- tone has reached a certain percentage, its further pro- * The difference between the strength of the acetic acid of the German Pharmacopoeia (25 per cent, of the anhydrous acid), in- tended by Evvald, and that of the U. S. P. (32 per cent.) is not sufficient to necessitate a change of proportion. 250 PHYSICAL DL4GN0SIS. duction is retarded, or even suspended, so that there may be an apparently slow reaction with even a very active gastric juice. Ewald happily reminds us that all laboratory attempts to imitate digestion are defective in the important respect that with our test-tubes and flasks we can neither imitate absorption on the one hand, nor, on the other, allow for the onward movement to the in- testines of the gastric contents, two important functions by which the stomach strives to maintain a fairly uni- form degree of concentration of its contents. The Action of Rennet, the Milk-coagulating Element of the Natural Gastric Juice. — The simplest method of estimating the action of rennet is that of Leo. To ten c. c. of raw milk are added two to five drops of stomach contents. Raw milk is used be- cause it coagulates ten times more rapidly than boiled milk, while neutralization is unnecessary because of the relatively small quantity of gastric juice used. The mixture is placed in the warm chamber at 100° F., and coagulation should take place in from one minute to several hours. The characteristic coagulation of rennet is a cake of casein floating in clear serum, while acids produce lumpy and flaky masses. The rennet-ferment, or enzyme (lab ferment), does not exist primarily as such but as a rennet zymogen or proenzyme, which itself has no action on milk, but is converted into rennet by the action of any acid, as hydrochloric, or of warm chloride of calcium. This may be shown as follows : If the spontaneous coagu- lating action of gastric juice on milk be destroyed by EXAMINATION OF GASTRIC CONTENTS. 25 1 neutralization by an alkaline carbonate, this property may be restored by digesting with dilute hydrochloric acid or by the addition of a five per cent, solution of calcium chloride. While fasting and at the beginning of digestion, zymogen only is present in the stomach, but later both it and the ferment are found. An acid reaction for the curdling action of rennet is not abso- lutely necessary. Digestion of Starch and Sugar.— It is well known that during digestion starch is converted into grape sugar, and cane sugar is converted into invert sugar — a mixture of cane and grape sugar. This action, commenced in the mouth by the ptyalin of saliva, is continued to a less degree so long as the acidity is slight (.01 per cenl. for HCl, .i or .2 per cent, for lactic, .4 per cent, for butyric) in the stomach, and is finished in the small intestine by the trypsin of the pancreatic juice. As in albumin digestion there are intermediate substances between albumin and peptone, so between starch and grape sugar there are similar intermediate products. The order is as follows : (i) Starch, (2) Dextrins (Erythrodextrin, Achroodex- trin), (3) Maltose, (4) Dextrose = grape sugar. Starch is recognized by the deep blue color struck with iodine or Lugol's solution (iodine i, iodide of potassium 2, distilled water 200), and the reaction grows less vivid as the starch is converted. Of the dextrins, erythrodextrin strikes not a blue but a purple color, while solutions of achroodextrin, maltose, and grape sugar take on only the yellow color of the iodine 2^2 PHYSICAL DLA.GNOSIS. solution. Where a mixture of these substances occurs, the first few drops of the iodine solution produce no color at all, or only a transitor}'^ one, being taken up by the dextrose and maltose, while the addition of more iodine strikes the purple of erythrodextrin or blue of starch. If, therefore, amylaceous transformation has pro- gressed normally in the mouth and stomach, so much starch should be changed into achroodextrin, maltose, or dextrose that the addition of small quantities of Lugol's solution does not strike the characteristic color. If, however, the blue or purple reactions appear, con- version has not been sufficiently rapid into maltose, the principal product of gastric conversion, the change into dextrose being completed in the small intestine. This may be due either to a deficiency of ptyalin or a too rapid production of acid in the stomach. From such event we might also infer a hyperacidity of the gastric juice. To Determine the Rapidity of Absorption from the Stomach. — Penzoldt's method is that gen- erally followed. A capsule containing iodide of potas- sium (.1 gram or gr. iss) is swallowed, being first care- fully wiped to remove any adherent particles. The appearance of the iodide in the saliva indicates that absorption has taken place from the stomach. To determine this, starch paper is first prepared by moistening with starch-paste and drying. Then, after the salt is swallowed, a piece of the paper is moistened every five minutes with the saliva, and the moistened EXAMINATION OF GASTRIC CONTENTS. 253 spot touched with fuming nitric acid. As soon as the iodine appears in the saliva the characteristic blue reaction is struck. When adsorption is normal this reaction tisnally takes place in ten or fifteen minutes, but where absorption is abnormally delayed,. the reaction is also delayed half an hour or more, or it may not occur at all. To Test the Motor Function of the Stomach. — Three methods are practised. First, reixiove the gastric contents six to seven hours after the ingestion of a large meal, or two and a half hours after an Ewald breakfast, and note the amount of solid substance remaining. The stomach should by this time be empty. Second, salol is administered and the product of its lysis sought for in the urine. Third, a definite quantity of ohve oil is introduced into the empty stomach and the remnant unabsorbed is withdrawn at the end of two hours. The second, though not without drawbacks, is preferred. Salol is composed of phenol and saHcylic acid, into which it is broken up by the action of the pancreatic juice, but not by the acid gastric contents. Salicyluric acid, a product of decomposition of salicylic acid, appears in the urine forty to sixty, or at most seventy-five, minutes after taking one gram (15 grs.) of salol when gastric peri- stalsis is normal. Salicyluric acid is readily detected in the urine by the violet color produced on the addition of neutral ferric chloride solution. The method em- ployed is to place a drop of urine on a piece of filter- paper and bring in contact with this a drop of a ten per 254 PHYSICAL DIAGNOSIS. cent, ferric chloride solution. The edge of the drop will strike a violet color in the presence of a mere trace of salicyluric acid. The objection to the salol test is that the decompo- sition of the salol may be delayed by an undue acidity of the gastiic contents discharged into the duodenum. But practically this is found not to be a serious drawback, tolerably constant results being obtained by Ewald and Sievers. To meet this objection, however, Huber sug- gested that the outside limit of excretion of salicyluric acid fails to appear in the urine after the ingestion of a gram (15 grs.) of salol. This sliould be at the end of tiuenty-foiir or thi?-ty hours. If, therefore, it is con- tinued after this, peristalsis must be slow. In Klemperer's oil test too c. c. {2)}'^ ozs.) of olive oil are introduced into the stomach by the stomach tube after the stomach is thoroughly washed out. Two hours later the stomach is aspirated, and if there is motor sufficiency the remnant of oil should be a mini- mum. If any decided quantity remains peristalsis is slow. To Determine the Capacity of the Stomach. — The capacity of the stomach in health is from 1600 to 1700 c. c. (say from 3 to ■^yi pints). Its normal limits and deviations therefrom can usually be deter- mined by percussion. This is rendered easier by distending the stomach with gas or liquid, as by having the patient drink a glass of water just before the exami- nation, or, as oiiginally suggested by Frerichs, by taking in rapid succession the two portions of a Seidlitz THE ROENTGEN RAY IN DIAGNOSIS. 255 powder — tartaric acid and sodium bicarbonate — or a glass of soda water. A better way is to iniiate the stomacli with air, as suggested by Runeberg, by means of the double bulb of a spray appratus. This should be done, if possible, in connection with the use of the tube for some other purpose, as removing the stomach contents after a test-meal. In fact, the simplest way is to fill the stomach with the washing-out fluid and meas- uring the quantity thus used. The air inflation is pre- ferable to gas, because if any excess is introduced it passes oul alongside of the tube, which is not the case with carbonic acid gas, which excites rather a spasmodic contraction of the cardiac orifice. THE ROENTGEN RAY IN DIAGNOSIS. The discovery in 1895 by Prof. Roentgen, of Wurz- burg, of the pecuHar ray to which he gave the name of X-ray, at once gave promise of important possible results in diagnosis. These rays were believed to ema nate from the cathode when induced electric currents were passed through a vacuum-tube (Crooke's tube). Recent studies by Prof. Trowbridge give reason to beheve that such rays emanate from the anode as well, but are less powerful. Their potency is shown in their ability to pass through solid objects. They are not sub- ject to reflection or refraction, and give rise to fluores- cence and phosphoroscence. The latter is, of course, 256 PHYSICAL DIAGNOSIS. best seen in a dark room, while fluorescence ordinarily ceases to exhibit light in the dark. The energy of the X-rays is, however, manifested in its penetrating power, since by their aid we can see through timbers a foot thick and see the beating of the human heart through the flesh. The examination is accomplished as follows, in a dark room : The body is placed between a Crooke's tube and a photographic plate placed in a box, under which circumstances the soft parts appear dark on the negative and the denser parts appear light. The posi- tives made from this exhibit the opposite, the bones being dark and the soft parts light. In lieu of the photographic plate the fluoroscope is used to study the effect of the rays. The advantages of the Roentgen rays have been greatest in connection with surgery, but they may also be applied to medical diagnosis. In the thorax, it is especially in the diagnosis of en- largements of the heart, of pericarditis, and of aneurism of the aorta and calcareous blood-vessels that the appa- ratus is available. Emphysema of the lungs, tumors in their substance, pleuritic effusions, and calcareous plates may also be recognized. A striking demonstration is the motion of the heart and lungs. In abdommal organs this mode of diagnosis has been of most service in recognizing stones in the kidney and ureters, although it has not always been successful. The same is true of biliary and vesical calculi. Not much help has as yet been secured in the diagnosis of diseases of the abdominal organs ; the organs them- THE ROENTGEN RAY IN DIAGNOSIS. 257 selves cannot be differentiated. Those penetrable by metallic sounds, such as the oesophagus and stomach, may be more successfully explored. So, too, foreign Fig. 46.—" Seal Fin " Deflexion of the Hand in a Case of Protracted Arthritis Deformans. From a photograph with the Roentgen ray, showing also erosion and dislocation oi joints. 258 PHYSICAL DIAGNOSIS. bodies accidentally introduced, such as coins, or jack- stones, have been well located. Diseases of the bones and joints have been, after the last-named objects, most satisfactorily investigated. Bony outgrowths can be easily outlined. The appended figure shows fairly well the changes in a case of rheu- matoid arthiitis, which may, by this means, be differen- tiated from those of gout. Caries of the vertebr?e and the changes of rickcfs have been similarly recognized, and it is more than likely, as the subject is further developed, that important aids to diagnosis will be further added. THE MAKING OF AN AUTOPSY.* Previous to section a general survey of the body should be made with a view to noting marks, scars, state of the body as to obesity or emaciation, and degree of rigor iiiorfis, post mortem lividity, and decomposition. A position to the right of the body is usually more convenient for the right-handed examiner, while the left side is more convenient to one who is left-handed. To the ambidexter it is indifferent on which side he stands. * The directions here given are for an autopsy for clinical pur- poses, and not for the medico-legal investigation, which is much more elaborate. The general plan adopted is that laid down by Virchow in his little book on " Post-mortem Examinations," which the writer has followed for many years with great satisfaction, THE IMAKING OF AN AUTOPSY. 259 The appended directions imply that the knife is held in the right hand The first incision is made with a strong, broad hand- led knife by a sweeping traction movement down the median hne from the suprasternal notch to the symphysis pnbis, passing to the left of the mnbilicus. Then the skin and adjacent muscles of the thorax are cut back and the section through the abdominal walls carefully completed, avoiding perforation of the intestines. The muscles are also separated from the edge of the thorax and the abdominal walls laid back, so as to expose as much as possible the abdominal viscera before opening the thorax. This is done in order to preserve the natural relations of the abdominal viscera to each other and to the diaphragm, relations which are altered as soon as the thorax is opened by the removal of the sternum and attached cartilages. An inspection of the abdominal contents is therefore first made, the absence or presence of fluid or abnormality noted, without^ how- ever, as yet removing or making any section of the ograns. Next the cartilages are cut through near their junc- tion with the ribs from the 2d downward; this is often done on each side by one sweep of the knife in the hands of the skilled sectionist, if the subject is not too old. If not complete, the section of the cartilages and muscular interspaces should then be thoroughly com- pleted, by the bone forceps, if necessary. The clavicle and ist rib should be disarticulated from the sternum, bearing in mind that the articulation is an oblique one, and that it can readily be found by grasping the 2 6o PHYSICAL DIAGNOSIS. clavicle and moving it. Or, if it is preferred, the knife may be drawn through the middle of the 2d cartilage, when it will strike the junction between the first and second bones of the sternum, leaving the manubrium, with the articulation of the clavicle and ist rib, intact. This, however, restricts the space over the origin of the great vessels rather inconveniently, and the former method is to be preferred unless the latter is necessi- tated for some special reason. The sternum should be raised, beginning with the tip, and the muscles and other tissues shaved close to its under surface. This act uncovers the mediastinum and opens the two pleural sacs, without, however, incising the pericardium, if the section has been successful. The superfluous integu- ment thus dissected off should be folded over the cut edges of the ribs to protect the hand against these rough edges. The pleural sacs should now be examined by insert- ing the hand between the lungs and the ribs and the diaphragm, with a view of finding adhesions or fluid, and the latter, if present, should be removed and measured. Outgrowths or inequalities of the pleural surfaces, pulmonary, costal, and diaphragmatic, should be looked for. The lungs should, however, be left as yet in situ. The pericardium should then be opened, and the position of the heart obser\-ed. If an abnormal amount of fluid is present in the sac, it should be removed and measured. The external appearance of the heart, its size, shape, and consistence, should be noted ; also the THE MAKING OF AN AUTOPSY. 26 1 state of fulness of the superficial vessels, the amount of superficial fat, adhesions, or other abnormality. The heaj't should then be opened in situ, with the pur- pose of examining the quantity and quality of blood in the separate cavities and the size of the orifices. In thus opening the organ it is held in the left hand with the index finger pressed well under and against the base, so that the ventricles project laterally. It is then rotated to the left until the rigid border comes into view, being easily recognized by the relative thinness of the wall here as compared with that of the left ventricle on the other side of the septum. At the right border, close to the base, the knife is deeply thrust into the right ventricle, and drawn, to the apex. With the heart still thus held, the right aiiricle is incised midway between the entrances of the two vense cavae. The blood is then removed from the right auricle, its quantity and quality observed. The index and middle fingers of the left hand are now passed from the auricle through the tricuspid orifice into the right ventricle. Then the blood is re- moved from the right ventricle. The right auriculo- ventricular orifice in the adult, if normal, should re- ceive three fingers, the index and middle finger of the left hand so far separated that the index finger of the right may be passed up between them from the right ventricle. To make the openings for the left side, the apex of the heart is drawn up to the left, and placed in the left hand in such a way that the fingers encircle it at the base. Pressure is now made so that the wall of the left 262 PHYSICAL DIAGNOSIS. ventricle bulges out a little and separates itself from the septum, when the incision is made behind the base through the middle of the external wall into the left ventricle and out at the apjex. For the left auricle the incision begins at the left superior pulmonary vein, and ends in front of the base usually indicated by the coronary vein, which should not be injured. The blood is now removed from the left cavities, and the size of the auriculo-ventricular orifice determined. Here we have to consider the contraction of the ventri- cle which closes the orifice, and we have to gradually overcome this contraction, when we may introduce the three fingers named with less facility than into the tricuspid orifice, the mitral being 4.5 cm. (1.8 in.) in diameter as against 5 cm. (2 in.) for the tricuspid. The fingers should be very carefully introduced and withdrawn, so that no abnormal vegetations or coagulae are removed, for the valves have not yet been examined. The next step is the removal of the heart. This is done by thrusting the index finger of the left hand into the left ventricle and the thumb into the right through the openings made. The heart is then raised and the vense cavse, the pulmonary artery, aorta, and pulmonary veins severed as far as possible from the heart. The orifices of the aorta and pulmonary artery are then examined with a view to discovering changes in their walls or lumen. The hydrostatic test is then applied for the sufficiency of the aorta and pulmonary valves by pouring water into each vessel while the heart is freely suspended. Previously, however, all coagula should be THE MAKING OF AN AUTOPSY. 263 carefully removed from the orifices and ventricles. The plane of the orifice should also be exactly horizontal, and for this two hands are necessary to accomplish the proper support, and the water must be poured in by a second person. The aorta should also be cut again, short enough to enable one to see from above the state of the valves. Care should be taken to avoid wounding the coronary arteries, for if this accident happens, the water may run off into them and give the impression of insuf- ficiency when it does not exist. There is no hydrostatic or other test available to show the sufficiency of the auriculo-ventricular valves. We are next ready to open the ventricles and explore the interior, including the valves. The heart is placed on a board or table, as nearly as possible in its position in the body. A long pair of scissors is the most satis- factory instrument for this purpose. For the right ven- tricle one blade is introduced at the center of the right ventricular incision previously made and carried well over toward the left side between the left anterior and posterior leaflets of the pulmonary valve, care being taken to pass above the insertion of the anterior papil- lary muscle of the tricuspid valve with its chordae tendinese. To display the left ventricle is more difficult. Intro- duce one blade of the scissors at the apex close to the septum, and while drawing the pulmonary artery to the right, cut close to the ventricular wall until the portion of the left dog's-ear which overlaps the ventricle is reached. If we pass too far to the left we will cut 264 PHYSICAL DIAGNOSIS. through the right border of the base of the mit?-al valve, which corresponds with the right border of the left auricle ; if too far to the right we cross the pulmonary orifice and may cut through the valves of the pulmonary artery. The auricles can be further opened by cutting with the scissors on the right between the openings of the vena cavje, and on the left between those of the pul- monary veins. The adult heart 'weighs in health in the male fifty to sixty years old about 335 grams (xi.8 oz., avoirdupois') ; in the female, 295 grams (10.44 oz.). The average thickness of the wall oi the left ventricle is T.6 to 1.7 cm. (^^ to 2/< in ) ; of the right ventricle .4 to .6 cm. (1/6 to 14^ in.) The lungs are now removed, their surface examined for emphysematous distension or subpleural deposits, and then incised longitudinally with a view to the dis- covery in their interior of tubercular infiltration, cavi- ties, changes in the bronchi, etc. The right lung can always be differentiated from the left by its three lobes. The lungs weigh, in the male, the right, 859.5 grams (30.3 oz.) ; the left, 8ri.6 giams (28.6 oz.) ; in the female, the right, 552 grams (19.48 oz.) ; the left, 296 grams (10.2 oz.). For the examination of the pharynx, larynx, ceospha- gus, and thyroid gland, the central incision should be carried up to an inch below the chin. The first three should be slit up with the enterotome, the last dissected THE MAKING OF AN AUTOPSY. 265 off. The thyroid varies a good deal in weight, usually about 30 grams or i>^ oz. These organs and a portion or all of the tongue can be removed by dissecting up under the skin and then making a transverse cut, thns obviating opening the skin on the neck. The abdominal organs are now examined in the fol- lowing order : 1. The omentum. 2. The spleen, which is longitudinally incised. The organ in health weighs about 176 grams (6.23 oz.). 3. The left and right kidney, with their suprarenal capsules and ureters ; the kidney being stripped of its capsule and longitudinally incised. The adult kidney weight, in the male, 113.5 to 170 grams (4 to 6 oz.) ; in the female a little less, 113.5 to 156 grams (4 to 5}^ oz.). The suprarenal capsules, 4 grams to 8 grams (60 to 120 grains). 4. The bladder, prostate gland, vesiculse seminales, urethra. The prostate weighs in health about 3 1 grams (i^oz.). 5. Testicles, spermatic cord, and penis. The testis with the epididymis weighs about 24.5 grams (J^ to ^ oz.). 6. Vagina, uterus. Fallopian tubes, ovaries, parame- tria. The weight of the uterus differs greatly at different ages. Thus, according to Robert Boyd's table, in 11 girls from fourteen to twenty, the minimum weight was 17.01 grams, the maximum 70.87 grams, average 29.48 grams (1.04 oz.) ; in 47 women between twenty and thirty, the minimum was 21.26 grams, the maximum 2 66 PHYSICAL DIAGNOSIS. 120.48 grams, average 49.04 grams (1.73 oz. ) ; in. 79 women between thirty and forty, the minimum was 14.17 grams, the maximum 127.57 grams, average 56.13 grams (1.98 oz.) ; of the ovaries 3.9 to 6.5 grams (60 to 100 grains) . 7. The rectum. 8. The duodenum., portio intestinalis of the ductus communis choledochus. 9. Stomach. Capacity i to 1.5 h"tres (2 to 3 pints). 10. Hepato-duodenal ligament, gall-ducts, venae portae, gall-bladder, liver. The stomach and duodenum, under ordinary circum- stances, should be examined /;/ situ. The duodenum should be opened first, its contents examined above and below the biliary papilla. The latter should be ex- amined, its contents expressed, and its patulousness determined by pressing gently on the gall-bladder. Finally, the common bile duct should be slit up. The vena cava should be examined, and not until then should the liver be removed and examined. Sections should be made through the organ horizontally, from right to left, to displa} its interior. The gall-duct should not be probed, as a duct essentially closed may thus be opened. The //?'