#f;v ' ^ 1 > I \ ;^^^v:^n. i^-:.>N (Enlumbta Hmu^mtg in tl\t (Uttg nf Nrm fork .^.rs.....C..B...G|»i7>tKaY:.. MEDICAL DIAGNOSIS A MANUAL OF CLINICAL METHODS BY J. GRAHAM BEOWN, M.D. FELLOW OP THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH ; LATE SENIOR PRESIDENT OF THE ROYAL MEDICAL SOCIETY OF EDINBURGH SECOND EDITION, ILLUSIBATED "Felix, qui potuit rerum cognoscere caiasas."— Vibg., Georg. U. 490 BERMINGHAM & COMPANY 28 Union Square, East New York 20 King William St. , Strand London 1884 PREFACE. It is a creditable characteristic of the treatment of dis- ease in the present day that it seeks to proceed on rational principles. Some there may still be who think it enough to give a name to a collective group of symptoms, and treat the disease as they have Ijeen told an affection bear- ing that name should be treated. There may be others who seize upon a few prominent symptoms, and direct their remedies exclusively to these. But every day is, happily, reducing the number of these routine practitioners, and teaching that the true physician is he who seeks thor- oughly to investigate the phenomena of the disease, that in this way he may the better arrive at a knowledge of that from which they proceed, and to which, therefore, his treat- ment should be directed. But this can only be arrived at by a thorough knowledge of every change which disease produces in the body, and by a clear conception of what that change imports. This constitutes the science of Diag- nosis, and, without accurate diagnosis, there can be no ra- tional treatment. The signs and symptoms of disease are changes produced in the animal economy, which are cognoscible by our senses — some by one, others by another ; while to assist these senses we call in the aid of instruments which extend their range or increase their power, and of the various ana- lytical processes which the science of Chemistry places at our disposal. In the following pages an attempt has been made to de- scribe these signs and symptoms of disease, and to show what is their value from a diagnostic point of view. If this attempt be at all successful, it may enable the student of disease to save much valuable time, by assisting him in analyzing and weighing the evidences of disease, and ex- tracting from the whole phenomena which are presented to 4 PREFACE. him those which are of value as indicating its nature. The attempt is made not with a view of checking but rather of encouraging minute inquiry, while it aims at giving to the result of that inquiry more definite form. A man who has clearly grasped a case in its entirety, who has separated the essential from the accidental, and who has ascertained the weight and bearing of each indi- vidual symptom, can go steadily forward in the treatment of his case without experiencing that harassing doubt which arises from partial or crude observation, and which, to a conscientious mind, cannot but prove a severe trial. I desire to express my thanks to my friends who have encouraged and aided me in carrying out my design; among others, to Professor Grainger Stewart, from whom I have uniformly received much kind sympathy and advice. To Professor C. S. Roy I am indebted not only for the heart and pulse tracings with which I have illustrated Chapter XIII., but for very valuable assistance which I have received at his hands. Dr. Alexander R. Coldstream, of Edinburgh, has materially assisted me in the correction of the proof- sheets. J. G. B. 63 Castle Street, Edinburgh, 15^^ September, 1882. TABLE OF CONTENTS. FAGS Introduction 13 Chap. i. The General Aspect, Condition, and Circum- stances of a Patient 15 Family History 16 Habits and General Surroundings 16 Previous General Health 16 Origin and Course of Illness 16 Present Condition of the Patient 17 Height and Weight 17 Development and Muscularity 17 Changes in the Color of the Skin 18 Pallor 18 Redness l8 Cyanosis 18 Jaundice 18 Bronzing 19 Grayness 20 CEdema of the Skin 20 Emphysema of the Skin 20 Perspiration 20 Expression of the Face 21 Temperament, Constitution, or Diathesis. . . 21 Sanguine Constitution 22 Nervous " 22 Strumous ** 22 Lymphatic " 22 Bilious " 22 Gouty " 22 Rheumatic " 22 Attitude of the Patient • . . 23 Evidence of Previous Disease 23 Temperature 23 Chap, ii. Alimentary System 25 Condition of the Lips 26 Color 26 Form 26 6 TABLE OF CONTENTS. Chap. ii. — Continued. page Movements 27 Condition of the Teeth 28 Condition of the Gums and Mucous Mem- brane of the Cheeks 28 Condition of the Tongue 28 Form of the Tongue 28 Movements 29 Surface 29 Fur on the Tongue 30 Saliva 31 Fauces 32 Mastication 33 Deglutition 34 Examination of the CEsophagus 34 Appetite 36 Thirst 36 Sensations during fasting 36 Sensations after eating 36 Acidity 37 Flatulence 38 Nausea and Vomiting 38 Examination of vomited Matter 39 Defaecation 1. 40 Character of the Faeces 41 Chap. hi. Examination of the Abdomen 42 Inspection of the Abdomen 42 General Prominence 43 Retraction 44 Local Tumefaction 44 Abdominal Movements 45 Chap. IV. Palpation of the Abdomen 46 Condition of the Abdominal Walls 47 Condition of the Peritoneal Cavity 47 Condition of the Liver. . *. 48 Surface 48 Tenderness 48 Consistence 48 Size 49 Shape 49 Condition of the Spleen 49 " " Pancreas 50 " " Stomach and Intestines... . 50 " " Mesenteric Glands 51 ** " Kidneys 52 " " Urinary Bladder 52 " " Abdominal Aorta 52 Chap. v. Percussion of the Abdomen 53 Peritoneal Cavity 53 Liver 54 Spleen 57 Kidneys.. 58 Stomach 59 Auscultation of the Abdominal Organs 60 TABLE OF CONTEN rs. 7 PACK Chap. vi. Haemopoietic System 60 Lymphatic Vessels 61 Inflammation 61 Narrowing and Dilatation 61 Rupture 62 Lymphatic Glands 62 Ductless Glands 63 Examination of the Blood 64 Microscopic Examination 64 Enumeration of the Blood-corpuscles 66 Estimation of Haemoglobin 68 Chap. vh. Circulatory System 69 Subjective Phenomena 69 Pain 70 Palpitation 70 Fainting 70 Chap. viii. Inspection 71 Cardiac Impulse 71 Pulsation at the root of the Neck 72 Epigastric Pulsation 74 Arterial Pulsation on Thoracic Wall 75 Chap. ix. Palpation 76 Cardiac Impulse 76 Alterations in Position 76 " Strength 77 •' Extent 78 Double Apex-beat 78 Endocardial Thrills 78 Pericardial Friction 79 Chap. x. Percussion 79 Position of the Heart 79 Absolute Cardiac Dulness 81 Relative Cardiac Dulness 81 Aortic Dulness 81 Chap. xi. Auscultation 83 Heart Sounds in Health 84 Areas for Auscultation 84 Modifications of the Normal Sounds of the Heart 85 Variations in Intensity 85 Impurity of the Sounds 86 Reduplication of the Sounds 86 Murmurs 87 Endocardial Murmurs 87 Method of production of Murmurs. 88 Rhythm 89 Intensity and Propagation 89 Condition of the Normal Sound at the Orifice at which the Mur- mur originates 90 Mitral Murmurs 9^ Tricuspid Murmurs 92 Aortic Murmurs. 93 8 TABLE OF CONTENTS. Chap. XI. — Continued. page Pulmonary Murmurs 93 Murmurs of Non- Valvular Origin., 94 Exocardial Murmurs 94 Pericardial Friction 94 Chap. XII. Examination of the Arteries 95 Inspection 95 Palpation 95 Radial Pulse 95 Frequency 95 Rhythm 96 Character 97 Expansion 97 Tension 97 Volume 98 Percussion 98 Auscultation 98 In Health 98 In Disease 99 Cephalic Murmurs 99 Examination of the Capillaries 100 Examination of the Veins 100 Inspection loo Auscultation lOO Bruit de Diable loi Graphic Clinical Methods 103 Sphygmograph 104 Typical Healthy Curve 114 Anacrotic Pulse Curve 114 Dicrotic Pulse Curve 114 Hyperdicrotic Pulse Curve 115 Cardiograph 115 Sphygmomanometer 117 Note on the Measurement of Tracings.. 117 Chap. XIII. Respiratory System 119 Subjective Phenomena 119 Cough 120 Sputa 121 Chemical Characters 122 Macroscopic Characters 122 Physical Characters 123 Microscopic Characters 124 Chap. XIV. Examination of Nares 128 Examination of the Larynx 129 Voice 129 Palpation of the Larynx 130 Laryngoscopic Examination 130 Chap. XV. Inspection of the Thorax I35 Regions of the Thorax 135 Form of the Thorax 136 Respiratory Movements 138 Frequency 139 Rhythm I39 Cheyne-Stokes Respiration, . ...... 139 TABLE OF CONTENTS. 9 Chap. XV. — Continued. pack Type 140 Pain and Difficulty in Breathing 140 Dyspnoea 140 Extent of Respiratory Movements 141 Chap. xvi. Palpation of the Thorax 141 Vocal Fremitus 142 Pleural, Bronchial, and Cavernous Thrills. . 143 Fluctuation 143 Chap. xvii. Mensuration 143 Tape Measure 143 Callipers 144 Cyrtometer 144 Thoracometer 145 Stethograph 145 Spirometer 145 Pneumatometer 145 Theory of Percussion 146 Chap, xviii. Percussion of the Chest 147 Methods of Percussion 152 Percussion Note of the Chest 152 The Intensity of the Percussion Sound 153 The Pitch of the Percussion Sound. ... ... 155 The Tympanitic Percussion Note 156 Cracked-Pot Sound 159 Amphoric Resonance 160 The Feeling of Resistance during Percussion 160 Topographical Percussion 161 Regional Percussion 162 Chap. XIX. Auscultation of the Lungs 163 Vesicular Breathing 164 Harsh Breathing , 165 Jerky Breathing 165 Vesicular Breathing with Prolonged Ex- piration 165 Systolic Vesicular Breathing 166 Bronchial Breathing 166 Amphoric Breathing 168 Broncho-Vesicular Breathing 169 Chap. XX. Adventitious Sounds accompanying Respira- tion 170 Moist Rales 170 Crepitant Rale 170 Fine and Course Bubbling Rales.. . 171 Dry Rales 173 Sonorous and Sibilant Rales 173 Pleuritic Friction 173 Auscultation of the Voice (Vocal Fremitus). 174 Succussion 176 Chap. xxi. Integumentary System 176 Subjective Symptoms I77 Eruptions 177 Distribution and Configuration 178 Elements of Skin Involved 17^ lO TABLE OF CONTENTS. Chap. xxi. — Continued. page Type of the Eruption 178 Etiology of the Eruption 181 Vegetable Parasites 182 Achorion Schonleinii 182 Trichophyton 183 Microsporon Furfur 185 Animal Parasites 186 Sarcoptes Scabiei 186 Pediculus 187 Pulex Irritans 187 Demodex Folliculorum 187 Chap. XXII. Urinary System 188 Subjective Symptoms 188 Examination of the Urine 189 Quantity 189 Color 190 Transparency 192 Odor 192 • Specific Gravity 192 ■' Reaction 194 Chap. XXIII. — — Normal Constituents of Urine 195 Urea 195 Estimation by means of Nitrate of Mer- cury 196 Estimation by means of Hypobromite of Soda 197 Uric Acid 199 Creatinin 200 Indican 201 Cholorides 202 Sulphates 203 Phosphates 204 Chap. XXIV. Abnormal Constituents of Urine 206 Albumen 206 Paraglobulin 209 Propeton 209 Fibrin 210 Pepton 211 Mucus 212 Sugar 212 Blood 217 Bile Pigment 218 Bile Acids 218 Chap. XXV. Urinary Sediments , 219 Blood Corpuscles 219 Pus Corpuscles 219 Epithelium > 220 Renal Tube-casts 220 Spermatozoa 221 Micro-Organisms 221 Inorganic Sediments of Acid Urine 225 Alkaline Urine 225 Chap. xxvi. Reproductive System 226 TABLE OF CONTENTS. II PAGE Chap. XXVI. — Cofttinued. The Female Reproductive Organs and Functions 226 Menstruation 227 Amenorrhoea 227 Menorrhagia 227 Dysmenorrhoea 228 Leucorrhoea 228 Pareunia 228 Pregnancy 228 Physical Examination of Female Organs. . . 228 Mammae 228 Abdomen 229 External Pudenation 230 Vaginal Examination 232 Bimanual Examination 232 Speculum 233 Uterine Sound 233 Instruments for dilating the Cervix 233 Chap, xxvii. Nervous System 233 Sensory Functions 234 Subjective Sensations 234 Pain 234 Paraesthesia 235 Giddiness 235 Abnormal Visceral Sensations 236 Cutaneous Sensibility , 236 Common Sensibility 236 Tactile Sensibility 236 Sense of Pressure 237 Sense of Temperature 237 ^ Sense of Locality 237 Muscular Sense 238 Special Senses 238 Sight 238 Diminution of Visual Acuteness... 239 Alterations of Visual Field 239 Alterations in the Perception of Colors 240 Movements of the Eyeball 240 Paralysis of Ocular Nerves. . . . 240 Spasm of Ocular Nerves 241 Changes in the Pupil 242 Ophthalmoscopic Examination 243 Hearing 244 Taste 245 Smell 246 Chap, xxviii. Motor Functions 247 Visceral Motor Functions 248 Voluntary Motor Functions 248 Voluntary Movements 248 Paralysis 248 Electrical Reactions 249 Spasm 250 Reflex Movements 251 12 TABLE OF CONTENTS. Chap, xxviii. — Continued. p^gg Superficial Reflexes 252 Deep Reflexes 252 Affections of Co-ordination 253 Labyrintliine Vertigo 253 Ataxia 253 Cerebellar Inco-ordination 254 Vaso-motor Functions , 254 Cutaneous Vaso-motor Affections 254 Visceral Vaso-motor Affections 255 Chap. XXIX. Trophic Functions 255 Trophic Affections of Muscles 255 " " Bones and Joints..' 255 Skin 256 ** " Secretory Glands., 256 " " Viscera 256 Chap. XXX. Cerebral and Mental Functions 256 Coma 257 Illusions 257 Hallucinations 257 Delusions 257 Delirium 257 Speech 258 Sleep 259 Chap. xxxi. Condition of Cranium and Spine 260 Chap, xxxii. Locomotory System 260 Condition of Bones 261 Condition of Joints 261 Condition of Muscles 261 Rigidity 261 Contracture 261 Flaccidity ?. ... 261 Fibrillary Twitching 261 Appendix A. — On the Examination of the Faeces 262 Appendix B. — Method of Preparing the Solution of Nitrate of Mercury used for estimating Urea 263 Index 265 MEDICAL DIAGNOSIS. INTRODUCTION. A PHYSICIAN, when consulted by a patient, is naturally enough expected to be an attentive listener to what, to his informed mind, is a strange medley and most confused ac- count of those deviations from health or actual sufferings by which the patient has been driven to seek aid. The more serious symptoms are often lightly touched upon, the more trivial exaggerated, and the whole jumbled to- gether without logical sequence or the slightest attempt at orderly arrangement. This story, trying as it is to the phy- sician, and all the more trying the more his own mind is duly trained, he ought to listen to; for this the patient ex- pects, and perhaps has a right to expect. During the te- dious narration it may give him patience to bear in mind two considerations: first, that from it he must obtain the right end of the clue which is to guide him in the difficult task of ascertaining the nature, extent, and seat of the dis- ease; and second, that by this often most prolix narrative, taken along with his attitude, manner, and expression, the patient, absorbed in his own sufferings, is giving his phy- sician, if he is careful and observant, the best opportunity of becoming acquainted with the ego with whom he has to deal. The most critical examination of symptoms, the most careful inquiry into the state of internal organs, the most logical deductions from these as to the morbid changes from which they have originated, will often be erroneous unless the physician is also a student of human nature, and is able to arrive almost intuitively at some knowledge of the men- tal characteristics and peculiarities of his patient. But sooner or later, and more often later than sooner, 14 INTRODUCTION. the patient will have arrived at the end of his narration, and then the physician must unravel for himself this tan- gled web; and, taking the different threads, he must follow them up, and by means of close physical examination as- certain the condition of the various organs of the body — particularly those which the train of symptoms detailed in- dicate to be implicated in the morbid process. It is only by a methodical examination of the different systems of the body that a satisfactory view of the condition of the patient can be obtained, and the very foundation of rational treat- ment laid. In the following pages an attempt will be made to explain the meaning and diagnostic significance of the chief symp- toms and physical signs which are met with in disease. These group themselves naturally round the different phy- siological systems of the body — Alimentary, Absorbent and Hsemopoietic, Circulatory, Respiratory, Integumentary, Urinary, Reproductive, Nervous, Locomotory; and under these headings they will be considered.* This is not, of course, to be looked upon as a rigidly accurate division, but for practical purposes it suffices, and it has this great advantage — viz., that those who are habituated to follow such an arrangement in the examination of patients are less apt to neglect minute points which might otherwise escape the memory. Nor is it to be supposed that every patient requires to be subjected to so exhaustive a catechizing as this arrangement, if fully carried out, would necessitate. Many trivial complaints call for no such exercise of patience either on the part of the physician or on that of his patient, and in severe or urgent cases the first examination must necessarily be at best rapid and limited. Nor even where close inquiry is desirable is it necessary to follow accurately the sequence here given; and to some it may seem more suitable to clear up, first of all, the details regarding that system which seems most profoundly implicated, and only thereafter, and more cursorily, to examine into the condi- tion of the others. It must be carefully borne in mind that in examining a * We follow in this respect the order of case-reporting which obtains in the wards under the care of the Professors of Clinical Medicine in the University of Edinburgh; and with this arrangement the author has long been familiar, as it closely corresponds to that which had been drawn up by Professor Grainger Stewart, and which was in use at the time the author was his Resident Physician in the Royal Infirmary. CONDITION AND CIRCUMSTANCES OF A PATIENT. 1 5 pati&nt we are dealing with a fellow-creature, and that all our inquiries and all our investigations must be conducted with the utmost courtesy, kindness, and patience. In the following pages attention will first be directed to certain preliminary inquiries which should be made, and then to the various systems, in the order already mentioned. CHAPTER I. The General Aspect, Condition, and Circumstances OF A Patient. Preliminary Inquiries — Family History — Habits and General Sur- roundings at Home and at Work — Previous General Health — Origin and Course of Present Illness. Present Condition — Height and Weight — Development and Muscularity — Color of the Skin — Cutaneous (Edema and Emphysema — Perspiration — Expression of Face — Tem- perament — Attitude — Obvious Evidence of Previous Disease or In- jury — Temperature. Before entering upon the more minute examination of a patient, there are several more general and preliminary inquiries which should be made, and it is needless to say that the care and extent of the investigation required must depend on two factors: first, on its necessity, in view of the special disease present; and second, on the mental and bodily condition of the patient. After noting the patient's name, age, occupation, resi- dence, etc., it is well to record in as brief words as possible, and in his own language, his chief complaint. This is not to be in any sense a statement of diagnosis, but simply the patient's own impression concerning his case. Both in cases of phthisis and bronchitis, for example, we might be told that the patient sought advice on account of severe cough, and of this symptom we would make note as the most prominent in his own mind. We further ascertain, as closely as we can, the duration of the present illness, and record it briefly — so many days, months, etc., as the case may be. Having thus formed in our minds a general idea, however ill-defined, of the case before us, we proceed to consider the l6 MEDICAL DIAGNOSIS. , Family History. — Inquiry into the general health of the patient's family should be specially directed to ascertain whether any of his near relatives have suffered from those forms of disease which are usually supposed to be heredi- tary, such as consumption, scrofula, syphilis, rheumatism, gout, heart disease, and various nervous disorders. Such inquiry must not limit itself to the near relatives, father, mother, brothers, and sisters, but ought to extend to the aunts, uncles, and grandparents. Habits and General Surroundings at Home and at Work. — Luxurious habits, " fast" living, and excesses of all kinds, are frequently the cause of disease, and any evidence of these must be sought for, and among them excessive alco- holic indulgence stands out prominently. To insufficient or unwholesome diet many ailments may be traced, as well as to long hours of work, and to the bad ventilation or de- fective drainage of the apartments used. It is also well known that certain occupations have a special tendency to produce disease, among which may be mentioned the pul- monary affections met with in miners, stone-masons, and cutlers, the anthrax which attacks wool-sorters, and the plumbism from which painters suffer. We next proceed to inquire, with some minuteness, into the Previous General Health. — Ascertaining the usual state of health, the date and nature of former ailments, liability to particular morbid conditions, present or previous residences, or other circumstances which may have influenced its pro- duction or development, exposure to contagion, etc.; and, if the patient be a female, it may be advisable to inquire into the condition of the reproductive functions. Origin and Course of the Present Illness. — It is impossi- ble here to do more than indicate certain general lines on which it is usual to proceed. Having already fixed the date of commencement of the illness, we would next en- deavor to gain some accurate idea of the manner in which it commenced; with what symptoms; whether it came on suddenly or gradually; to what cause the patient traces his loss of health; and, if his statement does not appear proba- ble to us, we must strive, by careful, guarded, and unob- trusive cross-examination, to satisfy ourselves on these points. Knowing the usual etiology of such a case as the CONDITION AND CIRCUMSTANCES OF A PATIENT. 1/ one we are studying, we possess a guide as to the direction in which our inquiries should be made. The sequence of symptoms may now be ascertained, the date of origin of each, and its severity; and, finally, we note to what medical treatment the patient has been subjected, and what was its result in his case. PRESENT CONDITION. Before proceeding to the examination of each system of the body; it is advisable first to note certain General Facts. 1. Height and Weight. — In almost all diseases the weight becomes diminished, and in the course of treatment the patient should, when it is practicable, be weighed at regu- lar intervals, when a very valuable indication of the progress of the malady will be in our hands. When, however, we have only the result of one weighing, it is of consequence to know what a man of a given height ought to weigh when in health. For this purpose, Mr. Hutchison has compiled a table (deduced from the examination of 3,000 persons), from which the following figures are taken: o in. ought to weigh about 92.26 lbs. 115.52 " 127.86 " 139.17 " 144.29 " 157.76 " 170.86 " 177.25 " 218.66 " 2. Development and Muscularity. — To be typical of per- fect health, the various parts of the body must be accu- rately proportioned one to another. A moderate amount of adiposity is quite consistent with health, provided that the muscular system is correspondingly developed. Gene- rally, as age advances, the tendency to the deposit of fat increases, and this must be borne in mind. At the same time, its rapid accumulation, after fifty years of age, is not a symptom of health. Spare people are often the longest livers. The presence of certain obvious morbid conditions may be noted at this stage. A man of 4 ft. 6 in. to 5 ft. 5 ' 5 I 5 2 ' 5 3 5 4 ' 5 5 5 6 ' 5 7 5 8 ' 5 9 5 10 ' 5 II 5 II ' 6 6 , • • • . ^ 1 8 MEDICAL DIAGNOSIS. 3. Changes in the Color of the Skin. (a.) Palloj' is due to defective filling of the capillaries, to deficiency in the quantity of the blood, or of the haemoglo- bin it contains. Pallor, consequently, may arise from any condition which prevents the proper assimilation of the food (dyspepsia, etc.) ; from any interference with the forma- tion of the blood (chlorosis, anaemia, etc.); from any dis- ease leading to loss of blood (hemorrhage), or its nutritive materials (Bright's disease), or, finally, from any affection of the vascular system interfering with the proper propul- sion of the blood (mental emotions, fatty heart, mitral dis- ease, etc.). Pallor occurs in connection with all grave or- ganic diseases, such as cancer and tuberculosis. The pale- ness of the skin can best be appreciated, if it is slight, on the ears, cheeks, eyelids, or lips. {b?) Redness of skin beyond the natural tint first, and prin- cipally, shows itself at those points which have just been mentioned in connection with pallor; but it must be borne in mind that those persons who are, by reason of their occu- pation exposed to heat, or to the weather, are usually ruddy in complexion. Apart, however, from these causes, redness occurs either as a result of increase of the amount of blood in the body, or of its haemoglobin (as is seen in "full-blooded " plethoric persons), or is due to dilatation of the capillaries. The latter cause accounts for the blushing caused by men- tal emotion, as well as that following the inhalation of ni- trite of amyl; and in a similar way may be explained the redness of the scalp and face in hemicrania, and the gene- ral redness of inflammation, and of fever. (., in two squares (counting ten or twenty squares, and taking the mean), ex- presses the percentage proportion of the corpuscles to that of health. The number of white corpuscles in ten or twenty squares is easily counted, and the proportion of white to red ascertained. The normal maximum of white per two squares (haemic unit) is .3. In all conditions of anaemia and cachexia the number of red corpuscles undergoes diminution, and by examining their number from time to time we can obtain most valu- able and trustworthy indications regarding the progress of the malady and the effect of our treatment. 3. Estimation of Haemoglobin. — Various instruments have been devised for this purpose by Malassez and others. That of Dr. Gowers,f which I prefer both on account of its simplicity and the accuracy of the results which it gives, consists of two glass tubes of the same diameter, one of which contains a standard color-solution \ (glycerine care- fully tinted by means of carmine and picrocarminate of ammonia), while the other, in which the blood to be tested is to 'be diluted, is graduated so that 100 degrees = two cubic centimetres. There is also a capillary pipette gradu- ated to hold twenty cubic millimetres, a bottle with a pipette- stopper to contain distilled water, and a guarded needle to prick the finger. * Probably it would conduce to greater accuracy if the mixture of blood and solution were accomplished by means of Potain's " Malan- geur," and if a special cover-glass ground absolutely level were supplied along with this apparatus; and, further, if this cover-glass were fixed in such a manner to the slip that it might be steadily lowered on to the drop by means of a rack movement. All of these arrangements have been adopted by Malassez in the newest model of his instrument. f Described in full by Dr. Gowers in the Transactions of the Clinical Society of London\ vol. xii., 1879, X The tint of this standard solution corresponds exactly to that of a dilution of twenty cubic millimetres of blood with 1980 cubic millimetres of distilled water, i.e.^ a dilution of one in a hundred. CIRCULATORY SYSTEM. 69 The method of using this instrument is as follows. The two tubes having been placed upright in the small wooden stand supplied for the purpose, a. few drops of distilled water are placed in the bottom of the graduated tube. The blood having been obtained from a prick in the manner already described, twenty cubic millimetres of the blood are measured off by means of the pipette, and injected into the distilled water in the graduated tube, which must then be quickly shaken to ensure thorough mixture. More dis- tilled water must now be added drop by drop until the tint of the diluted blood is the same as that of the standard. The degree of dilution as indicated by the graduation ex- presses the amount of haemoglobin as compared with that of the standard, and as this is a dilution of one hundred, the degrees of dilution required to obtain the same tint represent the percentage proportion of the haemoglobin to that of normal blood.* If the corpuscular richness of the blood is ascertained by means of the hsemacytometer, we are able to compare this with the amount of haemoglobin in a very instructive man- ner. Thus, a fraction, of which the numerator is the per- centage of haemoglobin, and the denominator the percen- tage of corpuscles, will express the average value of each corpuscle. CHAPTER VII. Circulatory System, subjective phenomena. Before addressing ourselves to the physical examination of the heart, there meet us for consideration certain symp- toms of a more or less subjective kind. I. Pain. — In anaemic persons, and particularly in women suffering from uterine disease, from chlorosis, or from ner- vous affections, pain over the region of the heart is fre- * Thus if the tints are identical when the dilution has reached 80 de- grees, the blood contains only 80 per cent of the normal quantity of hsemoglobin. 70 MEDICAL DIAGNOSIS. quently complained of, and true cardiac pain may likewise be simulated by neuralgia in the chest wall. In heart dis- ease of any kind, and particularly in fatty degeneration as- sociated with gout, pain may be a more or less prominent symptom. In its most pronounced form — angina pectoris — it comes on in recurring attacks of short duration, but of extreme severity. The first of the attacks usually occurs when the patient is making some exertion. The chest feels as if held in a vice, the pain, which is always severe, and which may be of the most intense character, radiates from the heart to the shoulders, and down the left arm, or down both arms to the wrist, breathing almost ceases, the coun- tenance sometimes becomes livid, and consciousness may be lost. In other cases the attacks may be very frequent, several in a day, or even one after the slightest exertion of body or of mind. The attack passes off as rapidly as it came on, and the patient may be free from its repetition for months or years. The pain of aortic aneurism is more lancinating and more continuous than angina pectoris." 2. Palpitation. — The abnormal perception of excited pul- sation in the heart or aorta is very frequently due to men- tal excitement, to dyspepsia, flatulence, anaemia, or nervous debility, and is also met with in cases of exophthalmic goitre. It also occurs as a result of organic disease of the heart, and in such cases it will be found to be aggravated by exertion. Derangements of rhythm will be noticed hereafter. 3. Fainting {syncope)^ which is primarily due to failure of the heart's action, is usually ushered in by a train of symptoms of which the chief are — pallor of the face, chilli- ness, cold perspirations, a feeling of weakness, of sinking in the epigastrium, and of sickness, pulse small and rapid, or slow and irregular, dimness of vision, ringing in the ears, and gradually increasing unconsciousness. Syncope may be due to organic disease of the heart, to nervous dis- turbance of the cardiac action (central or reflex), to intense mental emotion (hysteria), to deficiency of the blood sup- ply to the heart muscle, or to want of blood in its cavities. CIRCULATORY SYSTEM. 7 1 CHAPTER VIII. Circulatory System — (contmued). INSPECTION. The cardiac or precordial region corresponds to the lower part of the anterior mediastinum. It may be said to extend vertically from the second interspace to the sixth cartilage, and transversely from the apex-beat to a point about three- quarters of an inch to the right of the sternum. The region so marked out overlies the heart, and the margins of both lungs which overlap it. More deeply still lie the organs contained in the posterior mediastinum. In this chapter will be considered (i) the form and ap- pearance of the praecordia; and (2) the various pulsatory movements which show themselves on the walls of the thorax. Prcecordia. — A slight degree of bulging of the thoracic wall in the cardiac region is more readily detected by sim- ple inspection than by means of measurement. It may be the result of curvature of the spinal column anteriorly and to the left, but is more commonly caused by cardiac hyper- trophy, pericardial effusion, aneurismal and other tumors adjacent to the heart, or circumscribed pleuritic effusions. When effusion takes place into the pericardial sac, the inter- costal spaces widen, they become raised to the level of the ribs, and ultimately may even protrude beyond them. Depression of the praecordial region, on the other hand, may take place during the absorption of a pericardial ef- fusion, and may remain permanently if adheston has taken place between the visceral and parietal layers of the peri- cardial sac. Bulgings caused by aneurisms lie almost without excep- tion above the fourth rib. Pulsations. I. The Cardiac Impulse. — In health the apex-beat is found in the fifth interspace, about two inches from the left mar- gin of the sternum, and its area does not exceed a square inch in extent. In childhood, however, and in persons who have a short and wide thorax, it may stand as high as the fourth interspace, and may be thrown somewhat farther to 72 MEDICAL DIAGNOSIS. the left; whilst in old age, and in persons whose thorax is very long and narrow, the cardiac impulse is depressed to the sixth interspace. While natural breathing does not affect its position, deep inspiration and expiration cause respectively depression and elevation of the apex-beat. When the patient lies on either side, the apex-beat is deflected in a corresponding direction. This alteration is more marked towards the left. [Pathological changes in the position of the apex-beat will be considered under the head of Palpation.] Systolic Indrawing of the thoracic wall is of two varieties. (i) A recession, which is exactly synchronous with each ventricular systole; and (2) an indrawing, which immedi- ately succeeds the retirement of the apex of the heart from the chest wall. The former variety (which is of little practical impor- tance) is sometimes met with in healthy persons (particularly children), in whom the chest walls are unusually thin. It occurs in the third and fourth interspaces, and is simply the result of that recession of the base of the heart which is synchronous with the forward movement of the ventricles. The chest walls are sucked inwards (or rather forced in- wards by atmospheric pressure) to prevent the formation of a vacuum behind them which would otherwise take place. The second form is seen at the apex, aud is, according to Skoda, pathognomonic of adherent pericardium.* If the adhesion be extensive, not merely the intercostal space but even the ribs may be drawn inwards, following the apex of the heart, 2. Pulsation at the Root of the Neck may be arterial or venous. Pulsation in the carotid arteries becomes evident when- ever the heart's action is increased in strength (as after great bodily exertion, or from mental excitement), but in its most pronounced form such pulsation is seen in cases of hypertrophy of the left ventricle, along with aortic incom- petence. Pulsation in the jugular fossa when well marked * This sign is not, however, invariably present in such cases, and though adherent pericardium is by far its most common cause, yet it may occur in cases in which the normal movements of the heart are otherwise hindered (Friedreich). CIRCULATORY SYSTEM. 73 usually points to simple or aneurismal dilatation of the aorta. Swelling of the jugular veins is found in cases in which there is some obstruction to the return of blood to the heart, whether that obstacle be situated in the systemic or pulmonary circulation. If from any cause the right ven- tricle be unable to empty itself completely of blood, it be- comes gorged, and, reacting on the right auricle, causes its dilatation; while the auricle so dilated in its turn retards the flow of blood through the jugular veins, which then exhibit distension. The same effect will, of course, be pro- duced by any obstruction to the return of blood to the heart, whether seated in the lungs themselves, or in the mitral orifice, or the valves which close it. This distension is necessarily accompanied with more or less of a pulsatory movement in the vein, the blood being only able to reach the heart during inspiration. This, how- ever, is not the only pulsatory movement which the veins in this region exhibit when they are in a state of distension. The systole of the right ventricle causes a vibration which passes through the tightly-stretched right auriculo-ventricu- lar valve, and the thrill thus communicated to the blood in the dilated auricle is thence transmitted to the jugular veins. In this case the tricuspid valve and the valves at the mouth of the jugular veins are competent, and there is, therefore, no backward flow of blood into auricle or vein; it is simply the impulse which is transmitted. This we can readily satisfy ourselves of by compressing the right jugu- lar vein high up in the neck, and then if the contents of the lower part of the vessel be pressed out, the vein will not fill again from below, since no valvular incompetency exists. When, however, the tricuspid valve is incompetent, or when the valves in the jugular vein cease to close the lumen of that vessel (either from destruction of its valves, or from extreme dilatation of the vein preventing the valves from doing their duty), the vein when so emptied will be seen to fill from below with regular pulsations corresponding to those of the right ventricle. Thus is formed the ''venous pulse," one of the most im- portant signs of tricuspid incompetence. Jugular pulsation may occasionally be praesystolic in rhythm, the movement resulting from the transmission of the impulse of the auricular systole into the vein. 74 MEDICAL DIAGNOSIS. Sudden collapse of the jugular veins during the ventri- cular diastole has been shown by Friedreich to be a sign of pericardial adhesions. 3. Epigastric Pulsation may be conveniently divided into two groups (i) those which are synchronous with the ven- tricular systole; (2) those which follow that systole after a slight but appreciable delay, {a?) SyncJu^onous tenth the Ventricular Systole. — When the right ventricle is hypertrophied and dilated, it may fre- quently be felt to pulsate in the epigastrium, and any con- dition which depresses the diaphragm or forces the heart towards the right may give rise to this pulsation.* The liver may also pulsate in the epigastrium, but if the impulse is exactly systolic in rhythm, it can only be occa- sioned by direct transmission from the adjacent right ventricle. {b?) Delayed Epigastric Pulsation^ i.e., that which succeeds the ventricular systole after an appreciable interval, may be due to the transmitted impulse of the abdominal aorta. The pulsation is then somewhat to the left of the middle line; it extends downwards towards the umbilicus, and is not diffused laterally. It may be conducted to the parieties by means of tumors, or through the overlying liver. The pulsation may be due to an aneurism on the abdominal aorta, or one of its branches, when it will have a distensile character. The venous pulsation which has been already noticed as occurring in cases of incompetence of the tricuspid valve is not limited to the jugular veins, it also takes place in the inferior vena cava. This pulsation may be communicated to the liver, and if the hepatic veins be likewise affected, pulsation becomes not merely heaving but distensile. f In all these conditions the pulsation follows the apex- beat after a slight interval of time. The delay can be best appreciated by fixing with wax, over each pulsating point, a bristle carrying a small flag. Systolic indrawing of the epigastrium occurs rarely, and is caused by extensive pericardial adhesions. * Rosenstein has proposed to call this pulsation "parepigastric," as it lies rather at the border of the left ribs than in the centre of the epigas- trium. f To discriminate the various epigastric pulsations mentioned requires the use of palpation as well as inspection, but to preserve the continuity of the subject, they are all grouped together in this chapter. CIRCULATORY SYSTEM. 75 TABULAR STATEMENT OF VARIOUS EPIGASTRIC PULSATIONS. 1, Synchronous with the ventricular systole. (a.) Pulsation of the left ventriclee. (d.) Pulsation of the liver transmitted from the left ven- tricle. 2. Delayed. (a.) Aortic pulsation (hysterical or other.) (d.) Aortic pulsation transmitted through the liver, over- lying tumors, etc. (c.) Aortic or other aneurisms in epigastrium (distensile). (d.) Pulsation of the inferior ve/ia cava in cases of tricus- pid incompetence transmitted through the liver. (., about an inch and a half to the left of the pulmonary area. Mitral prcesystolic and diastolic murmurs arise from the same cause, viz. — stenosis (narrowing) of the mitral orifice. Im- mediately after the ventricles of the heart have contracted they relax and begin to refill with blood, and during the period of time represented by the second or diastolic 92 ' MEDICAL DIAGNOSIS. sound, and by the long pause, this process of filling goes on. At first the blood follows the retreating walls of the ventricles, propelled partly by gravity and partly by the ordinary intra-thoracic pressure, and so flows slowly through the patent orifices (mitral 'and tricus- pid) into the respective ventricular cavities. But toward the end of the long pause the auricular connection takes place, and the remainder of the blood is thus more power- fully forced into the ventricles. In ordinary circumstances these actions take place noiselessly; but when stenosis of the mitral orifice arises (we Speak now of the left side of the heart alone) as a result of endocarditis, the narrowing may be sufficient to throw the fluid into sonorous yibra- tions. It depends on the rapidity of flow, and the narrow- ness of the orifice in relation to the size of the ventricular cavity, whether or not a murmur will occur — if so whether it will be diastolic or praesystolic in rhythm, or in other words, whether it will be produced when the blood is flowing into the ventricle immediately after the ventricular systole, or later on, during the auricular systole. These murmurs sometimes coexist, and may either run into one another, and so fill up the whole time occupied by the ventricular diastole, or the)^ may be separated by a very short interval of silence. The diastolic portion is usually soft, whilst praesystolic (or auricular-systolic) murmurs are almost invariably rough in character. Tricuspid murmurs resemble those at the mitral valve in regard to their causation. Systolic tricuspid inurmurs are indicative of incompetence of the valve, with consequent regurgitation of blood into the right auricle during the ventricular systole. This results either from deformity of the valve, produced, as in the case of the mitral valve, by endocarditis, or from dilation of the orifice. The latter condition may be occasioned by such causes.as produce a corresponding state of matters on the left side of the heart (fevers, anaemia, etc.), but more com- monly this relative incompetence, as it has been called, is caused by distension of the i-ight auricle and ventricle, the result of obstruction to the circulation through the lungs, produced most markedly in stenosis, or incompetence of the mitral valve. Prcesystolic tricuspid murmurs are very rarely met with, and never without other valvular complications. They are the result of stenosis of the tricuspid orifice, and the mechanism CIRCULATORY SYSTEM. 93 of their production is similar to that which produces the corresponding mitral murmur. Aortic murmurs are of two varieties — systolic and dias- tolic. These usually coexist. Systolic aortic viurmurs are those produced at the aortic orifice as the blood is propelled into the aorta by the con- traction of the left ventricle. Such a murmur arises when the orifice is contracted or roughened as a result of endo- carditis. The murmur is usually loud and sawing, occa- sionally musical, and whilst it is loudest in the aortic area, it can most frequently be heard over the whole front of the heart. Diastolic aortic murmurs are the result of incompetence of the aortic valves, the blood regurgitating from the aorta into the left ventricle during the ventricular diastole. The position of maximum intensity of this murmur varies very much. In many cases it is best heard in the aortic area; not uncommonly it is loudest at the ensiform cartilage; rarely the apex-beat is the situation at which it is most dis- tinct. Most usually these two murmurs are heard together, the so-called double aortic murmur, for the valves are rarely incompetent without presenting some obstruction to the flow of blood over them into .the aorta. Pulmofiary murrnurs. — Among these we do not include those haemic murmurs which arise at the mitral valve, and have their seat of greatest intensity an inch or more to the left of the pulmonary area. True pulmonary murmurs are of very rare occurrence. They are systolic and diastolic in rhythm. Systolic ptilmonary murmurs are either inorganic or or- ganic. The former have been supposed by Quincke to be produced where from some cause the left lung is retracted, and the heart in its systole so compresses the pulmonary artery as to give rise to sonorous waves in that vessel. Organic systolic murmurs are almost invariably due to congenital constriction of the pulmonary artery. Such cases are rare, and differ much from one another according to the period of cardiac development at which the constric- tion commenced. The ventricular septum is usually defi- cient, with cyanosis as a consequence. Diastolic pulmonary 7nur7nurs are still more rare. They result from incompetence of the pulmonary valves, and are invariably accompanied by systolic pulmonary murmurs. 94 MEDICAL DIAGNOSIS. 2. Endocardial murmurs of non-valvular origin are prob- ably of very rare occurrence indeed. They may result from — (i.) Congenital deficiency of some part of the septum, which divides the two sides of the heart ; and in that case they only intensify the valvular murmurs already existing. (2.) Flakes of lymph attached to the valves are said to cause such murmurs. (3.) Changes in the density of the blood in anaemia, chlo- rosis, etc., may allow of murmurs forming under conditions under which no such sonorous vibrations would arise in blood of normal composition. It has been already pointed out that many of the hsemic murmurs are mitral in their origin, resulting from incompetence caused by relaxation of the cardiac muscle. A small proportion of these mur- murs may, however, arise in the blood-stream, where no incompetence exists. Such murmurs are soft, invariably systolic, and usually heard most distinctly over the base of the heart. 2. Exocardial Murmurs. — These murmurs are caused by the friction of the two pericardial surfaces on one another, when these surfaces have become roughened as a result of pericarditis, etc. Such friction murmurs are, for the most part, readily distinguished from endocardial murmurs. They are rough and grating, never blowing. They are localized, and are not propagated in the direction of the blood current; and as they usually arise first toward the middle of the heart, the point of greatest intensity does not generally coincide with any one of the cardiac areas. They can always be perceived by the hand, if at all intense, which is only exceptionally the case as regards endocardial mur- murs. Further, the rhythm of exocardial murmurs is ir- regular. They are not confined to any particular phase of the cardiac action, are neither permanently systolic nor diastolic, but vary from minute to minute. Exocardial murmurs are also sometimes occasioned by friction of two roughened surfaces of the pleura overlying the heart on one another. Such friction murmurs vary in intensity with the movements of respiration. CIRCULATORY SYSTEM. 95 CHAPTER XII. Circulatory System — (continued). THE EXAMINATION OF THE ARTERIES CAPILLARIES, AND VEINS. ARTERIES. The physical examination of the arteries may be con- ducted by means of inspection, palpation, percussion and auscultation. Of these we will speak in their turn. Inspection. — In health the pulsation of the arteries of the body is but little visible, except under the influence of mental emotion or bodily strain. As the result of disease, however, pulsation may become visible in all the super- ficial arteries of the body, particularly in the carotid, tem- poral, and radial vessels. All disturbances of cardiac inner- vation, such as arise in Graves's Disease, and all feverish conditions, are liable to produce such excited action of the heart as will occasion this visible pulsation. Still more marked is the pulsation when the left ventricle is hyper- trophied, and, above all, when the aortic valves have been rendered incompetent. Dilated, tortuous, and visibly pul- sating temporal or radial arteries are usually found to have undergone atheromatous changes ; and finally, inspection may show us the localized pulsation of aneurism. Palpation of the arterial system is almost confined to the radial artery, the carotid, brachial, and femoral being but rarely palpated. The radial pulse is, in health, equal on the two sides; but abnormal distribution, compression, or other pathological condition may so act as to make one pulse weaker than the other. So, also, the pulse-wave propagated from the heart outwards toward the periphery may not arrive at the two wrists synchronously. This condition occurs where there is simple or aneurismal dilatation of the aortic arch, and is particularly noticeable if the aneurism be situate between the innominate and the left subclavian. We may further notice that in this affection the interval of time which oc- 96 MEDICAL DIAGNOSIS. curs between the cardiac systole and the arrival of the blood-wave at the wrist is considerably longer than usual. Such delay arises either from stenosis of the aortic orifice rendering the systole slow and difficult, or from aortic in- competence where (as Tripier has pointed out with great probability) the onward wave meets with, and is delayed by, the regurgitating blood. It will probably conduce to greatest clearness if the con- ditions of the pulse are considered under three headings — viz., (i) frequency, (2) rhythm, (3) character. 1. Freqitcficy of the pulse, which in the male adult averages about seventy beats per minute (slightly higher in women), varies in healthy individuals according to the age, accord- ing to the time of day, the external temperature, and may be greatly influenced by mental emotions and by the ad- ministration of certain drugs. In disease the pulse is some- times abnormally slow, as for example, in jaundice, in fatty degeneration of the heart, and in some affections of the brain. More frequently, however, the pulse rate is increased in rapidity. The rapid pulse of fever, of collapse, and of the various cardiac neuroses is well known. Very generally the pulse is rapid in diseases of the valves of the heart (particularly the mitral). 2. Rhythm. — The radial pulsations, which are normally separated by regular intervals of time, and so are rhythmi- cal, may be altered in this relation to each other in a great variety of ways, the normal rhythm being sometimes changed into total irregularity; while at other times the beats, although following each other in an abnormal man- ner, still possess a certain rhythm. Amongst the latter may be mentioned the (i) pulsus bigeininus, in which each two beats form a group separated from the two which pre- cede and the two which succeed by longer pauses than the interval which separates each pair. (2) The pulsus para- doxus is that variety of pulse, so carefully described by Kussmaul, where with each inspiration the pulse-wave be- comes smaller, or is completely lost. When it is present in all the arteries of the body, it may be due to one of two causes — either to fibrous adhesions between the aorta and the sternum, or some other obstruction which, during in- spiration, prevents the free passage of the blood into the aorta; or it may result from any obstruction to the entrance of air into the lungs, which during inspiration lessens the pressure within the thorax. When the pulsus paradoxus CIRCULATORY SYSTEM. 97 occurs only in one radial artery, it is due, as Weil has pointed out, to inflammatory adhesion between the pleura and the subclavian artery. In \.\\^ pulsus alternans there is a regular alternation between a small and a large pulsation. When, after a series of regular pulsations, one or more beats are omitted, the pulse is said to be intennitteiit. These intermissions, due either to momentary cessation of the heart's action or to the blood-wave in question being too feeble to reach the wrist, may be regular or irregular, and often occur independently of heart disease. Most frequently, however, the intermittent pulse is associated with some cardiac affection, generally mitral disease. Very irregular pulsations, in which no rhythm of any kind can be detected, are commonly (although by no means always) due to affec- tions of the mitral valve, generally to mitral constriction, of which affection an extremely irregular pulse, even in the early stages, is an important symptom, and one to which considerable diagnostic importance may attach. 3. The character of the ptdse varies in a great number of ways, giving rise, especially in the works of the older writers, to a very extensive nomenclature. It will be suf- ficient for ordinary purposes to notice the following points: (^.) The expansion of the pulse. A pulse which reaches its full expansion quickly, and as rapidly collapses again, giving to the finger the impression of a very quick stroke, is denominated tht pulsus celer, and this celerity is, as Cor- rigan first pointed out, most distinct where there is aortic incompetence (hence called Corrigan's pulse). The opposite condition, the pulsus tardus, is distinguished by the slow manner in which the artery fills and empties, and this slug- gishness may be due to slowness in the contractions of the heart, to a hindrance in the capillary and venous circulation, or to loss of elasticity in the arterial wall itself. It is per- haps most frequently met with as a result of arterial sclerosis. {b.) The tension of the pulse, or, in other words, the blood- pressure on the inner surface of the artery, may be approx- imately estimated by the pressure of the finger required to obliterate the pulse. When the tension is high (as in hy- pertrophy of the left ventricle, lead colic, peritonitis, etc.), we speak of a hard or te?ise pulse, and under the reverse cir- cumstances (as in mitral disease), of a soft and compressi- ble pulse. Above all things, however, it must be borne in mind that the impression of tension or hardness may be 98 MEDICAL DIAGNOSIS. given to the finger by a rigid condition of the arterial wall, and it is only when this factor can be eliminated that any safe deductions can be drawn regarding the blood-pressure itself. When the radial artery has undergone calcification, the irregular prominences can usually be felt, and this will prevent error.* (c) The volimie of the pulse. A full pulse may be pro- duced by one or more of three factors: powerful ventricu- lar contraction, loss of elasticity of the arterial well, andin- .terference with the blood flow from the arteries into the capillaries. The opposite conditions may give rise to an empty pulse. The pulse is also spoken of as large or small, tremulous, thready, etc. All these varieties of pulse are best studied with aid of the sphygmograph. Percussion of the Arteries is almost entirely limited to cases of thoracic aneurism, of which mention has been al- ready made. Auscultation of the Arteries. I. In Health. — As in cardiac auscultation, so also in aus- cultation of the arteries, we have to distinguish two phe- nomena — sounds and murmurs. In health, if the stetho- scope be placed over the carotid artery as lightly as possi- ble, two sounds are usually to be heard, corresponding respectively to the expansion and contraction of the artery. Of these the latter is simply the second aortic sound con- ducted into the carotid, and it seems most probable (Weil, Heynsiusf ) that the sound coinciding with the arterial ex- pansion ought also to be regarded as the conducted aortic systolic sound (Guttmann,J however, regards it as in part originating in vibrations of the arterial wall). These two sounds can also generally be heard in the subclavian; and occasionally the first can also be detected in the abdominal aorta, the brachial, and the femoral; but in the more peri- pheral vessels no auscultatory phenomenon is present in health. If pressure be made with the stethoscope upon an artery, such as the brachial just above the elbow, where normally no sound can be heard, the narrowing of the lu- men of the vessel thereby occasioned gives rise to vibrations * The tension may be more accurately estimated by means of the sphygmomanometer of Von Basch, which will be hereafter described. \ Loc, cit. \ Lehrb. der Untersuchungs Methods. r CIRCULATORY SYSTEM. 99 in the blood stream, and to an audible murmur coincident with the arterial expansion. If the pressure be increased, this murmur passes into a sharp sound. 2. In Disease. — Sounds or murmurs may be heard in the arteries under three pathological conditions: (<7.) Murmurs cofiducted from the Heart. — It is, as a rule, aortic murmurs (both systolic and diastolic) which are pro- pagated into the arteries, although mitral murmurs are oc- casionally to be heard very faintly in the carotids. (^) Sou7ids a?td Murmurs originating i7i the Arteries in con- sequence of general Circulatory Disease. — In aortic incompe- tence a sound coinciding with the arterial expansion may be heard in all the accessible arteries of the body, due al- most certainly to the rapid transition from extreme relaxa- tion to extreme tension which the arterial coats then un- dergo. A double sound over the femoral artery is also sometimes to be heard in such cases, as was first pointed out by Conrad,* and subsequently more fully studied by Duroziez,f Traube,J Friedreich, § and others, and lately by Senator.il The first of these sounds, that coinciding with the arterial expansion, originates in the arterial coats, as already described; and the second arises, in the majority of cases, not in the artery, but in the femoral vein, as a re- sult of coexisting tricuspid incompetence. Very rarely, in- deed, cases occur in which later sounds are of arterial origin (the tricuspid valve being intact), and these result from aortic incompetence. A double murmur may be produced in the femoral artery in cases of aortic incompetence by pressure with the stetho- scope, the one murmur being caused by the pulse wave, the other by the returning backward wave, which in such cases flows towards the heart during the arterial collapse. This double murmur may also occasionally be heard in cases of anaemia, typhoid fever, etc. (^.) Murmurs originating in the Arteries in consequence of Local Changes. — Such murmurs are to be heard over aneu- risms and vascular tumors, but more important are the sub- clavian murmurs. While occasionally occurring in healthy persons, murmurs over the subclavian arteries are much * Zur Lehre iiber die Auskultation der Gefdsse. Giessen, i860. \ Arch. gen. de mM., 1861. X Vide Bert. kl. Woch, 1867, No. 44. kDeutsches Arch, fur kl. Med., xxi. p. 205., and xxix., 1881. \Zeitschr.f. kl. Med., iii., 1881. 100 MEDICAL DIAGNOSIS. more frequently heard incases of phthisis, due probably to adhesions between the pleura and the vascular walls, and hence much influenced by the respiratory movements. The encephalic murmur which Fisher discovered in chil- dren has, so far as our present knowledge goes, no diagnos- tic significance. The cephalic murmur which Tripier has recently shown to be present in anaemia over the mastoid process, the occi- put, and the eyeball, is supposed by him to be of arterial origin. It is coincident with the expansion of the arteries; but it is a little difficult to see why, if it be an arterial mur- mur, it should be loudest in these three positions, and hence Gibson has referred it to vibrations in the internal jugular vein produced by the systolic stroke of the neighboring carotid artery, and conducted into the venous sinus. This ingenious explanation does not, however, seem to me satis- factory. I am inclined to regard this cephalic murmur as venous, but as the product of the systolic augmentation of the venous current which takes place within the skull, and within the eyeball, due to the fact that in each case we are dealing with a closed box, which is practically incapable of expansion. Hence, when a sudden increase of arterial blood takes place in them, when the arteries are distended, an equally sudden outflow must occur through the veins. To the vibrations in this sudden venous current I am inclined to ascribe this very interesting cephalic murmur. The watery condition of the anaemic blood is, of course, the im- portant factor. Capillaries. The state of the capillary vessels need not be specially noticed here, seeing that the more noteworthy points have been elsewhere discussed. Veins. Knowledge concerning the condition of the veins may be obtained by inspection and by auscultation. Palpation by the fingers, and percussion, are not fitted materially to aid the physician. Inspection. — By inspecting the veins we ascertain, firstly, their state as to fulness, and secondly, whether the blood contained in them undulates or pulsates. CIRCULATORY SYSTEM. lOI Overfilling of the veins results either from local obstruc- tion, when the vein becomes tense on the distal side, and such of the collateral branches as are not compressed en- large so as to carry on the circulation, or from interference with the venous circulation generally. Examples of the variety of engorgement arising from local obstruction are to be found in cases of thrombosis of any of the larger venous trunks, or where the pressure of an aneurism or other mediastinal tumor gives rise to overfilling of the veins of the arm. The distension of the cervical veins which arises where the general circulation is interfered with has already been described. Undidatloji of the Veins of the Neck. — The pulsations in the cervical veins which correspond to the movements of the heart have been already remarked upon. It only remains to mention the undulation which the respiratory move- ments sometimes produce in the jugular veins. When the cervical veins are overfilled as a result of pulmonary em- physema, or of mitral stenosis, each inspiration diminishes the venous distension, while each expiration increases it, and so the veins show a constant undulation. Auscultation. — Although in cases of tricuspid incompe- tence systolic sounds are occasionally to be heard over the jugular and femoral veins, the only auscultatory sign which here demands attention is the humming murmur, the so- called bruit de diable which is very frequently to be heard in chlorotic females over the bulb or dilatation of the internal jugular vein, and more rarely over the large intrathoracic venous trunks, the superior vena cava, and the innominatic veins. Venous murmurs in the former are best heard at the right border of the sternum, from the first right inter- costal space to the third costal cartilage. The murmur in the right innominate vein is usually loudest at the sternal end of the first right costal cartilage, and that in the left over the manubrium sterni. Occasionally a venous hum is to be heard in dilated thyroid veins, and in the subclavians, axillary, brachial, and femoral veins. In venous ausculta- tion, it must be borne in mind that the slightest unneces- sary pressure with the stethoscope may develop an artificial murmur. The bruit de diable., as met with in the jugular vein (gene- rally loudest on the right side), is usually of a continuous soft humming character, and occurs very frequently in 102 MEDICAL DIAGNOSIS. health. Winterich * detected it in 80 per cent of the Bava- rian cuirassiers whom he examined. Only when the mur- mur is strong and loud is it pathological, or can it be taken as evidence of the existence of anaemia; and we may, with Friedreich,! define the pathological venous murmur as limited to those cases in which a thrill is perceived when the finger is applied over the jugular bulb, or in which the murmur is sufficiently loud to be heard when the ear is re- moved a little way from the stethoscope, or to become ap- parent to the patient himself, and finally, when a murmur can be perceived over the intrathoracic venous trunks. These venous murmurs appear to depend for their pro- duction upon three factors — ist, upon the rapidity of the blood current; 2d, upon the change in the calibre of the vein at any particular point (such as occurs in a marked manner at the jugular bulb); and 3d, upon alteration in the quality of the blood, whether this consists in an actual or only a relative increase of the watery elements. Usually the jugular humming murmurs are continuous, but they very often vary in intensity, and occasionally are actually intermittent. They are influenced in the following ways: 1. Changes in the Posture of the Patient. — When the head is turned to the opposite side the murmur becomes much intensified, owing to the compression of the vein by the muscles and fascia. Even when no murmur exists when the head is held straight, a faint bruit may be developed when the head is rotated; especially if firm pressure be made wath the stethoscope in addition. Owing to the acceleration of the blood flow in the veins the murmur is louder when the patient sits or stands than in the recumbent posture. 2, The Move7nents of Respiration. — Sometimes the venous murmur in the jugular is only audible during deep inspira- tion, and if it be continuous it is almost invariably intensi- fied by that action, in both cases, for this reason — viz., that during inspiration the flow of blood in the vein is acceler- ated. The same usually holds good with regard to mur- murs in the femoral vein, although in rare instances the reverse obtains, and we meet with the remarkable phenom- * Deutsche Klinik, 1850. f Deutsch. Arch. f. kl. Med., vol. xxix. (1881) p. 263. CIRCULATORY SYSTEM. 103 enon of a femoral murmur which is expiratory in rhythm,* this probably resulting from the increased abdominal pres- sure which the descent of the diaphragm occasions, and which retards the blood current in the femoral vein. 3. The Movements of the Heart. — The anaemic murmur in the jugular vein is sometimes diastolic in rhythm, as was first pointed out by Chauveau,f who ascribed it to the in- creased blood current in the vein which is the result of the diminution of pressure in the superior vena cava produced during diastole, and which stands closely related to the negative diastolic pressure in the ventricle. While this is no doubt one cause of this diastolic venous hum, it appears to the author extremely probable that the cause suggested by Friedreich is likewise operative — viz., that the pulsa- tions of the aorta compress the superior vena cava during the cardiac systole, thus allowing an uninterrupted flow of venous blood during diastole. CHAPTER XIII. Circulatory System — {Continued), GRAPHIC CLINICAL METHODS. When Chauveau and Marey first introduced to the notice of the profession the sphygmograph and cardiograph, it was hoped that a new and more accurate examination of the heart and circulatory system would soon replace the former methods. This hope has not been realized. There is, indeed, little difficulty in obtaining tracings of the pulse wave and heart beat, and these tracings, moreover, are found to vary greatly in different diseases; but the true meaning of these differences is as yet by no means thor- oughly understood. The reason for this lies partly in the fact that the meaning of the normal pulse and heart curve has not yet been explained, in all its details, in a fully satis- factory manner. Still, even now, certain trustworthy facts can be obtained by the use of the recording instruments referred to, and the number of these facts will necessarily increase as the characteristics of the normal pulse wave and * Friedreich, loc. cit. \ Gaz. MM. de Paris, 1858. 104 MEDICAL DIAGNOSIS. heart beat and the modifications which they may undergo in health become more fully understood. Moreover, the permanence of the records which may be obtained by the use of such instruments, their value in illustrating the history of individual cases, together with the fact that these instruments give results which are more purely objective than those obtainable by other methods, amply justify a somewhat full description of the manner of using the sphygmograph and cardiograph, together with some ac- count of the results obtainable by their help. Sphygmograph. — The original instrument of Chauveau and Marey which, since its introduction, has been re- peatedly modified in detail by Marey himself and by others, in its present form (as supplied by Breguet) is the most favorite form of instrument employed at the present day. Some have sought to introduce the so-called transmission sphygmograph, but it seems to be generally accepted that the advantages which this form of instrument presents in certain particulars are more than counterbalanced by very obvious defects. All of these transmission sphygmographs are similar in principle, consisting of two closed Marey's tambours — one being influenced through the medium of a button pressing on the radial artery, while the second tambour, joined to its fellow by an india-rubber tube, is arranged to move a recording lever which w^rites on the blackened surface of a revolving cylinder. The great ad- vantage presented by this form of sph3'gmograph is that by its means we can obtain curves of practically indefinite length, more especially if the revolving cylinder move round a spiral spindle. On the other hand, these instru- ments are all more or less cumbersome and expensive, while the introduction of a long column of air to transmit the form of the pulse wave to the recording lever introduces many serious possible errors. However, for investigation of certain special points, as, for example, where simultane- ous tracings of the pulse, heart, and respiratory movements are desired, the transmission sphygmograph is the only instrument which can be employed. Of these Marey's polygraph * is probably the most perfect and convenient. On account of its comparatively small cost and conven- ient size, it is probable that the original Chauveau and * Vide Marey, La Circulation du sang a V^tat physiologique et dans Us Maladies. Paris, i88i. CIRCULATORY SYSTEM. 105 Marey's sphygmograph, in its most recent modification, will still continue, at least for some time, to be the most com- monly used instrument. The principle of its construction is to be found in all text-books of physiology, and need not therefore be dealt with here; and I will confine myself to a description of the typical pulse curve, and the modifications which it undergoes in health and in disease. The typical healthy curve, of which the accompanying trac- ing (Fig. i) is an example, is usually divided into an as- cending and descending portion, either or both of which may present certain secondary undulations. In its most typical form (as in Fig. i) the ascending line [a to h) rises abruptly at first, and afterwards more slowly, till it reaches its highest point. Then descending more obliquely, it usu- ally presents a more or less well-defined notch or indenture {c) before it reaches the principal notch or valley (^). This latter notch is best known as the dicrotic notch, and is of great importance, corresponding as it does exactly to the closure of the aortic valves. After the dicrotic notch, the curve describes a slight elevation before descending to its lowest level, in the course of which descent a low wave-like eminence (/) is not unfrequently to be discovered. Since the point (a) corresponds to the opening of the aortic valves, and the point (^) to their closure, the artery is, during the time represented by the interval between these two lines, in free communication with the interior of the ventricle, while, during the time of the rest of the curve the artery is cut off from the heart. f The point d^ therefore, * For this curve and those which follow, as well as for much help and advice in the preparation of this chapter, I am indebted to the kindness of my friend Dr. C. S. Roy, of the Brown Institute, whose surpassing skill in instrumentation is well known. \ The whole pulse wave is delayed in its transmission from the com- mencement of the aorta to the radial artery, but the delay of the differ- ent parts of the curve is usually tolerably equal, so that the relative distance between the up-stroke and the dicrotic notch remains the same. Fig. I.— Normal Pulse Curve.* I06 MEDICAL DIAGNOSIS. forms the most natural division of the pulse wave into its more fundamental parts, the causes which influence its form during the first half being essentially different from those which modify the second half. Keeping this fact in view, and premising that it is almost always easy to find in any curves, of whatever form the point which corresponds to d in our typical curve, I now proceed to describe the modifications of the pulse wave which are to be met with. And, first, with regard to changes in the first half of the curve. Anacrotic Pulse. — The typical pulse curve, of which I have given an example above, is not infrequently called dicrotic, owing to the fact that it presents a fairly well-marked notch in its descending part, although some authors prefer to restrict the term dicrotism of the pulse wave to cases in which that notch is abnormally well marked. In contra- distinction to the dicrotic pulse, it is the custom to call those pulse waves in which a more or less well-marked notch occurs in the ascending line as anacrotic. The trac- ing (Fig. 2) annexed shows a fairly typical example of the anacrotic pulse wave. It can be seen that it differs from the dicrotic or normal pulse-wave only in the part which lies be- tween the lines a and d; in other words, in that part of the pulse wave which corre- sponds to the time when the aortic valve is open. We would, therefore, expect, a priori., that this change in the Fig. 2.— Anacrotic Pulse Wave. form of that part of the pulse wave must be due to some difference in the relation between the quantity of blood thrown out of the left ventricle and the elastic resistance offered by the aorta and larger arteries. Let us suppose that the arteries are relatively lax, and that the quantity of blood thrown out of the ventricle is not above normal, then it is not difficult to understand that the ventricle will more readily and more rapidly empty itself than when the vessels are relatively rigid. The result of this is that the point of the pulse wave, where the highest pressure exists, and which corresponds to the highest point of the pulse curve, will occur nearer its commencement than would otherwise CIRCULATORY SYSTEM. 10/ be the case. Let us, on the other hand, suppose an ex- treme case, in which the arteries are very rigid, as in well- marked atheroma, or calcification of the larger vessels, these latter, as the contents of the ventricle are forced into them during systole, do not expand to receive the contents of the ventricle, but act more like rigid tubes, the result of which is that during the cardiac systole the inflow into the vessels, which is always greater than the outflow at that period, produces a continuous rise in arterial pressure dur- ing the whole time of systole. The point of highest pres- sure of pulse wave, or, in other words, the highest part of the pulse tracing, is thus thrown toward the end of the ventricular part of the pulse curve, or, in other words, closer to the dicrotic notch, d^ which marks the end of the systole. In other words, in cases where the larger arteries are not fitted to contain the quantity of blood contained in the ventricle, the latter forces the blood at first against a comparatively weak resistance, which, however, goes on in- creasing very rapidly as the large arteries become gradually more and more tensely filled; and the pressure within these latter necessarily rises from the commencement to the end of the cardiac systole. This, then, is the reason why, in such circumstances, the highest part of the pulse curve is nearest our line d^ or the dicrotic notch which corresponds to the end of the ventricular systole. I have as yet said nothing of the indenture (c) which pre- cedes the dicrotic notch, and which, on that account, is usually described as the pre-dicrotic notch. The exact significance of this notch is still by no means so fully understood as is desirable. It would seem that its appear- ance results from the fact that, at the moment when the aortic valves are forced open, the column of blood con- tained in the aortic arch and larger branches receives a sudden impulse towards the periphery, and the inertia of this column of blood, thus set in comparatively rapid motion, produces a negative wave at the commencement of the aorta, which is propagated towards the periphery in the same manner as the positive wave which preceded it. I have spoken of the causes which may theoretically produce anacrotism, and also the probable cause of the pre-dicrotic notch, and must now proceed to refer to the conditions under which, in practice at the bedside, we find the ventri- cular part of the pulse wave so modified. If the glottis be closed, and the pressure within the thorax Io8 MEDICAL DIAGNOSIS. and abdomen be raised by powerful continuous contraction of the respiratory muscles, we produce a change in the dis- tribution of the blood in the arteries and veins. The intra- abdominal and intra-thoracic veins are relatively empty, and an abnormally large quantity of blood accumulates in the systemic arteries. During this state the arterial walls are more or less powerfully distended, and, following known laws regarding arterial elasticity, they are in that condition more rigid than when their calibre is normal. Even in tolerably young subjects, by this means we can easily pro- duce artificially an anacrotic pulse wave, the arteries being rendered relatively rigid in relation to the quantity of blood which is forced into them at each ventricular contraction. This arterial engorgement or high pressure, only temporary in such an experiment, is, however, lasting in certain dis- eased conditions, the most marked of these being the ar- terial high pressure which accompanies certain forms of chronic kidney disease, in which latter case the conditions are still more favorable for the production of an anacrotic pulse wave, seeing that not only are the arteries abnor- mally rigid from the distension, but also that the quantity of blood forced into them with each contraction of the ventricle is relatively and absolutely great, owing to the existence of eccentric hypertrophy of the left ventricle. Analogous conditions occur, as already indicated, in cases of atheroma or calcification of the larger arteries, such as occur in old age. The conditions, therefore, which produce the anacrotic pulse wave are in practice either abnormal distension of the larger arteries, accompanied or not by hy- pertrophy of the ventricle, or rigidity of the arterial w^alls due to changes in molecular structure of their middle coats. The more marked these conditions are, the more is the second elevation (c) higher than the first. (^ in Figs, i and 2.) In practice, all imaginable intermediate forms between the typical pulse wave of health and the typical anacrotic pulse wave, as in Fig. 2, are encountered, and it is usually easy in each individual case to tell from the other phe- nom.ena whether the anacrotism be due to simple distension of the arteries from high pressure, to molecular change in the arterial coats, or to hypertrophy of the heart. From what I have said it will be understood that although the anacrotic pulse wave very often means an abnormally high arterial pressure, this is by no means always the case. Fi- nally, before leaving the changes confined chiefly or en- CIRCULATORY SYSTEM. IO9 tirely to what I have named the ventricular part of the pulse wave, a word may be said regarding the conditions which favor the appearance of a well-marked pre-diastolic notch. The condition fitted to produce this notch in its most marked form is that in which the part of the syste- mic arteries nearest the heart is abnormally rigid; for it need scarcely be said that if this latter part of the systemic arterial system is fairly elastic, it will contract behind the suddenly impelled first wave, and prevent more or less com- plete!}" the formation of a negative wave or tendency towards a vacuum at the commencement of the aorta. We now turn to consider a different series of changes in the form of the pulse wave, which are due to changes in the arterial circulation of an entirely different kind from those above referred to, and in which practically invariably the dicrotic notch is abnormally exaggerated. Abnormally Dicrotic Pulse Waves.- — I have said above that on closing the glottis and contracting powerfully the respi- ratory muscles, the systemic arteries are at first abnormally filled with blood; this abnormal distension very soon, how- ever, gives place to an abnormal emptiness of these vessels, owing to the fact that the pressure on the intrathoracic veins diminishes the quantity of blood which reaches the vertricle, the result being that the blood accumulates chiefly in the veins of the head and limbs. The artificial arterial anaemia so produced leads to a characteristic change in the form of the pulse wave, which becomes, as in Fig. 3, smaller in size and more markedly dicrotic than even the nor- mal pulse, while all trace of anacrotism completely disappears. It is unnecessary for us to go minutely into the theory of the production of the abnormally dicrotic pulse wave. For practical purposes it will suffice to refer to the conditions which lead to the appearance of this form of curve. Roughly speaking, these may be said to consist in abnormal emptiness of the arterial system, such as is produced, for example (^), by anaemia after venesection, in which case the ^}'^- s-^'^bnormaiiy , , . r 1 1 1 . 1 • • Dicrotic Pulse W ave. absolute quantity of blood m the arteries is diminished, although these latter contain relatively normal amount; {p^ in cases of unusual expansion of the arterioles and capillaries leading to a relatively rapid outflow from 1 10 Medical diagnosis. the arteries, as in the condition produced by amyl-nitrite inhalation; or finally, dicrotism may be produced by {c) diminution in the quantity of blood which enters the aorta through the ventricle — the most marked examples of which are to be found in cases of uncompensated mitral regurgi- tation.* Such are the conditions which, in practice, are found to produce the dicrotic pulse wave; and it may be noted in passing that simple or pure dicrotic pulse wave invariably results from abnormally low arterial pressure, the cause of which, in individual cases, it is rarely difficult to discover. Hyperdicrotic is the term applied to that form of the di- crotic pulse in which the dicrotic notch descends lower than the commencement of the systolic rise. This is due to the fact that each successive cardiac systole follows its prede- cessor before the pressure within the artery has fallen be- low that which it presented at the dicrotic notch. This form of curve (Fig. 4), although presenting a notch in its ascending part, is due to entirely different conditions from those which produce the true anacrotic pulse wave, with which it can never in practice be confounded, owing to the fact that the rounded smooth emi- nences of which it is made up shows it at a glance to be of the dicrotic type; it is, in fact, an exaggerated dicrotic pulse-wave. Fig. 4.-Hy^erfkrotic Pulse The anacrotic and the dicrotic pulse waves are the two principal simple modifications which are met with, but there are various intermediate or combined pulse waves due to combination of the conditions fitted to produce the anacrotic and the dicrotic waves — for example, in cases of aortic regurgita- tion with hypertrophied ventricle, the first or ventricular part of the curve usually is of the true anacrotic type, while, on cessation of the systole, the reflux into the heart causes more or less powerful negative wave producing an abnormally deep dicrotic notch. In addition to this, the rapid filling of the comparatively empty arteries with each * Not unfrequently two or more of these causes may be combined, as happens in fevers. CIRCULATORY SYSTEM. HI ventriculatory systole leads to an abnormally steep and high ascending limb of the curve. We have given the conditions which lead to the two prin- cipal forms of pulse wave met with in disease; but, as I have said, all possible combinations of these conditions are constantly occurring, leading to some less well-defined type of pulse curve. Into a detailed account of these more com- plicated pulse curves we cannot enter here. What we have already said will enable the observer to understand the meaning of each. Examples of these are found in the vari- ous modifications of pulse curve in prolonged fever cases, in the early stages of which it is often high, bounding with a tendency towards the anacrotic type, but gradually from day to day becoming more and more dicrotic, and not un- frequently being eventually hyperdicrotic. Cardiograph. — The results w^hich may be obtained by the use of the cardiograph are on the whole less satisfactory than those of the sphygmograph. This is in part due to the fact that none of the instruments at present in use for re- cording the contractions of the human heart can compare with the sphygmograph, in so far as compactness and accuracy are concerned. While some observers, such as Landois, have attempted to record the form of the apex beat by applying to the surface of the chest the sphygmo- graph of Marey, the majority of the instruments employed at the present day are transmission instruments, being con- structed in the same manner as the transmission sphygmo- graph, which I have already described. It is extremely desirable that we should have at our disposal some direct acting cardiograph similar in principle to the sphymograph of Chauveau and Marey. Such, however, has not as yet been described. In the meantime the transmission cardio- graph is the one which is almost universally employed. That of Burdon Sanderson,* or the polygraph of Marey,f are amongst the best, if not the very best. I need not enter upon the manner of using these and similar instru- ments, but will proceed to describe, firstly, the typical nor- mal heart curve; and secondly, the principal modifications which it may present. Normal Heart Curve. — In Fig. 5 is represented a typical * " Handbook of the Physiological Laboratory," edited by Burdon Sanderson. f Loc cit. tI2 MEDICAL DIAGNOSIS. normal curve of this kind. The curve, it will be seen, immediately after rising from its lowest point (/), de- scribes a more or less well marked rounded elevation be- tween/and «, and from a it ascends at first rapidly, after- wards somewhat more slowly, to its highest point b, from whence it describes a more or less obliquely descending, usually undulating line to e^ after which the curve descends, at first slowly, then more rapidly, and finally with increas- ing slowness, until the point /is reached. That part of the curve lying between / and « corresponds in time to the con- FiG. 5.— Normal Heart Curve. traction of the auricles, and when the curve is taken from the apex, the elevation between /and a is due to the more or less sudden filling of the ventricles which results from the auricular contractions. That part of the curve lying between the lines a and e is produced during the time of con- traction of the ventricular muscle, while the part from e to/ corresponds with the passive expansion of the ventricular muscle. In so far as the ventricles are concerned, we may divide the whole heart curve into two parts — viz., first, that from a to e, during which the ventricular muscle is in a state of contraction; and second, that from e to a, which corfe- CIRCULATORY SYSTEM. II3 ponds to the ventricular diastole. The sudden rise from <3! to (^ is produced by the tightening of the ventricles over their contents, and the point b corresponds in time to two important phases of each heart beat — viz., first, the moment of closure of the auriculo-ventricular valves; and secondly, the moment when the heart muscle has fairly grasped its contents. The height of b over e gives some indication of the difference in antero-posterior diameter of the heart at commencing systole as compared with the end of the sys- tole, for it need scarcely be said that the larger the quan- tity of blood contained in the ventricle at the commence- ment of the ventricular systole, the greater will be its antero-posterior diameter, and therefore the more powerful impulse will be given to the chest wall and cardiograph button. As the heart empties itself during systole the an- tero-posterior diameter of the ventricles diminishes with corresponding rapidity, and the pressure against the chest wall and cardiograph button falls in the same ratio. The result of this is that, ccEfej'is paribus, the degree to which the line joining b and e descends gives a valuable indication regarding the quantity of blood thrown out by the ventri- cles at each systole. The meaning of the notches c and d is not satisfactorily understood. This much, however, is certain — viz., that they are not due to inertia vibrations of the recording lever, as has been asserted by some, and. also that in not a few cases the form of the curve lying between the lines a and d of the cardiogram resembles very closely that lying between the lines a and ^ of our normal pulse curve (Fig. i.) In other words they are probably due to oscillations of the column of blood contained in the ventri- cles and larger arteries. The notch d, when well marked, corresponds to the conclusion of the outflow of blood from the heart, and is therefore the analogue of the dicrotic notch of the pulse wave. It must be added, however, that it is by no means uniformly to be seen. Of greater importance is the position of the last elevation or corner of the curve at e, which can in almost all curves clearly be made out. This elevation marks the commencing relaxation of the ven- tricular muscle, and by measuring the distance between the lines a and e in the manner which will be described in a note appended to this chapter, we are enabled to learn with absolute accuracy the duration of the ventricular systole in any given case. I must mention, in passing, that the duration of the ventricular systole, and the duration of the 114 MEDICAL DIAGNOSIS. outflow from these cavities, by no means necessarily or even usually correspond. The ventricular muscle contracts with a certain definite force, and remains contracted for a cer- tain definite time, neither of these being influenced by the quantity of blood contained in the ventricle at the com- mencement of its contraction. The result of this is, that where a very small quantity of blood is contained in the ventricles at the commencement of their contraction, the outflow from them may have concluded some tenths of a second before the ventricles begin to relax. The distance between the lines e and /" gives some indication of the rapid- ity with which the heart muscle has relaxed after the con- clusion of its contraction. Where the elasticity of the heart muscle is modified, as when the blood contains a largely diminished quantity of oxygen, the ventricular muscle takes a longer time to relax than is normally the case, and the curve from such a beat descends less rapidly than in health. The cardiographic curve then enables us to measure with very considerable accuracy the absolute and relative dura- tion of the different phases of the cardiac revolution. It also gives us some idea of the force of the ventricular con- traction corresponding to the height of the line a to b, and it further affords valuable information regarding changes in the force and frequency of the heart's action which make up the different forms of irregularity of the heart. It is unnecessary to refer more in detail to the normal typical heart curve, and I turn now to mention those dis- eased conditions which modify its form; and first, with re- gard to the cardiogram in aortic regurgitation. After what has been said regarding the meaning of the various parts of the normal heart curve, it is not difficult to understand in what way these may be modified in a typical case of aortic regurgitation. In the first place, the ventricle, be- fore the contraction of the auricles, is abnormally distended with blood; and on the auricles propelling their contents into the already filled ventricle, an abnormally great dis- tension of the ventricles occurs. The result of this is that, in cases where there is no failure in the power of the auri- cular walls, the elevation between the letters/" and a is ab- normally high. On ventricular contraction occurring, the antero-posterior diameter of the heart diminishes very rapidly, corresponding with the abnormally large quantity of blood contained in the ventricle, so that the line joining points corresponding to a and e is unusually steep, while CIRCULATORY SYSTEM. II5 the regurgitation of blood through the incompetent aortic valves, after the cessation of the systole, causes a dilatation of the relaxing cardiac muscle sufficient to produce in most cases a very well-marked rise after e. It is important to note that, in the heart-curve of well marked aortic regurgi- tation, it is often impossible to find the exact point corre- sponding to e in the normal curve at which the systole sud- denly ceases. The corner of the curve preceding the de- scent is usually in the aortic regurgitation cardiogram some fraction of a second later that the time of commencing re- laxation. In all, or nearly all, cases of aortic regurgitation, the heart curve presents two well-marked peaks, and this may be said to be the distinguishing character of the card- iogram of that disease, and, roughly speaking, the more marked this bicornual character is, the greater is the in- competence of the valve. Such is the curve when the ven- tricular muscle is comparatively unimpaired in contracting power, as, for example, in sudden rupture of one of the .cusps of the valve, or when one of these is artificially de- stroyed in the lower animals; but where the ventricle no longer completely empties its contents at every contraction, the fall of the line from ^^ to somewhere about rrhages. ip.) The Optic Nerve. — Of abnormalities there may be — (i.) Simple Co?igestioft of the Disc — Vascularity; edges ill defined. (2.) CEdematous Congestion of the Disc — Disc red; swol- len; edges obscured. (3.) Neuritis — Increased redness and swelling; the edges of the disc totally obscured. * The arrangement of the morbid appearance of the fundus oculi here given corresponds pretty closely to that adopted by Dr. Gowers in hig work on " Medical Ophthalmoscopy." 244 • MEDICAL DIAGNOSIS. (4.) Atrophy — Disc white or gray; may be simple or secondary to congestion or to neuritis. (r.) The Retina. — The chief abnormalities to be detected by the ophthalmoscope are hemorrhages, white spots, and patches. (^.) The Choroid. — White spots occur, either new forma- tions or the results of atrophy, with destruction of the pig- ment normally found there. It may be convenient here to indicate shortly the ophthal- moscopic appearances in one or two diseases in which reti- nal changes are most frequent and important. Cerebral Tumors. — In most cases optic neuritis is present. At first there is congestion, increased redness, swelling, and cloudiness in the disc; then neuritis sets in, with ob- scuration of the edges, followed by great swelling and strangulation of the papilla (choked disc). Locomotor Ataxia. — Atrophy of the optic nerves is a fre- quent symptom in locomotor ataxia, and it is also some- times seen in general paralysis, and occasionally in insular sclerosis. The disc is pale, small in size, and excavated, and the retinal vessels are usually diminished in calibre. Bright' s Disease. — Particularly in the cirrhotic form of this disease, special retinal changes (retinitis albuminurica) take place. These consist in {a) oedematous swelling of the retina; [b) white degenerative spots and patches; (c) small extravasations; (d) inflammation of the papilla; (