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A MANUAL 
 
 OP 
 
 Auscultation and Percussion; 
 
 EMBRACING THE 
 
 PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNGS 
 AND HEART, AND OF THORACIC ANEURISM. 
 
 BY 
 AUSTIN FLINT, M.D., 
 
 PROFESSOR OF THE PRI^X•IPLES AND PRACTICE OF MEDICINE AND OF 
 
 CLINICAL MEDICINE IN THE BELLEYUE HOSPITAL 
 
 MEDICAL COLLEGE, ETC., ETC. 
 
 THIRD EDITION, REVISED. 
 
 PHILADELPHIA: 
 
 HENRY C. LEA^S SON & CO. 
 
 1883. 
 
Entered, according to Act of Congress, in the year 1880, by 
 
 HENRY C. LEA, 
 
 In the office of the Librarian of Congress. All rights reserved. 
 
 
 SHKUMAN & CO., riMNTERS. 
 
PREFACE TO THE THIRD EDITION. 
 
 In the revision of this manual for a third edition, it 
 has been deemed advisable, as in the previous editions, 
 to restrict its scope to auscultation and percussion con- 
 sidered chiefly with reference to their practical applica- 
 tion, and to present these with as much condensation as 
 possible. In the present edition, the modes by which 
 pulmonary signs may be reproduced in the lungs re- 
 moved from the body, and by artificial illustrations, 
 have been briefly stated. The author has also intro- 
 duced some practical points kindly suggested by his 
 friend and colleague, Professor Janeway. The speedy 
 exhaustion of the second edition may, perhaps, be fairly 
 regarded as evidence, not alone of the usefulness of the 
 work to the medical student and practitioner, but of an 
 increasing appreciation of the importance of the study 
 of auscultation and percussion, as well as of the analytical 
 method by which the study is facilitated, and knowledge 
 of the physical signs made readily available in diag- 
 nosis. 
 
 New York, March, 1883. 
 
PREFACE TO THE SECOND EDITION. 
 
 This work contains the substance of the lessons which 
 the author has for many years given, in connection with 
 practical instruction in auscultation and percussion, to 
 private classes composed of medical students and prac- 
 titioners. 
 
 In his courses of practical instruction his plan has 
 been, 1st. To simplify the subject as much as possible, 
 avoiding all needless refinements ; 2d. To consider the 
 distinctive characters of the different physical signs as 
 determined, not by analogies, nor by deductions from 
 physics, but by analysis, and as based especially on 
 variations in the intensity, pitch, and quality of sounds ; 
 3d. To impress the fact that the significance of physical 
 signs relates to certain physical conditions, and the im- 
 portance of a familiar acquaintance with these conditions, 
 as well as with the distinctive characters of the signs by 
 which they are represented ; 4th. To enforce the neces- 
 sity of sufficient study of the physical conditions and the 
 signs of health, as a sine qua non for success in the 
 study of the physical diagnosis of diseases; and, 5th. 
 To waive discussion of the mechanism of signs, when- 
 
Vlll PREFACE TO THE SECOND EDITION. 
 
 ever this is open for discussion, taking the ground that 
 our knowledge of the significance of signs rests solely on 
 the constancy of their connection with the physical con- 
 ditions which they represent. 
 
 This plan, of which the utility has been confirmed by 
 continued experience, has been followed throughout the 
 present volume, and the favor with which the work has 
 been received has seemed to show that no radical changes 
 were required. In revising it for a second edition, there- 
 fore, the author has confined himself to such additions as 
 seemed likely to render it more useful not only to stu- 
 dents engaged in the practical study of the subject, but 
 also to practitioners as a hand-book for ready reference. 
 
 New York, January, 1880. 
 
CONTENTS. 
 
 CHAPTER 1. 
 
 INTRODUCTION. 
 
 PAGE 
 
 Definition of percussion and auscultation — The sounds obtained 
 by these methods representing healthy and morbid physical con- 
 ditions — Definition of signs— The basis of our knowledge of 
 signs the constancy of association of certain sounds with certain 
 physical conditions in health and disease — The present state of 
 perfection of our knowledge of signs furnished l)y auscultation 
 and percussion — Requirements for the successful study of these 
 methods of exploration — The anatomy and physiology of the 
 chest — An enumeration of the points relating thereto which are 
 of especial importance — The physical conditions incident to the 
 different diseases of the chest ; the conditions relating to the res- 
 piratory system stated, and a summary of them — The distinctive 
 charactersof healthy and morbid signs ; variations in intensity, 
 pitch, and quality, considered as the chief source of the char- 
 acters distinguishing the signs of disease from each other and 
 from those of health — Other distinctions than those of intensity, 
 pitch, and quality — The analytical method of the study of aus- 
 cultation and percussion — The significance of the signs as re- 
 gards the physical conditions which they severally represent — " 
 Morbid conditions, not individual diseases, represented by the 
 morbid signs — Regional divisions of the chest — Anatomical re- 
 lations of the regions severally to the parts within the chest, . 13 
 
 CHAPTER II. 
 
 PERCUSSION IN HEALTH. 
 
 Percussion with the fingers or with a percussor and pleximeter 
 — The normal vesicular resonance on jiercussion ; its distinctive 
 characters relating to intensity', pitch, and quality — Variations 
 in the characters of the normal vesicular resonance in different 
 
CONTENTS. 
 
 PACE 
 
 persons — Relation of the pitch of resonance to the vesicular 
 quality — Tympanitic resonance over the abdomen — Variations 
 of the normal resonance in the diflferent regions of the chest 
 — Enumeration of the regions in which the resonance on the 
 two sides varies, and those in which it is identical in health 
 — Influence of age on the normal resonance — Influence of the 
 acts of respiration on the resonance — Eules in the practice of 
 percussion, 38 
 
 CHAPTER III. 
 
 PERCUSSIOX IN DISEASE. 
 
 Enumeration of the signs of disease furnished by percussion — Re- 
 quirements for practical knowledge of these signs — The dis- 
 tinctive characters of, the morbid physical conditions repre- 
 sented by, and the difierent diseases into the diagnosis of which 
 enter, these signs, severally, to wit, 1. Absence of resonance or 
 flatness ; 2. Diminished resonance or dulness ; 3. Tympanitic 
 resonance ; 4. Vesiculo-tympanitic resonance ; 5. Amphoric re- 
 sonance; 6. Cracked-metal resonance — Sense of resistance felt 
 in the practice of percussion, as a morbid sign, .... 54 
 
 CHAPTEE IV. 
 
 AUSCULTATION IN HEALTH. 
 
 Importance of the study of the auscultatory sounds in health — 
 Immediate and mediate auscultation — Advantages of the bin- 
 aural stethoscope — Rules to be observed in auscultation — Di- 
 visions of the study of auscultation in health — The normal 
 laryngeal and tracheal respiration — The normal vesicular mur- 
 mur ; its distinctive characters, and the variations in the differ- 
 ent regions on the same side, and in corresponding regions on 
 the two sides of the chest — The normal vocal resonance — The 
 laryngeal and tracheal voice and whisper — The normal thoracic 
 vocal resonance and fremitus ; the distinctive characters of 
 each ; the variations in difierent regions on the same side, and 
 in corresponding regions on the two sides of the chest — The 
 normal bronchial whisper, with its variations in different re- 
 gions on the same side, and in corresponding regions on the 
 two sides of the chest, 65 
 
CONTENTS. Xi 
 
 CHAPTEK V. 
 
 AUSCULTATION IN DISEASE. 
 
 PAGE 
 
 The respiratory signs of disease: — Abnormal modifications of 
 the normal respiratory sounds: — Increased vesicular murmur 
 — Diminished vesicular murmur — Suppressed respiratory sound 
 — Bronchial or tubular respiration — Broncho-vesicular respira- 
 tion — Cavernous respiration — Broncho-cavernous respiration — 
 Vesiculo-cavernous respiration — Amphoric resinration — Short- 
 ened inspiration — Prolonged expiration — Interrupted respira- 
 tion. Adventitious respiratory sounds or rales : — Laryngeal and 
 tracheal rales. Moist bronchial rales, coarse, fine, and subcrepi- 
 tant — Vesicular or crepitant rale — Cavernous or gurgling rale 
 — Pleural friction rales, metallic tinkling and splashing. In- 
 determinate rales — The vocal signs of disease : — Bronchophony 
 — Whispering bronchophony — ^gopbony — Increased vocal re- 
 sonance — Increased bronchial whisper — Cavernous whisper — 
 Pectoriloquy — Amphoric voice or echo — Diminished and sup- 
 pressed vocal resonance — Diminished and suppressed vocal fre- 
 mitus — Metallic tinkling. Signs obtained by acts of coughing 
 or tussive signs, 85 
 
 CHAPTEK VI. 
 
 THE PHYSICAL DIAGNOSIS OF DISEASES OF THE RESPIRATORY 
 
 ORGANS. 
 
 Affections of the larynx and trachea — Bronchitis seated in large 
 bronchial tubes — Bronchitis seated in small bronchial tubes, or 
 capillary bronchitis — Collapse of pulmonary lobules — Lobular 
 pneumonia — Asthma — Pulmonary or vesicular emphysema — 
 Pleurisy, acute and chronic— Empyema — liydrothorax — Pneu- 
 mothorax — Pneumo-hydrothorax — Pneumo-pyothorax — Acute 
 lobar pneumonia — Circumscribed pneumonia — Embolic pneu- 
 monia — Hsemorrhagic infarctus — Pulmonary apoplexy — Pul- 
 monary gangrene — Pulmonary oedema — Carcinoma of lung — 
 Tumor within the chest — Acute miliary tuberculosis — Pulmo- 
 nary phthisis — Fibroid phthisis, interstitial pneumonia, or cir- 
 rhosis of lung — Diaphragmatic hernia, 136 
 
Xll CONTENTS. 
 
 CHAPTEE YII. 
 
 THE PHYSICAL CONDITIOKS OF THE HEART IN HEALTH AND 
 DISEASE. THE HEART-SOUNDS AND CARDIAC MURMURS. 
 
 PAGE 
 
 Physical conditions of the heart in health : — Boundaries of the 
 prsBcordia — Normal situation of the apex-beat — Boundaries of 
 the deep and of the superficial cardiac space — Relations of the 
 aorta and the pulmonary artery to the walls of the chest — The 
 heart-sounds — Characters distinguishing the first and the second 
 sound — Mechanism of the production of the heart-sounds — Aus- 
 cultation of the pulmonic and the aortic second sound separately 
 — Movements of the auricles and ventricles in relation to each 
 other. Physical conditions of the heart in disease : — Enlarge- 
 ment of the heart — Hypertrophy and dilatation — Abnormal im- 
 pulses of the heart, and modifications of the apex-beat — Valvu- 
 lar lesions — Roughness of the pericardial surfaces — Liquid 
 with in the pericardial sac — Abnormal modifications of the heart- 
 sounds — Reduplication of heart-souuds — Cardiac murmurs — 
 Normal and abnormal blood-currents within the heart, and 
 their relations with the heart-sounds — Mitral direct murmur — 
 Mitral regurgitant murmur — Mitral systolic non-regurgitant, 
 or intra-ventricular murmur — Aortic direct murmur — Aortic 
 regurgitant murmur, and an aortic diastolic non-regurgitant 
 murmur — Coexisting endocardial murmurs — Tricuspid direct 
 murmur — Tricuspid regurgitant murmur^Pulmonic direct 
 murmur — Pulmonic regurgitant murmur — Facts of practical 
 importance in relation to endocardial murmurs — Pericardial 
 . or friction murmur, 181 
 
 CHAPTEE VIII. 
 
 THE PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART AND OF 
 THORACIC ANEURISM. U 
 
 Enlargement of the heart by hypertrophy and dilatation — Val- 
 vular lesions, mitral, aortic, tricuspid, and pulmonic — Fatty 
 degeneration and softening of the heart— Endocarditis — Peri- 
 carditis — Functional disorders— Thoracic aneurism, . . 217 
 
MANUAL 
 
 OF 
 
 AUSCULTATION AND PERCUSSION. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 Definition of percnssion and auscultation — The sounds obtained by 
 these methods representing healtliy and morbid physical conditions 
 — Definition of signs — The basis of our knowledge of signs the con- 
 stancy of association of certain sounds with certain physical condi- 
 tions in health and disease — The present state of perfection of our 
 knowledge of signs furnished by auscultation and percussion — Ee- 
 quirements for the successful study of these methods of exploration 
 — The anatomy and physiology of the chest — An enumeration of the 
 points relating thereto which are of especial importance — The phys- 
 ical conditions incident to the difl'erent diseases of the chest : the 
 conditions relating to the respiratory system stated, and a summary 
 of them — The distinctive characters of healthy and morbid signs; 
 variations in intensity, pitch, and quality, considered as the chief 
 source of the character distinguishing the signs of disease from each 
 other and from those of health — Other distinctions than those of 
 intensity, pitch, and quality — The analytical method of the study 
 of auscultation and j)ercussion — The significance of signs as regards 
 the physical conditions which they severally represent — Morbid con- 
 ditions, not individual diseases, represented by the morbid signs — 
 Eegional divisions of the chest — Anatomical relations of the regions 
 severally to the parts within the chest. 
 
 Physical Exploration. 
 
 The physical exploration of the chest embraces six 
 different methods, namely : auscultation, percussion, in- 
 spection, palpation, mensuration, and succussion. Of 
 these, auscultation and percussion, dealing with sounds, 
 involve the sense of hearing. In percussion, the sounds 
 
14 INTRODUCTION. 
 
 are produced by striking upon the walls of the chest ; in 
 auscultation, they are caused by acts of breathing, speak- 
 ing, and coughing. 
 
 The sounds in auscultation and percussion are, 1st, 
 normal or healthy sounds, being produced when there is 
 no disease of the chest; and, 2d, abnormal or morbid 
 sounds, being produced when the chest is the seat of dis- 
 ease. The sounds, healthy and morbid, constitute what 
 are known as physical signs. Frequently, for the sake 
 of brevity, the terms signs, without the word physical, is 
 used to denote these sounds. Conventionally, physical 
 signs, or signs, are terms employed in a sense of contra- 
 distinction from the term symptoms. The signs are dis- 
 tinguished, of course, as normal or healthy, and abnormal 
 or morbid. 
 
 The sounds which constitute signs represent certain 
 physical conditions pertaining to the chest. The normal 
 or healthy signs represent physical conditions existing 
 when the organs are not affected by disease; the abnormal 
 or morbid signs represent physical conditions which are 
 deviations from those of health, being incident to the 
 various diseases of the chest. The physical conditions 
 represented by signs may be distinguished as normal or 
 healthy, and abnormal or morbid conditions. 
 
 The representation of healthy and morbid physical 
 conditions by certain healthy and morbid signs is estab- 
 lished by having ascertained a constancy of association 
 of the siffus with the conditions. This constancv of as- 
 sociation is ascertained by observation or experience. 
 The sounds which are constantly obtained by percussion 
 and auscultation in health are thereby establislied signs 
 of healthy conditions, and the sounds which are only 
 obtained in cases of disease are therebv established siffus 
 
PHYSICAL EXPLORATION. 15 
 
 of m()rl)i(l conditions. Our knowledge of certain sounds 
 as the signs of certain physical conditions can have no 
 reliable basis other than the constancy of the connection 
 of the former with the latter. This constancy of connec- 
 tion is determined by the study of the sounds during life 
 and examination of the organs after death. The exist- 
 ence of certain conditions is not to be inferred from the 
 characters of certain sounds until the connection of the 
 sounds with the conditions has been ascertained by ex- 
 perience ; then, and then only, are the sounds to be 
 reckoned as signs of these conditions. So, also, it is not 
 to be inferred from certain physical conditions found 
 after death, that certain sounds must have been produced 
 during life, until the connection between the conditions 
 a!id the sounds has been ascertained by experience. In 
 other words, our knowledge of signs as representing 
 physical conditions, can rest on no other than a purely 
 empirical foundation. 
 
 Our knowledge of the signs representing the physical 
 conditions in healtli and disease, thanks to the labors of 
 Laennec and of those who have followed in his footsteps, 
 has been brought to great perfection. The practical ob- 
 ject of this knowledge is to determine by means of aus- 
 cultation and percussion, together with the other methods 
 of exploration, the existence of either healthy or morbid 
 physical conditions, and to discriminate the latter from 
 each other; that is to say, the practical object is diag- 
 nosis. The signs now known to represent physical con- 
 ditions, healthy and morbid, taken in connection with 
 symptoms and pathological laws, render, for the most 
 part, the diagnosis of diseases of the chest easy and 
 positive. Hence, it becomes the duty of the medical 
 student and practitioner to give to auscultation and per- 
 
16 INTRODUCTION. 
 
 cussion attention sufficient, at least, for their practical 
 application to the diagnosis of the diseases commonly 
 met with in medical practice ; and this duty is the more 
 imperative because it involves neither peculiar difficul- 
 ties nor great labor. In entering upon the undertaking 
 it is important to consider the requirements for the suc- 
 cessful study of this })rovince of practical medicine. 
 These requirements relate to : 1st,, the anatomy and 
 physiology of the chest; 2d, the morbid physical condi- 
 tions incident to the different diseases of the chest; 3d, 
 the distinctive character of healthy and morbid signs, 
 and 4th, the signiticance of the signs as regards the 
 physical conditions whicii they severally represent. 
 
 Anatomy and Physiology of the Respiratory Organs. 
 
 The necessity of a certain amount of knowledge of the 
 anatomy and physiology of the chest, as a requirement 
 for the study of auscultation and percussion, together 
 with the other methods of physical exploration, is too 
 obvious to need any discussion. The physical condi- 
 tions of health must be known as preparatory for aj)pre- 
 ciating the piiysical conditions of disease. It would be 
 absurd to think of studying the latter until the former 
 are known. The student, therefore, who is not acquainted 
 with the anatomy and physiology of the chest, must defer 
 entering upon the study of physical diagnosis until this 
 requirement is fulfilled. Familiarity with the morbid 
 physical conditions is necessary ; and for the advanced 
 medical student or the practitioner, it is advisable to re- 
 fresh the memory with a reviewal of certain anatomical 
 and physiological points before beginning the study of 
 auscultiition and percussion. These points, relating es- 
 pecially to the physical conditions of health, cannot be 
 
ANATOMY AND PHYSIOLOGY OF GUEST. 17 
 
 considered in this work. A simple enumeration of thcni 
 can only be introduced, the reader being referred for 
 details to treatises on anatomy and physiology. 
 
 Important anatomical conditions relate to the bones 
 of the chest, namely, the general conformation of the 
 thorax; the differences in respect of the obliquity of the 
 ribs, from above downward ; the direction of the costal 
 cartilages, the connection with the sternum, and the 
 angles formed by the junction of the ribs and cartilages; 
 the differences in width of the intercostal spaces in the 
 upper, middle, and lower portions of the anterior, lateral 
 and posterior aspects of the thorax, together with the re- 
 lations of the scalpula and clavicle. The relative thick- 
 ness of the muscular covering of the chest in different 
 situations is to be considered, and, in women, the varying 
 size of the mammce. The attachments of the diaphragm 
 to the thoracic walls, and its relations to the organs be- 
 low, as well as above it, are points of importance. 
 
 Important physiological conditions relate to the parts 
 -which the ribs, costal cartilages, sternum and diaphragm 
 severally play in the movements of respiration. The 
 differences, in respect of these movements, in tranquil 
 and in forced breathing ; the contrast between the two 
 sexes, and between early and advanced life are points to 
 be studied. Other points are, the frequency of the 
 respirations in health, and the relative duration, rapidity, 
 and force of the respiratory and the expiratory move- 
 ments. 
 
 Certain anatomical and physiological points pertain 
 to the organs within the chest. The more important of 
 these, relating to normal physical conditions, are the fol- 
 lowing : 1st, as regards the lungs, the connections of the 
 pleura, and the smoothness of the pleural surfaces in 
 
1<S INTRODUCTION. 
 
 contact with each other ; the relations of the apex and 
 base of each hing to the chest-walls, and the differences 
 of the two lungs in tliis respect; the relative spaces 
 occupied respectively by the two lobes of the left, and 
 the three lobes of the right lung; the situation of the 
 interlobar fissures in either side on the posterior, lateral, 
 and anterior aspects of the chest ; the arrangement of the 
 air-vesicles, pulmonary lobules, and the different-sized 
 intra-pulmonary bronchial tubes ; the expansion of the 
 air-vesicles, and the movement of the current of air from 
 larger to smaller bronchial tubes in the act of inspiration, 
 the vesicles diminishing in size, and the current of air 
 moving from smaller to larger tubes in the act of expira- 
 tion ; the difference in respect of the relative proportion 
 of air and solids at the end of ins})iration and at the end 
 of expiration ; the extent to which the volume of the 
 lungs may be diminished by a forced act of expiration, 
 and increased by a forced act of inspiration ; the rela- 
 tions of the apices to the subclavian arteries, and the 
 variable extent to which the apex rises on either side 
 above the clavicle. 2d, as regards the larynx, trachea, 
 and the bronchial tubes without the lungs, the anatomy 
 and physiology of the vocal chords, of the muscles con- 
 cerned in the movements of respiration and of phonation, 
 with the relations of each to the recurrent laryngeal 
 nerve, the size of the rima glottidis in youth, after pu- 
 berty, and relatively in the two sexes, the enlargement 
 of the rima in the act of inspiration, the diminution of 
 its size in the act of expiration, and the closer approxima- 
 tion of the chords in the act of coughino^ ; the difference 
 in the amount of areolar tissue above the vocal chords in 
 chiklren and in adults; the situation of the trachea, and 
 the point of its bifurcation ; the length, direction and 
 
DISEASES OF RESPIRATORY SYSTEM. 19 
 
 size of the two primary bronchi contrasted with each 
 other, and the secondary branches which penetrate the 
 lungs. 3d, as regards the heart, the boundaries of the 
 space which it occupies — that is, of the precordial space; 
 the relation of the aorta and pulmonic artery to the 
 walls of the chest; the portions of the pr^ecordial space 
 in which the heart is covered and uncovered by lung; 
 the situations of the auricles and ventricles respectively; 
 the rehitions of these to each other, and the arrangements 
 of the valves; the currents of blood through the orifices 
 within the heart, and the relations of each of these to 
 the heart-sounds ; the rhythmical succession of these 
 sounds ; the differences which distinguish each from 
 the other in respect of loudness, duration, tone, quality, 
 extent of diffusion, and the situation in which each has 
 its maximum of intensity ; the mechanism of these sounds, 
 and the situation of the apex-beat. 
 
 The foregoing are the anatomical and physiological 
 points which especially claim attention with reference to 
 normal physical conditions, j^reparatory to entering on 
 the study of abnormal physical conditions represented 
 by the signs furnished by auscultation and percussion 
 together with the other methods of physical exploration. 
 
 The Physical Conditions Incident to the Different Diseases 
 of the Respiratory System, 
 
 The varied physical conditions incident to different 
 diseases must be known, 'for it is the immediate object of 
 auscultation, percussion, and the other methods of ex- 
 ploration, to ascertain either the existence or the absence 
 of these morbid conditions. Knowledge of all the im- 
 ])()rtant conditions which are deviations from those of 
 health, and the relations of each to different diseases, is, 
 therefore, an essential requirement. 
 
20 INTRODUCTION. 
 
 Deviations from the normal conformation of the chest 
 and the various abnormal movements of respiration, be- 
 long properly among the physical signs obtained by in- 
 spection, palpation, and mensuration. For the most part, 
 these signs represent morbid physical conditions within 
 the chest. Certain conditions relate to the presence of 
 liquid, either serous, sero-fibrinous, or purulent, within 
 tlie pleural sac. The quantity of liquid may be large 
 enough to compress the lung into a solid mass, and to 
 enlarge the affected side, at the same time restraining or 
 annulling the respiratory movements ; the chest on the 
 affected side, then, will contain only lung solidified by 
 compression, and liquid. In other cases the quantity of 
 liquid is either small, moderate, or considerable, the 
 lung, then, containing a lessened quantity of air, and its 
 volume diminished in proportion to the amount of liquid. 
 These morbid conditions are incident to simple pleurisy 
 with effusion, pyothorax or empyema, and hydrothorax. 
 
 The pleural surfaces, in cases of pleurisy, may be 
 more or less covered with recent fibrinous exudation, 
 and, when not separated by the presence of liquid, they 
 do not move upon each other smoothly and noiselessly. 
 The friction of the opposed surfaces is still more pro- 
 ductive of audible and sometimes tactile signs after the 
 absorption of liquid, when the exudation has become 
 more adherent and dense than when it is recent. 
 
 The presence of air in the pleural space, either alone 
 or with more or less li(|uid, in pneumothorax, may com- 
 press the lung into a solid mass, also dilating the affected 
 side, and restraining or annulling its movements ; and 
 the air, with or without liquid, when not in sufficient 
 quantity to produce these effects, may diminish more or 
 less the volume of the lung and the amount of air in the 
 
DISEASES OF RESPIRATORY SYSTEM. 21 
 
 pulmonary vesicles. These morbid conditions give rise 
 to characteristic physical signs. The perforation of lung, 
 usually existing in cases of pneumothorax, occasions ad- 
 ditional siorns which are characteristic. 
 
 Solidification of lung is an important physical condi- 
 tion incident to several diseases, irrespective of the con- 
 densation, just referred to, caused by the compression of 
 liquid or air in the pleural sac. Complete consolidation 
 of an entire lobe, or of two and even three lobes, exists 
 in tlie second stage of lobar pneumonia. Certain physi- 
 cal signs represent this condition of complete solidifica- 
 tion. The different degrees of solidification, namely, 
 slight, moderate, and considerable, occur during the stage 
 of resolution in cases of pneumonia, and these gradations 
 are severally represented by well-defined characters per- 
 taining to physical signs. Solidification, circumscribed, 
 forming nodules which vary in size and number, situated 
 in the upper, lower, or middle portion of the lung, either 
 on one side or on both sides, exists in phthisis, in broncho- 
 pneumonia and collapse of pulmonary lobules, in hyda- 
 tids, in hajmorrhagic infarctus and embolic pneumonia, 
 in pulmonary gangrene, and in carcinoma. It exists, 
 greater or less in degree and more or less extended, in 
 interstitial pneumonia. In these different connections 
 the existence of solidification, its degree and extent, its 
 limitation to one situation or its existence at different 
 points, are determinable by means of physical signs. 
 
 A morbid condition the o{)posite of solidification is 
 an abnormal accujnulation of air within the air-vesicles 
 of the lungs. This is incident to pulmonary or vesicular 
 emphysema, involving a morbid dilatation of the air- 
 vesicles. Tiie permanent expansion and increased vol- 
 ume of the upper lobes in some cases of this disease, 
 
22 INTRODUCTION. 
 
 occasion a characteristic deformity of the chest, together 
 witli certain deviations from the normal movements of 
 respiration, which are also characteristic. This morbid 
 condition is represented by distinctive signs furnished 
 by auscultation and percussion. The extravasation of 
 air in the connective tissue, constituting interlobular and 
 subpleural emphysema, in like manner ^ives rise to 
 signs furnished by these methods of exploration. 
 
 The presence of a viscid exudation within the air- 
 vesicles and bronchioles, is a morbid physical condition 
 incident to lobular pneumonia, especially in its first 
 stage, agglutinating the walls of the cells and bronchioles 
 which may be brought into contact or close proximity at 
 the end of the act of expiration. The separation of the 
 walls thus agglutinated, in the act of inspiration, gives 
 rise to an auscultatory sign (the crepitant rale) which is 
 pathognomonic of that disease. 
 
 An accumulation of serum within the air-vesicles con- 
 stitutes the condition called pulmonary oedema. This 
 condition gives rise to signs furnished by auscultation 
 and percussion. 
 
 I^iquid within the bronchial tubes (serum, pus, blood, 
 or thin mucus) is a condition incident to pulmonary 
 oedema, abscess either of the lung or situated elsewhere 
 and evacuating through the bronchial tubes, phthisis, 
 bronchorrhagia,pneumorrhagia, bronchorrhoea, and bron- 
 chitis. The passage of air through the different varie- 
 ties of liquid in the tubes causes bubbling sounds which 
 are ap})reciable in auscultation. The apparent size of 
 the bubbles (coarseness or fineness) denotes the size of 
 the tubes in which they are produced, and the pitch of 
 the bubbling sounds denotes either solidification or other- 
 wise of the pulmonary substance surrounding the tubes 
 
DISEASES OF RESPIRATORY SYSTExM. 23 
 
 in which the bubbles are produced. Bubbling sounds 
 more intense and on a larger scale are caused by the 
 presence of liquid within the trachea and larynx, known 
 as the tracheal rales or the death rattle. 
 
 Diminished calibre of the bronchial tubes within the 
 lungs, either localized or diffused, is a condition due to 
 the presence of tenacious mucus, and the swelling of the 
 mucous membrane in cases of bronchitis. In cases of 
 so-called capillary bronchitis the condition may involve 
 an alarmino; decree of obstruction. The same morbid con- 
 dition is incident to bronchial spasm in asthma, occasion- 
 ing; in this disease g-reat suffering;, but without immediate 
 danger. The condition is represented by auscultatory 
 sig-ns which enable the auscultator to differentiate the 
 obstruction due to capillary bronchitis from that due to 
 bronchial spasm. Permanent obliteration of more or less 
 of the bronchial tubes is an occasional morbid condition. 
 Obstruction of a bronchial tube, either within or with- 
 out the lung, is a morbid condition involving the loss of 
 respiratory sound within the area of the bronchial 
 branches and vesicles not receiving air in consequence 
 of the obstruction. The obstruction may be temporary, 
 being caused by a plug of mucus of sufficient size to pre- 
 vent the passage of air ; the morbid condidon is then 
 incident to bronchitis. One of the primary bronchi may 
 be obstructed temporarily by a plug of mucus; and ob- 
 struction of the larynx in childhood thus produced may 
 be sufficient to cause death by suffocation. The inhala- 
 tion of foreign bodies is another cause of obstruction 
 within the larynx, trachea, or bronchi. A primary 
 bronchus or the trachea may be pressed upon by an aneu- 
 rismal or other tumor, and, in this way, more or less ob- 
 struction to the passage of air is produced. However pro- 
 
24 INTRODUCTION. 
 
 duced, the situation of the obstruction and its degree are, 
 in general, determinable by means of auscultatory signs. 
 
 Dilatation of bronchial tubes occasions two morbid 
 physical conditions differing as regards their auscultatory 
 signs, namely, 1st, an enlargement of greater or less ex- 
 tent, the tubes preserving their cylindrical form ; and 
 2d, a sacculated enlargement. The former occurs gen- 
 erally in connection with solidification around the tubes 
 from hyperplasia of the areolar tissue, and is thus inci- 
 dent to interstitial pneumonia. The latter may give rise 
 to signs which represent pulmonary cavities. 
 
 Sacculated dilatations of bronchial tubes, and the cavi- 
 ties incident to phthisis, })ulmonary abscess, and circum- 
 scribed gangrene of lung, are represented by well-marked 
 and highly distinctive signs furnished by auscultation 
 and percussion. The signs denote either that cavities 
 have flaccid walls, which collapse in expiration and ex- 
 pand in ins})iration, or that, owing to solidification of 
 lung, they remain open during both acts of respiration. 
 
 More or less of the space within the chest which, nor- 
 mally, is occupied by lung, may be encroached upon by 
 aneurisms or other intra-thoracic tumors. This is a phy- 
 sical condition giving rise to notably morbid signs fur- 
 nished by auscultation and percussion. 
 
 Finally, an extremely rare morbid physical condition 
 is the presence of more or less of the hollow viscera of 
 the abdomen within the chest, in consequence of either a 
 congenital deficiency in the diaphragm, or a wound pene- 
 trating this muscle (diaphragmatic hernia). 
 
 The foregoing morbid physical conditions relate to 
 the respiratory organs. Those relating to the heart are de- 
 ferred in order that they may precede more immediately 
 
DISEASES OF RESPIRATORY SYSTEM. 25 
 
 an account of the signs of cardiac disease. As a re- 
 quirement for the study of morbid physical signs, the 
 foregoing morbid physical conditions must be understood 
 and memorized. To assist the student in the latter, a 
 summary of these conditions is appended. 
 
 Summary of Morbid Physical Conditions Incident to 
 Diseases of the Respiratory Organs. 
 
 1. An accumulation of liquid, serous, sero-fibrinous, or 
 purulent, sufficient to fill the affected side of the chest, and 
 sometimes causing more or less enlargemeut. 
 
 2. Au accumulation of liquid partially filling the affected 
 side of the chest, the quantity being either small, moderate, 
 or considerable. 
 
 3. Fibrinous exudation on the pleural surface. 
 
 4. Air with liquid within the pleural cavity, and perfora- 
 tion of lung. 
 
 5. Air without liquid in the pleural cavity. 
 
 6. Solidification of lung, either complete or approximat- 
 ing to completeness. 
 
 7. Solidification of lung, slight or moderate in degree. 
 
 8. Dilatation of the air-vesicles, involving within them 
 an abnormal accumulation of air. 
 
 9. Extravasation of air Avithin the pulmonary connective 
 structure. 
 
 10. Exudation within air-vesicles and bronchioles. 
 
 11. Liquid in the air-vesicles. 
 
 12. Liquid (mucus, serum, pus, or blood) within bronchial 
 tubes of large, medium, or small size. 
 
 13. Liquid within bronchial tubes of minute size. 
 
 14. Obstruction of the pulmonary bronchial tubes by 
 mucus, swelling of the mucous membrane, and spasm of the 
 bronchial muscular fibres. 
 
 15. Obstruction of larynx, trachea, or bronchi exterior 
 to the lungs, by plugs of mucus or foreign bodies. 
 
26 INTRODUCTION. 
 
 16. Obstruction of the trachea or a primary bronchus by 
 aneurismal or other tumors. 
 
 17. Dilatation of bronchial tubes, cylindrical or saccu- 
 lated. 
 
 18. Pulmonary cavities. 
 
 19. Tumor within the chest. 
 
 20. Diaphragmatic hernia. 
 
 The Distinctive Characters of Healthy and Morbid Signs. 
 
 For the practice of auscultation and percussion, it is 
 essential to be able to recognize the signs, severally, 
 which represent the different physical conditions in 
 health and disease. It is essential to distinguish the 
 morbid from the healthy signs, and to discriminate from 
 each other, severally, the signs of disease. This recogni- 
 tion and discrimination of signs require a knowledge of 
 the distinctive characters belono;ino; to each of them. In 
 entering upon the study of the signs, therefore, it is a 
 necessary requirement to know whence their distinctive 
 characters are derived. To this point of inquiry the 
 attention of the student is now invited. 
 
 The signs being sounds, they are to be recognized and 
 discriminated in the way in which we practically recog- 
 nize and discriminate other sounds. It is not necessary, 
 in order to do this, to study the science of acoustics. 
 In becoming familiar with other sounds, for example 
 musical notes produced by different instruments, or the 
 varieties of the human voice, we do not have recourse to 
 that science. It suffices for all practical purposes to 
 contrast the sounds obtained by auscultation and per- 
 cussion with reference to very simj)le and obvious dif- 
 ferences ; and, yet, it is necessary to understand very 
 clearly in what these differences consist, or, in other 
 
HEALTHY AND MORBID SIGNS. 27 
 
 words, the sources of the distinctive characters of these 
 sounds. The more important of the differences between 
 the sounds obtained by auscultation and percussion re- 
 late to intensity, pitch, and quality. The distinctive 
 characters of most of the signs are derived from these 
 three sources. In becoming practically acquainted with 
 the signs, they are to be contrasted as regards intensity, 
 pitch, and quality, precisely as we would bring other 
 sounds into contrast in these three aspects. The dis- 
 tinctive characters of the signs, severally, are especially 
 derived from their differences in these respects. The 
 distinctions expressed by the terms intensity, pitch, and 
 quality, are, therefore, to be made clear. 
 
 Differences in the intensity of sounds are easily under- 
 stood. One sound is more intense than another sound 
 when it is simply louder, and varying degrees of inten- 
 sity are expressed by such terms as feeble or weak and 
 loud, to which may be prefixed adjectives of quantity, 
 such as very, moderate, etc. This is ail that need be 
 said with reference to the first of the three aspects under 
 which sounds are contrasted. It will be seen hereafter 
 that intensity is an essential element in the distinctive 
 characters of certain of the signs. 
 
 Differences in the pitch of sounds are easily under- 
 stood by those who have given any attention to music. 
 The differences are expressed by the terms high and 
 low, to which may be prefixed words denoting a greater 
 or less degree of highness or lowness. A nice appreci- 
 ation of variations in the pitch of musical notes, requires 
 what is known as a "musical ear;'' but a very nice 
 appreciation is not essential in comparing, as regards 
 pitch, the sounds studied in auscultation and percussion. 
 For the most part, these sounds are not musical notes ; 
 
28 INTRODUCTION. 
 
 nevertheless, differences in pitch are readily perceived. 
 A musical ear is undoubtedly an advantage in readily 
 distinguishing differences in pitch ; but it is by no means 
 a sine qua non. For those who have given no attention 
 to music, some difficulty may be at first experienced in 
 judging correctly of differences in this regard ; but the 
 difficulty disappears after a little practice. Differences 
 in pitch now enter pretty largely into the distincive 
 characters of physical signs ; but by Laennec, and those 
 who immediately followed him, comparatively little at- 
 tention was paid to the study of sigus with reference to 
 these differences. The writer was led to engage in this 
 study a quarter of a century ago, and hereafter, in giv- 
 ing an account of the different signs, he will claim to 
 have been the first to have clearly indicated certain char- 
 acters from this source.^ 
 
 Differences relating to quality are apt, at first, to be 
 confounded with those relating to pitch ; hence the dis- 
 tinction between pitch and quality must be clearly under- 
 stood. We may say of the quality of a sound, that it 
 embraces whatever is not embraced in the terms intensity 
 and pitch. This is true as a general statement. The 
 sense of the term quality, in distinction from intensity 
 and pitch, may be most readily made clear by an illus- 
 tration. Let it be supposed that we hear the notes of an 
 instrument which is unseen — the performer, for example, 
 being in another room. We recognize at once the in- 
 strument by the notes, provided it be one with which 
 we arc familiar, such as a violin, a flute, a clarionet, etc. 
 We do not need to see the instrument; we recognize it 
 
 ' Vide Prize Essay on "Yiiriations of Pitch in Percussion and 
 Respiratory Sounds, and their Api)lication to Piiysicul Diagnosis." 
 Transactions of tlie American Medical Association, 1852. 
 
HEALTHY AND MORBID SIGNS. 29 
 
 by the sounds. Now, how do we recognize it? Cer- 
 tainly not by the intensity of the sounds; it matters not 
 whether these be loud or weak, so that we hear them. 
 Certainly not by the pitch; for if a piece of music be 
 performed, we get both high and low notes. We recog- 
 nize the instrument by the quality of the sounds. Each 
 musical instrument, owing to its peculiarity of construc- 
 tion, yields sounds which are peculiar to it; and after 
 we have become familiar with the quality of sounds 
 peculiar to an instrument, we immediately thereby rec- 
 ognize it. Precisely in the same way we may recognize 
 certain sounds produced by auscultation and percussion 
 in health and disease. The signs differ in quality ac- 
 cording to the physical conditions which they severally 
 represent ; and differences in quality will be found here- 
 after to constitute essential and obvious distinctions by 
 which the signs of health and disease are recognized and 
 discriminated. This is a source of some of the most dis- 
 tinctive of the characters of certain of the physical signs. 
 Of the peculiar quality of any particular sound one 
 can form no definite idea otlierwise than by direct obser- 
 vation. That is to say, no one could describe to another 
 the peculiar quality of a particular sound so that it would 
 be clearly apprehended without the sound having been 
 heard. Imagine the attempt to describe the sound of a 
 violin to a person who had never listened to the notes 
 from that instrument — it would be impossible to give a 
 correct idea of it in language. The only way in which 
 an approximative idea could be conveyed in words, would 
 be by comparing the quality to that of some other in- 
 strument to the notes of which there was some resem- 
 blance — that is, by analogy. To atteinpt to describe the 
 quality of sounds to one who had never heard them, 
 
 3 
 
30 INTRODUCTION. 
 
 would be like describing colors to one blind. It will be 
 seen hereafter tliat the quality of certain sounds obtained 
 by auscultation and percussion is peculiar to them, and 
 their distinctive characters in this respect can be known 
 only by direct observation ; they cannot be learned by 
 means of any verbal description, nor by any comparisons 
 — that is, by analogy. 
 
 Appreciable variations in the quality of sounds are 
 infinite. This may be illustrated by the human voice. 
 Almost every person may be recognized from a peculiar 
 quality of the voice by one who is familar with it; and 
 the voices of thousands of persons, if compared, would 
 present shades of difference — in fact, as is well known, 
 it is extremely rare for the voices of any two persons to 
 be so nearly identical in quality that they cannot be dis- 
 tinguished from each other. As the diversities in quality 
 of different sounds cannot be described, so they can only 
 be designated by names which are significant from cer- 
 tain resemblances. Terms based on analogies which are 
 used to denote qualities of the sounds furnished by aus- 
 cultation and percussion are the following: rough, harsh 
 and rude, soft, blowing, hollow, musical, moist, dry, 
 bubbling, gurgling, crackling, clicking, rubbing, grating, 
 creaking, tubular, cracked metal, sibilant or whistling, 
 sonorous or snoring. All these names owe their signifi- 
 cance to resemblances to other sounds. One sound fur- 
 nished both by auscultation and percussion has a quality 
 which is sui generis^ and the term used to distinguish it 
 is derived from its source, namely, the vesicular reso- 
 nance, and the vesicular murmur of respiration. 
 
 In addition to intensity, pitch, and quality, as sources 
 of the distinctive characters of the signs furnished by 
 
HEALTHY AND MORBID SIGNS. 31 
 
 auscultation and percussion, there are some other points 
 of difference; namely, the duration of certain sounds, 
 tlieir continuousness or otherwise, their apparent near- 
 ness to, or distance from, the ear, their rhythmical suc- 
 cession, and their strong resemblance to particular sounds, 
 such as the bleating of the goat, the chirping of birds, etc. 
 These points of difference are of lesser importance, the 
 more important relating to intensity, pitch, and quality. 
 
 The study of the different sounds furnished by auscul- 
 tation and percussion, with reference to distinctive char- 
 acters relating especially to intensity, pitch, and quality, 
 distinct signs being determined from points of difference 
 as regards these characters, may be distinguished as the 
 analytical method. It may be so distinguished in con- 
 trast with the determination of signs by deductively 
 taking as a standpoint either the physical conditions inci- 
 dent to diseases or the sounds. If we undertake to decide, 
 a jyriori, that certain sounds must be produced by auscul- 
 tation and percussion when certain conditions are present, 
 we shall be led into error; and so, equally, if we under- 
 take to conclude from the nature of the sounds that they 
 must represent certain conditions. The only reliable 
 method is to analyze the sounds with reference to differ- 
 ences relating especially to intensity, pitch, and quality, 
 and to determine different signs by these differences, the 
 import of each of the signs being then established by the 
 constancy of association with physical conditions. It is 
 by this analytical method only that the distinctive char- 
 acters of signs can be accurately and clearly ascertained. 
 This is to be borne in mind by the student in physical 
 exploration. He is to become acquainted with the differ- 
 ent signs, and to recognize them in practice, by acquiring 
 
32 INTRODUCTION. 
 
 a knowledge of the distinctive characters of each, as de- 
 rived mainly from differences relating to intensity, pitch, 
 and quality. The individuality of the signs, severally, 
 can rest on no other solid basis. 
 
 The Significance of the Signs as regards the Physical 
 Conditions which they severally represent. 
 
 Knowledge of the significance of the physical signs is 
 the complemental requirement in the study of ausculta- 
 tion and percussion. For the successful employment of 
 these methods, in addition to the recognition of each sign 
 by its distinctive characters, must be known its sig- 
 nificance, that is, the physical condition which it repre- 
 sents. In this respect the signs may be compared to the 
 substantives in language, each having a definite mean- 
 ing. The signs furnished by these methods may be said 
 to constitute a language with a very small vocabulary ; 
 or, taking as the stand{)oint the things signified, the dif- 
 ferent physical conditions manifest or express themselves 
 by means of the signs. 
 
 It is to be noted that the significance of the morbid 
 signs relates immediately, not to diseases, but to the 
 physical conditions incident thereto. Very few signs are 
 directly diagnostic of any particular disease. They 
 represent conditions not peculiar to one, but common to 
 several, diseases. Thus, solidification of lung exists in 
 pneumonia, phthisis, pleurisy with effusion, collapse, and 
 pulmonary cancer ; now, certain signs tell us that this 
 morbid condition exists, together with its situation, its 
 degree, and its extent. With this information the diag- 
 nosis of the disease is made by connecting with it patho- 
 logical laws, together with the history and symptoms. 
 The student in physical exploration should by no means 
 
REGIONAL DIVISIONS OF THE GUEST. 33 
 
 imagine that, for the diagnosis of diseases, exclusive re- 
 liance is to be placed on the signs; they are always to 
 be taken in connection with pathological laws, the his- 
 tory, and the symptoms. Disconnected from these, the 
 signs would often lead to error, and it is no disparage- 
 ment to physical diagnosis that its reliability depends 
 on other facts than those which belong exclusively to it. 
 To repeat a statement already made more than once, 
 the significance of the signs, as regards the conditions 
 which they severally represent, is based on the constancy 
 of their association with the latter, our knowledge of 
 this association being derived from examinations during 
 life and after death. 
 
 Eegional Divisions of the Chest. 
 
 Before entering on the study of physical exploration, 
 the student should become acquainted with the divisions 
 of the surfaces of the anterior, posterior, and lateral 
 aspects of the chest into circumscribed spaces which are 
 called regions. These divisions, deriving their bounda- 
 ries and names from their anatomical relations, are suffi- 
 ciently simple. 
 
 Anteriorly the chest is divided into regions as follows: 
 The supra or post-clavicular region extends from the 
 clavicle upward a short distance, corresponding to the 
 variable height to which the lung rises above this bone. 
 The clavicular region embraces the space occupied by 
 the clavicle. The infra-clavicular reg^ion embraces the 
 space between the clavicle and the third rib. The mam- 
 mary region is bounded above by the third and below 
 by the sixth rib, and the infra-mammary region is the 
 portion of the chest below the sixth rib. 
 
 Posteriorly the divisions are Into the scapular, the 
 
34 INTRODUCTION. 
 
 infra-scapular, and inter-scapular regions. The scapular 
 region is the space occupied by the scapula, and is divi- 
 ded by the spinous ridge into the upper and lower scapu- 
 lar space. The infra-scapular region is the portion 
 below a horizontal line at the lower angle of the scapula. 
 The inter- scapular region is the space between the pos- 
 terior margin of the scapula and the spinal column. 
 
 Laterally there are two regions, namely, the axillary 
 and the infra-axillary. The axillary region is the space 
 above a horizontal line extending from the lower border 
 of the mammary region, i. e., the sixth rib. The infra- 
 axillary region is the portion below the axillary region. 
 
 The portion of the anterior surface occupied by the 
 sternum is divided into the upper and the lower sternal 
 region, the space above the sternal notch being the 
 supra-sternal region. 
 
 In order to become familiar with the foregoing 
 regional divisions, it is recommended to the student to 
 delineate them with ink on the chest of the living sub- 
 ject or a cadaver. 
 
 It is advisable to study sections, extending from the 
 surface to the centre of the chest, corresponding to the 
 different regions, so as to become familiar with the rela- 
 tion of each section to the parts contained within it. An 
 enumeration of the more important of the anatomical 
 relations of the different regions is as follows : 
 
 1. Supra- Clavicular Region. — This is relative to the 
 upper extremity or apex of the lung, which rises above 
 the clavicle in different persons from half an inch to an 
 inch and a half. The height is generally greater on one 
 side, and this side is usually the left. 
 
 2. Clavicular Region. — A small portion of the lung 
 
REGIONAL DIVISIONS OF THE CIIEST. 35 
 
 at or near the apex is contained in the section corre- 
 sponding to this region. 
 
 3. Infra- Clavicular Region. — The parts situated iierc, 
 exclusive of the upper sternal region [vide No. 7), are 
 the upper portion oflhe lung, and the extra-pulmonary 
 bronchi. The differences between the two primary 
 bronchi, as regards direction, size, and length, are im- 
 portant points in the st#ly of this section. 
 
 4. Mammary Region. — The differences between the 
 two sides in the sections corresponding to this region 
 are important. These differences relate especially to the 
 prsecordia, and are involved in the physical diagnosis 
 of enlargement of the heart. The commencement of 
 the interlobular fissures are in this region. On the left 
 side the fissure is between the fourth and fifth ribs. 
 On the right side the fissure between the upper and 
 middle lobes begins at the fourth costal cartilage, and 
 between the middle and lower lobes a short distance 
 below. The situations of the fissures, however, differ 
 considerably during the acts of inspiration and expi- 
 ration. 
 
 5. Infra-mammary Region, — This region differs in its 
 anatomical relations considerably on the two sides of the 
 chest. On the right side the liver pushes upward the 
 diaphragm nearly or quite to the upper boundary, 
 namely, the sixth rib. On the left side the section cor- 
 responding to the region embraces, together^ with the 
 anterior portion of the lower lobe of the lung, portions 
 of the stomach, spleen, and the left lobe of the liver. 
 The variable volume of the stomach at different times 
 occasions considerable variations in the relative spaces 
 occupied by these different parts. 
 
36 INTRODUCTION. 
 
 6. Supr^a-sterrial Region. — This region is in relation 
 to the trachea. 
 
 7. Tlie Upper Sternal Region. — The bifurcation of 
 the trachea is beneath the sternum at the centre of a line 
 connecting the second ribs. Below this line the lungs 
 on the two sides are nearly in contact at the mesial line, 
 covering the primary bronchi. 
 
 8. Lower Sternal Region. — The sternum in this re- 
 gion covers a large portion of the right and a little of 
 the left ventricle. 
 
 9. Scapular Region. — The sections corresponding to 
 this region contains the posterior portion of the uj)per 
 lobe and a portion of the upper part of the lower lobe of 
 the lung. At the upper part of the lower scapular 
 space, terminates the fissure separating the npper and 
 the lower lobe. The line of this fissure pursues an 
 oblique course to the fourth or fifth rib on the anterior 
 aspect of the chest. 
 
 10. Infra-scapular Region — On the right side the 
 lung extends from the upper boundary of this region to 
 the eleventh rib, the liver rising to the latter point. On 
 the left side the section contains a portion of the spleen. 
 
 11. Inter -scapular Region. — The trachea extends in 
 this section to the fourth dorsal vertebra, where it bifur- 
 cates. Below this point, on the two sides, are situated 
 the primary bronchi. 
 
 12. Axillary Region. — The section corresponding to 
 this region contains a portion of tiie upper lobe with 
 large bronchial tubes. 
 
 13. Infra-axillary Region. — This is in relation to the 
 upper part of the liver on the right side, and on the left 
 side to a j)ortion of the spleen and stomach, the remainder 
 of the section occupied by lung. 
 
REGIONAL DIVISIONS OF THE CHEST. 37 
 
 It is recommended to the student to become familiar 
 with the sections corresponding to the different regions, 
 by dissections for this purpose, and the study of anatom- 
 ical illustrations. 
 
 Askino' the student's careful attention to the intro- 
 ductory considerations which have been presented, aus- 
 cultation and percussion in health and disease, and the 
 physical signs involved in the diagnosis of diseases of 
 the respiratory system and of the heart, will be consid- 
 ered as follows : Chapter II., Percussion in Health ; 
 Chapter III., Percussion in Disease ; Chapter IV., Aus- 
 cultation in Health ; Chapter Y., Auscultation in Dis- 
 ease; Chapter VI., The Physical Diagnosis of the Dis- 
 eases of the Kespiratory System ; Chapter VIL, The 
 Physical Conditions of the Heart in Health and Dis- 
 ease; Chapter VIII., The Physical Diagnosis of Dis- 
 eases of the Heart; and, as properly embraced in the 
 scope of this treatise. Chapter IX. will be devoted to 
 the Diagnosis of Thoracic Aneurisms. 
 
38 PERCUSSION IN HEALTn. 
 
 CHAPTER 11. 
 
 PEECrSSION IN HEALTH. 
 
 Percussion with the fingers or with a percussor and pleximeter — The 
 normal vesicular resonance on percussion ; its distinctive characters 
 relating to intensity, pitch, and quality — Variations in the charac- 
 ters of the normal vesicular resonance in difi'crent persons — Rela- 
 tion of the pitch of resonance to the vesicular quality — Tympanitic 
 resonance over the ahdomen — Variations of the normal resonance in 
 the different regions of the chest — Enumeration of the regions in 
 which the resonance on the two sides varies, and those in which it 
 is identical in health— Influence of age on the normal resonance — 
 Influence of the acts of respiration on the resonance — Rules in the 
 practice of percussion. 
 
 Percussion may be performed with either the fingers 
 or artificial instruments. The fingers suffice for the study 
 and in ordinary practice. Instruments are preferable 
 only when it is desired to produce sounds to be heard at 
 a distance, as in class illustrations, and when, from 
 the number of patients to be percussed, as in dispensary 
 or hospital practice, the frequent repetition of the blows 
 renders the fingers tender and painful. The instruments 
 area pleximeter and a percussor. The simplest and most 
 convenient pleximeter is an oval disk of ivory or hard 
 india-rubber, with projecting handles or auricles suffi- 
 ciently large and roughened on their outer aspect so as 
 to be conveniently held by the fingers. The author has 
 lately used with satisfaction a pleximeter consisting of 
 a piece of hard rubber bent upward at one extremity, 
 and ending in a handle. Tiie best percussor is a double 
 cone of caoutchouc inclosed by a ring, with a handle of 
 convenient length and size, the ring and the handle 
 
NORMAL RESONANCE. 39 
 
 made of vulcanized rubber. The instrument is very 
 durable. When percussion is performed with the fin- 
 gers, the palmar surface of one or more of those of the 
 left hand should ba applied to the chest, with pressure 
 sufficient to condense the soft structures, and the blows 
 are given with one or more of the fingers of the right 
 hand bent at the second phalangeal joint so as to form a 
 riofht anofle. In trivins: the blows, the movements should 
 be limited to the wrist-joint, the ends, not the pulp, of 
 the percussing fingers being brought into contact with 
 the dorsal surface of the finger or fingers applied to the 
 chest. The percussing fingers should be withdrawn in- 
 stantly the blow is given. The type of perfect percus- 
 sion is the movement of the hammers when the keys of 
 a piano-forte are struck. The force of the percussion 
 should never be sufficient to give pain to the patient ; 
 generally either light or moderately forcible blows suf- 
 fice. The requisite tact in the performance of percus- 
 sion is acquired by a litle practice. 
 
 The first object in the study of percussion is to become 
 acquainted with the characters which are distinctive of 
 the sound obtained thereby from the healthy chest. For 
 this object the percussion may be made either in the in- 
 fra-clavicular region of either side, or in the infra-scapu- 
 lar region, the sound in these situations being louder 
 than in other regions. Percussion being performed, a 
 sound or resonance is produced. This sound or reso- 
 nance is now to be analyzed with reference to characters 
 derived from intensity, pitch, and quality. What are 
 these characters? The intensity will depend, other 
 things being equal, on the force of the blow; the reso- 
 nance is comparatively feeble with a slight, and loud 
 with a strong, percussion. Other circumstances affect 
 
40 PERCUSSION IN HEALTH. 
 
 the intensity, irrespective of the force of the blow, 
 namely, the volume of the lung, the elasticity of the cos- 
 tal cartilages, and the thickness of the soft parts which 
 cover the chest. Owing to these circumstances, the in- 
 tensity of the resonance is by no means similar, in the 
 same situation, in all healthy persons ; it is comparatively 
 feeble in some and loud in others. There is nothing dis- 
 tinctive of this normal resonance to be derived from inten- 
 sity, and we say, therefore, that the intensity is variable. 
 
 What is the pitch of tliis normal resonance? The pitch 
 of a sound is always relative; and, comparing this reso- 
 nance with all the morbid signs obtained by percussion, 
 it is lower in pitch. We say, therefore, that the pitch 
 of this normal resonance is low. The pitch, howevc^r, 
 is found to vary in different healthy persons. 
 
 What is the quality of this normal resonance? It has 
 a quality which is peculiar to it. In this respect it is 
 not identical with any sound produced otherwise than by 
 percussion over healthy lung either within or without the 
 chest. The quality cannot, therefore, be learned by an- 
 alogv, nor can it be described ; it can only be appreciated 
 by direct observation. The peculiar quality is due to 
 the fact that the resonance is from air contained in the 
 pulmonary vesicles. This arrangement causes the pecu- 
 liar quality, just as the construction of any particular 
 musical instrument causes the quality of tone peculiar to 
 that instrument; hence, as it is convenient to give the 
 quality a name, we call it the vesicular quality. This 
 quality is not equally marked in all healthy persons, 
 being as a rule more marked in proportion to the inten- 
 sity of the resonance. 
 
 The normal resonance, then, obtained by percussion, 
 may be thus defined : 
 
VARIATIONS IN NORMAL RESONANCE. 41 
 
 A resonance of v^ariable intensity, low in pitch and 
 having a peculiar quality called vesicular. The word 
 vesicular is frequently embraced in the name of this 
 healthy sign ; it is also called the normal resonance, the 
 normal pulmonary resonance, or the normal vesicular 
 resonance. The last of these names is to be preferred. 
 
 The normal vesicular resonance on percussion, as has 
 been seen, is not uniform in all healthy persons ; not 
 only is its intensity variable, but it varies in pitch and 
 in the amount of vesicular quality. This may be easily 
 illustrated, by percussing successively in the same situa- 
 tion, and with the same force, a series of persons who 
 are assumed to be free from disease. Is there not in 
 this fact an obstacle in practically determining this 
 healthy sign ? The fact occasions no embarrassment for 
 this reason : we determine, in each case, that the reso- 
 nance is normal by a comparison of the two sides of the 
 chest, percussing in corresponding situations on the two 
 sides and with the same force. There is no abstract 
 standard of the normal vesicular resonance, but, by com- 
 paring the two sides of the chest, the standard of health 
 proper to each person is obtained. The laws of disease 
 are such that, for all practical purposes, the standard of 
 health is in this way almost always available. Notwith- 
 standing the variations within the range of health, the 
 lowness in pitch and the vesicular quality are sufficiently 
 distinctive of this normal sign as compared with the 
 morbid signs. 
 
 The pitch of the vesicular resonance and its vesicular 
 quality are in a uniform relation to each other; that is, 
 the conditions giving rise to the peculiar quality, also 
 render the pitch low. In proportion as the vesicular 
 quality is marked, the pitch is lowered, and, conversely, 
 
42 PERCUSSION IN HEALTH. 
 
 with diminution of the vesicular quality the pitch is rel- 
 atively higher. This relation between the pitch and 
 quality will be found to hold good in the resonance 
 modified by disease as well as in health. Another rela- 
 tion may be here stated, namely, whenever, in health or 
 disease, a tympanitic quality is combined with the vesic- 
 ular, and in proportion as the former predominates, the 
 pitch of the resonance is raised. 
 
 The pitch and quality of the normal vesicular reso- 
 nance may be readily illustrated by percussing succes- 
 sively over the chest and the abdomen. The different 
 sections of the alimentary canal generally containing 
 more or less gas, a resonance is obtained by percussion 
 over the abdomen. This resonance is, of course, devoid 
 of the vesicular quality; in contradistinction to the 
 latter, its quality is called tympanitic. This tympanitic 
 resonance is not uniform in all parts of the abdomen, 
 but everywhere the quality is tympanitic, that is, non- 
 vesicular, and the pitch is everywhere higher than that 
 of the normal vesicular resonance. The tympanitic 
 resonance over the stomach is generally high in pitch, 
 and frequently has a ringing or metallic intonation. 
 The gastric tympanitic resonance recognized by these 
 characters, will be found to be involved frequently in 
 sounds produced by percussing over the chest. Gas in 
 the caecum gives a still higher pitch of resonance. Over 
 the colon the resonance is lower than over the caecum 
 and stomach, and it is still lower over the small intes- 
 tines. In all these situations, bringing the tympanitic 
 in contrast with the normal vesicular resonance, tlie 
 peculiar quality of the latter and its lowness of pitch are 
 rendered apparent. The term tympanitic resonance will 
 be found to enter into the names of two of the morbid 
 signs obtained by percussion. 
 
RESONANCE IN DIFFERENT REGIONS. 43 
 
 Having stiuliod the characters of the normal vesicular 
 resonance, and become practically familiar with them by 
 percussing different healthy persons, the student should 
 study the variations which this resonance presents in the 
 different regions of the chest. In doing this he acquires 
 more and more tact in the performance of percussion, 
 and becomes more and more familiar with the characters 
 in general of the normal vesicular resonance. 
 
 Sitprctf or Post-clavicular Region. — The resonance 
 here varies much in intensity in different persons. The 
 vesicular quality is most marked in the central portions. 
 Towards the sternal extremity the resonance acquires a 
 tympanitic quality from the proximity to the trachea ; 
 it bec^omes vesiculo-tympanitic, a term which will be 
 applied to one of the morbid signs. 
 
 Clavicular Region. — Near the sternum the resonance 
 is somewhat tympanitic from the proximity to tlie tra- 
 chea. At the central portion the vesicular quality is 
 more or less marked, and the intensity is diminished at 
 the acromial extremity. 
 
 Infra-clavicular Region. — The resonance in this re- 
 gion is more intense than elsewhere, except in the axil- 
 lary and the infra-scapular regions. The vesicular 
 quality is combined with a tympanitic quality toward 
 the sternum, the latter being derived from the primary 
 and secondary bronchi. As always when the vesicular 
 and the tympanitic quality are combined, the pitch is 
 raised. This combination in health and disease is rec- 
 ognized by the intensity, pitch, and quality. 
 
 Scapular Region. — The resonance in this region is 
 notably less intense than in the infra-clavicular region, 
 owing to the presence of the scapula and its muscles. In 
 proportion as the intensity is less, the vesicular quality 
 
44 PERCUSSION IN HEALTH. 
 
 is less marked. The resonance in health, however, is 
 quite sufficient for morbid signs to be available in this 
 situation. 
 
 Inter-scapular Region. — The resonance in this region 
 is weak in comparison with other regions, except the scap- 
 ular, owing to the muscles which here cover the chest. 
 In the upper part of the region the resonance is somewliat 
 tympanitic from the relation to the trachea and bronchi. 
 
 Mamriuiry Region. — The right and the left mammary 
 retrion are to be studied with reference to differences re- 
 lating to the liver and the heart. On the right side, 
 from the fourth rib downward, the resonance is dimin- 
 ished, the convex extremity of the liver extending up to 
 this heiirht. At or a little below the lower border of 
 this region on the mammary line, that is, a vertical line 
 passing through the nipple, resonance ceases, the lower 
 lobe of the right lung not extending below this point. 
 Between the third and fifth ribs on this side near the 
 sternum, the resonance is diminished, from the presence 
 of a portion of the right auricle and ventricle. On 
 the leftside the resonance is diminished, within the pre- 
 cordial space. This space extends vertically from the 
 third rib to the fifth intercostal space, and horizontally 
 from the sternum to a point at or a little within the mam- 
 mary line. The resonance is considerably diminished 
 within what is called the superficial cardiac space. This 
 space is represented by a right-angled triangle, the right 
 angle formed by a vertical line drawn from a point on 
 the median line intersected by a horizontal line connect- 
 ing the fourth ribs, and a horizontal line intersecting 
 the point of apex-beat in the fifth intercostal space; an 
 oblique line drawn from the centre of the sternum on a 
 level with the fourth rib and the point of apex-beat 
 
RESONANCE IN DIFFERENT REGIONS. 45 
 
 forms the hypothenusc of the right-angled triangle. 
 Within this space the heart is in contact witli the tho- 
 racic wall. Without this space and within the prsecor- 
 dia the heart is covered with lung, and the resonance 
 on percussion is less diminished. It is a useful exer- 
 cise for the student to observe the diminution of the 
 area of the superficial cardiac space by a forced in- 
 spiration, as determined by percussion. Aside from 
 the presence of the heart and the convex extremity of 
 the liver, the resonance over the mammary is less than 
 in the infra-clavicular region, being diminished by the 
 pectoral muscle, which varies considerably in bulk in dif- 
 ferent persons, and in women by the mammary gland, 
 tlie size of the latter varying very much in different 
 women. The development of the mammoe, however, is 
 never so great as to preclude the useful employment of 
 percussion in this region. 
 
 Infra-mammary Region. — In this region, as in the 
 region above it, the two sides present notable differences 
 owing to the situation of organs below the diaphragm. 
 On the right side, over the greater part, and sometimes 
 the whole of tliis region, resonance is wanting, that is, 
 percussion gives flatness. It is easy to delineate the 
 boundary between the lower border of the right lung 
 and the liver, or as it is called, the line of hepatic flat- 
 ness. It is also easy to distinguish above this line the 
 height to which the lower extremity of the liver extends, 
 or, as it is called, the line of hepafie diilncss. The situa- 
 tion of both these lines varies considerably in different 
 healthy persons. The distance between the two lines is 
 from one to two inches. Both lines are affected consid- 
 erably by a forced inspiration and a forced expiration. 
 A forced inspiration depresses the line of flatness about 
 
46 PERCUSSION IN HEALTH. 
 
 one and a half inch. A forced inspiration causes the 
 line to rise from two and a half to five and a half inches. 
 The distance, therefore, between this line at the end of 
 a forced expiration, and at the end of a forced inspira- 
 tion varies from four to seven inches. With reference 
 to the practice of percussion, as well as for the purpose 
 of verification, these points should be studied. Not in- 
 frequently percussion over the right infra-mammary 
 region yields a tympanitic resonance due to the disten- 
 sion with gas of the transverse colon. 
 
 On the left side, the resonance in this region varies in 
 different persons, in the same persons at different times, 
 and in different portions of the region at the same time, 
 the variations depending on the organs below the dia- 
 phragm. Flatness is caused by the extension of the left 
 lobe of the liver into this region about three inches to the 
 left of the median line. The left portion of the region 
 is in relation to the spleen, an organ which varies con- 
 siderably in size in health as well as disease, its average 
 dimensions being about four inches in length and three 
 inches in width. Between the spleen and the liver lies 
 the stomach, the volume of which is constantly fluctuat- 
 ing, owing to its varying solid, liquid, and gaseous con- 
 tents. Distension of the stomach with gas occasions a 
 tympanitic resonance which frequently is transmitted 
 above into the mammary region in health as well as in 
 disease. The space corresponding to the spleen is de- 
 termined by the vesicular resonance above and the tym- 
 panitic resonance below, the latter boundary, however, 
 not being very reliable on account of the ready conduc- 
 tion of tympantic resonance for a certain distance. The 
 distension of the stomach with solid or liquid contents, of 
 course, occasions flatness. The study of the infra-mam- 
 
RESONANCE IN DIFFERENT REGIONS. 47 
 
 mary regions with reference to the variations in resonance 
 arising; from the relations to the oro-ans below the dia- 
 phragm, is of much utility from the practice, as well as 
 the knowledge, which it involves. The exercise, of en- 
 deavoring to define the boundaries of these different or- 
 gans in healthy persons, will be of great service to the 
 student in acquiring tact in percussion, and in discrimi- 
 nating differences in the sounds obtained by this method. 
 
 Sternal Regions. — In the upper sternal region, that is, 
 above the lower margin of the second rib, the resonance 
 is non-vesicular, being derived from air in the trachea 
 above the point of bifurcation. Being non-vesicular, 
 it is, of course, tympanitic, this term embracing all 
 sounds which are devoid of the vesicular quality. Be- 
 tween the second and third ribs, the inner borders of the 
 two lungs approximating, the resonance has a vesicular 
 quality more or less marked ; but owing to the remnant 
 of the thymus gland, together with adipose substance, 
 and the presence of the large vessels, the resonance is 
 not intense in this situation. Below the third rib the 
 resonance has modifications due to the combination of 
 several different organs situated beneath the lower sternal 
 region. On the right side of the mesial line is the inner 
 border of the right lung, the greater part of the right 
 and a portion of the left ventricle of the heart lying 
 beneath ; a portion of the liver extends into the lower 
 part of this region, and a portion of the stomach when 
 distended. The resonance thus varies in different situa- 
 tion.s, and often presents a mixed character. It is a use- 
 ful exercise to endeavor to define by percussion the 
 boundaries of the several organs which are here in jux- 
 taposition. 
 
 Infra- scapular Regions. — The resonance below the 
 
48 PERCUSSION IN HEALTH. 
 
 scapula is intense as compared with that over the scapula, 
 and the vesicular quality is marked. The resonance ex- 
 tends to the eleventh rib, which is the lower boundary of 
 the lung. On the right side, at or near this point, is the 
 line of hepatic flatness, hepatic dulness extending from 
 one to two inches above this line. The line of hepatic 
 flatness and of hepatic dulness is lowered from one to 
 two inches by a deep inspiration, and raised by a forced 
 expiration. On the left side the resonance may receive 
 a tympanitic quality from the presence of gas in the 
 stomach. 
 
 Lateral Regions. — In these regions the resonance is 
 relatively intense, and notably vesicular. On the right 
 side the line of hepatic flatness is at the eighth rib, 
 hepatic dulness extending above this line as in front and 
 behind. On the left side the resonance may be rendered 
 somewhat dull by the presence of the spleen, but it 
 oftener acquires a tympanitic quality from the presence 
 of gas in the stomach. 
 
 As has been stated, the normal vesicular resonance is 
 not in all persons identical as regards intensity, pitch, 
 and quality. There is, therefore, no fixed standard in 
 these respects by which we can determine whether the 
 resonance be normal or not. The standard proper to 
 each person is to be ascertained by a comparison of the 
 two sides of the chest; each person, in other words, 
 furnishes his own standard of health. But it is to be 
 observed, that all the regions do not normally correspond 
 in respect of the resonance on the two sides. In the 
 following regions the resonance is notably dissimilar on 
 the two sides: The mammary, the infra-mammary, the 
 infra-axillary, and the infra-scapular. On the other 
 hand, in the following region the resonance on the two 
 
RESONANCE IN DIFFERENT REGIONS. 49 
 
 sides is nearly or quite identical : The supra-clavicular, 
 clavicular and infra-clavicular, the scapular and inter- 
 scapular, and the axillary. In some of the latter the 
 resonance has normally some points of disparity, and it 
 is of practical importance to note the small dissimilarity 
 which thus belongs to health. This statement applies 
 especially to the-infra-clavicular region, a region which, 
 as will be seen hereafter, is of great importance with 
 reference to the signs of phthisis. In this region the 
 resonance on the left side is somewhat more intense, 
 more vesicular, and lower in pitch than is the resonance 
 on the right side ; per contra^ the resonance is less intense, 
 less vesicular, and higher on the right side. This dis- 
 parity is observable in all persons, but is more marked 
 in some than in others. The student should becouie 
 practically familiar with this normal difference between 
 the two sides, and in becoming so, the practical experi- 
 ence acquired in performing percussion will be of use. 
 
 The normal resonance is affected by age. In early 
 life, when the costal cartilages are flexible and elastic, 
 the resonance is more intense and lower in pitch than in 
 old a2;e, when the cartilao:es are rio;id and the vesicular 
 structure of the lung more or less atrophied. 
 
 The resonance varies considerably in the different 
 regions at the end of a full inspiration and at the end of 
 a forced expiration. With regard to this disparity, the 
 following is an extract from a work on physical explora- 
 tion, published by the author in 1856 : 
 
 '' The percussion-sound may also be found to vary at 
 different periods of an act of respiration in the same 
 individual. The quantity of air contained within the 
 air-cells, and consequently the relative proportion of air 
 and solids, are by no means equal after a full inspiration 
 
60 PERCUSSION IN HEALTH. 
 
 and after a forced expiration. This difference in lung 
 expansion may occasion an appreciable disparity in reso- 
 nance, according as the percussion is made at the conchi- 
 sion of a full inspiration, or a forced expiration. The 
 disparity is not appreciable uniformly in different persons. 
 This fact I have ascertained by noting the results of 
 examinations made with reference to the point. When 
 it does exist, it usually consists, contrary to what might 
 perhaps have been anticipated, and the reverse of what 
 is usually stated in works on physical exploration, in 
 diminished resonance and elevation of pitch at the con- 
 clusion of inspiration. This is probably to be explained 
 by the greater degree of tension of the lungs and thoracic 
 walls produced by inspiration voluntarily prolonged and 
 maintained — aconditiou presenting physical obstacles to 
 vSonorous vibrations more than sufficient to counterbalance 
 the increased proportion of air within tlie cells. It is a 
 curious fact, worthy of notice, that the two sides of the 
 chest are not always found to be affected equally as 
 regards the percussion-sound, at the conclusion of a full 
 inspiration, contrasted with that after a forced expira- 
 tion. I have observed the contrast to be more striking 
 on the right than on the left side ; and in one instance 
 on the left side, the resonance was less intense and some- 
 what tympanitic after a full inspiration, while on the 
 right side the o])posite effect was produced, and the 
 sound became quite dull after a forced expiration. In 
 view of these variations in a certain proportion of in- 
 stances incident to different periods of a single act of 
 respiration, in some cases of disease in which it is de- 
 sirable to observe great delicacy in the correspondence 
 of the two sides, pains should be taken to percuss cor- 
 responding points at a similar stage of respiration, and 
 
KULES IN PRACTICE OF PERCUSSION. 51 
 
 the close of a full inspiration is, perhaps, the period to 
 be preferred. Ordinarily, the liability to error from 
 this source is obviated, either by repeating a series of 
 strokes, first on one side and next on the other, or by 
 percussing both sides repeatedly in quick succession, in 
 order mentally to obtain the average intensity and other 
 characters of the sound during the successive stages of a 
 respiration. The instances of disease, however, are ex- 
 ceedingly rare, in which such nicety of discrimination is 
 important. ^^ 
 
 Prof. Da Costa has recently studied more fully the 
 variations in this respect in the different regions in dis- 
 ease as well as in health, and he has distinguished this 
 as '^respiratory percussion."^ 
 
 Rules in the Practice of Percussion. 
 
 1. Prior to a comparison of the two sides of the chest, 
 as regards the resonance on percussion, either in health 
 or disease, an examination by inspection should be made, 
 in order to determine whether there be any deviation 
 from the normal conformation. In what has been stated 
 concerning percussion in health, it is assumed that the 
 chest is symmetrical. Want of symmetry may be due 
 to congenital deformities, and to those caused by rachitis, 
 chronic pleurisy, curvature of the spine, and injuries. 
 Any deviation from the normal conformation will affect 
 more or less the resonance in corresponding regions on 
 the two sides. Due allowance is to be made for want of 
 symmetry in determining morbid signs, and often the 
 existence of these cannot be determined with positiveness 
 when there is considerable deformity. The signs ob- 
 
 ' Vide work on Diagnosis, fourth edition, 1876. 
 
52 PERCUSSION IN HEALTH. 
 
 tained by auscultation are less affected by want of sym- 
 metry than those obtained by percussion. 
 
 2. Attention to the position of the person examined is 
 important with reference to the normal symmetry of the 
 chest. If the person be standing or sitting, the position 
 should be upright and the shoulders brought to a level. 
 A little inclination of the body to one side, or a depres- 
 sion of one shoulder, will be found to affect perceptibly 
 the normal resonance, when the two sides are compared. 
 If the body be recumbent, it should be as near as possible 
 on a level plane. These conditions are indispensable 
 for a nice comparison of the two sides either in iiealth or 
 disease. 
 
 3. In making a nice comparison, the person who per- 
 cusses should be, as nearly as possible, directly either in 
 front or behind the person percussed. Percussion made 
 by one standing or sitting by tlie side of the person per- 
 cussed, is almost certain to produce disparity in resonance. 
 
 4. Percussion made successively on one side, and the 
 other side, must be in all respects the same, in regard to 
 the mode, the force of the blow, and the situation, A 
 light percussion on one side, and a strong percussion on 
 the other side, will, of course, cause a disparity in the 
 intensity of resonance. The percussion must be made in 
 succession at points as nearly as possible equidistant from 
 the median line, and from the summit or base of the chest. 
 With reference to great nicety, the percussion, if made 
 on the rib or intercostal space on one side, must be made 
 on the rib or intercostal space on the other side. Great 
 nicety of comparison also requires that, if the percussion 
 
RULES IN PRACTICE OF PERCUSSION. 53 
 
 be made on one side during the act of inspiration, it 
 should be made on the other side during this act. The 
 signs of disease, however, are generally so well marked, 
 that very close attention to these points is not necessary. 
 
 5. A series of blows in rapid succession (5 or 7) is to 
 be preferred to one or two, in j^racticing percussion, dif- 
 ference in intensity, pitch, and quality being thereby 
 better appreciated. 
 
 6. Percussion may be made lightly or forcibly, the 
 former being called superficial, and the latter deep per- 
 cussion. With light blows the resonance comes from the 
 superficies of the lung, and from within a limited area. 
 With forcible blows the resonance is from a greater depth, 
 and a wider space. The results of these different modes 
 of practising percussion may be illustrated within the 
 prsecordia in health. Comparing the resonance over the 
 superficial cardiac space with that in a corresponding 
 situation on the right side, dulness is more marked with 
 light than with forcible blows, the resonance from the 
 latter coming from a wider area. On the other hand, 
 comparing the resonance over the deep cardiac space, 
 dulness is more marked with forcible than with li^ht 
 blows, owing to the presence of lung between the heart 
 and the walls of the chest. This rule is of importance 
 in its application to percussion in disease. 
 
 7. Percussion over the anterior portion of the chest, 
 the person percussed leaning against a door, a board 
 partition, or a lathed wall, gives an increased intensity 
 of resonance. It is often useful to resort to this proce- 
 dure in the practice of percussion. 
 
 5 
 
54 PERCUSSION IN DISEASE. 
 
 CHAPTER III. 
 PERCUSSION IN DISEASE. 
 
 Enumeration of the signs of disease furnished by percussion — Re- 
 quirements for a practical knowledge of these signs — The distinctive 
 characters of, the morbid physical conditions represented by, and the 
 different diseases into the diagnosis of which enter, these signs, sev- 
 erally, to wit, 1. Absence of resonance or flatness; 2. Diminished 
 resonance; 3. Tympanitic resonance; 4. Vesiculo-tympanitic reso- 
 nance; 5. Amphoric resonance; 6. Cracked-metal resonance — Sense 
 of resistance felt in the practice of percussion, as a morbid sign. 
 
 Percussion in disease furnishes signs which represent 
 certain of the morbid physical conditions incident to the 
 different pulmonary affections; with these physical con- 
 ditions and their relations to pulmonary affections the 
 student is supposed to be familiar {vide page 19 et seq.). 
 
 The signs of disease furnished by percussion are re- 
 solvable into six, namely: 1. Absence of resonance or 
 flatness; 2. Diminished resonance or dulness ; 3. Tym- 
 panitic resonance ; 4. Vesiculo-tympanitic resonance ; 5; 
 Amphoric resonance, and 6. Cracked-metal resonance. 
 The two last named signs are properly varieties of tym- 
 panitic resonance, but it is most convenient to consider 
 them as distinct signs. 
 
 Knowledge of these six signs sufficient for their avail- 
 ability in physical diagnosis requires, first, a practical 
 acquaintance with the characters which distinguish each 
 from the others, as well as from the normal resonance; 
 and fiecondy a clear apprehension of the significance of 
 
ABSENCE OF RESONANCE OR FLATNESS. 55 
 
 each, that is, the morbid physical conditions which they 
 severally represent. Under tliese two asj)ects the signs 
 will now be considered. 
 
 1. Absence of Resonance or Flatness. 
 
 This sign is sufficiently defined by its name. It is 
 absence of resonance or sound. Nothing is heard but a 
 noise such as may be produced by percussing over a solid 
 mass, for example a limb composed of muscle and bone, 
 or over a collection of liquid, for example the abdomen 
 in hydro-peritoneum or ascites. There being no reso- 
 nance or sound, the sign has no characters pertaining to 
 pitch or quality. It may be illustrated on the healthy 
 chest by percussing in the right infra-mammary region 
 below the line of hepatic flatness. 
 
 There are four classes of morbid physical conditions 
 giving rise to flatness on percussion, namely, 1st, a cer- 
 tain quantity of liquid either in the pleural sac, or in 
 the substance of the lungs, or in pulmonary cavities : 2d, 
 liquid filling the air-vesicles; 3d, complete solidification 
 of lung; and 4th, a tumor within the chest. Flatness on 
 percussion always represents one of these morbid phys- 
 ical conditions. 
 
 These conditions are incidents to different diseases, as 
 follows : 
 
 1st. Liquid in the pleural cavity is incident to pleurisy 
 with effusion, empyema, and hydrothorax. A collection 
 of liquefied exudation within the lungs is incident to 
 phthisis. A collection of pus constitutes pulmonary 
 abscess, and phthisical cavities, or those caused by cir- 
 cumscribed gangrene, may become filled with morbid 
 liquid products. 
 
 2d. Serous effusion into the air-vesicles constitutes 
 
56 PERCUSSION IN DISEASE. 
 
 pulmonary oedema. Liquid blood extravasated charac- 
 terizes hsemorrhagic infarctus, pneumorrhagia or pulmo- 
 nary apoplexy. Pus infiltrating more or less of the 
 parenchyma may be derived from an abscess either within 
 the lung, or elsewhere, for example the liver, and from 
 the pleural cavity in empyema when perforation of lung 
 takes place. 
 
 3d. Solidification of lung occurs in pneumonia from 
 an exudation within the air-cells ; it is produced by con- 
 densation from compression by liquid or air in the pleural 
 sac, the pressure of a tumor, and by collapse; it exists 
 in cases of phthisis, in interstitial pneumonia, and in 
 carcinomatous infiltration of lung. 
 
 4th. Tumors within the chest are of diflPerent kinds, 
 for examples, aneurisms and cancerous growths. In 
 proportion to their size they occupy space belonging to 
 the lung, as well as condensing the latter by pressure. 
 Flatness may also be caused by the encroachment of 
 organs situated below the diaphragm upon the thoracic 
 space, as in cases of enlargement of the liver and spleen. 
 
 Flatness on percussion in all these conditions is the 
 same. The sign alone does not enable us to discriminate 
 the conditions from each other, nor to determine the ex- 
 isting disease. 
 
 Finding this sign present, the particular condition and 
 the disease in each case are to be determined by the 
 situation of the riatness, its extent, the associated physi- 
 cal signs furnished by auscultation, together wntli the 
 other methods of exploration, and by the symptomatic 
 phenomena. 
 
DIMINISHED RESONANCE OR DULNESS. 57 
 
 2. Diminished Resonance or Dulness. 
 
 The resonance on percussion is diminislied, or there is 
 dulness, when the solids or liquids within the chest are 
 morbidly increased without increase in the quantity of 
 air, the increased amount of solids or liquids not being 
 suffi jient to cause flatness. Diminution of air without in- 
 crease of either solids or liquids, as in collapse of pulmo- 
 nary lobules, also gives rise to dulness. We may forrau- 
 larize the physical conditions by saying that they consist 
 in an abnormal proportion of solids or liquids over the 
 air in the pulmonary vesicles. 
 
 Dulness varies in degree. It may be slight, moderate, 
 considerable, or great. These adjectives of quantity ex- 
 press sufficiently the variations in this regard. The 
 degree of dulness corresponds to the amount of the rela- 
 tive disproportion of solids or liquids over the air within 
 the chest. 
 
 The pitch of sound is higher than that of the normal 
 resonance of the persons percussed. This is invariable; 
 with dulness there is always more or less elavation of 
 pitch. The quality is altered only in amount; there is, 
 of course, less vesicular quality in proportion as the in- 
 tensity of the resonance is diminished. 
 
 The characters which distinguish this sign, thus, are, 
 lessened intensity of resonance, elevation of pitch, and 
 weakened vesicular quality. 
 
 The morbid conditions giving rise to this sign are those 
 which, existing in a greater degree, give rise to flatness. 
 Morbid products within the pleural sac, serum, pus, 
 lymph, if not sufficient to cause flatness, give rise to dul- 
 ness. The sign, therefore, occurs in pleurisy, empyema, 
 and hydrothorax. The same is true of pulmonary oedema, 
 hemorrhagic infarctus, pneuraorrhagia, and purulent in- 
 
68 PERCUSSION IN DISEASE. 
 
 filtration of lung. Solidification of lung, when not com- 
 plete, occasions dulness ; hence it is a sign in pneumonia, 
 vesicular and interstitial, in phthisis, in condensation of 
 lung from compression, in collapse of pulmonay lobules, 
 and in carcinomatous infiltration. A tumor within the 
 chest, not sufficiently large to cause flatness, gives rise 
 to dulness. 
 
 There are, however, some conditions giving rise to 
 dulness, which are never sufficient to cause flatness. 
 Pulmonary congestion limited to a lobe may diminish 
 the resonance appreciably. The dulness may exist in 
 the first stage of pneumonia, before solidification from 
 pneumonic exudation has taken place. A layer of lymph 
 upon the pleural surfaces causes dulness after the liquid 
 effusion in pleurisy has been removed, and after the 
 vesicular exudation in pneumonia is absorbed. Dulness 
 may also be caused by a considerable accumulation of 
 mucus or coagulated blood within the intra-pulmonary 
 bronchial tubes. 
 
 The particular morbid condition which gives rise to 
 dulness cannot be inferred from the characters of the 
 sisrn : the si^rn onlv denotes that some one of the difler- 
 ent morbid conditions exists. The condition which ex- 
 ists in each case, and the disease, are to be determined 
 by the situation, extent, and degree of dulness, taken in 
 connection with the Information derived from other 
 methods of exploration than percussion, together with 
 the history and symptoms. 
 
 3. Tympanitic Resonance. 
 
 Resonance is tympanitic whenever it is entirely devoid 
 of the vesicular quality; in other words, any resonance 
 which is non-vesicular is tympanitic. The leading dis- 
 
TYMPANITIC RESONANCE. 69 
 
 tinctlve character of the preceding sign (dulness) relates 
 to intensity, whereas, the leading distinctive character 
 of this sign relates to quality. Tympanitic resonance 
 derives no distinctive character from intensity; it may 
 be either more or less intense than the resonance of 
 health in the person percussed. This point is to be im- 
 pressed, inasmuch as with many the idea of a tympan- 
 itic resonance involves increased intensity of sound ; a 
 resonance, be it never so feeble, if it be non-vesicular, 
 is tympanitic. If, however, the resonance be quite fee- 
 ble, it is not always easy to determine whether there be, 
 or be not, any appreciable vesicular quality. The term 
 used by Stokes, namely, '^tympanitic dulness,^^ is prop- 
 erly enough applied to a resonance with diminished in- 
 tensity, in which a vesicular quality cannot be appreci- 
 ated. As regards pitch, a tympanitic resonance is higher 
 than the normal vesicular resonance. If there be any 
 exceptions to this rule, they are extremely infrequent. 
 The tympanitic resonance over different parts of the ab- 
 domen is always higher in pitch than the resonance over 
 healthy lung. 
 
 The following are the morbid physical conditions 
 which give rise to tympanitic resonance: 
 
 1st. Air in the pleural cavity. It is, therefore, a 
 sign of pneumothorax. Frequently, in this affection, 
 the tympanitic resonance is more intense than the reso- 
 nance of health, the pitch being more or less raised. 
 
 2d. Pulmonary cavities containing air. It occurs, 
 therefore, in cases of phthisis. In this disease the tym- 
 panitic resonance is limited to a circumscribed space cor- 
 responding to the site and size of the cavity, whereas, in 
 pneumothorax, it frequently exists over a considerable 
 part or the whole of the affected side of the chest. 
 
60 PERCUSSION IN DISEASE. 
 
 3cl. Comj)lete solidification of the whole or a part of 
 the upper lobe of a lung. The tympanitic resonance, 
 under these circumstances, must be derived from the air 
 in the lower part of the trachea and the bronchial tubes 
 exterior to the lungs. This is the explanation of the 
 sign in the second stage of pneumonia affecting an upper 
 lobe, and in certain cases of phthisis prior to the stage 
 of excavation. Dilatation of the intra-pulmonary bron- 
 chial tubes, with solidification surrounding them, as in 
 some cases of interstitial pneumonia or cirrhosis of lung, 
 may give rise to tympanitic resonance. 
 
 4th. Conduction of resonance from the stomach or 
 colon containing air or gas. A gastric tympanitic reso- 
 nance is frequently conducted over a part, and some- 
 times over the whole, of the left side of the chest. This 
 is more likely to occur when the left lung is solidified. 
 On the right side less frequently a tympanitic resonance 
 may be conducted upward from the colon to a greater or 
 less extent. 
 
 4. Vesiculo-Tympanitic Resonance. 
 
 This name was proposed by the author many years 
 ago to denote a sign with the following distinctive char- 
 acters : The resonance increased in intensity ; the quality, 
 a combination of the vesicular with a tympanitic, and 
 the pitch high in proportion as the tympanitic quality 
 predominates over the vascular. 
 
 The sign represents especially one morbid physical 
 condition, namely, an abnormal accumulation of air 
 in consequence of dilatation of the air-vesicles, that is, 
 pulmonary or vesicular emphysema. The sign also is 
 
AMPHORIC RESONANCE. 61 
 
 present in interstitial or interlobniar emphysema. The 
 relation of the si^n to these adections renders it of sreat 
 value in physical diagnosis. 
 
 A vesiculo-tympanitic » resonance is obtained, when 
 tlie pleural sac is partially filled with liquid, by percuss- 
 ing over the lung on the affected side. Although the 
 pressure of the liquid diminishes the volume of the lung, 
 as a rule it yields this sign. The resonance is vesiculo- 
 tympanitic above the liquid when the latter is sufficient 
 to fill a third, a half, or even two-thirds of the intra- 
 thoracic space. The sign is also obtained over the upper 
 lobe when the lower lobe is solidified in the second stage 
 of pneumonia, and over the lower lobe when the upper 
 lobe is solidified. 
 
 5. Amphoric Resonance. 
 
 Resonance is said to be amphoric when it has a musi- 
 cal intonation analogous to that produced by blowing 
 over the mouth of an empty bottle. An amphoric sound 
 is easily illustrated by filliping the cheek made tense, 
 the mouth not completely closed, and the jaws separated, 
 as is done when the sound of a liquid fiowing from a 
 bottle is imitated. By varying the size of the cavity of 
 the mouth, the amphoric sound thus })roduced may be 
 made to vary much in pitch. This illustration exempli- 
 fies the mechanism of the sign in disease. 
 
 The sign represents a pulmonary cavity which is gen- 
 erally phthisical. The conditions, aside from the exist- 
 ence of the cavity, are, rigidity of its walls, so that they 
 do not collapse, the presence, of course, of air within the 
 cavity, and free communications with the bronchial 
 tubes. These accessory conditions are not constant, so 
 
 G 
 
62 PERCUSSION IN DISEASE. 
 
 that an amphoric resonance over a cavity is sometimes 
 found, and other times wanting. Directly after having 
 been wanting, it may be reproduced if the patient expec- 
 torate freely. ' 
 
 When percussion is made with reference to this sign, 
 the mouth of the patient should be open, and one or two 
 rather forcible blows are better than a series of four or 
 six. The amphoric sound may be often distinctly per- 
 ceived if the ear be brought into close proximity to the 
 patient's open mouth, when the sign is not apj^reciable 
 otherwise. It may be rendered still more distinct by 
 means of the binaural stethoscope, the pectoral extremity 
 being close to the mouth of the patient. 
 
 As a cavernous sign the amphoric resonance is very 
 reliable; but it does not invariably denote a pulmonary 
 cavity. It is obtained in some cases of pneumothorax, 
 the pleural space filled with air forming a cavity which 
 communicates wnth the bronchial tubes through a per- 
 foration of the lung situated above the level of the liquid. 
 It is sometimes obtained over a solidified portion of lung 
 situated in close proximity to a primary bronchus, the 
 resonance being derived from the air within the latter. 
 It is occasionally produced by percussing over the site 
 of the primary bronchus in the second stage of pneu- 
 monia affecting an upper lobe. In children, owing to 
 the yielding of the costal cartilages, it may even be pro- 
 duced in health over a primary bronchus. In all these 
 exceptional instances, the associated signs and symptoms 
 will prevent the error of attributing the sign to a pul- 
 monary cavity. 
 
 This sign is properly a variety of tympanitic reso- 
 nance. 
 
CRACKED-METAL RESONANCE. 63 
 
 6. Cracked-metal Resonance. 
 
 The name of this sign, expressing an analogy to the 
 sound produced by striking a cracked metallic vessel, 
 denotes its peculiar character. It may be imitated by 
 folding the hands so as to form a cavity and striking 
 them upon the knee, in the familiar trick of producing 
 in this way a sound as if metal coins were between the 
 palms. This illustration, also, exemplifies the mecha- 
 nism of the sign. Like the sign last described, it is a 
 variety of tympanitic resonance. 
 
 The cracked -metal, like the amphoric, resonance rep- 
 resents generally a phthisical cavity. Percussion is to 
 be made in the same way as for the production of the 
 amphoric resonance, and, like the latter, the cracked- 
 metal character is often perceived if the ear be brought 
 close to the patient's mouth when otherwise it is not ap- 
 preciable. 
 
 The cracked-metal and the amphoric resonance are 
 often associated ; and the statements made with respect 
 to the exceptional instances in which the latter is pro- 
 duced, without the existence of a pulmonary cavity, will 
 apply equally to the former. 
 
 In addition to the acoustic phenomena produced by 
 percussion with the fingers applied to the chest instead 
 of a plexi meter, an abnormal sense of r^esistance is felt in 
 certain conditions of disease. In health, with a some- 
 what forcible percussion, the walls of the chest are felt 
 to yield in proportion as the costal cartilages are flexible. 
 This yielding is diminished or ceases when a collection 
 of liquid in the pleural cavity, or liquid in the air-vesicles, 
 and solidification of lung, offer a mechanical obstacle 
 
64 PERCUSSION IN DISEASE. 
 
 thereto. An abnormal sense of resistance on percussion, 
 thus determinable by comparison of the two sides of the 
 chest, is a sign representing some one of the morbid phys- 
 ical conditions just named. This properly belongs among 
 the signs obtained by palpation. The sign is to be 
 taken in connection with other signs in determining the 
 condition which exists in particular cases. 
 
AUSCULTATION IN HEALTH. 65 
 
 CHAPTER IV. 
 
 AUSCULTATION IN HEALTH. 
 
 niportance of the study of the auscultatory sounds in health — Imme- 
 diate and mediate auscultation — Advantages of the binaural stetho- 
 scope — Eules to be observed in auscultation — Divisions of the study 
 of auscultation in health — The normal laryngeal and tracheal respi- 
 ration — The normal vesicular murmur ; its distinctive character?, 
 and the variations in the different regions on the same side, and in 
 correspondingregionsonthe two sidesof the chest — The normal vocal 
 resonance — The laryngeal and tracheal voice and whisper — Tlie nor- 
 mal thoracic vocal resonance and fremitus ; the distinctive charac- 
 ters of each ; the variations in different regions on the same side, 
 and in corresponding regions on the two sides of the chest — The nor- 
 mal bronchial whisper, with its variations in diiferent regions on the 
 same side, and in corresponding regions on the two sides of the chest. 
 
 The terra auscultation, limited in its application to 
 the respiratory system, denotes the act of listening to the 
 normal and abnormal sounds produced by respiration, 
 voice, and cough. In this and the next chapter, the 
 method of exploration thus named will be considered in 
 its application to the respiratory system ; it will be con- 
 sidered subsequently, as applied to sounds relating to 
 the circulatory system. 
 
 The study of auscultatory sounds in health is essential 
 as preparatory for the study of auscultation in disease. 
 The student must be familiar with the normal sounds be- 
 fore undertaking to become acquainted with those which 
 represent morbid conditions. Ample time and attention 
 should be given to the study of auscidtation in health. 
 The omission to do this is a frequent cause of difBculty 
 
66 AUSCULTATION IN HEALTH. 
 
 and want of success in attaining to a satisfactory profi- 
 ciency in physical diagnosis. The practical tact and 
 skill required in diagnosis may be obtained in advance 
 by devoting sufficient study to the healthy chest before 
 entering on the study of the auscultatory signs of disease. 
 Moreover, as will be seen, some of the most important 
 morbid signs have their analogues in certain normal 
 sounds pertaining to the respiratory system. 
 
 Auscultation is either immediate or mediate. It is 
 immediate when the ear is applied directly to the chest, 
 which may be either denuded or covered with a cloth or 
 more or less of the clothing. It is mediate when the 
 sounds are conducted to the ear by means of an instru- 
 ment called a stethoscope. The student should practice 
 both immediate and mediate auscultation. The direct 
 application of the ear to the chest suffices for diagnosis 
 in many cases of disease; but there are sometimes ob- 
 jections to this by the patient on the score of delicacy, 
 and by the auscultator on the score of the uncleanliness 
 of the person examined. There are certain parts of the 
 chest which can only be explored by the stethoscope, and 
 this instrument has the advantage of circumscribing the 
 space whence the auscultatory sounds are derived. More- 
 over, by means of the stethoscope which is to be pre- 
 ferred over tiie great variety of instruments heretofore 
 in use, the sounds are heard much better than by imme- 
 diate auscultation. 
 
 The stethoscope which is to be preferred conducts the 
 sounds into both ears, that is, it is binaural. In this con- 
 sists its great superiority. At tlie present time wh;it is 
 known as Catnniann's stethoscope^ seems to combine more 
 recommendations than any otherformof abinaural instru- 
 
 ' Invented by the late Dr. Cauimunn, of New York. 
 
AUSCULTATION IN HEALTH. G7 
 
 ment. The conduction into both ears renders the sounds 
 much louder and more distinct than when they are heard 
 with one ear in either mediate or immediate auscultation. 
 Another advantage is, the mind is not distracted by 
 sounds entering the ear not employed in auscultation. 
 The advantages, however, of Canimann's stethoscope are 
 not appreciated until after some practice. At first, a 
 humming sound is heard which divides the attention and 
 thus obscures the intni-thoracic sounds. After a little 
 practice this humming sound is not heeded, and it ceases 
 to be any obstacle. Many wiio use the instrument only 
 a few times are dissatisfied with it and discontinue its 
 use, when, if they had used it longer, they would not have 
 been willing to dispense with it. The author's experi- 
 ence with a large number of classes in private instruc- 
 tion has been this: at first, most members of a class 
 prefer the ear applied directly to the chest; but, before 
 the course of instruction is ended, the binaural stetho- 
 scope is so much ])referred that it is difficult to enforce a 
 fair proportion of practice in inmiediate auscultation. 
 
 Another reason for the fact that this stethoscope is not 
 sufficiently appreciated in this country is, many of the 
 instruments sold are defectively made. Unless proper 
 attention has been paid to all the nice points of the 
 stethoscope as devised by Cammann, an instrument is 
 worthless. An instrument must be very good, or it is 
 without any value. The knobs which are to enter the 
 ears must be of the right size ; if they enter too far they 
 occasion ])ain. The curves at the aural extremity must 
 be such that the aperture is in the direction of the meatus 
 of the ear. The flexible tubes must not be stiff, and 
 their movements must be noiseless. All the tubes must 
 be unobstructed, for it is the air within the tubes which 
 
68 AUSCULTATION IN HEALTH. 
 
 chiefly conducts the sounds. In the use of the instru- 
 ment it should be applied to the chest without any inter- 
 vening clothing.^ 
 
 The rules to be observed in the practice of ausculta- 
 tion, in health and disease, may be here introduced. 
 
 In auscultation, as in percussion, corresponding situa- 
 tions on the two sides of the chest are to be explored 
 successively, and compared. When the stethoscope is 
 used, tliB pectoral extremity must be applied on each side 
 with the same degree of pressure; this is especially 
 essential in the comparison of vocal sounds. In imme- 
 diate auscultation, the ear is to be applied with a certain 
 degree of force, and a thin layer of clothing does not 
 interfere materially with the perception of auscultatory 
 sounds. The ear not applied to the chest may or may 
 not be closed by the finger in listening to the respira- 
 tory sounds ; it should be closed in listening to the vocal 
 sounds, in order to prevent confusion from attention to 
 the voice from the patient's mouth. In immediate aus- 
 cultation, whenever practiced, the auscultator should 
 take a position which will not interfere with the sense of 
 hearing, and not occasion a feeling of discomfort. These 
 difficulties are in the way of auscultating with the body 
 bent forward ; the sense of hearing is dulled by the de- 
 tention of blood in the head, and the position cannot be 
 maintained without discomfort. The person examined, 
 if practicable, should be sitting, and the position for the 
 auscultator is that of kneeling on one knee, and lower- 
 ing, if necessary, the body, so that the head may be kept 
 upright. These points are less important if the binaural 
 stethoscope be used. 
 
 ^ The stetlioscopes made by Tieinann & ('o. nnd Ford ik Co. are 
 reliable. 
 
AUSCULTATION IN HEALTH. 69 
 
 When listening to respiratory sounds, it is generally 
 desirable that the person examined should breathe with 
 somewhat greater fo roe than in ordinary breathing; but 
 it is important that the normal rhythm of respiration 
 should be unchanged. Persons when requested to breathe 
 with increased force are apt to err in breathing violently, 
 and sometimes too slowly. The readiest mode of obtain- 
 inir what is desired, is for the examiner to illustrate it 
 by his own breathing. A complete exi)iration is impor- 
 tant in order to secure a satisfactory inspiration. It 
 should, therefore, be made clear by explanation and 
 illustration, that each expiration should be finished be- 
 fore the following inspiration. Breathing through Dr. 
 E. Holden's *' Resonator," a flexible tube of consider- 
 able size, with a mouth-piece, secures the requisite force 
 of the resi)iratory acts, and is in this way useful. 
 
 The ability to abstract the mind from thoughts and 
 other sounds than those to which the attention is to be 
 directed, is essential to success in auscultation. All per- 
 sons do not possess equally this ability, and herein is an 
 explanation in part of the fact that all are not alike suc- 
 cessful. To develop and cultivate by practice the power 
 of concentration, is an object which the student should 
 keep in view. Generally, at first, complete stillness in 
 the room is indispensable for the study of auscultatory 
 sounds; with i)ractice, however, in concentrating the 
 attention, this becomes less and less essential. 
 
 The study of auscultation in health embraces the fol- 
 lowing: 
 
 1. The sounds produced by respiration as heard over 
 the larynx and trachea, or the normal laryngeal and 
 tracheal respiration. 
 
70 AUSCULTATION IN HEALTH. 
 
 2. The sounds heard over the chest in the acts of res- 
 piration. These sounds, coming cliiefly from the air- 
 vesicles, constitute what is called the normal vesicular 
 murmur. 
 
 3. The resonance as heard over the chest, and the vi- 
 bration or thrill produced by the loud voice, or the 7ior- 
 mal vocal resonance and fremitus. 
 
 4. The sounds as heard over the chest, with the whis- 
 pered voice, or, inasmuch as these sounds are conducted 
 chiefly by the air in the bronchial tubes, the normal 
 hroncldal whisper. 
 
 These four normal signs will be considered in the 
 forego i no; order. 
 
 Normal Laryngeal and Tracheal Respiration. 
 
 Forall practical purposes the laryngeal and the tracheal 
 respiration may be considered to be identical, that is, the 
 shades of difference between the sounds in these two situ- 
 ations are not of importance as regards the application 
 to physical diagnosis. The laryngeal respiration is more 
 readily studied than the traclieal, and for the study of 
 both the stethoscope is necessary. 
 
 Applying the stethoscope over the side of the larynx, 
 the person examined breathing with some increase of 
 force, but without any alteration in rhythm, a sound is 
 heard with each of the two acts of respiration. The 
 inspiratory and the expiratory sound, studied separately 
 and contrasted with each other, have the following char- 
 acters relating to intensity, pitch, quality, duration, and 
 rhythm: The inspiratory sound is of variable intensity. 
 In ordinary breathing it varies much in different persons, 
 and in different acts of breathing in the same person. 
 It is always considerably intense in forced breathing. 
 
NORMAL LARYNGEAL RESPIRATION. 71 
 
 The pitch is high when compared with the inspiratory 
 sound as heard over the chest. The quality of tlie 
 sound is well defined by the word tubular ; the sound at 
 once suffsrests a current of air through a tube. Tlie 
 duration of the sound is from the beginning to nearly, 
 not quite, the end of the inspiratory act. The characters 
 of the inspiratory sound, thus, are more or less intensity, 
 a high pitch, a tubular quality, and a duration a little less 
 than that of the act of inspiration. 
 
 An expiratory sound is always heard with forced 
 breathing. As regards duration, it is as long as, or 
 longer than, the sound of inspiration. In general it is 
 more intense than the sound of inspiration. The pitch 
 is higher than that of the inspiratory sound. The 
 quality is the same as that of the inspiratory sound, 
 namely, tubular. 
 
 Repeating the characters distinctive of the normal 
 laryngeal respiration, they are as follows : The inspira- 
 tory sound is of variable intensity, high in pitch, and 
 tubular in quality. The expiratory sound is as long as, 
 or longer than, the inspiratory sound ; it is higher in 
 })itch, and usually more intense. Owing to the ins})ira- 
 tory sound not continuing quite to the end of the inspira- 
 tory act, there is a very short interval between the two 
 sounds. In this latter point consists the only variation 
 between the rhythm of the acts of breathing and that of 
 the sounds. ^ 
 
 The foregoing characters should not only be verified 
 by the student, but he should become so familiar with 
 them by practice that it requires no effort of the mind to 
 recollect them. It will be seen hereafter that these 
 characters of the normal laryngeal respiration are pre- 
 cisely those which distinguish an important morbid phys- 
 ical sign, namely, the bronchial or tubular respiration. 
 
72 AUSCULTATION IN HEALTH. 
 
 Normal Vesicular Murmur. 
 
 This is the name usually given to the respiratory 
 sounds heard over the different regions of the chest. 
 These sounds should be studied with the ear applied 
 directly to the chest (immediate auscultation), as well as 
 with the stethoscope. In commencing the study, the 
 middle of the anterior surface of the chest on the right 
 side, to avoid the sounds of the heart, or still better, 
 the posterior aspect below the scapula on either side, 
 should be selected. The person exaiuined should breathe 
 somewhat more forcibly than in ordinary breathing, but 
 not violently nor quickly, nor too slowly, the normal 
 rhythm being unchanged. Children are better than 
 adults for this study, owing to the greater intensity of 
 the murmur in early life. 
 
 The characters which belong to the inspiratory and 
 the expiratory sound in the normal vesicular murmur 
 are as follows : The inspiratory sound is of variable in- 
 tensity. There is a wide variation in different healthy 
 persons. In some persons it is so feeble as scarcely to 
 be appreciable even with the binaural stethoscope. The 
 pitch of the sound, compared with the inspiratory sound 
 in the normal laryngeal or tracheal respiration, is nota- 
 bly low. The quality of the sound is peculiar; no dis- 
 tinct idea of the quality can be formed by any com- 
 parison. The name used to designate the quality is 
 vesicular, this name only denoting that the air-vesicles 
 are in some way concerned in the production of the sound. 
 This vesicular quality must be impressed upon the per- 
 ception and memory by direct observation. The dura- 
 tion of the inspiratory sound is from the beginning to 
 the end of the inspiratory act. 
 
NORMAL VESICULAR MURMUR. 73 
 
 An expiratory sound is not always, altliongh generally, 
 appreciable. It is much less intense than the sound of 
 inspiration. It is notably lower in pitch than the sound 
 of inspiration. The quality of the sound is neither vesicu- 
 lar nor tubular. It may be called simply a blowing 
 sound, and may be imitated by blowing with the mouth 
 partially opened. The duration is much shorter than 
 that of the inspiratory sound. 
 
 The characters, thus, which distinguish the normal 
 vesicular murmur are, an inspiratory sound variable in 
 intensity, low in pitch, and vesicular in quality; an ex- 
 piratory sound less intense than the inspiratory, still 
 lower in pitch, non-vesicular and non-tubular, or simply 
 blowing; the inspiratory sound continuing from the be- 
 ginning to the end of the inspiratory act, and the expira- 
 tory sound beginning with the expiratory act but ending 
 before this act is completed, its duration, relatively to 
 the inspiratory sound, being variable, but averaging 
 about a fifth. The inspiratory sound continuing to the 
 end of inspiration, and the expiratory sound beginning 
 with the act of expiration, it follows that there is no in- 
 terval between the two sounds. It is to be remarked 
 that an interval is not infrequently produced by the per- 
 son examined holding the breath after inspiration is 
 completed. This variation in the rhythm of the acts, of 
 course, produces a corresponding variation in sounds of 
 breathing. 
 
 The student should verify these characters, compare 
 them with the characters of the normal laryngeal respira- 
 tion, and become practically familiar with the ditferen- 
 tial points. He should then proceed to study the normal 
 vesicular murmur in the different regions of the chest. 
 The murmur will be found to present variations in the 
 
74 AUSCULTATION IN HEALTH. 
 
 different regions on the same side, and in tlie correspond- 
 ing regions on the two sides of the chest. The variations, 
 within the range of health, in the latter are especially 
 important. The following account of the murmur in the 
 different regions embodies the results of the analysis of 
 a series of recorded examinations of healthy persons. 
 
 Right and Left Infra ■clavicular Region. — The mur- 
 mur in this region, on either side, differs more or less 
 from the murmur as heard in the anterior regions below, 
 or in the infra-scapular region. The vesicular quality 
 in the inspiration is less marked. The pitch is higher. 
 The expiratory sound is longer, less feeble, and higher 
 in pitch. The difference between the two sides in this 
 region is especially important with reference to diagnosis. 
 The intensity of the inspiratory sound is almost invaria- 
 bly greater on the left side. Its vesicular quality is 
 more marked, and the pitch is lower. Per contra, the 
 inspiratory sound on the right side, in this region, is less 
 intense, less vesicular, and higher in pitch than the in- 
 spiratory sound on the left side. In forced breathing 
 the intensity of the murmur is increased more on the 
 left than on the right side. The expiratory sound is 
 sometimes wanting on the left, when it is heard on the 
 right side. On the right side, the expiratory sound is 
 longer than on the left side. It may be prolonged on 
 the right side to nearly or quite the length of the inspi- 
 ratory sound. Sometimes on the right side the pitch of 
 the expiratory is higher than that of the inspiratory on 
 the same side, and it may have a tubular quality. A 
 rare peculiarity is a prolonged, higli, tubular expiratory 
 sound on both sides, analogous to the laryngeal or tra- 
 cheal expiration. When this is the case, the pitch of 
 
NORMAL VESICULAR MURMUR. 75 
 
 the expiratory sound is higher on the left than on the 
 riocht side. 
 
 These several modifications of the respiratory murmur 
 in the infra-clavicular region are marked in proportion 
 as the sounds are studied near the sternum, that is, over 
 the site of the primary bronchi. The respiratory mur- 
 mur in this situation has been called the normal bronchial 
 respiration, from its resemblance to the morbid sign so 
 named. It may be more properly called a vesiculo- 
 tubular, or the normal broncho-vesicular respiration, the 
 characters beino; those of the morbid sig-n which, under 
 the latter name, will be described in the next chapter. 
 
 In the diagnosis of diseases, especially of phthisis, due 
 allowance must be made for the points of disparity which 
 exist normally between the two sides of the chest in the 
 infra-clavicular region. Without a practical knowledge 
 of these points of disparity^ error in diagnosis can hardly 
 be avoided. 
 
 Rigid and Left Scapular Region. — As compared with 
 the infra-clavicular region, the respiratory murmur heard 
 over the scapula on either side is feeble, and the vesicu- 
 lar quality is less marked. Tiie inspiratory sound is 
 generally weaker and the pitch higher on the right than 
 on the left side. Tiie expiratory sound is more con- 
 stantly heard on the right than on the left side. It may 
 be prolonged on the right side, and is sometimes higher 
 in pitch than the inspiratory sound. Compared with the 
 left side, the murmur on the right, in this region, thus 
 may have vesiculo-tubular or broncho-vesicular charac- 
 ters more or less marked. 
 
 Right and Left Lnter- scapular Region. — In tlie upper 
 and middle portions of this region, the normal characters 
 are the same as in the sterno-clavicular portion of infra- 
 
76 AUSCULTATION IN HEALTH. 
 
 clavicular region. The same points of disparity between 
 the two sides are more or less marked here as they are 
 anteriorly over the site of the primary bronchi. 
 
 Right and Left Infra-scapular Region. — The inten- 
 sity of the murmur is greater than over the scapular 
 region. In most persons there is no notable disparity 
 between the two sides ; when a disparity exists, the in- 
 tensity is greater and the pitch lower on the left side. 
 A prolonged, high-pitched, bronchial expiratory sound 
 is sometimes transmitted below the scapula on the right 
 side. 
 
 Right and Left Mammary and Infra-mammary Re- 
 gions. — The inspiratory sound in these regions is less 
 intense than in the infra-clavicular region ; the vesicular 
 quality is more marked, and the pitch is lower. An ex- 
 piratory sound is often wanting. 
 
 Right and Left Axillary and Infra-axillary Regions. 
 — The inspiratory sound in these regions is as intense 
 as in any portion of the chest. The intensity is less in 
 the infra-axillary than in the axillary region, and the 
 pitch is lower. In some persons the murmur on the 
 two sides presents no disparity, but in other persons the 
 vesicular quality is somewhat more marked and the pitch 
 is lower on the left than on the right side. An expira- 
 tory sound is oftener heard than in the mammary and 
 infra-mammary regions. 
 
 Normal Vocal Rescnance. 
 
 Laryngeal and Tracheal Voice. — It will prepare the 
 student for the appreciation of the distinctive characters 
 of tlie morbid signs pertaining to the voice, to study the 
 vocal signs over the larynx and trachea. Applying the 
 
NORMAL VOCAL RESONANCE. 77 
 
 stethoscope either over the broad surface of the thyroid 
 cartilage, or just abov^e the stenial notch, and requesting 
 the person examined to count with a moderate intensity 
 of voice, the auscultator perceives a strong resonance, 
 with a sensation of concussion or shock, and a sense of 
 vibration, thrill, or fremitus. The voice seems to be 
 concentrated and near the ear. Sometimes the articulated 
 words are transmitted so as to be heard more or less dis- 
 tinctly. The laryngeal or tracheal voice, thus (laryn- 
 gophony, tracheophony) embraces different elements, 
 namely, 1st, the vocal resonance; 2d, the concentration 
 and nearness to the ear; 3d, the vibration, thrill, or 
 fremitus ; and 4th, the transmission of the speech, the 
 latter corresponding to pectoriloquy. These different 
 elements will be found to enter into the distinctive char- 
 acters of morbid vocal signs. 
 
 The sounds heard over the larynx and trachea when 
 words are spoken in a w^hisper should bestudied, inasmuch 
 as important morbid signs relate to the whispered voice. 
 Whispered words occasion little or no shock or thrill, but 
 an intense, high-pitched tubular sound, with a sensation 
 as if a current of air were directed into the ear throuorh 
 the stethoscope. This sound corresponds to the sound 
 of expiration in laryngeal or tracheal respiration; the 
 two sounds are, in fact, identical if, as is the case with 
 some exceptions, the person whisper with the expiratory 
 breath. Articulated words are transmitted with more 
 or less distinctness, thus corresponding with the morbid 
 sign called whispering pectoriloquy. 
 
 Normal Thoracic Vocal Resonance and Fremitus. — 
 The vocal resonance over the chest is to be studied both 
 by means of the stethoscope and by immediate ausculta- 
 tion. When the latter is employed, the car not applied 
 
 7 
 
78 AUSCULTATION IN HEALTH. 
 
 to the chest should be closed, in order to exclude the 
 entrance of sound from the mouth of the person exam- 
 ined. When the stethoscope is employed, care must 
 be taken, in making a comparison between the two sides 
 of the chest, or between different regions on the same 
 side, that the pectoral extremity of the instrument be 
 pressed \vith an equal amount of force against the chest. 
 The intensity with which the vocal resonance is trans- 
 mitted, is much affected by the degree of pressure with 
 the stethoscope. 
 
 The situations in which the student should commence 
 the study of the normal vocal resonance are those selected 
 for beginning the study of the normal vesicular murmur, 
 namely, the middle of the anterior aspect of the chest on 
 the right side, and below the scapula behind. 
 
 With the stethoscope or the ear directly applied in 
 the situations just named, the person examined should 
 be requested to count one, two, three, in a uniform tone, 
 and with moderate force. The examiner should himself 
 pronounce these numerals, in order to show the manner 
 of counting. This is far better than asking a question 
 and studying the resonance during the answer of the 
 person examined. The objection to the latter mode is, 
 the attention of the examiner is divided between the 
 characters of the thoracic resonance and the idea con- 
 veyed by the answer. The characters of the vocal reso- 
 nance in these situations are as follows : 
 
 The voice is heard with an intensity which varies 
 very much in different persons ; in some the resonance 
 is feeble, and it may be almost inappreciable, while in 
 others it is quite intense. The intensity depends greatly 
 on the loudness and lowness in pitch of the voice of the 
 person examined. The resonance is notably weaker in 
 
NORMAL VOCAL RESONANCE. 79 
 
 women than in men. It is rarely attended with a sense 
 of concussion or shock. It is diffused; tliat is, it does 
 not seem to be concentrated, like the tracheal or laryn- 
 geal vocal resonance. It evidently comes from a certain 
 distance; that is, the sound does .not seem to be near the 
 ear. This latter character is distinctly appreciable, and 
 is highly distinctive of the normal resonance as com- 
 pared with a morbid vocal sign (bronchophony). The 
 resonance is accompanied by a sense of vibration, thrill, 
 or fremitus, the intensity of which, like the resonance, 
 varies much in diiferent persons. This fremitus is prop- 
 erly not an acoustic but a tactile sign. The normal vocal 
 fremitus, together with its abnormal modifications, be- 
 longs to the method of physical exploration called pal- 
 pation. It is, however, appreciated by the ear as well 
 as by the touch, and may be studied in the practice of 
 auscultation. The student should practically distinguish 
 from each other, and study separately, the vocal reso- 
 nance and vocal fremitus. 
 
 From the foregoing characters the normal vocal reso- 
 nance may be defined as, diffused, distant, variable in 
 intensity, and accompanied with more or less vibration, 
 thrill, or fremitus. 
 
 Having become practically familiar with these char- 
 acters of the normal vocal resonance in the situations in 
 which they are first to be studied, the next object of 
 study relates to the normal variations in the different 
 regions on the same side of the chest, and in correspond- 
 ing regions on the two sides. In giving an account of 
 these variations, based on a series of recorded examina- 
 tions in healthy persons, the different regions will be 
 considered in the same order as in the study of the vari- 
 ations of the respiratory sounds (vide p. 74 et seq.). 
 
80 AUSCULTATION IN UEALTH. 
 
 Infra-clavicular Region. — The vocal resonance in this 
 region on either side is more intense than in the anterior 
 regions below, the intensity, however, in different per- 
 sons being very variable ; irrespective of intensity, it is 
 less diffused, nearer the ear, and the pitch is somewhat 
 higher. These latter variations are marked chiefly in 
 the sterno-clavicular extremity of the region, that is, 
 over the site of the primary bronchi. In some persons 
 the concentration, nearness to the ear and elevation of 
 pitch, especially on the right side, are such as to approx- 
 imate the normal resonance to the morbid sign called 
 bronchopliony. The characters of this sign will be con- 
 sidered in the next chapter, but it is important to know 
 that exceptionally these characters may be, in a measure, 
 illustrated in health in the infra-clavicular region. The 
 resonance may then be termed normal bronchophony. 
 
 A comparison of the resonance in the region on the 
 right and on the left side always shows a disparity. The 
 resonance on the right side is invariably greater. The 
 degree of difference between the two sides varies in dif- 
 ferent persons. The resonance may be more or less 
 marked on the right and nearly wanting on the leftside. 
 Allowance is to be made for the points of normal dis- 
 parity between the two sides in the diagnosis of disease; 
 hence the student must become practically familiar with 
 them. 
 
 The vocal vibration or fremitus varies fully as much 
 as the vocal resonance in different persons. Its intensity 
 is not always proportionate to that of the resonance ; that 
 is, the resonance may be com[)aratively weak when the 
 fremitus is strong, and vice-versa. The fremitus, like the 
 resonance, is always greater on the right than on the 
 
NORMAL VOCAL RESONANCE. 81 
 
 left side, the disparity, like that of the resonance, vary- 
 ing; considerably in difl'erent persons. 
 
 Sca'pular Region. — The resonance in this rei2:ion is 
 notably less intense than in the infra-clavicnlar region. 
 It is also more diffused and dis-tant. The intensity is 
 always greater on the right side. These statements are 
 alike ap[>licable to the vocal fremitus. 
 
 Jntcr-^capular Rajion. — The intensity of the reso- 
 nance here is nearly or quite as great as in the sterno- 
 clavicular extremity of the infra-clavicular region. The 
 resonance has in some |)ersons in this region the charac- 
 ters of bronchophony. The intensity is always greater 
 on the right sitle. The fremitus is more or less marked, 
 and always more marked on the right than on the left 
 side. 
 
 Infra-scapular Region. — As a rule, the resonance in 
 this region is stronger than over the scapula. It is 
 always characterized by diffusion and distance. As in 
 all the regions, it varies niuch in different persons, and 
 is stronger, on the right than on the left side. These 
 statements are also applicable to fremitus. 
 
 Mammary and Infra-mammary Region>>. — The reso- 
 nance is notably less than at the summit of the chest. The 
 characters of bronchophony are never present. The 
 intensity is greater on the right side. The same is true 
 of fremitus. 
 
 Axillary and Infra-axillary Regions. — The resonance 
 in these regions, and especially in the axillary region, is 
 greater than over the mammary and infra-mammary re- 
 gions. It is, of course, stronger on the right side. The 
 characters as contrasted with those of bronchophony, 
 namely, distance and diffusion, are marked. Fremitus 
 
82 AUSCULTATION IN HEALTH. 
 
 is more or less marked, and, of course, more marked on 
 the right than on the left side. 
 
 Normal Bronchial Whisper. 
 
 Prior to the publication of the author's work on the 
 "Physical Exploration of the Chest," in 1856, signs in 
 heaUh and disease relating to the whispered voice had 
 received but little attention. In that work, and more 
 fully in the second edition, published in 1866, a series 
 of signs accompanying whispered words were described 
 and named. As a point of departure for the study of 
 the morbid signs thus obtained, of course the signs in 
 health must first be studied. The sounds which are 
 heard over different parts of the chest in health I have 
 embraced under the name, the normal bronchial whis- 
 per. The pertinency of this name is derived from the 
 fact that the conduction of the sound produced by the 
 whispered voice must be chiefly by the air contained in 
 tlie bronchial tubes. The sound heard over the trachea 
 and larynx may be distinguished as the laryngeal or 
 tracheal whisper, the characters of which have been 
 already stated (vide page 77). 
 
 It will facilitate the study of the normal bronchial 
 whisper, as well as of the morbid signs, to consider that 
 the characters of the sounds produced with the whispered 
 voice are identical with those produced by the act of 
 expiration in all respects save intensity. Whispered 
 words are produced, as a rule, by an act of expiration, 
 the sounds being more intense generally than those which 
 accompany even forced breathing. Curiously enough, 
 there are exceptions to this rule. Some persons insist 
 upon whispering with the act of inspiration, and there 
 are some persons who have never acquired the ability to 
 
NORMAL BRONCHIAL WHISPER. 83 
 
 whisper. It will be at once evident that the pitch and 
 quality of sounds produced by whispered words with 
 the act of expiration, must be the sanae as those of the 
 sounds of expiration in breathing. 
 
 Selecting for the study of the normal bronchial 
 whisper the same situations as in commencing the 
 study of the normal respiratory murmur, and the nor- 
 mal vocal resonance, namely, the middle of the chest in 
 front, on the right side, and the infra-scapular region be- 
 hind, with the whispered voice in these situations is heard, 
 in most persons, a feeble, low-pitched blowing sound, 
 these characters corresponding to those of the expiratory 
 sound in forced breathing. The normal bronchial whis- 
 per in these situations is not in all persons appreciable. 
 
 In the infra-clavicular region, the bronchial whisper is 
 heard, with variable intensity, in most persons. It is 
 somewhat higher in pitch than the whisper below this 
 reoion. It is louder and hioher in the sterno-clavicular 
 than in the acromial extremity. In the former situation 
 it has not infrequently a tubular quality. It is louder 
 on the right than on the left side of the chest. It is 
 sometimes heard on the right when it is inappreciable on 
 the left side. When heard on both sides the pitch of the 
 sound is higher on the left than on the right side. It 
 will be observed that these variations correspond to 
 those of the sound with expiration in the infra-clavicu- 
 lar region [vide page 75). Occasionally w' hispered w^ords 
 are partly transmitted, constituting incomplete wdiisper- 
 ing pectoriloquy. 
 
 In the scapular region the bronchial w^hisper is not 
 infrequently wanting. It may be present on the right 
 and not on the left side, and if present on both sides, it 
 is ahvays louder on the right side. 
 
84 AUSCULTATION IN HEALTH. 
 
 In the inter-scapular region, as a rule, it is nearly or 
 quite as marked as over the site of the primary bronchi 
 in front. The pitch is more or less high, and has a 
 tubular quality. It is louder on the right and higher in 
 pitch on the left side, and in this situation there may be 
 incomplete pectoriloquy. 
 
 In the infra-scapular region, it is not infrequently 
 -wanting. When present it is generally feeble, the pitch 
 being low and the quality non-tubular or blowing. It is 
 oftener wanting on the left than on the right side, and, 
 if present on both sides, it is louder on the right side. 
 
 In the mammary and infra- mammary regions it is not 
 infrequently wanting, and the statements Just made with 
 reference to the infra-scapular region arealike applicable 
 to these, as, also, to the axillary and infra-axillary 
 regions. 
 
AUSCULTATION IN DISEASE. 85 
 
 CHAPTER Y. 
 
 AUSCULTATION IX DISEASE. 
 
 The respiratory signs of Disease : — Abnormal modifications of the nor- 
 mal respiratory sounds : — Increased vesicular murmur — Diminished 
 vesicular murmur — Suppressed respiratory sound — Bronchial or 
 tubular respiration — Broncho-vesicular respiration — Cavernous res- 
 piration — Broncho-cavernous respiration — Vesiculo-cavernous res- 
 piration — Amphoric respiration — Shortened inspiration — Prolonged 
 expiration — Interrupted respiration. Adventitious respiratory 
 sounds or rales: Laryngeal or tracheal rales — Moist bronchial 
 rales, coarse, fine, and subci'epitant — Vesicular or crepitant rale — 
 Cavernous or gurgling rale — Pleural friction rales, metallic tink- 
 ling and splashing — Indeterminate rales. The vocal signs of dis- 
 ease : Bronchophony — Whispering bronchophony — ^gophony — In- 
 creased vocal resonance — Increased Bronchial whisper — Cavernous 
 whisper — Pectoriloquy — Amphoric voice or echo — Diminished and 
 suppressed vocal resonance — Diminished and suppressed vocal fremi- 
 tus— Metallic tinkling. Signs obtained by acts of coughing or tus- 
 sive signs. 
 
 The importance of becoming perfectly familiar with 
 the signs of health before entering upon the study of mor- 
 bid signs, cannot be too strongly enforced. The aus- 
 cultatory signs of disease, which are to be considered in 
 this chapter, should not be studied until the student has 
 made himself complete master of all the characters be- 
 longing to the normal signs obtained by auscultation. 
 
 Auscultation in disease embraces the signs produced 
 by respiration, by the voice, and by acts of coughing. 
 The respiratory signs will be first considered. 
 
 8 
 
86 AUSCULTATION IN DISEASE. 
 
 The Respiratory Signs of Disease. 
 
 The signs produced by respiration may be classified 
 as follows : 1st. Those which are abnormal modifica- 
 tions of the normal respiratory sounds. 2d. Those 
 which have no analogues in health, being entirely 
 new or adv^entitious sounds. The latter are embraced 
 under the name rale^. 
 
 Abnormal Modifications of the Normal Respiratory Sounds. 
 
 In order to appreciate the distinctive characters of 
 the signs embraced in this class, the characters which 
 distinguish the normal vesicular murmur must be kept 
 in mind. The abnormal modifications which character- 
 ize these morbid signs relate to intensity, pitch and 
 quality of sound, together with certain alterations in 
 rhythm. Twelve modifications or signs are included 
 under this heading, namely : 1. Increased vesicular 
 murmur; 2. Diminished vesicular murmur; 3. Suppres- 
 sion of respiratory sound ; 4. Bronchial or tubular res- 
 piration ; 5. Broncho-vesicular respiration ; 6. Cavernous 
 respiration ; 7. Broncho-cavernous respiration ; 8. Ve- 
 siculo-cavernous respiration ; 9. Amphoric respiration ; 
 10. Shortened inspiration; 11. Prolonged expiration; 
 and, 12. Interrupted inspiration or expiration. 
 
 These signs are to be studied, first, with reference to 
 their distinctive characters severally, each being con- 
 trasted, as respects these characters, with the other mor- 
 bid respiratory signs as well as with the normal vesicu- 
 lar murmur; and, second, with reference to the morbid 
 physical conditions which they represent, that is, the 
 diagnostic significance which belongs to each. 
 
MODIFICATIONS OF NORMAL SOUNDS. 87 
 
 Increased Yes'iGular Murmur. — This sign has but a 
 single distinctive character, nanjely, increase of intensity. 
 The murmur is abnormally loud, the characters of the 
 normal vesicular murmur being in other respects not 
 materially changed, that is, the pitch is low and the 
 quality vesicular as in health. Now, it has been seen 
 {vide page 73) that the intensity of the healthy murmur 
 varies much in diiferent persons ; there is no ideal stand- 
 ard of normal intensity by reference to which an abnor- 
 mal increase is to be determined. Yet the increase under 
 certain conditions of disease is such that the fact is suf- 
 ficiently evident. It occurs on the healthy side of the 
 chest when the respiratory function on the other side is 
 annulled or much compromised by disease. This takes 
 place in cases of pleurisy with large effusion, pneumonia, 
 especially if more than one lobe be affected, obstruction 
 of one of the primary bronchi, and pneumothorax. The 
 sign does not possess great diagnostic importance, inas- 
 much as the nature and extent of the disease are ascer- 
 tained by the signs obtained on the affected side. 
 
 The sign has been called supplementary and puerile 
 respiration. 
 
 If the murmur be much intensified, it may possibly be 
 mistaken for other morbid signs, namely, bronchial or 
 broncho-vesicular respiration. This error, howev^er, can 
 never be made if the distinctive characters of these signs 
 relating to pitch and quality have been correctly studied. 
 
 Diminished Vesicular 3Iurmur. — The intensity of the 
 vesicular murmur may be on the one hand diminished, 
 when it is evident that in otiier respects there is no 
 material change, and the murmur, on the other hand, 
 may become so feeble that characters aside from the 
 intensity are not determinable. From the latter fact it 
 
88 AUSCULTATION IN DISEASE. 
 
 follows that the murmur must sometimes be considered 
 as only weakened, when, were the diminished intensity 
 not as great, morbid changes in pitch and quality might 
 be appreciable. 
 
 The murmur is more or less weakened in cases of dila- 
 tation of the air-cells, or vesicular emphysema, the sign, 
 in these cases, being often accompanied by changes in 
 rhythm, namely, a shortened inspiration and a prolonged 
 expiration. Simple weakness of the murmur may also 
 be incident to partial blocking of the air-vesicles with 
 blood or serum in cases of j)iilmonary extravasation and 
 oedema. A deficient expansion of the chest, either on 
 one side or on both sides, occasions weakness of the re- 
 spiratory murmur. Deficient expansion of one side, or of 
 both sides, may be caused by paralysis, bilateral, or 
 unilateral, of the costal muscles. A similar effect is 
 caused by paralysis of the diaphragm. The incomplete 
 descent of the diaphragm from pain, as in peritonitis, or 
 from mechanical obstacles, as in peritoneal dropsy, preg- 
 nancy, and abdominal tumors, weakens the respiratory 
 murmur, the increased action of the costal muscles not 
 being fully compensatory. Unilateral deficiency of ex- 
 pansion of the chest is caused by pain in intercostal neu- 
 ralgia, pleurodynia, acute pleurisy, and pneumonia; it 
 is also caused by the presence of a stratum of liquid, air, 
 or a thick layer of lymph between the lung and the chest- 
 wall in pleurisy, hydrothorax,and pneumothorax. Swell- 
 ing of the bronchial mucous membrane in bronchitis 
 affecting the larger tubes, must diminish somewhat the 
 intensity of the murmur. In primary bronchitis the 
 murmur is diminished on both sides. In bronchitis affect, 
 ing the smaller tubes, the murmur is greatly diminished, 
 if not suppressed, on both sides. Incomplete obstruction 
 
MODIFICATIONS OF NORMAL SOUNDS. 89 
 
 of bronchial tubes from the presence of mucus, serum, 
 blood, or pus, has this etfect over an area corresponding 
 to the size of the tubes obstructed. Spasm of the bron- 
 chial muscular fibres in paroxysms of asthma, diminishes, 
 if it do not suppress, murmur on both sides. Another 
 cause of diminution, unilateral, or within a limited space 
 on one side, is the pressure of a tumor on bronchial tubes, 
 as in cases of aneurism. A permanent contraction or 
 stricture of bronchial tubes is another cause. Not in- 
 frequently the pressure of an aneurismal tumor or an 
 enlarged bronchial gland on a primary bronchus, occa- 
 sions notable weakness of the murmur over the whole of 
 one side; and the pressure of a tumor on the trachea 
 weakens the murmur, more or less, on both sides. A 
 foreign body in one of the primary bronchi w^eakens it 
 on one side. Diminution of the calibre of the trachea 
 or larynx from morbid growths, the presence of foreign 
 bodies, fibrinous exudations, accumulations of mucus, 
 submucous infiltration, spasms of the laryngeal muscles, 
 and swelling of the mucous membrane, weakens, in pro- 
 portion to the amount of obstruction, the murmur on 
 both sides Avithout any material change in its quality 
 and pitch. 
 
 Weakened murmur at the summit of the chest, with- 
 out other appreciable- abnormal characters, occurs in 
 some cases of phthisis, due to obstructed bronchial tubes 
 from coexisting circumscribed bronchitis, or to deficient 
 superior costal movements of the chest, as well as to the 
 presence of exudation in the air-vesicles. 
 
 Diminished intensity of the vesicular murmur is thus 
 seen to be a respiratory sign entering into the diagnosis 
 of a considerable number of diseases, namely, emphy- 
 sema, paralysis affecting the respiratory muscles, asthma, 
 
90 AUSCULTATION IN DISEASE. 
 
 abdominal affections interfering with the diaphragmatic 
 movements, intercostal neuralgia, pneumonia, hydro- 
 thorax, bronchitis, aneurismal and other tumors, per- 
 manent constriction or stricture of bronchial tubes, lar- 
 yngitis, oedema of the glottis, spasm of the glottis, the 
 various lesions which occasion obstruction of the larynx 
 or trachea, and phthisis. 
 
 In determining a slight abnormal weakness of the re- 
 spiratory murmur at the summit of the chest on the right 
 side, the normal disparity between the two sides in this 
 situation is to be borne in mind. The vesicular murmur 
 is normally less intense on the right than on the left side. 
 
 This sign occurring in so many diseases, it is obvious 
 that, taken alone, that is, independent of other signs, 
 it has not any special diagnostic significance. It is, how- 
 ever, often of value in diagnosis, when taken in connec- 
 tion with other signs. It is chiefly useful when it exists 
 either over the whole or in a part of the chest on one 
 side. 
 
 Suppressed Respiratory Sound. — This sign is easily 
 defined, namely, absence of all respiratory sound, as the 
 name signifies. It cannot, of course, have any charac- 
 ters relating to intensity, pitch, and quality. 
 
 Su|)pression of respiratory sound represents the same 
 physical conditions as diminished vesicular murmur; 
 the physical conditions represented by the latter sign, 
 existing in a greater degree, occasion absence of all 
 sound. It suffices, therefore, to recapitulate the various 
 conditions and diseases in connection with which the 
 murmur may cither be diminished or suppressed. Sup- 
 pression over portions of the chest may be due to dilata- 
 tion of the air-cells in cases of emphysema. It occurs 
 from the exclusion of air from the vesicles by the pros- 
 
MODIFICATIONS OF NORMAL SOUNDS. 91 
 
 ence of blood and serum in cases of pulmonary extrav- 
 asation and cedema. Respiratory sound is sometimes 
 wanting over lung solidified in cases of pneumonia and 
 phthisis. Paralysis of tiie muscles concerned in respira- 
 tion may possibly involve feebleness of the respiratory 
 acts sufficiently to render the murmur inappreciable. In 
 intercostal neuralgia, pleurodynia, acute pleurisy, and 
 pneumonia, the movements of the affected side may be 
 so much restricted as to abolish the murmur. In pleu- 
 risy with much effusion, empyema, hydrothorax, pneumo- 
 thorax, the murmur is suppressed over either a part or 
 the whole of the affected side, the extent of the suppres- 
 sion corresponding to the quantity of serum, pus, or air 
 within the pleural cavity. Swelling of the mucous mem- 
 brane in cases of bronchitis affectino; the laro;er bronchial 
 tubes is never sufficient to suppress the murmur, but plug- 
 ging of more or less of the tubes with mucus or other 
 morbid products may have this effect. In cases of bron- 
 chitis, the murmur is sometimes found to have disap- 
 peared over a certain area, and to return after an act of 
 expectoration. In bronchitis affecting the smaller tubes, 
 suppression of the murmur is not infrequent. It occurs 
 from spasm of the bronchial muscular fibres in cases of 
 asthma. The pressure of a tumor, morbid growths, or 
 deposits upon bronchi within the lungs, may abolish re- 
 spiratory sound over a portion of the chest, and perma- 
 nent stricture or obliteration of bronchial tubes may have 
 this effect. Respiratory sound may be suppressed over 
 the whole of one side from the pressure of an aneurismal 
 or some other tumor upon one of the primary bronchi. 
 If the tumor press upon the trachea, the obstruction may 
 be sufficient to suppress the murmur on both sides. A 
 foreign body lodged in a primary bronchus may suppress 
 
92 AUSCULTATION IN DISEASE. 
 
 the murmur on one side, and, lodged in the larynx or 
 trachea, the murmur may be suppressed on both sides. 
 The different affections of the larynx and trachea which, 
 in proportion to the amount of obstruction, weaken the 
 murmur, may render it inappreciable. 
 
 Bronchial or Tubular Respiration. — The analogue of 
 this sign is the normal laryngeal or tracheal respiration 
 {vide page 70). The characters which distinguish the 
 latter normal sign from the normal vesicular murmur, are 
 those which are distinctive of the bronchial or tubular 
 respiration. These characters, relating to the inspiratory 
 and the expiratory sounds, are as follows: The inspira- 
 tory sound is of variable intensity. Intensity does not 
 enter into the distinctive characters of this sign ; the 
 sound may be either louder or weaker than the inspira- 
 tory sound in health. The })itch of the inspiratory sound 
 is high. The quality is expressed by the term tubular; 
 it is like the sound produced by blowing through a tube, 
 this quality taking the place of that ex])ressed by the 
 term vesicular in the normal respiration. The expiratory 
 sound is prolonged ; it is as long as, or longer than, the 
 sound of expiration, and is* usually louder. The pitch 
 is still higher than that of the inspiratory sound. The 
 quality, like that of the inspiratory sound, is tubular, 
 thi.squality taking the place of the simple blowing quality 
 of the expiratory sound in the normal vesicular murmur. 
 With the normal rhythm of the respiratory acts there is 
 a very brief interval between the sounds of inspiration 
 and expiration, due to the fact that the inspiratory sound 
 ends a little before the end of the inspiratory act. 
 
 The morbid physical condition represented by this im- 
 portant sign is either complete or considerable solidifica- 
 tion of lung. Whenever the chest is auscultated over 
 
MODIFICATIONS OF NORMAL SOUNDS. 93 
 
 lung solidified, if there be not absence of respiratory 
 sound, the sound is tubular. This significance renders 
 the sif^n of diagnostic value in the diseases which involve 
 solidification. The sign per se denotes simply this mor- 
 bid physical condition ; the particular disease which ex- 
 ists is ascertained by means of the associated signs and 
 the symptoms. 
 
 Solidification of lung is incident to several different 
 diseases. In lobar })neumonia it is due to a fibrinous 
 exudation within the air-vesicles. In phthisis it is caused 
 by an exudation in the same situation. In chronic or 
 fibroid pneumonia the lung is solidified by an interstitial 
 growth. The compression of lung from either pleuritic 
 effusion, an accumulation of air in the pleural cavity, or 
 the pressure of a tumor, causes solidification by conden- 
 sation. Collapse of pulmonary lobules also solidifies by 
 condensation. Coagulation of blood within the air-vesi- 
 cles (hsemorrhagic infarctus), and cancerous infiltration 
 or growth, are other causes of solidification. In these 
 different affections, if the solidification be complete or 
 considerable, this sign is usually present; it is always 
 present if there be not suppression of respiratory sound. 
 
 It is sometimes the case that either the inspiratory or 
 the expiratory sound is wanting. The characters of the 
 sign suffice for its recognition if either the inspiratory or 
 the ex[)iratory sound be alone present; the pitch and 
 the quality are distinctive. Both sounds are often so 
 intense that they are diffused more or less without the 
 limits of the solidified portion of lung. The expiratory 
 sound, being more intense than the inspiratory, is trans- 
 mitted further tlian the latter. This ex])lains the con- 
 junction sometimes of a vesicular inspiration with a 
 tubular expiration ; and a cavernous inspiration may be 
 
94 AUSCULTATION IN DISEASE. 
 
 conjoined with a tubular expiration, showing the prox- 
 imity of solidified lung in the former case to healthy 
 lung, and, in the latter case, to a pulmonary cavity. 
 
 The sound may seem near the ear or to come from a 
 certain distance. The latter is appreciable in some cases 
 of large pleuritic effusion ; the tubular respiration is more 
 or less distant, and it is sometimes diffused over the 
 whole of the side which is filled with liquid. 
 
 Broncho-vesicular Respiration. — This name was intro- 
 duced by me in 185G to denote the combination, in vary- 
 ing proportions, of the characters of the bronchial or 
 tubular, and of the normal vesicular respiration. The 
 name expresses such a combination. It embraces modi- 
 fications to which have been applied the terms, rudcj 
 rough, and harsh respiration, ajid those included by Ger- 
 man authors under the name indeteiininate respiratory 
 sounds. 
 
 The sign represents the different degrees of solidifica- 
 tion of lung, between an amount so slight as to occasion 
 only the smallest appreciable modification of the respira- 
 tory sound, and an amount so great as to approximate 
 closely to the degree giving rise to bronchial or tubular 
 respiration. In other words, all the gradations of re- 
 spiratory modifications, caused by incomplete or an in- 
 considerable solidification, which fall short of bronchial 
 or tubular respiration, are embraced under the name 
 broncho-vesicular. The gradations correspond to the 
 amount of solidification, that is, tlieyshow the solidifica- 
 tion to be either very slight, slight, moderate, or nearly 
 sufficient to be considered as considerable or complete. 
 The sign is therefore important as evidence, first, of the 
 existence of solidification, and second, of the degree of 
 solidification. 
 
MODIFICATIONS OF NORMAL SOUNDS. 95 
 
 Analyzing tliis sign, the nnost distinotive feature is the 
 combination of the vesicular and the tubular quality in 
 the inspiratory sound. These two qualities niay be 
 combined in variable proportions. The pitch of the 
 sound is raised in proportion as the tubular predominates 
 over the vesicular quality. The expiratory sound is 
 more or less prolonged, tubular in quality, and the pitch 
 is raised. The prolongation of this sound, its tubular 
 quality, and the highness of pitch, are proportionate to 
 the predominance of the tubular over the vesicular 
 quality in the inspiratory sound. If the solidification of 
 luncr be slio^ht, tlie characters of the normal vesicular 
 respiration predominate ; that is, the inspiratory sound 
 has but a small proportion of the tubular quality, and is 
 but little raised in pitch, the expiratory sound being not 
 much prolonged, its tubularity not marked, the pitch not 
 high. If, on the other hand, the solidification of lung 
 be almost enough to give a bronchial respiration, the 
 inspiratory sound has only a little vesicular quality, the 
 tubular quality ])redominating, the pitch proportionately 
 raised ; and the expiratory sound is prolonged, tubular, 
 and high, nearly to the same extent as in the bronchial 
 respiration. The less the solidification the more the 
 characters of the normal vesicular predominate over those 
 of the bronchial respiration, and, per contra, the greater 
 the solidification the more the characters of the bronchial 
 predominate over those of the normal vesicular respira- 
 tion. Daily auscultation in a case of lobar pneumonia 
 during the stage of resolution, affords an opportunity to 
 study all the gradations of this sign. After resolution 
 has made some progress, the inspiratory sound is no 
 longer ])urely tubular, but the ear ap])reciates a little 
 admixture of the vesicular quality, and the pitch is 
 
96 AUSCULTATION IN DISEASE. 
 
 sliglitly lowered. As resolution goes on, the vesicular 
 quality increases, the pitch is correspondingly lowered, 
 until, at length, no tubularity remains, and the pitch 
 becomes normal. Meanwhile, as the vesicular quality 
 increases in the inspiratory sound, the expiratory sound 
 is less and less prolonged, high and tubular, until it be- 
 comes, as in health, short, low, and blowing. 
 
 The broncho-vesicular respiration is an important 
 diagnostic sign in all the affections which involve partial 
 solidification of lung. In lobar pneumonia, as just stated, 
 it denotes the progress made from day to day in resolu- 
 tion. It is found also in an earlier stage, before the 
 solidification is sufficient to give rise to a purely bron- 
 chial respiration. It is a valuable sign in phthisis, afford- 
 ing evidence, not only of the fact of solidification, but 
 of its degree and extent. The sign enters into the diag- 
 nosis of interstitial pneumonia, hsemorrhaglc infarctus, 
 condensation of lung from the pressure of either liquid, 
 air, or a tumor, and from collapse of pulmonary lobules. 
 It may be stated with respect to this sign, that it is 
 always present if the lung be partially solidified, pro- 
 vided there be not either suppression of respiratory 
 sound, or such a degree of feebleness that the distinctive 
 characters are undeterminable. As with the bronchial 
 respiration, so with the broncho-vesicular, either the in- 
 spiratory or the expiratory sound may be wanting. The 
 characters of the sign are then to be determined as they 
 are manifested in the sound which is present, namely, 
 the combination of the vesicular and the tubular (juality, 
 with more or less elevation of pitch, if only an insj)ira- 
 tory sound may be heard, and the amount of prolonga- 
 tion, tubularity, and elevation of pitch, if there be only 
 an expiratory sound. 
 
MODIFICATIONS OP NORMAL SOUNDS. 97 
 
 In deteriiiininf^ the presence of this morbid sign, at 
 tlie summit of tlie chest on the right side, it is to be 
 borne in mind that the respiratory murmur on this side 
 has, in health, as compared with the res})iratory murmur 
 at tlie summit on the left side, more or less of the char- 
 acters of the broncho-vesicular respiration (^Me Normal 
 Broncho- vesicular Respiration, page 94). 
 
 Caver-nous Respiration. — The modifications which con- 
 stitute the distinctive characters of this sign, are ])roduccd 
 by the entrance of air into a cavity with the act of inspi- 
 ration, and its exit from the cavity with the act of expi- 
 ration. This passage of air into and from a cavity can 
 only take place where the walls of the cavity collapse 
 more or less in expiration and exj)and in inspiration. 
 Pulmonary cavities occur chiefly in cases of phthisis. 
 They occur, but with com|)arative infrecpiency, as a re- 
 sult of circumscribed abscess and gangrene of lung. 
 
 A well-marked cavernous respiration has characters 
 which are highly distinctive when this sign is contrasted, 
 on the one hand, with either the bronchial or broncho- 
 vesicular respiration, and, on the other hand, with the 
 normal vesicular murmur. These distinctive characters 
 relate both to the inspiratory and expiratory sound. 
 The inspiratory sound is neither vesicular nor tubular in 
 quality, and the pitch is low as compared with the bron- 
 chial respiration. As regards quality, we may say of it, 
 as of the expiratory sound in the normal vesicular respi- 
 ration, it is simply a blowing sound. The expiratory 
 sound has the same quality as the inspiratory, and it is 
 lower in pitch. Its duration is variable. The intensity 
 of both the inspiratory and the expiratory sound varies; 
 intensity does not enter into the distinctive characters of 
 this sign more than into those of the bronchial and the 
 
98 AUSCULTATION IN DISEASE. 
 
 broncho-vesicular respiration. These distinctive char- 
 acters of the cavernous respiration, as regards pitch and 
 quality, especially of the expiratory sound, were first 
 pointed out by me in 1852.^ Prior to this date the 
 bronchial and the cavernous respiration were considered 
 as having identical characters, or, at all events, as not 
 distinguishable from each other. Following Skoda, 
 these two signs are still considered as essentially identi- 
 cal by German authors. With a practical knowledge 
 of the foregoing characters distinctive of the cavernous 
 respiration, there is no difficulty in discriminating this 
 sign from the bronchial respiration. The sign is more 
 likely to be confounded with the normal vesicular mur- 
 mur, inasmuch as it differs from the latter only in the 
 absence in the inspiratory sound of the vesicular quality. 
 Against this error the student is to be cautioned. It is 
 most likely to be made when the inspiratory sound is 
 much weakened, and, consequently, the vesicular quality 
 less distinctly appreciable than when the sound is more 
 or less intense. 
 
 A cavernous respiration is limited to a space more or 
 less circumscribed, the area corresponding to the site and 
 the size of the cavity. Occurring, for the most part, in 
 cases of phthisis, it is much oftener found at the summit 
 than elsewhere over the chest. It is not constantly found 
 where there is a cavity witii flaccid walls. It may be 
 temporarily suppressed by the presence of liquid within 
 the cavity, and by obstruction of the orifices communi- 
 cating with bronchial tubes, or of the latter. It may be 
 wanting at one moment, and an act of expectoration may 
 
 1 Prize Essay on Variations of Pitch in tlie Sounds obtained by 
 Percussion and Au-;cultation. Transactions of the American Medi- 
 cal Association, 1852. 
 
MODIFICATIONS OF NORMAL SOUNDS. 99 
 
 cause it to reappear. Hence absence of cavity cannot 
 be predicated on the absence of tlie sign at a single ex- 
 amination. Moreover, if a cavity be not situated near 
 the pulmonary superficies, and solidified lung intervene 
 between it and the walls of the chest, the cavernous sign 
 may be drowned in a loud bronchial respiration. For 
 this reason, while the cavernous sign is positive evi- 
 dence of a cavity, the absence of the sign is not proof 
 that a cavitv does not exist. 
 
 In some cases of perforation of lung with pneumo- 
 thorax, the passage of air to and fro through the perfor- 
 ation may give rise to the cavernous respiration. As a 
 rule, however, under these circumstances, another sign is 
 produced, namely, the amphoric respiration. 
 
 Broncho -cavernous Respiration. — In this sign, as the 
 name denotes, the characters of the bronchial and the 
 cavernous respiration are combined. These characters 
 may be combined in different ways, as w^ell as in varia- 
 ble proportions. If a cavity be situated in proximity to 
 solidified lung, the quality and pitch of the inspiratory 
 and the expiratory sound may show an admixture of the 
 characters of the two signs, and to a practiced ear, the 
 combination is distinctly recognizable. This is one of 
 the forms of broncho-cavernous respiration ; the sounds 
 are not sufficiently high and tubular for bronchial, nor 
 sufficiently low and blowing for cavernous respiration. 
 Another form consists of an inspiratory sound, the first 
 part of which is tubular, and the latter part cavernous. 
 Examples of this form are not extremely infrequent. 
 This form has been recently described by Seitz under 
 the name, " metamorphosing respiration.''^ Still another 
 form is a cavernous inspiratory, with a bronchial or 
 tubular expiratory sound. In the latter form, the bron- 
 
100 AUSCULTATION IN DISEASE. 
 
 chial expiration proceeds from solidified lung situated 
 near tlie cavity, the intensity of the sound being suffi- 
 cient to drown the cavernous expiration. 
 
 When, as often happens, a cavity is situated in close 
 proximity to, or, it may be, surrounded by solidified 
 lung, the cavernous and the bronchial respiration are, as 
 it were, in juxtaposition, and such instances offer an 
 excellent opportunity to study the points distinguishing 
 these signs from each other; and, generally, at a short 
 distance the normal vesicular murmur may be found, so 
 that both morbid signs may be compared with the latter. 
 Within a circumscribed area, sometimes, are exemplified 
 the characters of the normal murmur, and of the two 
 morbid signs just mentioned, together with those of the 
 broncho- vesicular respiration. 
 
 Vesiculo- cavernous Respiration. — It is sometimes evi- 
 dent that the vesicular and the cavernous quality are 
 combined in the inspiratory sound. This occurs when a 
 cavity is surrounded, not by solidified, but by healthy 
 lung. Under these circumstances, over the site of the 
 cavity, the inspiratory sound may be as loud as, or louder 
 than that around the cavity, but the quality is not purely 
 cavernous; some vesicular quality is appreciable. A 
 vesiculo-cavernous respiration, then, is a cavernous res- 
 piration plus some vesicular quality derived from the air- 
 vesicles which are proximate to the cavity. This sign is 
 corroborated by other associated signs showing the ex- 
 istence of a cavity and its localization. 
 
 Amphorie Respiration. — The term amphoric has a 
 significance when applied to auscultatory sounds, analo- 
 gous to that which it has in percussion ; it denotes a 
 musical intonation which may be compared to the sound 
 produced by blowing upon the open mouth of a decanter 
 
MODIFICATIONS OP NORMAL SOUNDS. 101 
 
 or pliial. Whenever the respiratory sound has this in- 
 tonation, it denotes a space containing air which is not 
 expelled with the act of expiration. Air in the pleural 
 cavity, with perforation of hin^, is the physical condition 
 most frequently represented by this sign. It is a valu- 
 able diagnostic sign in cases of pneumothorax ; but it is 
 not always present in that affection, certain accessory 
 conditions being requisite, namely, perforation above the 
 level of liquid, and an unobstructed communication of 
 the bronchial tubes, through the opening, with the pleu- 
 ral space containing air. While, therefore, its presence is 
 significant of pneumothorax, its absence is by no means 
 sufficient to exclude this affection. Not infrequently, it 
 is a sign of phthisical cavity with rigid walls which do 
 not collapse with the act of expiration. The same con- 
 tingencies affect its production here as in cases of pneu- 
 mothorax. Whenever amphoric respiration is present, 
 if pneumothorax be excluded by the absence of the other 
 signs which are diagnostic of this affection, the sign is 
 proof of the existence of a pulmonary cavity, the walls 
 of which aie not flaccid. The sign then takes the place 
 of the ordinary cavernous respiration which has been 
 described. 
 
 The amphoric sound may accompany either respira- 
 tion or expiration, or both. 
 
 Slwrtened Inspiration. — The inspiratory sound is 
 somewhat shortened in bronchial or tubular respiration. 
 This modification enters into the characters of that sign, 
 the quality of the sound being tubular;, and the pitch high. 
 The shortening is due to the sound ending before the 
 inspiratory act ends ; the sound is said to be unfinished. 
 Shortening of the sound occurs, however, when it is not 
 an element in the bronchial respiration. The shortening 
 
 9 
 
102 AlfSCULTATION IN DISEASE. 
 
 is then due to tlie sound not beginning with the inspira- 
 tory act; this is distinguished as deferred inspiratory 
 sound. A deferred inspiratory sound not tubular in 
 quality, but more or less vesicular, and not notably raised 
 in pitch, is a sign of pulmonary or vesicular emphysema. 
 It is a sign of value in connection with the diagnosis of 
 that disease. 
 
 The student should note the distinctions just stated 
 which relate to pitch and quality. Suppose an inspira- 
 tory sound to be present without an expiratory sound: 
 if the sound be shortened at the end of the inspiration, 
 the pitch high and the quality tubular, it is bronchial 
 respiration, denoting complete or considerable solidifica- 
 tion of lung, but if the shortening be at the beginning of 
 respiration, the pitch comparatively low, and vesicular 
 quality be appreciable, the sign denotes emphysema. The 
 differential points thus are, the inspiratory sound either 
 unfinished or deferred, the pitch either high or low, and 
 the quality either tubular or vesicular. Attention to these 
 points is essential in order to avoid error in the interpre- 
 tation of the sign. 
 
 Prolonged Expiration. — The length of the expiratory 
 sound in health varies in different persons. The sound 
 is sometimes considerably prolonged ; it may be nearly 
 as long as the sound of inspiration. There is no diffi- 
 culty in recognizing this as a normal peculiarity, from the 
 fact that the murmur has the pitch and quality of health. 
 An unusual length of the expiratory sound, within the 
 range of health, is usually observed at the summit of the 
 chest, and especially on the right side. It is important 
 to bear in mind that at the summit of the chest on the 
 right side, and sometimes also on the left side, a pro- 
 longed expiratory sound, more or less raised in pitch, and 
 tubular in quality, may be a normal peculiarity. It fol- 
 
MODIFICATIONS OF NORMAL SOUNDS. 103 
 
 lows that a prolonged, and even a high and tubular ex- 
 piration at the summit of the chest, must not be reckoned 
 as a morbid sign unless it be associated with other signs 
 denoting disease. The laws of the disparity between the 
 two sides of the chest at the summit are to be taken into 
 account {vide p. 74). If the expiration be longer on 
 the left than on the right side^ it is abnormal ; so, also, 
 is a high-pitched tubular expiration heard on the left and 
 not on the right side. 
 
 The significance of an abnormally prolonged expira- 
 tion depends on its pitch and quality. If it be high and 
 tubular, it denotes solidification of lung. It is, in fact, 
 bronchial respiration. As already stated, in bronchial 
 or tubular respiration, the inspiratory sound is some- 
 times wanting, and the presence of the sign is then to be 
 determined by the characters, relating to pitch and qual- 
 ity, of the expiratory sound. The same statement holds 
 true with respect to broncho-vesicular respiration, when 
 this approximates to the bronchial. At the summit of 
 the chest, the characters of the inspiratory sound, and 
 associated morbid signs, always enable the auscultator to 
 determine whether a prolonged high and tubular expira- 
 tion be, or be not, abnormal. A prolonged expiration, 
 which is low in pitch and blowing in quality, that is, 
 with the characters of health, aside from length, may 
 belong to a cavernous expiration. This is to be deter- 
 mined by the characters of the inspiration, and by other 
 associated signs. Exclusive of cavernous respiration, an 
 abnormally prolonged expiratory sound of low pitch and 
 non-tubular, denotes vesicular emphysema. It is asso- 
 ciated then with a weakened and deferred inspiratory 
 sound. A prolonged expiratory sound, in cases of emphy- 
 sema, is invariably low and non-tubular. If it have 
 
104 AUSCULTATION IN DISEASE. 
 
 not these characters, it is not a sign of emphysema, but 
 belongs to bronchial or broncho-vesicular respiration. 
 Attention to these differential points is to be enjoined 
 upon the student. 
 
 A prolonged expii'ation at the summit of the chest on 
 the right side is sometimes incorrectly considered to be 
 evidence of phthisis. It is to be recollected, in the first 
 place, that prolongation of this sound with a normal 
 pitch and quality, is never evidence of solidification of 
 lung either from phthisis or any other disease; and in 
 the second place, even if the pitch be high, and the qual- 
 ity tubular, that it is not to be regarded as abnormal, 
 provided the inspiratory sound is unchanged, and other 
 signs of disease are not present. At times in bronchitis 
 there is a prolonged expiratory sound which may be dis- 
 tinguished as a sonorous expiration, not amounting to a 
 rale. This is liable to be mistaken for broncho-vesicu- 
 lar breathing. 
 
 Interrupted Respiration. — To this sign have been ap- 
 plied other names, such as jerking^ wavy, cogged icheel, 
 and by French writers the names entrecoupee and sacca- 
 dee. The modification is either of the inspiration or of 
 the expiration, or of both. The inspiratory, however, 
 much more frequently than the expiratory, sound is in- 
 terrupted. Tlie sound, instead of being continuous, is 
 broken into one, two, or more parts. This is the char- 
 acteristic of the sign. If at the same time there be altera- 
 tions in pitch and quality, the interruption is merely 
 incidental to other signs ; namely, the bronchial, broncho- 
 vesicular, or cavernous respiration. To constitute it a 
 distinct sign, the interruption must be the only appreci- 
 able change. As a distinct sign it has but little diag- 
 nostic value. 
 
MODIFICATIONS OF NORMAL SOUNDS. 105 
 
 Interrupted respiration is sometimes found in healthy 
 persons. It is confined to the summit of the chest, and 
 oftener on the left tiian the right side. Existing without 
 anv other signs, therefore, it is not evidence of disease. 
 It is of value only in the diagnosis of phthisis. Associ- 
 ated with other signs, when the latter are not marked, it 
 is entitled to a certain amount of weight in the diagnosis. 
 
 Interrupted respiratory sounds, of course, occur when 
 there is interruption in the respiratory movements. This 
 happens in cases of pleurisy, pleurodynia, or intercostal 
 neuralgia. Owing to the pain caused by the movements 
 in respiration, the })atient may breathe, not continuously, 
 but with a series of jerking movements. Sometimes in- 
 terrupted breathing is observed in persons who are ex- 
 cited or agitated when auscultation is practiced. In all 
 these instances, interruption in the respiratory sounds is 
 found over the ^vliole chest, whereas, when it is an ab- 
 normal sign in cases of phthisis, it is limited to the sum- 
 mit on one side of the chest, and there is no interruption 
 manifested in the mode of breathing. 
 
 Reviewing the foregoing signs, they may be distributed 
 into three classes, as ibllows : 1st. Signs, the distinctive 
 characters of which relate to either the absence or the 
 intensity of sound. This class embraces, (a) increased 
 intensity of the vesicular murmur; (b) diminished in- 
 tensity of the vesicular murmur; and (c) suppression of 
 respiratory sound. 2d. Signs, the distinctive characters 
 of which relate especially to pitch and quality. In this 
 class belong, (a) bronchial or tubular respiration ; (b) 
 broncho-vesicular respiration ; (c) cavernous respiration; 
 (d) broncho-cavernous respiration ; (e) vesiculo-cavern- 
 ous respiration, and (f) amphoric respiration. 3d. 
 
106 AUSCULTATION IN DISEASE. 
 
 Signs, the distinctive characters of which relate especially 
 to rhythm, namely, (a) shortened inspiration ; (b) pro- 
 longed expiration ; and (c) interrupted respiration. 
 
 Adventitious Respiratory Sounds, or Rales. 
 
 Adventitious respiratory sounds, or, adopting the 
 French term, rales, are distinguished from the morbid 
 signs already considered, by the fact that they have no 
 analogues in health ; in other words, they are not normal 
 sounds abnormally modified, but wholly new sounds. A 
 convenient classification of these signs is based on the 
 different anatomical situations in whicli they are pro- 
 duced. This classification is as follows : 1st. Laryngeal 
 and tracheal rales ; 2d. Bronchial rales ; 3d. Vesicular 
 rales; 4th. Cavernous rales; 5th. Pleural raies; and 
 6th. Indeterminate rales. Compared with each other, 
 as regards their characters, they admit of being divided 
 into dry and moist rales, the latter being evidently due 
 to the presence of liquid. 
 
 Laryngeal and Tracheal Rales. — The rales produced 
 within the larynx and trachea may be either moist or 
 dry. The moist or bubbling sounds are produced when 
 mucus or other liquid accumulates in these sections of the 
 air-tubes. This occurs frequently in the moribund state, 
 and the sounds are then known as the '^ death rattles.^' 
 When not incident to this state, they denote either insen- 
 sibility to the presence of liquid, as in coma, or inability 
 to effect the removal of the liquid by acts of expectoration. 
 The sounds are heard at a distance. They exemplify, on 
 a large scale, moist or bubblingauscultatory sounds which 
 are produced within the bronchial tubes. The dry rales 
 j)roduced within the larynx or trachea are caused by 
 spasm of the glottis, and by diminution of the calibre, 
 
MOIST BRONCUIAL RALES. 107 
 
 either at or below the glottis, from oedema, exudation, 
 the presence of a foreign body, or the pressure of a 
 tumor. The dry sounds are distinguished as whistling, 
 wheezing, crowing, whooping, etc. They are heard at 
 a distance, and they also exemplify auscultatory sounds 
 representing analogous conditions in the bronchial tubes. 
 Characteristic sounds produced at the glottis by spasm 
 enter into the diagnosis of certain aifections, namely, 
 laryngismus stridulus, [)ertussis, croup, and aneurism 
 involving: excitation of the recurrent larvno-eal nerve. 
 Other sounds are due to paralysis of the laryngeal 
 muscles. Again, dry sounds, called stridor, produced 
 by stenosis of the trachea from the pressure of an aneu- 
 rismal or other tumor, cicatrization of ulcers, and morbid 
 growths, are of diagnostic importance. Although audi- 
 ble without auscultation, these different sounds, with 
 reference to the precise situation at which they are pro- 
 duced, may sometimes be studied with advantage by 
 means of the stethoscope. 
 
 Moist Bronchial Rales. 
 
 The moist bronchial rales are bubbling sounds pro- 
 duced in diiferent branches of the bronchial tree. They 
 are sounds of which the "tracheal rattles^' are an ex- 
 aggerated type. They may be imitated by blowing into 
 liquids through tubes differing in size. They may also 
 be produced in the lungs of the sheep or the calf, after 
 removal from the body, by injecting into the bronchi 
 glycerin or some other liquid, and imitating the respi- 
 ratory acts by means of a pair of bellows, auscultation 
 being practiced with the stethoscope ap])lied upon the 
 lung, or with several thicknesses of cloth intervening. 
 The bubbles seem to be laro;e or small, accordino; to the 
 
108 AUSCULTATION IN DISEASE. 
 
 size of the bronchial tubes in which they are produced. 
 Apparent differences in the size of the bubbles are dis- 
 tinguished by the names coarse and fine. In the primary 
 and secondary bronchial branches the moist sounds are 
 relatively quite coarse; they are less so in tubes of the 
 third or fourth dimensions; in smaller tubes they be- 
 come fine, and in those of minute size they become ex- 
 tremely fine. Extremely fine bubbling sounds consti- 
 tute what is known as the subcrepitant rale, so called 
 because it approaches in character to the crepitant rale 
 produced within the air-vesicles and bronchioles. We 
 may thus judge of the size of the bronchial tubes in 
 which the rales are produced by their comparative 
 coarseness or fineness. Frequently, however, coarse and 
 fine rales are intermingled, and generally those which 
 are either coarse or fine are not uniform, but appear to 
 be of unequal size. In all the varieties of the moist 
 bronchial rales, tne bubbling character of the sounds is 
 sufficient! V distinctive for their recognition. The differ- 
 entiation of the subcrepitant from the crepitant rale alone 
 involves some nice points of distinction. 
 
 Coarse bubbling rales sometimes occur in acute bron- 
 chitis affecting the larger bro.ichial tubes. Their occur- 
 rence is exceptional, because, in general, the mucus 
 within the tubes does not accumulate sulficiently and is 
 too consistent for the production of bubbling sounds. 
 These rales occur in cases in which the mucus is un- 
 usually thin and either more abundant than usual or an 
 accumulation takes place in consequence of inability to 
 expectorate freely. These conditions are wanting in the 
 majority of the cases of ordinary acute bronchitis. A 
 muco-purulent liquid in cases of chronic bronchitis is 
 better suited for the production of bubbling sounds than 
 
MOIST BRONCHIAL RALES. 109 
 
 simple mucus. Moreover, coarse rales are heard oftener 
 in children than in adults, because the former do not 
 voluntarily expectorate as freely as the latter. Serous 
 transudation (bronchorrhoea) into tubes of large size may 
 give rise to coarse bubbling rales, and also the presence 
 of blood in some cases of profuse haemorrhage. In bron- 
 chitis and bronchorrhoea the rales are heard on both 
 sides of the chest. The bubbling rales, whether coarse 
 or fine, are heard cither with the act of inspiration or of 
 exj)iration, or with both acts. 
 
 Fine bubbling sounds and the subcrepitant rale occur 
 in various pathological connections. The charac^ters of 
 the subcrepitant rale are to be borne in mind with refer- 
 ence to the discrimination from the crepitant. The most 
 distinctive character is the moist sound or bubbling; 
 this is sufficiently appreciable. Other characters are, 
 their occurrence frequently, but not constantly, in expi- 
 ration as well as in inspiration, and the inequality of the 
 fine bubbling sounds. 
 
 The subcrepitant rale, existing over the chest on both 
 sides, is diagnostic of bronchitis affecting the smaller 
 bronchial tubes (capillary bronchitis), when taken in 
 connection with other signs and the symptoms. The rale 
 exists on both sides, because this, as well as bronchitis 
 affecting the larger tubes, is a bilateral affection. The 
 sign is of great j)ractical value in the diagnosis of that 
 variety of bronchitis. The rale also occurs on both 
 sides, and is more or less diffused in pulmonary oedema. 
 The connection with the latter affection is shown by the 
 associated j)hysical signs, together with the symptoms. 
 In so-called capillary bronchitis, the bubbling is due to 
 the presence of thin mucus, and in pulmonary oedema 
 
 10 
 
110 AUSCULTATION IN DISEASE. 
 
 to serous transudation within the small bronchial rami- 
 fications. 
 
 Fine bubbling or a subcrepitant rale has other patho- 
 logical connections, as follows: 
 
 1. It occurs in lobar pneumonia during the stage of 
 resolution. Here it is due to the presence of mucus from 
 a bronchitis limited to the aifected lobe or lobes, and, in 
 a measure, to liquefied pneumonic exudation. It is con- 
 sidered as denoting commencing and progressing reso- 
 lution in pneumonia. Sometimes it is intermingled with 
 rales which are more or less coarse. 
 
 2. In circum-cribed pneumonia, hsemorrhagic infarc- 
 tus, and pulmonary apoplexy, the fine or subcrepitant 
 rale, often associated with those which are more or less 
 coarse, denotes the presence of mucus or of blood within 
 the bronchial tubes. The rales are localized in space, or 
 in spaces, corresponding to the situation and extent of 
 the affection. 
 
 3. During and shortly after a haemoptysis, fine rales 
 limited to a particular situation are sometimes heard, 
 proceeding from blood in the small bronchial tubes, and 
 indicating the situation of the haemorrhage. 
 
 4. A purulent liquid admits of bubbling much more 
 readily than mucus ; hence, in cases of chronic bron- 
 chitis with an expectoration of pus, fine and coarse bron- 
 chial rales are more frequent tlian in acute bronchitis. 
 Pus, also, may be present within bronchial tubes of small 
 size, not as a product of bronchitis, but from the evacua- 
 tion of an abscess of either the pulmonary parenchyma, 
 of the liver or some other adjacent part, and from per- 
 foration of lung in some cases of empyema. 
 
 5. In the different stages of phthisis, moist bronchial 
 rales are usually present. The liquid in the tubes, if the 
 
MOIST BRONCHIAL RALES. Ill 
 
 disease be advanced, is derived, in part, from associated 
 bronchitis, and, in part, from liquefied tuberculous ex- 
 udation. The bubbling sounds may be more or less 
 coarse or fine, and both are often intermingled. Early 
 in the disease, before softening of the exudation has 
 taken place, fine bubbling, or the subcrepitant rale, lim- 
 ited to the summit of the chest, is an important diagnostic 
 sign. It belongs among the accessory physical signs on 
 which the diagnosis may depend. Here the liquid is 
 derived from a coexisting circumscribed bronchitis. 
 
 In cases of fibroid phthisis, or cirrhosis of lung, moist 
 rales, coarse and fine, are generally more or less abun- 
 dant and diffused over the whole, or the greater part, of 
 the chest on the affected side. 
 
 In the foregoing account of the moist bronchial rales, 
 the subcrepitant rale is not reckoned as a sign distinct 
 from fine bubling sounds. Inasmuch as the mechanism 
 and the significance are the same, and it is not easy to 
 draw a line of demarcation between the two, the distinc- 
 tion is unimportant. It is sufficient to bear in mind that 
 very fine bubbling sounds are called subcrepitant, be- 
 cause they are somewhat analogous to the crepitant rale, 
 The points which distinguish the latter are, however, 
 w-ell-marked, as will appear when the characters of that 
 sign are considered. The moist rales are often called 
 mucous rales. This name is obviously inappropriate, 
 since, not only are the sounds produced by other liquids 
 than mucus, but other liquids are best suited for their 
 production, especially in the large and medium-sized 
 tubes. The several varieties of the moist bronchial rales 
 may be produced by the injection of a liquid in varying 
 quantity into the bronchi of the lungs removed from 
 
112 AUSCULTATION IN DISEASE. 
 
 the body of an animal of sufficient size, e. g. of the sheep 
 or calf. 
 
 The moist bronchial rales, whether coarse or fine, vary 
 in pitch accordingly as the lung surrounding the tubes 
 in which they are produced is, or is not, solidified. If 
 the lung be solidified, the pitch is high ; if there be no 
 solidification, the pitch is comparatively low. Tims, the 
 pitch of the rales is high in the second stage of pneu- 
 monia and in phthisis with considerable solidification, 
 whereas the pitch is low in bronchitis and pulmonary 
 oedema. If, therefore, the respiratory sound be sup- 
 pressed, it is easy to determine by the pitch of these 
 rales whether the lung be solidified or not, and to judge 
 measurably of the degree of solidification. Attention to 
 the pitch in connection with these rales is sometimes of 
 value in diagnosis. 
 
 Dry Bronchial Rales. 
 
 All adventitious sounds which are not moist, produced 
 within the air-tubes below the trachea, are embraced 
 under the name dry bronchial rales. The sounds are 
 many and varied in character. They are often musi- 
 cal notes. Frequently they are suggestive of certain 
 familiar sounds, such as the chirping of birds, the cry 
 of a young animal, snoring in sleep, cooing of pigeons, 
 humming of the mosquito, the note of the violoncello, 
 etc., etc. They are often heard at a distance, and 
 characterized as wheezing sounds. An interrupted or 
 clicking sound is not uncommon. All these varieties 
 are practically unimportant, and it would be a needless 
 refinement to consider particular varieties as distinct 
 signs. The only distinction which it is desirable to 
 make is into the sibilant and sonorous rales. This dis- 
 
DRY BRONCHIAL RALES. 113 
 
 tinction is based on difference in pitch ; sibilant rales 
 are hi^^h, and sonorous rales are low in pitch. As a 
 rule, the sibilant rales are produced in the small and the 
 sonorous rales in the larger sized bronchial tubes. The 
 sounds may accompany either inspiration or expiration, 
 or both. The sibilant and sonorous rales are often in- 
 termingled. There may be sibilant rales with inspira- 
 tion, and sonorous rales with expiration, within the 
 same situation. Moreover, these rales are found often 
 to vary from minute to minute, being at one instant sibi- 
 lant and at another sonorous. Students are liable to 
 confound sonorous rales with bronchial breathing and 
 sometimes friction- sounds. 
 
 The ])hysical condition represented by the dry rales is 
 diminished calibre of the air-tubes at certain points, 
 and especially in consequence of spasm of the bronchial 
 muscular fibres. The latter constitutes the essential 
 pathological condition in a paroxysm of asthma; and in 
 this affection the dry rales are always marked. Their 
 diagnostic importance relates chiefly to asthma. Both 
 sibilant and sonorous rales are present and diff'used over 
 the entire chest. Wheezing sounds with expiration are 
 heard by the patient, and by others at a distance. A 
 single paroxysm of asthma affords an opportunity for the 
 student to observe all the varieties and fluctuations of 
 these rales. Taken in connection with other signs and 
 the symptoms, the rales are pathognomonic of asthma. 
 
 More or less spasm of the bronchial muscular fibres 
 occurs in certain cases of bronchitis, without being suffi- 
 ciently great and extensive to give rise to a paroxysm 
 of asthma, or even any embarrassment of respiration. 
 Under these circumstances the rales are less marked 
 and diffused. An asthmatic element may be said to 
 
114 AUSCULTATION IN DISEASE. 
 
 enter, more or less, into these cases. Narrowing of 
 bronchial tubes by tenacious mucus which gives rise to 
 no bubbling sounds, and, perhaps unequal swelling of 
 the mucous membrane, may also occasion sibilant and 
 sonorous rales. 
 
 Dry rales at the summit of the chest are not infrequent 
 in cases of phtiiisis, due to spasm, the presence of mucus, 
 or to swelling of the mucous membrane. They are some- 
 times quite annoying to phthisical patients. 
 
 Clicking sounds are suggestive of the sudden separa- 
 tion of tenacious mucus from the walls of the bronchial 
 tubes. These are sufficiently common in bronchitis and 
 in phthisis. 
 
 Vesicular or Crepitant Rale. 
 
 This is the only vesicular rale. It is usually con- 
 sidered to be produced within the air-vesicles, but prob- 
 ably, the terminal bronchial tubes or bronchioles par- 
 ticipate in its production. 
 
 It is to be distinguished from very fine bubbling sounds, 
 or the subcrepitant rale. The points of distinction are 
 as follows : The sounds are not moist but dry ; they are 
 crackling, not bubbling in character. They may be de- 
 fined to be very fine, dry, crackling sounds. This point 
 of difference is very distinctive. There are, however, 
 other differential points. The crackling sounds are equal, 
 whereas, fine bubbling sounds are unequal, that is, they 
 give the impression of bubbles of unequal size. The 
 crepitating sounds are heard at the end of the inspira- 
 tory act, and especially at the end of a forced inspira- 
 tion, the subcrepitant rale, on the other hand, being heard 
 often with or near the beginning of inspiration, and, per- 
 haps, ceasing before the end of the inspiratory act. An- 
 other distinctive feature is the abrupt development of 
 
VESICULAR OR CREPITANT RALE. 115 
 
 tlie crepitant rale; there Is a shower of crackles, as it 
 were, at the end of a forced inspiration. Finally, the 
 rale is never heard in expiration. The apparent excep- 
 tions to this statement are instances in which the crepi- 
 tant and the subcrepitant rale are associated. This is 
 not very infrequent, and, with a practical knowledge of 
 the characters of each, it is by no means difficult to ap- 
 preciate the combination of the two signs. In fact, the 
 combination affords an excellent opportunity to illustrate 
 the distinctive characters of each ; the fine bubbling at 
 or near the beginning of inspiration, followed by the fine 
 crackling at the end of this act, and the former perhaps 
 reproduced in the act of expiration. 
 
 There are various modes in which the crepitant rale 
 may be irnitated; for examples, rubbing together a lock 
 of hair near the ear, throwing fine salt upon live coals 
 or into a heated vessel, igniting a train of gunpowder, 
 and alternately pressing and separating the thumb and 
 finger moistened with a solution of gum arable and held 
 near the ear. A perfect representation is afforded by 
 squeezing a piece of an artificial preparation known as 
 the india-rubber sponge, and observing the sound pro- 
 duced by the separation of the walls of the interstices 
 when the piece expands from its elasticity. This pre})a- 
 ration exemplifies the true mechanism of the sign as 
 described, first, by the late Dr. Carr, of Canandaigna, 
 N. Y., in an article published in the American Journal 
 of 31edical Sciences, in October, 1842.^ Expansion of 
 the lungs of the sheep or calf, after removal from the 
 body, the stethoscope being applied to the lung-surface, 
 gives, in certain situations, a well-marked crepitant rale. 
 
 "• Vide article by the author in the New York Monthly Med. 
 Journ. for Feb., 1869. 
 
116 AUSCULTATION IN DISEASE. 
 
 The crepitant rale is the diagnostic sign of pneumonia. 
 It very rarely occurs in any other })athological connec- 
 tion. Of all respiratory signs, this is most entitled to 
 be called pathognomonic. It belongs especially to the 
 first stage of acute pneumonia. It is not invariably 
 present, but it occurs in the majority of cases of acute 
 pneumonia. In the second stage, or tiie stage of solidifi- 
 cation, the rale generally disappears. It not infrequently 
 is rej)roduced in the stage of resolution, and it is then 
 called the returning crepitant rale. In the latter stage 
 it is often found in combination with the subcrepitant 
 rale. The practical value of this sign relates chiefly to 
 the diagnosis of pneumonia. 
 
 It is stated that the crepitant rale is sometimes found 
 in cases of pulmonary oedema, and during or directly 
 after an attack of haemoptysis. If it ever occur in these 
 cases, the instances must be extremely rare. The state- 
 ment is perhaps based on the occurrence of the subcrepi- 
 tant, this being confounded with the crepitant rale. It 
 occurs transiently under the following circumstances: A 
 patient wlio has been confined for some time in bed, 
 lying on the back, and much enfeebled with any disease, 
 if suddenly raised to a sitting posture and auscultated, a 
 crepitant rale is often found on the posterior aspect of 
 the chest at the end of a forced inspiration. The rale 
 disappears after a few forced inspirations. It is heard, 
 not on one side only, but on l)oth sides. The explana- 
 tion is, that during the recumbent posture continued for 
 some time, and the patient breathing feebly, enough of 
 the air-vesicles and bronchioles become agglutinated by 
 means of a little sticky transudation to give rise to 
 crackling sounds in a few forced inspirations. It may be 
 
CAVERNOUS OR GURGLING RALE. 117 
 
 of use to mention that if the stethoscope be applied to 
 the anterior surface of a cliest much covered with hair, 
 the movements of the pectoral extremity of the instru- 
 ment in the act of inspiration may produce a sound iden- 
 tical with the crepitant rale. 
 
 A crepitant rale at the summit of the chest, within a 
 circumscribed space, is one of the accessory signs of 
 phtliisis. It denotes a circumscribed pneumonia which 
 clinical experience shows to be generally secondary to 
 phthisis; hence the diagnosti(3 significance of the sign. 
 
 Cavernous or Gurg^ling Rale. 
 
 A pulmonary cavity of considerable size, containing a 
 certain quantity of liquid, and communicating freely with 
 bronchial tubes, furnishes a rale which is characteristic. 
 The character of the sound is expressed as fully as 
 possible by the term gurgling. The sound is produced 
 by large bubbling and the agitation of the liquid within 
 the cavity. It may be compared to the sound produced 
 by the boiling of a liquid in a flask or large test-tube. 
 The sound is sometimes high pitched and amphoric, but 
 generally it is low in pitch. It is heard with more or 
 less intensity within a circumscribed space almost in- 
 variably at or near the summit of the chest; but, if 
 intense, the sound is diffused, and it may be sometimes 
 heard at a distance. Its diagnostic importance relates 
 to the advanced stage of phthisis. The rale is heard 
 chiefly or exclusively in the act of inspiration. It may 
 be produced by the act of coughing sometimes with 
 greater intensity than by respiration. 
 
118 AUSCULTATION IN DISEASE. 
 
 Pleural Rales — Friction-Sounds — Metallic Tinkling — 
 
 Splashing. 
 
 The signs embraced under the name pleural rales are, 
 1st. Sounds produced by the rubbing together of the 
 pleural surfaces, and hence called friction-sounds ; 2d. 
 Metallic tinkling; and 3d. Splashing or succussion 
 sounds. 
 
 Friction- Sounds. — Movements of the pleural surfaces 
 upon each other take place in inspiration and expiration; 
 but in health these movements occasion no sound. 
 Sounds are produced when the surfaces are covered with 
 a recent fibrinous exudation which prevents the normal 
 continuous, unobstructed movements, and when the sur- 
 faces are roughened with dense lymph or other morbid 
 products. The sounds are generally interrupted, that 
 is, two, three, or more sounds occur during the act of 
 inspiration or expiration, or during both acts. The 
 intensity of the sounds varies much in different cases. 
 A slight grazing sound only may be heard, or, on the 
 other hand, the sounds may be so loud as to be heard by 
 the patient and by others at a distance. The character 
 of the sounds is variable. The slight rubbing or grazing 
 character may be imitated by placing over the ear the 
 palmar surface of one hand, and moving over its dorsal 
 surface slowly the pulpy portion of a finger of the other 
 hand. In some instances, however, the rough character 
 of the sounds is expressed by such terms as rasping, 
 grating, and creaking. In these instances the sounds 
 denote density of the morbid product which roughens the 
 pleural surfaces. In connection with very rough sounds, 
 vibration of the walls of the chest, or fremitus, is some- 
 times perceived by palpation. 
 
 Aside from the character of the sounds as just stated, 
 
FRICTION-SOUNDS. 119 
 
 they are distinguished by their apparent nearness to the 
 car; they seem sometimes to be produced upon the sur- 
 face of tlie chest. They are sometimes intensified by 
 firm pressure of the stethoscope upon the chest. After 
 a little practical knowledge of these sounds they can 
 hardly be confounded with any other rales. 
 
 Pleuritic friction-sounds generally denote pleurisy. 
 In cases of pleurisy with effusion, slight rubbing or 
 grazing is sometimes heard before much liquid accumu- 
 lates within the pleuritic cavity. The physical condi- 
 tions, however, after the effusion has been removed, are 
 much morefavorable for the production of friction-sounds, 
 and they are often now rough in character. They may 
 be transient, or they may continue for a considerable 
 period, their duration depending on the arrest of the 
 movements of the pleural surfaces by means of either 
 agglutination with lymph, or adhesion from the growth 
 of areolar tissue. 
 
 Pleuritic friction-sounds occur not infrequently in 
 cases of pneumonia, denoting, in this connection, coex- 
 isting pleurisy. 
 
 Slight rubbing or grazing at the summit of the chest 
 is one of the accessory signs of phthisis. It denotes a 
 circumscribed, dry j)leurisy, which, as clinical experience 
 show^s, is generally secondary to phthisis, and hence the 
 diao-nostic sio;nificance of the siirn. 
 
 In the foregoing instances in which friction-sounds 
 are stated to occur, their significance relates to pleurisy. 
 In some rare instances the sounds are produced by 
 miliary tubercles or carcinomatous nodules projecting 
 beyond the plane of the visceral pleural surface, without 
 pleuritic inflammation. 
 
120 AUSCULTATION IN DISEASE. 
 
 Metallic TinhUng. — This is a vocal as, well as a re- 
 spiratory sign. It is also produced by acts of coughing, 
 and sometimes by the act of deglutition. The name ex- 
 presses the distinctive character of the sign. It consists 
 in a series of tinkling sounds of a high-f)itched, silvery, 
 or metallic tone. The number of sounds varies from a 
 single sound, to two, three, or more sounds, during an 
 act of either iufspiration or expiration. Tins sign may 
 be imitated in various way<«, by means of an india-rubber 
 bag of considerable size. Forcing a liquid into the bag 
 with Davidson's Syringe, tapping the bag with the finger, 
 or shaking it, will produce tinkling sounds. The best 
 mode of artificial representation of the sign is to connect 
 the bag with a flexible tube, the latter containing a few 
 drops of liquid, and blowing into the tube so as to pro- 
 duce bubbles at the communication of the tube with the 
 bag. In this latter experin)ent it is not necessary that 
 the bag contain any liquid. It occurs irregularly, that 
 is, it is not ])resent in every act of breathing, but is heard 
 at variable intervals. It may sometimes be produced by 
 forced, when it is not heard iu tranquil, breathing. It 
 can only be confounded with tinkling sounds sometimes 
 produced within the stomach. The latter, however, are 
 easily discriminated by their situation, and the absence 
 of associated signs denoting the affections of the chest in 
 which the sign occurs. 
 
 Metallic tinkling is the sign of pneumothorax with 
 perforation of lung. In the great majority of the cases 
 in which it is found, it is diagnostic of this aifection. It 
 is, however, always associated with other physical signs 
 corroborative of the diagnosis. 
 
 It is a rare sign, in cases of phthisis, of a large pulmo- 
 nary cavity, the conditions for its production being analo- 
 
INDETERMINATE RALES. 121 
 
 gous to those in pneiimo-hydrothorax, namely, a space of 
 considerable size containing air, the space communicating 
 with bronchial tubes. 
 
 Splashing, or Succussion Sounds. — This sign is pro- 
 duced by succussion, which is reckoned as one of the 
 different modes of j)hysical exploration. Sounds thus 
 produced are not infrequently heard at some distance; 
 generally, however, succussion is practiced while the ear 
 is a})plied to the chest, so that properly enough the sign 
 may be embraced among the auscultatory signs, although 
 not produced by respiration. 
 
 Splashfng is pathognomonic of either pnenrao-liydro- 
 thorax or pueumo-pyothorax. It is especially valuable as 
 a sign of these affections because it is almost invariably 
 available. The instances are extremely few in which the 
 sign is wanting when air and liquid are contained in the 
 pleural cavity. It is obtained by jerking the body of the 
 patient with a quick, somewhat forcible movement, the 
 ear being very near to, or in contact with, the chest. 
 
 The sound is like that produced when a bottle par- 
 tially filled with liquid is shaken. The sound is often 
 high-pitched and amphoric in quality. The only liability 
 to error is in confounding with this sign, splashing pro- 
 duced within the stomach. Attention to other signs will 
 always protect against this error. 
 
 Indeterminate Bales. — Under this head may be em- 
 braced some sounds sufficiently recognizable, but inde- 
 terminate as regards the rationale of their production 
 and the physical conditions which they represent. They 
 may be designated crumplingand crackling sounds. The 
 former are probably due to pleuritic rubbing, and the 
 latter to the separation of some slightly adherent air- 
 vesicles or bronchioles. Their diagnostic value relates 
 
122 AUSCULTATION IN DISEASE. 
 
 only to the early stage of phthisis. In conjunction with 
 other signs, any indeterminate rale, if limited to the 
 summit of the chest, and especially to one side, has some 
 weight in the diagnosis. Crumpling and crackling sounds, 
 however, are not uncommon in healthy persons at the 
 end of forced inspiration. The fact of their presence at 
 both summits, and the absence of other morbid signs, are 
 the grounds for not considering them as evidence of dis- 
 ease. They are found in health especially if the binau- 
 ral stethoscope be employed. Their diagnostic signifi- 
 cance, thus, depends on limitation to the summit of the 
 chest on one side, and association with other signs point- 
 ing to incipient phthisis. 
 
 The Vocal Signs of Disease. 
 
 The vocal signs of disease, with the exception of 
 metallic tinkling, which is a vocal as well as respiratory 
 sign, may all be considered as abnormal modifications of 
 the normal vocal resonance and of the normal bronchial 
 whisper. The student must, therefore, be familiar with 
 the distinctive characters of these two normal signs before 
 he is prepared to enter upon the study of the abnormal 
 modifications {vide pages 77 and 82). He must bear in 
 mind the facts which have been presented in relation to 
 the normal vocal fremitus {vide page 77). The rules 
 given for auscultation of the voice are also to be observed 
 {vide page 7G). Embracing the abnormal modifications 
 of the loud voice, the whisper and fremitus, the following 
 are the signs to be considered: Bronchophony; Whis- 
 pering Bronchophony ; ^Kgophony ; Increased Vocal 
 Resonance; Increased Bronchial Whisper; Cavernous 
 Whisper; Pectoriloquy; Amphoric Voice or Echo; 
 Diminished and Suppressed Vocal Resonance; Dimin- 
 
BRONCHOPHONY, 123 
 
 ished and Suppressed Vocal Fremitus, and Metallic 
 
 Tinkling. 
 
 Bronchophony. 
 
 Bronchophony has the same import as bronchial or 
 tubular respiration. Like the latter sign, it represents 
 complete or considerable solidification of lung. Gene- 
 rally the two signs are associated, but either may be 
 present without the other. 
 
 The characters which are distinctive of bronchophony, 
 as compared with the normal vocal resonance, are these: 
 The vocal sound seems concentrated, in most cases near 
 the ear, and the pitch is more or less raised. These 
 characters are in contrast with the diffusion, distance, 
 and lownessof pitch of the normal vocal resonance. The 
 intensity of the sound is variable; it may be greater or 
 less than the intensity of the normal resonance. A con- 
 centrated, high-pitched sound, however feeble, is not less 
 a sign of complete or considerable solidification of lung, 
 that is, it is not less bronchophony, than when the sound 
 is intense. 
 
 Vocal fremitus is always to be discriminated from 
 vocal resonance. The fremitus associated with broncho- 
 phony may, or may not, be greater than the fremitus of 
 health. Not infrequently the fremitus is less than in 
 health. 
 
 It is to be borne in mind that in some healthy persons 
 bronchophony exists at the summit of the chest, espe- 
 cially on the right side, over the primary bronchus. 
 Existing alone in this situation, it may not be abnormal. 
 
 Representing complete or considerable solidification 
 of lung, this sign occurs in the different affections in 
 which bronchial or tubular respiration has been seen to 
 occur [vide page 9fS), namely, lobar pneumonia, phthisis, 
 
124 AUSCULTATION IN DISEASE. 
 
 chronic or fibroid pneumonia, condensation of lung from 
 either pleuritic eifusion, the accumulation of air in the 
 pleural cavity or the pressure of a tumor, collapse of 
 pulmonary lobules, coagulation of blood within the air- 
 vesicles, and carcinoma of lung. 
 
 For the production of bronchophony, a less degree of 
 solidification is requisite than for the production of bron- 
 chial or tubular respiration. Hence, bronchophony may 
 be associated with a broncho- vesicular, as well as with a 
 purely bronchial respiration. This is illustrated in the 
 resolving stage of pneumonia. When resolution has pro- 
 gressed sufficiently for the bronchial to give place to the 
 broncho- vesicular respiration, well-marked bronchophony 
 is often found to continue, ceasing at a later period in 
 the resolving stage. 
 
 The apparent nearness to the ear of the vocal sound 
 in bronchophony is wanting if a certain quantity of liquid 
 intervene between the solidified lung and the w^alls of 
 the chest at the situation auscultated. The voice under 
 these conditions seems to be more or less distant. This 
 difference is readily appreciated, ^¥ith this apparent 
 distance of the bronchophonic voice, in some instances is 
 associated the modification which is characteristic of 
 another sign, namely, legophony. 
 
 Whispering Bronchophony. 
 
 The characters of this sign correspond to those of the 
 expiratory sound in the bronchial or tubular respiration 
 {vide page 93). The sound is more or less intensified, 
 high in pitch and tubular in quality. If the patient 
 pronounce numerals in a forced whisper, the characters 
 are generally more marked than in the expiratory sound 
 in forced breathing. The significance of this sign is the 
 
^GOPHONY. 125 
 
 same as that of the bronchial or tubular respiration, and 
 of bronchophony with the loud voice. 
 
 JEgophony. 
 
 This sign is a modification of bronchophony. As 
 regards concentration and pitch, it has the characters of 
 bronchophony, the distinctive features being apparent 
 distance from the ear, and tremulousness or a bleating 
 tone. From the latter the name is derived, the term 
 signifying the cry of the goat. The characters which 
 distinguish the sign from bronchophony are readily 
 enough appreciated, and it represents a physical con- 
 dition added to solidification of lung. This physical 
 condition is the presence of liquid effusion. The sign is 
 rarely present in cases of large effusion. It occurs 
 usually when the chest is about half filled with liquid, 
 and the lung at the level of the liquid is sufficiently con- 
 densed to give rise to bronchophony. This condition, 
 under these circumstances, involves agglutination of lung 
 above the portion condensed by pressure. The sign also 
 sometimes occurs in cases of pleuro-pneumonia, the 
 solidification in these cases being due to pneumonic 
 exudation. As a sign of liquid eifusion it possesses 
 diagnostic value, although, owing to the fact that the 
 existence of eifusion is easily determined by other signs, 
 it may be said to be superfluous. When the person 
 examined speaks with the teeth approximated, broncho- 
 phony has somewhat of the character of liegophony. 
 
 Increased Vocal Resonance and Fremitus. 
 
 The distinctive character of this sign is an increase of 
 the intensity of the resonance without notable change in 
 other respects. The resonance may be more or less 
 
 11 
 
126 AUSCULTATION IN DISEASE. 
 
 intensified, but it is distant, diffused, and comparatively 
 low in pitch ; in other words, the characters of broncho- 
 phony are wanting. The differential points between 
 bronchophony and increased resonance should be clearly 
 apprehended, bearing in mind that the intensity of the 
 sound in bronchophony may, or may not, be greater than 
 the normal resonance. 
 
 Increased vocal resonance occurs when the lung is 
 solidified, the solidification not sufficient in degree to 
 produce bronchophony. Lung slightly or moderately 
 solidified gives rise to an increase of intensity ; if the 
 solidification become considerable or complete, broncho- 
 phony takes the place of the simple increase of intensity. 
 Thus, at an early period in pneumonia, increased vocal 
 resonance precedes bronchophony ; and in the stage of 
 resolution the reverse of this takes place, namely, in- 
 creased vocal resonance follows bronchophony, the lat- 
 ter ceasing when resolution has progressed to a certain 
 extent. 
 
 Contrary to what would perhaps be anticipated in the 
 instances just cited, the intensity of the sound when 
 bronchophony is present may be not only not increased, 
 but diminished below that of health ; that is, in the first 
 stage of pneumonia the increased intensity may cease 
 when bronchophony occurs, and return when broncho- 
 phony disappears. 
 
 Increase of the vocal resonance occure in connection 
 with pulmonary cavities. Over a cavity of considerable 
 size situated near the superficies of the lung, the vocal 
 resonance is sometimes extremely intense without any 
 bronchophonic characters. The latter, if present, denote 
 considerable solidification either around the cavity, or 
 between it and the walls of the chest. From the pres- 
 
INCREASED VOCAL RESONANCE AND FREMITUS. 127 
 
 ence or tlie absence of bronchoi)lionic characters with 
 greatly increased intensity of resonance, the auscultator 
 can judge whether the cavity be, or be not, in proximity 
 to considerable solidification of Itmg. 
 
 Irrespective of the cavernous stage of phthisis, the 
 sign is of diagnostic importance in the different affections 
 which involve moderate or slight solidification of lung, 
 namely, pneumonia early in the disease and in the stage 
 of resolution, phthisis, over the compressed lung in pleu- 
 risy with moderate effusion, collapse of pulmonary lob- 
 ules, hsemorrhagic infarctus, and carcinoma of lung. Into 
 the diagnosis of all these affections, both bronchophony 
 and increased vocal resonance enter; the former when 
 solidification is considerable or complete, and the latter 
 when it is slight or moderate. IncreavSed vocal resonance 
 is especially valuable in the diagnosis of early or incipi- 
 ent phthisis. An abnormal resonance, however slight, at 
 the summit of the chest on one side, is an important sign 
 in that affection. In determining an abnormal resonance 
 on the right side, either at the summit or elsewhere, al- 
 lowance must always be made for the normally greater 
 resonance on this side. 
 
 Increased vocal resonance has the same import as 
 broncho- vesicular respiration. These two signs, how- 
 ever, are not always in the same proportion ; that is, the 
 characters of the latter maybe marked out of proportion 
 to the amount of the increase of the vocal resonance, and 
 vice versa. 
 
 Increased vocal fremitus generally accompanies in- 
 creased vocal resonance, and it denotes solidification of 
 lung. Fremitus, however, and resonance are not always 
 in equal proportion, that is, either may be increased 
 more than the other. An increased fremitus is some- 
 
128 AUSCULTATION IN DISEASE. 
 
 times of value in the diagnosis of phthisis. The greater 
 fremitus on the right side of the chest is always to be 
 borne in mind, and due allowance is to be made for this 
 disparity in determining that the fremitus is increased. 
 
 Increased Bronchial Whisper. 
 
 The significance of this sign is the same as that of 
 increased vocal resonance and the broncho-vesicular 
 respiration; it represents the same physical condition as 
 the two latter signs, namely, solidification of lung, 
 greater or less, but below the degree requisite to give 
 rise to bronchophony and bronchial respiration. Its 
 diagnostic application is, therefore, involved in the same 
 pulmonary affections. 
 
 The characters of the sign are those which belong to 
 the expiratory sound in the broncho-vesicular respira- 
 tion. They consist, therefore, of increase of intensity, 
 a quality more or less tubular, and the pitch raised, 
 these modifications of the normal expiratory sound 
 varying in degree between the slightest appreciable 
 morbid change and a close approximation to the bron- 
 chophonic whisper. The modifications in degree cor- 
 respond to the degree of solidification. To appreciate 
 the characters of this sign, it must be studied in com- 
 parison with those of the normal bronchial whisper in 
 different portions of the chest. The most important 
 of the diagnostic applications of the sign is in cases of 
 phthisis in its early stage. In this application, the 
 points of normal disparity between the two sides of the 
 chest at the summit are to be borne in mind, and due 
 allowance made for them {vide page 83). 
 
 A greater intensity of the bronchial whisper at the 
 right than at the left summit is not evidence of disease; 
 
PECTORILOQUY. 129 
 
 but greater intensity at the left summit is always abnor- 
 mal. As a rule, the |)it('h of the normal bronchial whisper 
 at the left, is higher than that at the right, summit; if, 
 therefore, with a greater intensity of the whisper at the 
 right summit, it be a matter of doubt whether it denote 
 disease or not, when the pitch is higher at this summit, 
 it is to be considered as morbid. 
 
 Cavenioiis Whisper. — The characters distinctive of 
 the cavernous whisper are those of the expiratory sound 
 in the cavernous respiration, namely, lowness of pitch, 
 and the quality blowing, that is, non-tubular. The in- 
 tensity of the sound is variable. It is limited to a cir- 
 cumscribed space corresponding to the situation and size 
 of the cavity. Not infrequently the characters of the 
 sign are brought into contrast with those of whispering 
 bronchophony, or increased bronchial whisper, these 
 latter signs existing in close proximity, and representing 
 solidification of lung in the immediate neighborhood of 
 the cavity. The diagnostic application of this sign is 
 chiefly to advanced phthisis. 
 
 Pectoriloquy. — In pectoriloquy, not merely the voice, 
 but the speech, is transmitted through the chest; the 
 auscultator recognizes words uttered by the patient. 
 The student, however, must not expect to be able to 
 carry on a conversation with the patient by means of the 
 stethoscope. Often single words only can be recognized. 
 To make sure that these are transmitted through the 
 chest, care must be taken to exclude their direct trans- 
 mission from the patient's mouth, and the auscultator 
 should not know beforehand the words which are to be 
 spoken. If these rules be not observed, the auscultator 
 may err in supposing that the words are transmitted 
 
130 AUSCULTATION IN DISEASE. 
 
 through the chest. When auscultation is practiced with 
 one ear, the other should be closed. 
 
 Tiie speech with either the loud or the whispered voice 
 may be transmitted, the latter, distinguished as whisper- 
 ing pectoriloquy, being much more frequent than the 
 former; moreover, in determining whispering pectorilo- 
 quy, there is less liability to error in mistaking the per- 
 ception of words coming directly from the mouth for the 
 transmission through the chest. In the production of 
 this sign, much depends on the distinctness with which 
 words are articulated by the patient. Normal pectorilo- 
 quy at the anterior superior portion of the chest is some- 
 times observed. 
 
 Pectoriloquy belongs among the cavernous signs ; but 
 it is by no means exclusively the sign of a cavity; the 
 speech may also be transmitted by solidified lung. It is 
 easy to determine in any case whether the sign denotes 
 a cavity or solidified lung. If, with transmitted speech, 
 the voice have the characters of bronchophony, the sign 
 represents solidification of lung; if, on the other hand, 
 the characters of bronchophony be wanting, the sign 
 represents a cavity. These statements apply equally to 
 the loud and to the whispered voice. Of course, asso- 
 ciated signs will be likely to show whether a cavity exists 
 or not. It is to be added that a cavity and solidification 
 of lung existing together, may conjointly be concerned 
 in the production of the sign. 
 
 Amphoric Voice or Echo. — This sign is identical in 
 character with am])horic respiration, with which it is 
 usually associated {vide page 100). The am])horic into- 
 nation may accompany the loud voice and the whisper; 
 generally, it is more appreciable or marked with the 
 latter. Its significance is the same as that of amphoric 
 
DIMINISHED VOCAL RESONANCE. 131 
 
 respiration. As a rule, it rcj)rescnts the conditions in 
 pnenmothorax, namely, a large space filled with air and 
 perforation of hint^. In this affection it is associated 
 with other signs which suffice for a prompt and positive 
 diagnosis. It is not invariably fonnd in pneumothorax, 
 and it may be present in a case at one time and wanting 
 at another time, its production being dependent on the 
 perforation being above the level of liquid, if the latter 
 exist, and on the bronchial tubes leading to the perfo- 
 ration being unobstructed. When not associated with 
 other signs which are diagnostic of pnenmothorax, or 
 pneumo-hydrothorax, it denotes a phthisical cavity of 
 considerable size. It is not infrequently a sign of a 
 phthisical cavity with rigid walls and communicating 
 freely with bronchial tubes. It has this significance 
 whenever pneumothorax can be excluded; and the asso- 
 ciated signs in the latter affection are such that its ex- 
 clusion is always practicable. 
 
 The amphoric sound sometimes is observed to follow 
 the oral voice; hence, the name amphoric echo. 
 
 Diminished and Suppressed Vocal Resonance. — 
 Diminution and suppression of the normal vocal reso- 
 nance occur especially when the pleural cavity contains 
 either liquid or air. Whenever the lungs are not in con- 
 tact with the walls of the chest, the vocal resonance, as 
 a rule, is either notably lessened or wanting:. The si<rn 
 is, therefore, of value in diagnosis in cases of pleurisy 
 with effusion, empyema, hydrothorax,and pneumothorax. 
 When the pleural cavity is partially filled with liquid, 
 there is diminution or suppression of the resonance from 
 the level of the liquid downward; and generally, just 
 above the level of the liquid, tlie resonance is increased, 
 owing to condensation of the lung. The sign is well 
 
132 AUSCULTATION IN DISEASE. 
 
 illustrated by the contrast in such cases above and below 
 the level of the liquid. As a rule, the changes of the level 
 of the liquid with changes in position of the body, may 
 be as well demonstrated by means of vocal resonance as 
 by percussion. Exceptionally, however, this rule is not 
 available. 
 
 The practical importance of diminished and suppressed 
 vocal resonance relates chiefly to the diagnosis of the 
 affections just named. In this application, however, the 
 associated signs must be taken into account. The vocal 
 resonance may be diminished or suppressed when the 
 lung is completely solidified in the second stage of 
 pneumonia ; also in pulmonary oedema, and over the site 
 of an intra-thoracic tumor. 
 
 If the vocal resonance be normal, that is, neither in- 
 creased nor diminished, we are warranted in excluding 
 all the affections which have been named ; the excep- 
 tional instances are so rare that, practically, they may be 
 disregarded. 
 
 Diminished vocal resonance maybe found over a pul- 
 monary abscess before the pus is evacuated, and over a 
 cavity filled with liquid. The sign is then limited to a 
 circumscribed space. Obstruction of a bronchial tube 
 diminishes resonance in so far as the column of air is a 
 medium for the conduction of vocal sound. 
 
 The normal disparity between the two sides of the 
 chest is to be borne in mind with reference to diminished 
 or suppressed, as well as to increased, vocal resonance; 
 otherwise the relative feebleness of the resonance on the 
 left side in health might be considered to be morbid. 
 The normally greater resonance on the right side ren- 
 ders it easier to determine a morbid diminution on this 
 than on the left side. 
 
COUGHING OR TUSSIVE SIGNS. 133 
 
 Diminished and Suppressed Vocal Fremitus. — This 
 tactile sensation, which is appreciable in auscultation, 
 as a rule, is, on the one hand, increased, and, on the 
 other hand, diminished or suppressed, under the same 
 physical conditions which occasion corresponding modifi- 
 cations of the vocal resonance. Diminished or sup- 
 pressed vocal fremitus, therefore, has the same diagnostic 
 significance as diminished or suppressed vocal resonance. 
 Usually the abnormal modifications of resonance and 
 fremitus go together, but either may be out of proportion 
 to the other. Thesio;ns relatincrto fremitus thus corrob- 
 orate those relating to resonance. The former may be 
 marked when the latter admit of doubt. Diminished or 
 suppressed fremitus is valuable in the diagnosis of pleu- 
 risy with effusion, empyema, hydrothorax, and pneumo- 
 thorax. It is, however, to be noted that in exceptional 
 instances, the fremitus persists over the site of liquid 
 within the chest. 
 
 With regard to vocal fremitus, as to vocal resonance, 
 it is essential to take cognizance of the normal disparity 
 between the two sides of the chest, the greater rela- 
 tive fremitus, on the right side, as a rule, being no less 
 marked than the relatively greater resonance on that side. 
 
 Iletalllc Tinkling. — This sign has the same characters 
 when it accompanies either the loud or whispered voice, 
 as Vvheu it is heard with respiration, and, of course, it 
 has the same significance (vide page SQ). It may be more 
 marked with acts of speaking than with the respiratory 
 acts. 
 
 Signs obtained by Acts of Coughing or Tussive Signs. 
 
 Acts of coughing may be made subservient to auscul- 
 tation of respiratory sounds in two ways : First, by the 
 
 12 
 
134 AUSCULTATION IN DISEASE. 
 
 removal of temporary obstruction from the accumulation 
 of mucus within bronchial tubes. If the respiratory 
 murmur be diminished or suppressed over a portion or 
 the whole of one side of the cliest, sometimes an act of 
 coughing effects dislodgment of a mass of mucus from 
 either a primary broncluis or one of its subdivisions, and 
 the normal murnuu' is at once restored. The dependence 
 of the morbid sign upon a temporary obstruction is thus 
 demonstrated. Second, by an act of coughing more air 
 is expelled than by an ordinary expiration, and in the 
 following inspiration the vesicles have a wider range of 
 expansion, giving rise to a proportionately loud inspira- 
 tory sound ; hence, the characters of this sound are more 
 pronounced and can be l)etter studied. For these two 
 objects it is often advisable to request the patient to 
 cough with a certain degree of force. 
 
 Acts of coughing, moreover, give rise to auscultatory 
 signs which have their analogues in signs obtained by 
 respiration and the voice. These tussive signs are of 
 less value than the respiratory and vocal signs, and in 
 most cases, owing to the latter being sufficient for diag- 
 nosis, they may be said to be superfluous ; nevertheless, 
 they may be observed sometimes with advantage. When 
 the conditions are present which are represented by 
 bronchial respiration, bronchophony and the broncho- 
 phonic whisper, sounds are obtained which correspond to 
 these in their characters. The cough is then said to be 
 bronchial. With the stethoscope applied over an empty 
 cavity of some size, situated near the surface of the lung, 
 the ear receives with acts of coughing a concussion or 
 shock which is sometimes so forcible as to be painful. 
 This corresponds to an intense vocal resonance. Limited 
 to a circumscribed space, it is a highly significant 
 
COUGHING OR TUSSIVE SIGNS. 135 
 
 cavernous sign. It may be present when the cavernoiis 
 respiration is wanting. A low-pitched blowing sound 
 corresponds to the expiratory sound in the cavernous 
 respiration and the cavernous whisper. An amphoric 
 intonation may be heard with acts of coughing, which 
 corresponds to amphoric respiration and amphoric voice. 
 This sign is sometimes more marked with cough than 
 with the breathing and voice. Cavernous gurgling may 
 also be obtained more distinctly with cough than with 
 respiration. Finally, metallic tinkling not infrequently 
 accompanies acts of coughing. 
 
136 PHYSICAL DIAGNOSIS. 
 
 CHAPTER yi. 
 
 THE PHYSICAL DIAGNOSIS OF DISEASES OF THE 
 EESPIRATORY ORGANS. 
 
 Affections of the larynx and trachea — Bronchitis seated in large hron- 
 chial tubes — Bronchitis seated in small bronchial tubes, or capillary 
 bronchitis — Collapse of pulmonary lobules — Lobular pneumonia — 
 Asthma — Pulmonary or vesicular emphysema — Pleurisy, acute and 
 chronic — Empyema — Hydrothorax — Pneumothorax — Pneumo- 
 hydrothorax — Pneumo-pyothorax — Acute lobar pneumonia — Cir- 
 cumscribed pneumonia — Embolic pneumonia — Hsemorrhagic infsirc- 
 tus — Pulmonary apoplexy — Pulmonary gangrene — Pulmonary 
 oedema — Carcint/ma of lung — Tumor within the chest — Acute 
 miliary tuberculosis — Pulmonary phthisis — Fibroid phthisis, inter- 
 stitial pneumonia, or cirrhosis of lung — Diaphragmatic hernia. 
 
 In the preceding chapters the physical conditions 
 incident to the morbid changes occnrring in the affections 
 of the respiratory organs hav^e been enumerated, and 
 the physical signs, obtained by percussion and ausculta- 
 tion, representing these conditions, have been considered, 
 severally, as regards their distinctiv^e characters and their 
 significance. The object of this chapter is to group the 
 physical conditions embraced in the different diseases of 
 the respiratory system respectively, together with the 
 representative signs on which rests the physical diagnosis 
 of each of the diseases. The scope of this manual is 
 limited to the physical diagnosis of these affections; but 
 the fact is not to be lost sight of that in practical medi- 
 cine physical signs are not to be disassociated from symp- 
 toms and pathological laws. An exclusive reliance on 
 physical signs would lead to errors in diagnosis, although, 
 
AFFECTIONS OF TUE LARYNX AND TRACHEA. 137 
 
 doubtless, errors more important and more frequent 
 necessarily occur when the practitioner ignores percus- 
 sion and auscultation. The signs furnished by percus- 
 sion and auscultation only have been thus far considered, 
 but in grouping these in this chapter, signs obtained by 
 other methods of physical exploration will be embraced 
 in so far as they enter into the diagnosis of the different 
 diseases of the respiratory system. These different dis- 
 eases will be taken up separately with the exception of 
 those seated in the larynx and trachea. With reference 
 to physical signs, the laryngeal and tracheal aifections 
 may be considered collectively. 
 
 Affections of the Larynx and Trachea. 
 
 The physical signs referable to the chest in diseases of 
 the larynx and trachea, denote more or less obstruction 
 to the free passage of air through these sections of the 
 air-tubes. The obstruction in the different diseases in- 
 volves different pathological conditions. Spasm of the 
 glottis is one of these conditions, constituting the affec- 
 tions known as laryngismus stridulus and spasmodic 
 croup, occurring also as a pathological element in laryn- 
 gitis, and sometimes in connection Avith aneurism, or a 
 tumor of some kind, involving the recurrent laryngeal 
 nerve. Another pathological condition is the opposite of 
 this, namely, paralysis of the muscles of the glottis, the 
 vocal chords remaining flaccid, and approximating during 
 inspiration. Other pathological conditions are, oedema 
 of the glottis, swelling of the membrane at the glottis in 
 laryngitis, together with, in the adult, submucous infil- 
 tration, diphtheritic exudation, cicatrization of ulcers, 
 morbid growths, and the presence of foreign bodies. 
 
138 PHYSICAL DIAGNOSIS. 
 
 In the affections inv^olving the foregoing pathological 
 conditions, percussion and auscultation are of use, first^ 
 by enabling the physician to exclude all diseases within 
 the chest. The absence of signs showing the existence 
 of pulmonary diseases renders it certain that the symp- 
 toms denoting embarrassment of respiration are referable 
 to the larynx or trachea. Second, by means of auscul- 
 tation the amount of obstruction may be determined 
 more accurately than by the subjective symptoms. The 
 amount of obstruction is represented by a proportionate 
 weakenino; of the vesicular murmur. This is more 
 reliable as regards determining a dangerous amount of 
 obstruction than the sense of the want of air or the suf- 
 fering of the patient. The degree of diminution of the 
 vesicular murmur is determinable with the more accuracy 
 the better the auscultator is acquainted with the normal 
 intensity, that is, the intensity prior to the occurrence of 
 obstruction. With this knowledge, the weakening of the 
 murmur is a correct criterion of the amount of obstruc- 
 tion. In all the pathological conditions named, the 
 respiratory murmur is more or less diminished in in- 
 tensity on both sides of the chest ; there are no signs 
 obtiiined by percussion, nor do vocal resonance or frem- 
 itus offer anything distinctive. 
 
 In cases of considerable or great obstruction during 
 inspiration, inspection furnishes marked signs. The ex- 
 pansion of the chest on boUi sides is restricted, the lower 
 part of the chest is contracted in the act of inspiration, 
 and in this act the soft parts above the clavicles are de- 
 pressed. The contrast between these abnormal move- 
 ments and the normal thoracic movements of the patient 
 is striking and distinctive. 
 
 An important application of auscultation is the localiz- 
 
BRONCHITIS IN LARGE BRONCHIAL TUBES. 139 
 
 ation of a foreign body which has been inhaled. If the 
 vesicular murmur on both sides be more or less weak- 
 ened, the foreign body must be situated in either the 
 larynx or the trachea. If, on the other hand, the vesicu- 
 lar murmur be weakened or suppressed on one side, and 
 increased on the other side, the body is lodged in a 
 primary bronchus. The importance of this application 
 of auscultation before opening the trachea to remove a 
 foreign body is sufficiently obvious. The situation of a 
 foreign body may be changed from one bronchus to the 
 other by an act of coughing, even after an operation has 
 been commenced ; this is, of course, at once determinable 
 by auscultation. 
 
 Bronchitis Seated in Large Bronchial Tubes. 
 
 In bronchitis, either acute or chronic, as it is ordinarily 
 presented in practice, the inflammation is seated in the 
 large bronchial tubes, in many cases probably not ex- 
 tending beyond the primary bronchi. The physical 
 conditions are, more or less swelling of the mucous 
 membrane, this, however, not being sufficient to occasion 
 any notable obstruction to the free passage of air, and 
 the presence, in different cases, in greater or less quan- 
 tity, of mucus, muco-purulent matter, pure pus, and 
 serum. 
 
 The physical diagnosis involves negative rather than 
 ])ositive points; in other words, the diseases from which 
 bronchitis is to be differentiated are excluded by the 
 absence of their diagnostic signs. These diseases are 
 pneumonia, pleurisy, and phthisis. Each of these is 
 characterized by the presence of signs, the absence of 
 which warrants its exclusion. In bronchitis there is no 
 disparity between the two sides of the chest in the 
 
140 PHYSICAL DIAGNOSIS. 
 
 resonance obtained by percussion, nor in vocal resonance, 
 the bronchial whisper, and fremitus. The swelling of 
 the bronchial mucous membrane may cause some diminu- 
 tion of the intensity of the vesicular murmur, but as 
 the affection is bilateral, and the bronchial tubes on each 
 side are affected equally, both in degree and extent, no 
 appreciable disparity in this respect between the two 
 sides is caused by this physical condition. Weakening 
 or suppression of the murmur over an area greater or 
 less, may be caused by bronchial obstruction from a 
 plug of mucus. This obstruction is sometimes removed 
 by an act of expectoration, after which the murmur is 
 found to have returned, or to have regained its normal 
 intensity. 
 
 The foregoing points, taken in connection with the 
 history and symptoms, suffice for the diagnosis. Signs 
 due directly to the disease represent diminished calibre 
 of the tubes at certain points from swelling of the mem- 
 brane, adhesive mucus, and spasm of bronchial muscular 
 fibres. These signs are the dry bronchial rales. They 
 are rarely prominent, and are oftener absent than pres- 
 ent, if the bronchitis be unaccompanied by asthma; 
 hence, they are of little value in the diagnosis. Other 
 signs are the bubbling sounds or the moist bronchial 
 rales. In acute bronchitis, these are oftener absent than 
 present. They occur when liquid morbid products with- 
 in the tubes are unusually abundant, or when the removal 
 of these is with difficulty effected by expectoration in 
 consequence of muscular debility or other causes. These 
 rales are abundant and loud in proportion as the liquid 
 within the tubes is either muco-j)urulent, purulent, or 
 serous in character. They are more or less coarse in 
 
CAPILLARY BRONCHITIS. 141 
 
 proportion to the size of the tubes in which the bubbling 
 takes place. 
 
 The diagnostic points, negative and positive, which 
 have been stated, are alike applicable to acute and 
 chronic bronchitis, it being, of course, understood that 
 the atfection is primary, that is, not secondary to some 
 other pulmonary disease. 
 
 Bronchitis Seated in Small Bronchial Tubes — Capillary- 
 Bronchitis — Collapse of Pulmonary Lobules — Lobular 
 Pneumonia. 
 
 Inflammation extending into the small tubes (capillary 
 bronchitis) occasions in these the same physical condi- 
 tions which are incident to bronchitis aifectino- tubes of 
 large size, namely, swelling of the membrane, and the 
 presence of liquid morbid products. The latter are not 
 as easily removed by expectoration as when they are 
 within large tubes, and, therefore, they are constantly 
 present in greater or less quantity. These conditions in 
 small tubes involve obstruction to the free passage of air 
 to and from the air-vesicles; hence, the vast difference 
 as regards the symptoms, the suffering, and the danger. 
 The affection is bilateral, a fact greatly enhancing the 
 gravity of the affection. An incidental physical condi- 
 tion.is solidification, generally in disseminated portions of 
 lung, the latter varying in number and size. These por- 
 tions of solidified lung denote either collapse of pulmo- 
 nary lobules or lobular pneumonia, or both in conjunction. 
 To this incidental affection, German writers apply the 
 name "Catarrhal pneumonia." Of course, any discus- 
 sion of pathological questions suggested by these names 
 would be here out of place. With reference to diagnosis 
 it is to be borne in mind that the solidified portions of 
 
112 PHYSICAL DIAGNOSIS. 
 
 liin^ in cases of bronchitis seated in small tubes are espe- 
 cially situated in the lower lobes. Another incidental 
 physical condition is temporary dilatation of the air-cells, 
 or vesicular emphysema, seated in the upper lobes. Both 
 of these incidental conditions are bilateral, like the bron- 
 chitis with which they are connected. Collapse of pul- 
 monary lobules, or lobular pneumonia, or both, and 
 emphysema occur in only a certain proportion of the 
 cases of bronchitis seated in small tubes. The signs, 
 therefore, admit of a division into those which relate, 
 ]st, to the bronchitis, and, 2d, to these incidental affec- 
 tions. With reference to the diagnosis, the fact is to be 
 borne in mind that bronchitis seated in small tubes occurs 
 chiefly in children and the aged. 
 
 The physical diagnosis of bronchitis seated in small 
 tubes, rests on negative points, together with a positive 
 sign which is uniformly present. This sign is the fine 
 moist bronchial or subcrepitant rale, present on both 
 sides and diffused over the chest. The bubbling sounds 
 are to be distinguished from the fine dry crackling sounds 
 or the crepitant rale, to the characters of which the 
 former in some measure approximate. 
 
 The bronchitis gives rise neither to dulnesson percus- 
 sion, nor to any notable change in vocal resonance, or 
 fremitus. The respiratory murmur, if not obscured by 
 rales, is weakened on both sides. Irrespective of being 
 drowned by rales, it may be suppressed by the amount 
 of bronchial obstruction. These are the negative points 
 in the diagnosis. In pulmonary oedema, fine moist 
 bronchial rales are present on both sides, but in this 
 affection there is notable dulness on percussion, and the 
 affection occurs in certain pathological connections, 
 namely, with mitral stenosis, and disease of the kidneys. 
 
LOBULAR PNEUMONIA. 143 
 
 Acute tuberculosis may present the moist bronchial rales 
 with the negative points which, in connection with symp- 
 toms, characterize bronchitis seated in the small tul)es. 
 The differentiation is to be based on difFerences pertaining 
 to the history and duration, together with the age of tlie 
 patient. 
 
 The coexistence of the incidental affections, namely, 
 collapse of pulmonary lobules, or lobular pneumonia, and 
 vicarious emphysema, occasions additional signs. If the 
 solidified portions of king be considerable in either num- 
 ber or size, there will be dulness on percussion in circum- 
 scribed situations on the posterior aspect of the chest. 
 This will be found on both sides, but perhaps more 
 marked on one side. Broncho-vesicular or the bronchial 
 respiration may be present, together witli the vocal signs 
 of solidification, namely, either increased vocal resonance, 
 or bronchoj)hony, and increased vocal fremitus. The 
 moist rales produced within solidified portions of lung 
 are higli in pitch, wliereas, if solidification do not exist, 
 these rales are comparatively low in pitch. The exist- 
 ence of solidification at any point may be determined by 
 the pitch of the rales, as well as by the foregoing respi- 
 ratory and vocal signs. 
 
 When there are emphysematous lobules on the ante- 
 rior aspect of the chest in the upper and middle regions, 
 on both sides, the resonance on percussion is vesiculo-tym- 
 ])anitic, the respiratory murmur weakened or suppressed, 
 and the rhythm altered — in short, the combination of 
 signs which will be stated under the head of emphysema. 
 
 In the cases in which the bronchitis occasions great ob- 
 struction in the small tubes, and, still more, if collapse of 
 lobules, or lobular pneumonia and vicarious emphysema 
 occur, important signs are obtained by inspection. Tlie 
 
144 PHYSICAL DIAGNOSIS. 
 
 anterior portion of the chest remains expanded, and re- 
 traction of the lower part of the chest takes place in the 
 acts of inspiration. 
 
 Asthma. 
 
 The pathologico-physical condition in a paroxysm of 
 asthma, is obstrnction in the small bronchial tnbes 
 attributable to spasm of the bronchial muscular fibres. 
 AVith thii^ condition is associated a temporary vesicular 
 emphysema, which exists often as a persistent aflTection 
 in persons who are subject to asthma. If the emphy- 
 sematous condition already exist, it is increased during 
 the paroxysm of asthma. Bronchitis generally coexists 
 either as a transient or a chronic affection. In an 
 asthmatic paroxysm, therefore, there are present the 
 signs which are proper to asthma, together with those of 
 emphysema, and the associated bronchitis may also oc- 
 casion additional signs. 
 
 The physical diagnosis of asthma, like that of bron- 
 chitis seated in small tubes, is based on negative points 
 taken in connection with a sign which is invariably 
 present, namely, dry bronchial rales. These rales are 
 more or less intense, and they are diffused over the 
 entire chest. They are generally heard at a distance. 
 The sibilant and sonorous varieties are mingled, and 
 they are constantly changing as regards the character of 
 the sounds. 
 
 The negative points are the same as in capillary 
 bronchitis, namely, absence of dulness on percussion, 
 vocal resonance and fremitus also being unaltered. 
 Asthma and bronchitis seated in small tubes agree in the 
 fact that obstruction is the important physical condition. 
 A highly important differential point relates to the fre- 
 
PULMONARY OR VESICULAR EMPHYSEMA. 145 
 
 quency of the respirations; they are much increased in 
 frequency in capillary bronchitis and not in asthma. Pa- 
 thologically they differ essentially in tiie fact that the 
 obstruction is due in the latter affection to bronchial in- 
 flammation, and in the former to spasm. The two affec- 
 tions differ in the signs representing these different con- 
 ditions, fine moist bronchial rales existing in one, and 
 loud diffused dry bronchial rales existing in the other. 
 
 Taking the difference as regards the positive physical 
 signs in connection with the history and symptoms, the 
 differentiation of the two affections may be made without 
 difficulty. 
 
 The signs which relate to the associated emphysema- 
 tous condition, are those which are diagnostic of this 
 condition existing irrespective of asthma; and the phys- 
 ical diagnosis of emphysema will be next considered. 
 Coexisting bronchitis may give rise to moist bronchial 
 rales more or less coarse. These are, however, often 
 wanting, and they are rarely marked during paroxysms 
 of asthma. AVhen present in this pathological connec- 
 tion, they are low in pitch, denoting the absence of 
 solidification of lung. 
 
 Pulmonary or Vesicular Emphysema. 
 
 This affection, as a rule, is seated exclusively or chiefly 
 in the upper lobes. When it is lobar, in contradistinc- 
 tion from the emphysema existing in comparatively a few 
 disseminated or isolated portions of lung, increase in vol- 
 ume of the affected lobes is an important physical condi- 
 tion standing in relation to certain signs. Diminished 
 range of expansion with acts of inspiration is another 
 physical condition ; the affected lobes arc in a permanent 
 state of expansion approximating to that at the end of the 
 
146 PHYSICAL DIAGNOSIS. 
 
 inspiratory act. It follows from these conditions that the 
 amount of air is in excess of the normal proportion to 
 the solids and liquids in the affected lobes. Both lungs 
 are affected, that is, the affection is bilateral. In the 
 great majority of cases chronic bronchitis coexists, and 
 patients affected with emphysema are often, but by no 
 means invariably, subject to paroxysms of asthma. Not 
 infrequently an asthmatic element, WMth or without pro- 
 nounced paroxysms of asthma, exists much of the time 
 in connection with emphysema. The emphysematous 
 condition, as a rule, with few exceptions, is greater in 
 the upper lobe of the left than of the right lung. A rare 
 condition, which is generally included under the name 
 emphysema, differs materially from the ordinary form of 
 this affection. This condition is that also known as 
 senile atrophy of the lungs. The volume of the lungs 
 is not increased in this variety of emphysema, the pro- 
 portion of air over the solids is, however, in excess, 
 owing to the diminution of the latter from atrophy. 
 
 The diagnostic evidence obtained by percussion is 
 quite distinctive of lobar emphysema. The resonance 
 over the upper and middle regions of the chest on both 
 sides is vesiculo-tympanitic, that is, the intensity of the 
 resonance is abnormally increased, the quality is a com- 
 bination of the vesicular and tympanitic, and the pitch 
 is more or less raised. Owing to the fact that the em- 
 physema is greater on the left than on the right side, 
 the vesiculo-tympanitic resonance is more marked on the 
 left side. The difference in intensity between the two 
 sides may load to the error of regarding the resonance 
 on the right side as dulness. The error is avoided by 
 attention to the pitch and the quality of the resonance. 
 If dulness existed on the right side, the pitch of the 
 
PULMONARY OR VESICULAR EMPHYSEMA. 147 
 
 sound should be higher on that side; on the other hand, 
 if tlie difference in intensity be due to the greater amount 
 of emphysema on the left side, the pitch is Iiigher on 
 that side, and the quality vesiculo-tympanitic. The 
 attention of the student is particularly called to the fore- 
 going points of distinction. Assuming that a vesiculo- 
 tympanitic resonance exists anteriorly on both sides, and 
 that it is marked on the left as contrasted with the right 
 side, how is the existence of this sign on the right side 
 to be determined ? The answer is, the resonance over 
 the upper is to be com])nred with that over the lower 
 lobe of the right lung. Percussing first over tiie upper 
 lobe of the right lung, and second over the lower lobe 
 of this lung, that is, posteriorly, below the scapula, or 
 in the infra-axillary region, the vesiculo-tym})anitic reso- 
 nance over the upper lobe is rendered manifest. In a 
 series of patients affected with emphysema, the uniformity 
 of the results of percussion is very striking; anteriorly, 
 over the left side, the resonance is vesiculo-tympanitic 
 as compared with the resonance on the right side, and 
 the resonance is shown to be vesiculo-tympanitic on the 
 right side anteriorly as compared with the resonance 
 posteriorly below the scapula. 
 
 As regards the abnormal modifications of the respira- 
 tory murmur in emphysema, there is, first, either weak- 
 ened respiratory murmur without notable change in pitch 
 or quality, or suppression of the murmur. Diminished 
 intensity of the murmur exists over the upper lobes on 
 both sides, as compared with the murmur over the lower 
 lobes; and in most cases the greater diminution or the 
 suppression is on the left rather than on the right side. 
 Exceptions to the latter statement may be caused by 
 obstruction of the bronchial tubes on the right, and not 
 
148 PHYSICAL DIAGNOSIS. 
 
 on the left side by an accumulation of mucus, and, in 
 rare instances, by the fact that the emphysema is greater 
 on the right side. Occasionally there is almost suppres- 
 sion below with preserved respiration above of the em- 
 physematous type, and this so continuous as not to be 
 explained by obstruction of tubes. Second, modifications 
 in rhythm are not infrequent. These consist in a short- 
 ened (deferred) inspiratory, and a prolonged expiratory 
 sound. In some instances an inspiratory sound is want- 
 ing, and an ex})iratory sound is alone heard. The pro- 
 longed expiratory sound in emphysema is always low in 
 pitch and blowing or non-tubular in quality, in these re- 
 spects differing from the prolonged expiration which 
 denotes solidification of lung, the latter being high in 
 pitch and tubular in quality. These essential points of 
 difference I claim to have been the first to have dis- 
 tinctly stated. 
 
 The foregoing signs obtained by percussion and aus- 
 cultation are those which are in a positive sense diagnostic 
 of emphysema. Associated with these are certain im- 
 portant negative points, as follows: vocal resonance, 
 vocal fremitus, and bronchial whis})er are not notably 
 altered. These negative points suffice to exclude other 
 affections than emphysema. 
 
 Signs obtained by inspection are quite distinctive of 
 this affection. Emphysema, existing in a marked degree, 
 causes a characteristic deformity of the chest; the anterior 
 surface is bulging, giving to the chest an abnormally 
 rounded, bow-windowed, o^ barrel-shaped appearance, 
 the lower part appearing to be contracted. This de- 
 formity occurs when the emphysema has been developed 
 in early life. The movements of the chest in inspiration 
 are characteristic. In tranquil breathing there is but 
 
PULMONARY OR VESICULAR EMPHYSEMA. 149 
 
 little movement of the upper and anterior regions, but 
 in forced breathing tlie sternum and ribs move together 
 as if they were one solid piece. The lower portion of 
 the chest and the epigastrium are retracted in inspira- 
 tion ;^ the costal angle is diminished, the ribs and carti- 
 lages connected with the sternum being sometimes on a 
 line ; the soft parts above the clavicle and sternum are 
 often notably depressed with inspiration. Owing to de- 
 pression of the heart downward and inward, the cardiac 
 impulses are seen and felt in the epigastrium. Percus- 
 sion and vocal resonance, at the same time, show the 
 superficial cardiac region to be diminished or lost, the 
 upper lobe of the left lung covering this space. There 
 may be more or less anterior curvature of the spine, and 
 the lower portions of the scapulae may project, so that 
 sometimes the plane of these bones is almost horizontal. 
 These striking appearances characterize cases in which 
 emphysema exists in a marked degree, and especially 
 when the affection dates from early life. They are less 
 marked or wanting if the emphysema be moderate in 
 degree, and it have taken place in middle-aged persons 
 or those advanced in years. 
 
 In the variety of emphysema distinguished as senile, 
 or senile atrophy of the lungs, in which there is coales- 
 cence of air-vesicles from destruction of the cell-walls 
 without increased volume of the affected lobes, the dias- 
 nosis is to be based on the vesiculo-tympanitic resonance 
 on percussion, weakened respiratory murmur, with, per- 
 haps, the alterations in rhythm, sinking of the soft parts 
 above the clavicles, and the negative points, exclusive of 
 deformity of the chest, which have been described. 
 
 ^ The retraction may be only apparent. Professor Janeway states 
 that he has made measurements showing in some cases that there is 
 no real retraction. 
 
 13 
 
150 PHYSICAL DIAGNOSIS. 
 
 Emphysema can hardly be confounded with any other 
 affection than phthisis. The diiferentiation between these 
 two affections is sufficiently easy if the diagnostic points, 
 positive and negative, of the former, be appreciated. 
 Phthisis occurring in a patient affected with emphysema 
 makes a somewhat difficult problem in diagnosis, but, 
 fortunately for the diagnostician, a patient with emphy- 
 sema very rarely becomes phthisical. 
 
 Owing to the frequency with which an asthmatic ele- 
 ment enters into the clinical history of emphysema, the 
 dry bronchial (sibilant and sonorous) rales are often pres- 
 ent, even when paroxysms of asthma do not occur. 
 
 Pleurisy, Acute and Chronic— Empyema — Hydrothorax. 
 
 In the first stage of acute pleurisy, that is, prior to 
 the effusion of liquid, the physical conditions are, the 
 presence of more or less recently exuded, soft lymph 
 upon the pleural surfaces, which are now in contact, and 
 restrained movements of respiration on the affected side 
 in consequence of the pain which they occasion. In the 
 second stage serous liquid accumulates within the pleural 
 cavity, the quantity varying in different cases, sometimes, 
 although rarely, filling the chest on the affected side. 
 In proportion to the quantity of liquid, the space over 
 which the pleural surfaces are in contact is restricted, 
 the movements of these surfa(!es over each other are 
 limited, and the lung is condensed. In the third stage 
 the quantity of liquid decreases, the space over which 
 the pleural surfaces are in contact increases, and the 
 compressed lung is more or less expanded. The lymph 
 upon the pleural surfaces becomes more dense and ad- 
 herent. Tlie surfaces may become agglutinated by the 
 intervening lymph. Finally, in convalescence, perma- 
 
PLEURISY, ACUTE AND CHRONIC. 151 
 
 nent adhesions result from the production or growth of 
 areolar tissue. 
 
 In subacute and chronic pleurisy there is the same 
 series of physical conditions, the points of difference 
 being, as a rule, a less amount of exudation, and a greater 
 amount of effused liquid. The quantity of liquid in 
 chronic pleurisy, is often sufficient to compress the lung 
 into a small solid mass, situated at the upper and j)os- 
 terior part of the chest, and to dilate the affected side. 
 The heart is often removed from its normal situation. If 
 the pleurisy be on the left side the heart may be pushed 
 laterally beyond the right margin of the sternum ; if the 
 pleurisy be on the right side the heart is pushed laterally 
 to the left of its normal situation. 
 
 In eraj)yema the accumulation of pus is apt to be still 
 greater than that of serous effusion in simple chronic 
 pleurisy, causing, of course, greater dilatation of the 
 chest, and more displacement of the heart. 
 
 In these varieties of pleurisy the affection, with rare 
 exceptions, is unilateral. 
 
 In hydrothorax the conditions differ, first, as regards 
 the absence of the exudation of lymph; second, the af- 
 fection is bilateral, the effusion of liquid taking place 
 in both pleural cavities; and, ^/wVcZ, although the quantity 
 of liquid may be considerably greater on one side, the ac- 
 cumulation very rarely, if ever, is sufficient to ca^ise much 
 dilatation of the chest on that side, with complete conden- 
 sation of the lung, and notable displacement of the heart. 
 
 The signs in the first stage of acute pleurisy are rela- 
 tive feebleness of the respiratory murmur on the affected 
 side, from the restrained respiratory movements on that 
 side, and a rubbing friction-sound. The former is not 
 distinctive of pleurisy, being present when the respira- 
 
152 PHYSICAL DIAGNOSIS. 
 
 tory movements on one side are restrained by pain in 
 intercostal neuralgia and pleurodynia. A friction-sound 
 is not ahvays obtained. In the absence of this sound 
 the physical diagnosis cannot be made with positiveness 
 prior to the effusion of liquid. Assuming that the gen- 
 eral and local symptoms ])oint to an acute inflammatory 
 affection, the differential diagnosis relates to pleurisy and 
 pneumonia. A pleural friction-sound may be present in 
 the latter as well as the former of these two affections. 
 The pathognomonic sign of pneumonia, the crepitant rale, 
 being wanting, the differentiation, in this stage, must 
 rest on diagnostic points pertaining to the symptoms.^ 
 
 In the second stage of acute pleurisy the diagnostic 
 signs are those which denote the presence of liquid 
 within the pleural cavity. These signs are simple and 
 distinctive. There is either dulness or flatness on per- 
 cussion at the base of the chest, extending upward a dis- 
 tance proportionate to the quantity of liquid. If the 
 trunk be in a vertical position, that is, the patient sitting 
 or standing, the line of demarcation between the dulness 
 or flatness and pulmonary resonance is, or approximates 
 to, a horizontal line on the anterior aspect of the chest. 
 This line denotes the level of the liquid and is easily 
 obtained by percussion. It is as easily determined by 
 auscultating the vocal resonance, this either abruptly 
 ceasing or being notably diminished at the level of the 
 liquid. Having ascertained the line forming the upper 
 boundary of dulness or flatness on the anterior aspect 
 of the chest, the patient sitting or standing, if the po- 
 sition be changed to recumbency on the back, and the 
 
 ' Professor Janeway states tliatliehas sometimes heard a crepitant 
 rale at the inception of pleurisy, without coexistinji: pneumonia. The 
 mechanism in these instances is the same as in pneumonia. 
 
PLEURISY, ACUTE AND CflRONIC. 153 
 
 pulmonary resonance be found then to extend more or 
 less below this line, this fact is demonstrative proof of 
 the presence of liquid. Proof in this way is obtained in 
 a large majority of cases, the exceptional cases being 
 those in which the pleural surfaces are united, either by 
 agglutination or permanent adhesions, above the level of 
 the liquid.^ The resonance on percussion over the lung 
 above the level of the liquid is generally vesiculo-tym- 
 panitic — the intensity increased, the pitch raised, the 
 vesicular and the tympanitic quality combined. Some- 
 times there is so little vesicular quality in this vesiculo- 
 tympanitic resonance, that it may seem to be purely 
 tympanitic, and is suggestive of pneumothorax. Asso- 
 ciated signs will always prevent this error of observa- 
 tion. As a rule, vocal resonance and fremitus are either 
 notably lessened or suppressed over the portion of the 
 chest situated below the level of the liquid. There are 
 occasional exceptions to this rule. The respiratory sound 
 below the level of the liquid is suppressed. If any be 
 heard, it is transmitted either from the lung above the 
 liquid, or laterally, from the lung on the other side of 
 the chest. Above the liquid tlie respiratory sound, as a 
 rule, is weakened. If the amount of liquid be sufficient 
 to produce much condensation of lung, the respiratory 
 sound is broncho-vesicular. Sometimes, owinu: to the 
 pleural surfaces above being adherent, a strip of lung at 
 
 ' The statement with regard to a horizontal line denoting the level 
 of the liquid does not a})ply to the posterior aspect of the chest. Ob- 
 servations show that posteriorly the lung extends more or less down- 
 ward near the spinal column, and that the level of the liquid forms 
 a curve which may be represented by the letter S. Vide article by 
 Professor G. M. Garland, in the New York MedicalJournal, number 
 for November, 1879. Also, treatise on "Pneu mono- Dynamics," by- 
 Professor G., 1878. 
 
154 PHYSICAL DIAGNOSIS. 
 
 the level of the liquid is sufficiently condensed by com- 
 pression to give a bronchial respiration. Under these 
 circumstances, there will be either bronchophony or the 
 modification of that sign known as segophony. If the 
 lung be not sufficiently compressed for the production of 
 these signs of solidification, the vocal resonance is sim- 
 ply more or less increased. The fremitus is usually in- 
 creased above the liquid. Over the unaffected side the 
 respiratory murmur is increased in intensity. 
 
 The foregoing signs are present when the pleural 
 cavity is partially filled ; a quarter, a half, or two-thirds 
 of the thoracic space being occupied by liquid. The 
 signs present when the cavity is completely filled, will 
 be presently stated in connection with chronic pleurisy. 
 
 The signs which have been stated show not only the 
 presence of liquid, but its quantity. By means of these 
 signs are readily ascertained the progressive increase or 
 decrease in the quantity of liquid, and its disappearance. 
 After the liquid has disappeared, often notable dulness 
 on percussion remains for some time, showing the 
 presence of lymph not yet absorbed. During the 
 decrease of the liquid, and after its disappearance, a 
 friction-murmur is often perceived. This murmur is 
 now apt to be rough — a rasping, grating, or creaking 
 sound. It may be loud enough to be heard by the 
 patient, and by others at a distance from the chest. It 
 continues sometimes for a considerable period. 
 
 The physical diagnosis in cases of chronic pleurisy, 
 when the liquid occupies a portion only of the thoracic 
 space, rests, of course, on precisely the same signs as in 
 cases of acute pleurisy. If, however, the chest on the 
 affected side be filled and dilated, certain of the signs 
 which have been stated are wanting, and others are 
 
PLEURISY, ACUTE AND CHRONIC. 155 
 
 added. The aifected side is everywhere flat on percus- 
 sion. Flatness on percussion over the whole of one side, 
 the affection being chronic, denotes, as a rule, with rare 
 exceptions, either chronic simple pleurisy or empyema. 
 Respiratory sound is wantin<^ except at the summit over 
 or near the compressed lun<^, where it is bronchial. 
 Some cases offer an important exception to this rule, 
 namely, the bronchial respiration is diffused over the 
 greater part, or even the whole, of the affected side. 
 The student should bear in mind this fact; otherwise 
 the diffusion of the bronchial respiration may lead to the 
 suspicion that the flatness on percussion denotes solidifi- 
 cation of lung, and not the presence of liquid. Other 
 signs, however, should always correct this error. A'^ocal 
 resonance and fremitus are, with some exceptions, either 
 suppressed or notably diminished over the whole of the 
 af!ected side. Generally, even when the chest is not 
 dilated, the intercostal depressions are lessened or 
 abolished. If the walls of the chest be thinly covered 
 with integument, the two sides present a marked contrast 
 in this respect. This is seen especially at the middle 
 and lower regions of the chest anteriorly and laterally. 
 It is especially marked at the end of the inspiratory act. 
 If the affected side be dilated, this is apparent on inspec- 
 tion, and may be determined accjurately by semicircular 
 or diametric mensuration, callipers being required for 
 the latter. The respiratory movements on the affected 
 side are diminished or annulled, and they are increased 
 on the healthy side, the two sides affording a marked 
 contrast in this regard. If the pleurisy be on the left 
 side, the impulses of the heart are not infrequently felt 
 on the right of the sternum. If the impulses cannot be 
 felt, auscultation shows the maximum of the intensity of 
 
156 PHYSICAL DIAGNOSIS. 
 
 the heart-sounds to be more or less removed to the right. 
 If the pleurisy be on the right side, the impulses or 
 sounds of the heart denote more or less displacement 
 laterally to the left. The intensity of the respiratory 
 murmur on the unaffected side is notably increased. 
 
 In cases of empyema the same signs are present as in 
 chronic pleurisy. Tlie character of the liquid does not 
 alter appreciably any of the signs which have been 
 stated. Dilatation of the affected side of the chest is 
 more apt to occur, and to be more marked than in simple 
 pleurisy. The differential diagnosis between these two 
 varieties of pleurisy is to be made with positiveness by 
 the introduction of the needle of a hypodermic syringe 
 having good suction force, previously cleaned and car- 
 bolized, and obtaining enough of the liquid to ascertain 
 its character. 
 
 When the left pleural cavity is filled with j)us, the 
 movements of the heart sometimes give to the affected 
 side of the chest an impulse ])erceived by the eye and 
 touch ; hence, the term pulsating empyema. After a 
 spontaneous perforation of the chest, followed by a cir- 
 cumscribed purulent collection beneath the integument, 
 communicating with the pus within the pleural cavity, 
 the tuinor thus formed sometimes has a strong pulsation 
 which is synchronous with the ventricular systole, and 
 may give rise to the suspicion of aneurism. 
 
 In cases of hydrothorax the signs denote partial filling 
 of the chest on both sides. The affection is bilateral. 
 Generally the quantity of liquid in the two sides is not 
 equal, and there is often a notable disparity in this 
 respect. Friction-sounds are never present. Variation 
 of the level of the liquid with change of the position of 
 the patient from the vertical to the horizontal, is nearly 
 
PNEUMOTHORAX. 157 
 
 always determinable. Hydrothorax, meaning by this 
 term a purely dropsical affection, is to be differentiated 
 from double pleurisy with effusion. The history and 
 symptoms, taken in connection with the signs, suffice for 
 this discrimination. 
 
 Pneumothorax — Pneumo-hydrotliorax — Pneumo- 
 pyothorax. 
 
 In the extremely rare cases of pneumothorax, that is, 
 as distinguished from pneumo-hydrothorax and pneumo- 
 pyothorax, the physical conditions are : the presence of 
 air partially or completely occupying the thoracic space, 
 and condensation of lung in proportion to the space oc- 
 cupied by air. 
 
 The diagnostic signs are, a purely tympanitic resonance 
 over a portion or the whole of the affected side of the 
 chest: suppression of the vesicular murmur over a space 
 corresponding to that in which tympanitic resonance is 
 obtained, with notable diminution or suppression of vocal 
 resonance and fremitus. Over the compressed lung, if 
 the condensation amount to complete or considerable so- 
 lidification, there will be bronchial respiration and bron- 
 chophony; if the solidification be neither complete nor 
 considerable, there W'ill be broncho-vesicular respiration 
 with increased vocal resonance and fremitus. The accu- 
 mulation of air may be sufficient to dilate the affected 
 side, and to restrain or annul the respiratory movements 
 on this side. The appearances on inspection are then 
 precisely the same as in the cases of chronic pleurisy and 
 empyema in which the affected side is dilated from the 
 presence of liquid. Pneumothorax is, however, at once 
 differentiated by the tympanitic resonance on percussion. 
 If one side of the chest be more or less dilated, and the 
 
 ,14 
 
158 PHYSICAL DIAGNOSIS. 
 
 resonance over the side be purely tympanitic, the thora- 
 cic space must be filled, not with liquid but with air. 
 The intensity of the respiratory murmur on the healthy 
 side is increased. 
 
 In the great majority of cases in which the pleural 
 cavity contains air, there is also present more or less 
 liquid, which may be serous or purulent. The affection 
 is then known as pneumo-hydrothorax if the liquid be 
 serous, and pneumo-pyothorax if it be purulent. The 
 physical conditions are the same as in pneumothorax, with 
 the addition of the presence of liquid. The relative 
 proportions of liquid and air in different cases are variable, 
 and, also, in the same case at different periods. 
 
 The physical diagnosis of pneumo-hydrothorax and of 
 pneumo-pyothorax, as distinguished from pneumothorax, 
 embraces the signs of liquid, in addition to those of air, 
 within the pleural cavity. If the quantity of liquid be 
 large or considerable, percussion at the base of the chest 
 gives flatness extending upward more or less, and tym- 
 panitic resonance above, the patient either sitting or 
 standing. A change from the vertical to the horizontal 
 position invariably causes variation of the upper limit of 
 the flatness, inasmuch as the liquid and air change their 
 relative situations without an exception. The quantity of 
 liquid is determined approximatively by ascertaining the 
 space over which the flatness on percussion extends. 
 The line which divides the flatness and the tympanitic 
 resonance does not accurately denote the level of the 
 liquid, because tympanitic resonance is transmitted a cer- 
 tain distance below this level, hence it is always to be 
 assumed that the level of the liquid is somewhat higher 
 than the upper boundary of the flatness. 
 
 In either pneumothorax, pneumo-hydrothorax, or 
 pneumo-pyothorax a group of auscultatory signs is often 
 
ACUTE LOBAR PNEUMONIA. 159 
 
 found which are highly diagnostic, indeed almost pathog- 
 nomonic. These signs are amphoric respiration, ampho- 
 ric voice or echo, and metallic tinkling. The amphoric 
 and the tinkling sounds may be present, either without 
 the other, but they are not infrequently associated. 
 Neither are present in every case, and they are not pres- 
 ent in the same case at all times; their absence, there- 
 fore, by no means excludes the affections, and they are 
 not essential to the diagnosis. When present they de- 
 note either air or air and liquid in the pleural cavity with 
 perforation of lung or a large phthisical cavity. Their 
 occurrence in the latter is comparatively rare, and when- 
 ever they are associated with other signs already stated, 
 their diagnostic import is demonstrative. 
 
 Pneumo-hydrothorax or pneumo-pyothorax may al- 
 most invariably be diagnosticated instantly by the pres- 
 ence of a succussion sound. Whenever distinct splash- 
 ing is produced by succussion and referable to the chest, 
 that is, not produced within the stomach, it is demon- 
 strative of the presence of air and liquid within the 
 pleural cavity. 
 
 Acute Lohar Pneumonia. 
 In the first stasfe of this disease there is an abnormal 
 accumulation of blood within the vessels of the affected 
 lobe (active congestion or hyper?emia), with some exu- 
 dation within the air-vesicles and bronchioles. Gener- 
 ally there is some exuded lymph upon the pleural surface, 
 this being due to circumscribed dry pleurisy. In most 
 cases there is also circumscribed bronchitis, which is lim- 
 ited to the tubes within the affected lobe. In the second 
 stage there is solidification due to the increase of exu- 
 dation within the air-vesicles. The solidification, at first 
 limited, extends either rapidly or slowly, as a rule, over 
 
160 PHYSICAL DIAGNOSIS. 
 
 the whole lobe. Exceptionally more or less liquid effu- 
 sion into the pleural cavity takes place (pleuro-pneumo- 
 nia), the pleurisy then extending beyond the limits of 
 the affected lobe. In this stage the pneumonia may in- 
 volve either another lobe of the lung primarily affected, 
 or a lobe of the opposite lung, and sometimes the dis- 
 ease, by successive invasions, extends over the whole of 
 one lung, together with a lobe of the opposite; lung. The 
 pneumonia, in these secondary invasions, is usually ac- 
 companied by pleurisy and bronchitis. In the stage of 
 resolution the solidification of the affected lobe or lobes 
 decreases, sometimes rapidly and sometimes slowly, until 
 the normal condition is restored. If resolution do not 
 take place, and the disease pass into the stage of puru- 
 lent infiltration, the air-vesicles and bronchial tubes con- 
 tain a puruloid liquid in greater or less quantity. Ex- 
 ceptionally pus is collected in a cavity, or in cavities, 
 constituting pulmonary abscess. 
 
 The physical diagnosis of acute lobar pneumonia in 
 the first stage must be based on the presence of the crep- 
 itant rale, with moderate or slight dulness on percussion 
 over the affected lobe. There is sometimes in this stage 
 a pleuritic rubbing sound over the affected lobe. The 
 crepitant rale is not always present, and hence the affec- 
 tion cannot be excluded by the absence of this sign. 
 When present, taken in connection with the symptoms, 
 this sign is pathognomonic of the disease. It is impor- 
 tant not to mistake for this sign fine bubbling or the 
 subcrepitant rale. When the crepitant rale is wanting, a 
 positive physical diagnosis must be deferred until more 
 or less of the affected lobe becomes solidified, that is, 
 when the disease passes into tlie second stage. 
 
 The diagnosis in the second stage is to be based on 
 
ACUTE LOBAR PNEUMONIA. 161 
 
 tl)e signs of solidification furnished by auscultation and 
 percussion. The auscultatory signs are the broncho- 
 vesicular, followed by the bronchial respiration; in- 
 creased vocal resonance, followed by bronchophony, and 
 increased bronchial whisper, followed by whispering bron- 
 chophony. The signs of solidification are manifest at 
 first within a circumscribed space, situated over either 
 the upper, the lower, or the middle portion of the affected 
 lobe, and either rapidly or slowly the signs extend in 
 most cases over the entire lobe. The crepitant rale, if 
 it have been present in the first, generally disappears in 
 the second stage. Sometimes, however, it is not entirely 
 lost in this stage. The broncho-vesicular respiration, 
 increased vocal resonance, and increased bronchial whis- 
 per are present when the solidification is slight or moder- 
 ate ; the bronchial respiration, bronchophony, and bron- 
 chophonic whisper take their place when the solidification 
 becomes considerable or complete. The latter signs, as 
 a rule, speedily follow, inasmuch as the solidification in 
 most cases quickly becomes complete or considerable. 
 The foregoing three signs, denoting considerable or com- 
 plete solidification, are usually present. Bronchial res- 
 piration, however, is sometimes present without broncho- 
 phony, and vice versa. Either, present alone, suffices to 
 show the existence and the extent of the solidification. 
 -Moist bronchial or bubbling rales are sometimes, but 
 rarely, heard over the affected lobe. 
 
 There is notable dulness on percussion in the second 
 stage. The dulness may approximate, and even amount 
 to flatness. If a single lobe be affected, the dulness or 
 flatness extends over a space corresponding to that occu- 
 pied by the lobe or the portion of it which is solidified. 
 In the antero-lateral aspects of the chest, the dividing 
 
1G2 PHYSICAL DIAGNOSIS. 
 
 line between the solidified and the healthy lobe is readily 
 ascertained by percussion, and this line is coincident 
 with the interlobar fissure. It sometimes happens that 
 the upper and the lower lobe of the right lung are 
 affected, the middle lobe not becoming involved. The 
 space corresponding to the middle lobe may then form 
 an island of resonance surrounded by notable dulness 
 on percussion. 
 
 Whenever one lobe of a lung is affected, the resonance 
 over the unaffected part of the same lung is abnormally 
 increased, the pitch is raised, and the quality is vesiculo- 
 tympanitic; vesiculo-tympanitic resonance, in other words, 
 13 produced. This renders more marked the contrast be- 
 tween dulness over the solidified, and resonance over the 
 healthy, lobe. 
 
 Over a portion of an upper lobe in the second stage, 
 instead of notable dulness or flatness, there may be 
 marked tympanitic resonance. Tliis resonance proceeds 
 from air within the trachea and the bronchi exterior to 
 the lungs, the lung substance being completely solidified; 
 it is chiefly or especially marked over the site of these 
 air-tubes. In some cases the tympanitic resonance has 
 either the cracked-metal or the amphoric intonation. 
 These signs, per se, might suggest either pneumothorax 
 or phthisical cavities ; the associated respiratory and vocal 
 signs, however, show only solidification of lung. In cases 
 of pneumonia affecting the left lung, a tympanitic reso- 
 nance is not infrequently propagated from the stomach 
 more or less upward over the affected side of the chest. 
 This may be readily traced to the stomach. On tlie 
 right side, a tympanitic resonance is sometimes propa- 
 gated a certain distance upward from the transverse 
 colon. 
 
ACUTE LOBAR PNEUMONIA. 1G3 
 
 The commencement of the stage of resolution is de- 
 noted by a broucho- vesicular respiration. The first 
 change observed is the presence of a little vesicular 
 quality in the inspiratory sound. When this is observed, 
 the respiration is no longer bronchial, but has become 
 broncho-vesicular, althou_o;h the pitch is still high, and 
 the expiration is prolonged, high, tabular. This slight 
 change shows that air begins to enter the pulmonary vesi- 
 cles. As resolution goes on, more and more of the ve- 
 sicular takes the place of the tubular quality in the in- 
 spiratory sound, and the pitch is lowered in proportion; 
 the expiratory sound becomes proportionally less and less 
 prolonged, its pitch lowered, its quality less tubular, 
 until, at length, the normal characters of the respiratory 
 murmur are regained. Kesolution is then complete. 
 
 While the broncho-vesicular respiration is undergoing 
 the modifications just stated, the vocal sounds have cor- 
 responding changes. Bronchophony persists for some 
 time after the respiration has become broncho-vesicular, 
 and then disappears, increased vocal resonance generally 
 taking its place and persisting until resolution is com- 
 pleted. The bronchial whisper loses its bronchophouic 
 characters, and is simply increased until its normal char- 
 acters are regained. While the solidification is com- 
 plete, the vocal fremitus may, or may not, be increased. 
 It is sometimes diminished. When, however, resolution 
 has so far progressed that bronchophony is lost, the frem- 
 itus is usually greater than in health, and so continues, 
 but progressively lessening until the solidification entirely 
 disappears. 
 
 During the progress of resolution, the dulness on per- 
 cussion diminishes in proportion as air enters the air- 
 vesicles. If tympanitic resonance have been present 
 
16i PHYSICAL DIAGNOSIS. 
 
 over the upper lobe, this gives place to a vesicular reso- 
 nance. Some dulness. however, remains after the com- 
 pletion of resolution, and persists until the exuded lymph 
 on the pleural surface is absorbed. The amount of dul- 
 ness remaining when the respiratory and vocal signs 
 denote resolution, is proportionate to the quantity of exu- 
 dation incident to the associated pleurisy. 
 
 In this stage the crepitant rale not infrequently returns, 
 if it have entirely disappeared during the second stage, 
 and if it have persisted, it is more marked and diffused. 
 It is now known as the returning crepitant rale. More 
 frequently the rale in this stage is a fine bubbling or 
 the subcrepitant. Both rales are not infrequently asso- 
 ciated, and, from the distinctive characters of each, they 
 are readily distinguished. Moist rales more or less fine 
 or coarse are not infrequent. 
 
 If the affection pass into the stage of purulent infiltra- 
 tion, the respiratory sounds are feeble or suppressed, 
 having, if present, more or less of the bronchial charac- 
 ters. Bubbling bronchial rales, coarse and fine, are 
 abundant. Weak bronchophony may persist, or the 
 vocal resonance may be diminished. Fremitus may, or 
 may not, be increased. Notable dulness or flatness on 
 percussion remains. 
 
 If the pneumonia result in pulmonic abscess, there 
 will be notable dulness or flatness on percussion within a 
 circumscribed space, together with absence of respiratory 
 murmur, and diminished or suppressed vocal resonance. 
 These signs warrant a probable diagnosis which is cor- 
 roborated by the sudden expectoration of pus in a con- 
 siderable quantity. The signs just stated may then be 
 followed by those denoting a cavity, namely, cavernous 
 respiration and whisper, with intense vocal resonance. 
 
EMBOLIC PNEUMONIA. 165 
 
 Circumscribed Pneumonia— Embolic Pneumonia — Haemor- 
 rhagic Infarctus or Pulmonary Apoplexy. 
 
 The form of pneumonia known as lobular pneumonia, 
 occurring chiefly in children, has been considered (vide 
 Bronchitis seated in small-sized tubes). Whenever cir- 
 cumscribed, as a rule, pneumonia is secondary to some 
 other pulmonary affection. Circumscribed pneumonia, 
 giving rise to an intra-vesicular exudation which may 
 disappear readily by resolution or absorption, is not very 
 infrequent in cases of phthisis. The signs are those which 
 represent solidification of lung within an area more or 
 less circumscribed ; but the differentiation from the 
 solidification proper to phthisis can only be made with 
 positiveness after the signs have shown that the solidifi- 
 cation has notably diminished or disappeared. 
 
 In embolic pneumonia there may be dulness on per- 
 cussion, with feeble bronchial or broncho- vesicular res- 
 piration, or suppression of respiratory sound, weak 
 bronchophony or increase of vocal resonance, within a 
 circumscribed space, or within spaces, generally on the 
 posterior aspect of the chest, and oftenest on the right side. 
 These signs, taken in connection with the symptoms and 
 pathological conditions which are consistent with the 
 supposition of emboli received into the right side of the 
 heart, namely, when the pulmonary symptoms follow 
 puerperal disease, ulcers, wounds, injuries, or venous 
 thrombosis, render the diagnosis quite positive. If, how- 
 ever, the pulmonary affection consist of small dissemi- 
 nated nodules, the foregoing signs will not be present. 
 The diagnosis then must be based on the history and 
 symptoms, taken in connection with the exclusion of other 
 pulmonary affections by the absence of signs which should 
 be present if they existed. Bubbling rales at different 
 
166 PHYSICAL DIAGNOSIS. 
 
 situations may indicate the probable sites of tiie nodules. 
 There may be pleuritic friction-sounds. The signs may 
 show, as a complication, pleurisy with effusion. 
 
 Extravasation of blood (pneumorrhagia), if it be in 
 small spaces, gives rise to no definite physical signs. If, 
 however, extravasation extend over a considerable space, 
 there will be dulness on percussion, with feeble or sup- 
 pressed respiratory sound within an area corresponding 
 to the extent of the extravasation. Within, and near 
 this area, there will be likely to be moist bronchial rales 
 more or less fine or coarse. The signs of solidification 
 will not be present if the extravasation be unaccompanied 
 by pneumonia. 
 
 Pulmonary Gangrene. 
 
 In diffused pulmonary gangrene the physical signs are 
 those of solidification, extending over the greater part or 
 the whole of a lobe. The diagnosis, however, can only 
 be made when, in connection with these signs, there are 
 present the characteristic fetor of the breath and expec- 
 toration. 
 
 In circumscribed gangrene there is dulness or flatness 
 on percussion within an area corresponding to the extent 
 of the affection, with either suppression of respiratory 
 sound, or bronchial respiration, and the vocal signs of 
 solidification. Within and near this space moist bron- 
 chial rales are likelv to be heard. The situation is usu- 
 ally on the posterior aspect of the chest. These signs 
 do not suffice for a positive diagnosis without the char- 
 acteristic breath and expectoration. Cavernous signs 
 may appear after the gangrenous portion of lung has 
 sloughed away and been expectorated. 
 
PULMONARY (EDEM.A. 1G7 
 
 Pulmonary (Edema. 
 
 The physical condition expressed by the term ])nlmo- 
 nary oedema is the presence of effused serum witliin the 
 air-vesicles. With this condition is associated more or 
 less pultnonary congestion. 
 
 In cases of pulmonary oedema developed ra])idly and 
 largely in connection with renal disease, with obstruction 
 at the mitral orifice of the heart, or with both these af- 
 fections combined, giving rise to great dyspnoea, and 
 liable to end speedily in death, the following are the diag- 
 nostic signs: Dulness on percussion on both sides of the 
 chest, especially over the lower lobes, line bubbling or the 
 subcrepitant rale diffused over the chest on both sides, 
 together with coarser bubbling sounds, and the murmur 
 of respiration notably weak or su})pressed over the lower 
 lobes. Inasmuch as thelungsare notsolidificd the rales 
 are low in pitch. The vocal signs of solidification are, 
 of course, wanting. Occasionally the crepitant rale is 
 mingled with the fine bubbling sounds. 
 
 This form of the affection is to be differentiated from 
 hydrothorax with large effusion, and from so-called ca- 
 pillary bronchitis. Hydrothorax is always associated 
 with more or less anasarca, or general dropsy, whereas, 
 pulmonary cedema, even when dependent on renal dis- 
 ease, may occur without dropsical effusion elsewhere. 
 Moreover, the presence of liquid within the pleural 
 cavities, and its amount, may always be determined de- 
 monstratively in cases of hydrothorax (vide Pleurisy 
 with effusion and Hydrothorax). Capillary bronchitis 
 occurs chiefly in children. The subcrej)itant rale on both 
 sides of the chest is the diagnostic sign of this affection, 
 but it is not accompanied by dulness on percussion, ex- 
 cept in so far as the bronchitis may be associated with 
 
168 PHYSICAL DIAGNOSIS. 
 
 lobular pneumonia or collapse of pulmonary lobules. 
 The rapid development of the oedema and its pathologi- 
 cal connections, are diagnostic points to be taken into ac- 
 count. 
 
 Pneumonia is excluded by the fact that the affection is 
 at the beginning bilateral, and by the absence of the signs 
 of solidification of lung. 
 
 Pulmonary oedema, less in degree and diffusion, has, of 
 course, the same signs, not as marked and not as exten- 
 sive, namely, dulness on percussion and fine bubbling 
 sounds or the subcrepitant rale. In this form the affec- 
 tion is bilateral, and seated especially in the posterior 
 and inferior portions of the lungs. Moreover, this form 
 has the same pathological connections, namely with dis- 
 ease of the kidneys, and mitral lesions of the heart. The 
 low pit.^h of the bronchial rales, and the absence of the 
 respiratory and vocal signs of solidification, together with 
 the fact of the affection being bilateral, and the coex- 
 istence of disease of the heart or kidneys, constitute the 
 basis of a positive diagnosis. 
 
 Hypostatic congestion of the lungs may occasion a 
 certain amount of pulmonary oedema. The physical 
 diagnosis is to be based on bilateral dulness on the pos- 
 terior aspect of the chest, with low-pitched, fine bubbling 
 sounds, or the subcrepitant rale on both sides, these signs 
 occurring under circumstances which lead to the suppo- 
 sition of this form of congestion. 
 
 Carcinoma of Lung — Tumors within the Chest. 
 
 Carcinomatous growths in the lungs are usually in 
 the form of nodules varying in size from that of a pea to 
 a hen's egg, disseminated throughout one lung or both 
 lungs, in greater or less numbers. These disseminated 
 
CARCINOMA OF LUNG. 169 
 
 nodules, if of small size, have no well-marked, definite 
 diagnostic signs. If limited to a lung, or if greater in 
 number in one lung, they may occasion an appreciable 
 dulness on percussion. They may also occasion feeble- 
 ness of the respiratory murmur, and, owing to coexist- 
 ing circumscribed bronchitis, moist bronchial rales may 
 be heard at different points. These signs warrant a di- 
 agnosis when, as is usually the case, cancer is known to 
 have existed elsewhere. With reference to diagnosis, it 
 is to be borne in mind that, when cancer of the lung is 
 secondary, both lungs are affected, and, when it is 
 primary, the affection is generally unilateral. 
 
 If there be nodules of considerable size, there will be 
 well-marked dulness on percussion in different situations, 
 and the signs of solidification may be present, namely, 
 either bronchial or broncho-vesicular respiration, either 
 increased vocal resonance or bronchophony, and in- 
 creased vocal fremitus. 
 
 In* some cases of unilateral carcinoma, the greater 
 part, or the whole, of a lung may be infiltrated with the 
 morbid growth, increasing its volume and giving rise to 
 enlargement of the affected side, diminished respiratory 
 movements or immobility, flatness on percussion, with 
 diminished or suppressed respiratory murmur, vocal 
 resonance, and fremitus. If, as is usual, there be also 
 more or less pleuritic effusion, the intercostal spaces may 
 be pushed out to a level with the ribs. Here are the 
 signs which denote chronic pleurisy with large effusion, 
 and the differential diagnosis cannot be made with posi- 
 tiveness until the Huid within the chest be withdrawn, 
 and it be found that, irrespective of the bulging of the 
 intercostal spaces, the physical signs remain. Explora- 
 tion with a small trocar, or hollow needle, will settle the 
 
170 PHYSICAL DIAGNOSIS. 
 
 diagnosis when there is no pleuritic effusion, and this 
 procedure is unobjectionable. 
 
 In other cases the carcinomatous growth induces 
 atrophy of the lung, diminishing its volume, and causing 
 notable contraction of the affected side. The appear- 
 ances on inspection are those which denote contraction 
 after chronic pleurisy, and they may be present also in 
 cases of cirrhosis of lung. The differential diagnosis 
 must be based chiefly on diagnostic points relating to the 
 history and symptoms. 
 
 Tumors within the chest, generally having their points 
 of departure in the mediastinum, displace the lung in 
 proportion to their size. They may cause considerable 
 displacement of the heart, and ])roduce more or less 
 enlargement of the chest with diminished respiratory 
 movements. Enlargement of the subcutaneous veins, 
 indicative of venous obstruction, is often to be observed. 
 Over the site of the tumor, there will be either dulness 
 or flatness on percussion. Generally respiratory sound 
 is wanting, vocal resonance and fremitus being either 
 diminished or suppressed. In the neighborhood of the 
 primary bronchi and over lung compressed by the tumor, 
 there may be bronchial respiration, with bronchophony 
 and increased fremitus. If the chest be enlarged, its 
 enlargement is not likely to be as uniform as when it is 
 dilated with liquid ; this is a diagnostic point. The 
 tumor, or the tumors, may not be confined to one side 
 of the chest. It is to be borne in mind that pleurisy 
 with effusion may exist as a complication, and this may 
 serve to obscure the diagnosis. 
 
 The physical diagnosis involves differentiation from 
 pericarditis with effusion and aneurisms. These affec- 
 
ACUTE MILIARY TUBERCULOSIS. 171 
 
 lions are to be excluded by the absence of their diagnostic 
 signs. 
 
 Acute Miliary Tuberculosis. 
 
 The physical condition in tliis affection is the presence 
 of a larcre number of the small bodies known as tubercles 
 or miliary granulations, disseminated throughout both 
 lungs. Bronchitis is an associated affection. 
 
 If the tubercles be about equally distributed in the 
 two lungs, there is no abnormal disparity of the reso- 
 nance on percussion betw'een the two sides of the chest. 
 A comparison, also, of the two sides may afford no 
 disparity as regards the respiratory murmur, vocal 
 resonance, and fremitus. Moist rales, due to the asso- 
 ciated bronchitis, maybe present in different situations. 
 A pln'sical diagnosis, under these circumstances, cannot 
 be made with positiveness. Physical exploration, how- 
 ever, is important, in order to exclude other affections ; 
 and the negative result, taken in connection with the 
 symptoms — hyperpyrexia, rapid pulse, accelerated 
 breathing, etc — renders the diagnosis extremely proba- 
 ble. The differential diagnosis involves discrimination 
 from capillary bronchitis, and an essential fever with a 
 bronchial complication. The affection has been re- 
 peatedly mistaken for typhoid fever. 
 
 The tubercles may be more abundantly distributed in 
 one lung. A disparity in the resonance on percussion 
 may then be apparent, and, perhaps, an abnormal 
 increase of vocal resonance and fremitus. These signs, 
 taken in connection with the symptoms, establish the 
 physical diagnosis. 
 
172 PHYSICAL DIAGNOSIS. 
 
 Phthisis. 
 
 With reference to physical diagnosis, cases of phthisis 
 may be conveniently distributed into three groups, as 
 follows: 1st. Cases in which the pulmonary affection is 
 small, or cases of incipient phthisis; 2d. Cases in which 
 the affection is moderate or considerable ; and 3d. Cases 
 in which the affection has progressed to the formation of 
 cavities, or cases of advanced phthisis. 
 
 In cases of incipient phthisis, the essential physical 
 condition is the presence of small solidified masses, or 
 nodules, the intervening vesicular structure not being 
 affected. These nodules vary from the size of a pea to 
 a filbert. In the vast majority of cases they are situated 
 at or near the apex of either the right or the left lung. 
 Generally, circumscribed capillary bronchitis coexists in 
 proximity to the nodules. An intercurrent circumscribed 
 pneumonia sometimes occurs, giving rise to transient 
 solidification within a limited area. Dry circumscribed 
 pleurisy, situated over the affected portion of lung, gene- 
 rally occurs from time to time. 
 
 In the cases of a moderate or a considerable pulmon- 
 ary affection, the difference, as compared with the pre- 
 ceding group of cases, consists in the presence of nodules 
 of larger size, or solidification from the phthisical deposit 
 extending over a space, or spaces, sufficient in size to 
 give rise to well-marked physical signs. The solidifica- 
 tion in these cases may be extended by the development 
 of circumscribed interstitial pneumonia. The circum- 
 scribed bronchitis is greater, as a rule, in degree and ex- 
 tent; attacks of dry pleurisy may continue to occur, and 
 the pleural surface becomes adherent. In these cases, 
 generally, the affection, existing primarily in one lung, 
 now exists in both lungs. The volume of the lung first 
 
PHTHISIS. 173 
 
 affected, at the summit, is more or less diminished. En- 
 largement of the bronchial glands is usual, and these 
 may be so situated as to press upon and diminish the 
 calibre of one of the primary bronchi. In some cases, 
 portions of lung in the neighborhood of solidified masses 
 or nodules are emphysematous (vicarious emphysema). 
 
 Cases of advanced phthisis are characterized by the 
 presence of a cavity, or, commonly, of cavities, varying 
 in number, size, rigidity or flaccidity of the walls, free- 
 dom of communication with bronchial tubes, and their 
 situation relatively to the superficies of the lung. In 
 cases of progressive phthisis, in addition to cavities, there 
 is more or less solidification from phthisical exudation 
 and interstitial pneumonia. The volume of the lung at 
 the summit is often notably diminished. The pleural 
 surfaces are firmly adherent. If, however, the disease 
 have been retrogressive, there may be little or no solidifi- 
 cation of lung, the cavity or cavities forming the only 
 lesion. In cases of advanced phthisis, with very rare 
 exceptions, both lungs are affected, and cavities often 
 exist on both sides. 
 
 The physical diagnosis in cases of incipient phthisis 
 embraces what may be called direct and accessory signs. 
 The accessory signs are those which represent incidental 
 aff'ections, namely, circumscribed bronchitis, pleurisy, 
 and pneumonia. The direct signs are those represent- 
 ing the essential condition, namely, the solidified masses 
 or nodules. 
 
 An important direct sign is dulness on percussion. 
 Slight dulness on percussion at the summit of the chest, 
 in front or behind, is a highly important sign, taken in 
 connection with symptoms, of incipient phthisis. In de- 
 termining that a relative dulness is abnormal, the student 
 
 15 
 
174 PHYSICAL DIAGNOSIS. 
 
 must bear in mind, in the first place, the normal disparity 
 between the two sides. The right side at the summit is 
 relatively somewhat dull on percussion in healthy persons. 
 Due allowance is to be made for this normal disparity. 
 In the second place, it is to be borne in mind that any 
 deformity affecting the symmetry of the chest will affect 
 the relative resonance on the two sides ; and that a devia- 
 tion from symmetry attributable to the position of the 
 patient will occasion a disparity on percussion. In the 
 third place, the rules for the practice of percussion must 
 be kept in mind, in order to avoid producing a disparity 
 by the non-observance of these rules {vide p. 51). Nor- 
 mal resonance on percussion on the two sides is a strong 
 point for the exclusion of incipient phthisis. 
 
 The direct respiratory signs in incipient phthisis are 
 the broncho-vesicular respiration and weakened vesicular 
 murmur. To these is to be added a localized inter- 
 rupted or wavy respiratory murmur as an occasional 
 sign. Of course, familiarity with the characters of 
 the broncho- vesicular respiration is indispensable — the 
 combination of the vesicular and the tubular quality in 
 the inspiratory sound, with the pitch raised in proportion 
 to the amount of tubularity, and the expiratory sound 
 more or less prolonged, high, and tubular. Not infre- 
 quently the only appreciable morbid modification is di- 
 minished intensity of the murmur. When this sign is 
 present, it is probable that the lack of intensity is the 
 reason for the absence of the characters of the broncho- 
 vesicular modifications, that is, the latter sign would 
 have been present were the respiratory sounds more in- 
 tense. 
 
 The direct vocal signs in incipient phthisis are, in- 
 creased vocal resonance, increased bronchial whisper, 
 
piiTOisis. 175 
 
 and increased fremitus. The other direct signs may be 
 present without an appreciable morbid increase of the 
 vocal resonance or fremitus. The increased whisper may 
 also be wanting, but more rarely than the two other vocal 
 signs. 
 
 In deciding on the presence or absence of each and 
 all of these direct signs, it is essential to know and to 
 judge correctly of the disparity between the two sides of 
 the chest at the summit in health. Normally the reso- 
 nance on percussion at the summit on the right side is 
 slightly dull as compared with the left side; the inspi- 
 ratory sound on this side has some tubularity in quality, 
 and is somewhat raised in pitch ; the expiratory sound 
 may be more or less prolonged, high, and tubular; the 
 vocal resonance on the right side is always greater, the 
 same being true of fremitus ; the bronchial whisper is 
 louder on the right side, and the intensity of the re- 
 spiratory murmur is a little less on this side. Whenever 
 it is a question as to a small phthisical affection at or 
 near the a[)ex of the right lung, it is a matter of expe- 
 rience and judgment to decide if the disparity in respect 
 of these points be greater than normal, and it is not 
 always easy to come at once to a decision. From the 
 want of a pro[)er appreciation of the several points of 
 disparity in health, it is not uncommon for an erroneous 
 diagnosis of phthisis to be based thereon. Appreciating 
 the normal points of disparity, it is obviously eiisier to 
 determine that the sevei-al direct signs of incipient 
 phthisis are present at the left than at the right sum- 
 mit; relative dulness on percussion, broncho-vesicular 
 or weakened respiration, increased vocal resonance, whis- 
 per, and fremitus, at the left summit are, of course, al- 
 ways abnormal. 
 
176 PHYSICAL DIAGNOSIS. 
 
 In connection with the foregoing direct signs may be 
 mentioned another sign which is often available, namely, 
 an abnormal transmission of the heart-sounds. This sign 
 is available only in the central portion of the infra-cla- 
 vicular region. A slight degree of solidification of the 
 summit of one lung renders the heart-sounds more audi- 
 ble in the situation just named. It is of assistance in 
 determining this sign to be familiar with the following 
 points of disparity which exist in health : on the right 
 side the second sound of the heart is somewhat more 
 audible than on the left side, and on the leftside the first 
 sound is a little louder than on the right side. Hence, 
 if the first sound be better conducted on the right than 
 on the left side, it is abnormal; and if the second sound 
 be louder on the left side, it is abnormal. This sign is 
 always to be taken in connection with other direct signs ; 
 it gives greater diagnostic strength to the latter, but it is 
 by no means, in itself, sufficient for the diagnosis. 
 
 Corroborative evidence of incipient phthisis may be 
 obtained by the presence of accessory signs. These are : 
 First, fine bubbling or the subcrepitant rale at the sum- 
 mit on one side. This sign denotes a circumscribed 
 capillary bronchitis, and this, at the summit on one side, 
 is usually associated with phthisis. Second, a crepitant 
 rale at the summit on one side denotes a circumbscribed 
 pneumonia which is usually secondary to plithisis. Third, 
 a pleuritic friction-sound limited to the summit on one 
 side is evidence of a dry circumscribed pleurisy which 
 occurs often in the early stage of phthisis. Fourth, in- 
 determinate rales, crumpling, and crackling, are signifi- 
 cant of phthisis if limited to the summit on one side. 
 These rales, it is to be recollected, are sometimes found 
 in healthy persons on forced breathing, especially if the 
 
PHTHISIS. 177 
 
 binaural stethoscope be employed. If they be normal 
 they are found on both sides. The accessory signs are 
 not sufficient for a positive diagnosis if they exist alone ; 
 but they are to be considered as corroborating the evi- 
 dence derived from the direct signs, together with the 
 symptoms and history. It is of service often in bring- 
 ing out the rales to cause the patient to cough. 
 
 As regards differential diagnosis, the affections with 
 which incipient phthisis is likely to be confounded are 
 chronic bronchitis and moderate emphysema. With 
 respect to the first of these affections, namely, bronchitis, 
 the differentiation must depend on the presence or the 
 absence of positive signs of phthisis ; in other words, 
 phthisis is either diagnosticated or excluded. The 
 physical signs in cases of moderate emphysema some- 
 times lead to the error of supposing this affection to be 
 phthisis. Owing to the relatively greater intensity of 
 the resonance on percussion at the left summit, dulness 
 is thought to exist at the right summit, and a prolonged 
 expiration, with the normally greater vocal resonance at 
 the right summit, are set down as signs of phthisis. This 
 error may be avoided by a careful study of the signs of 
 emphysema and the normal disparity in respiration, vocal 
 resonance, and fremitus, existing between the two sides 
 of the chest. 
 
 The physical diagnosis of a phthisical affection which 
 is considerable or moderate in amount, is, in most cases, 
 an easy problem. Inspection often furnishes marked 
 signs. The upper anterior portion of the chest on one 
 side is depressed or flattened, and the superior costal 
 movements of respiration are diminished, the chest else- 
 where being symmetrical in both size and motions. 
 
178 PHYSICAL DIAGNOSIS* 
 
 There is more or less marked dulness on percussion at 
 the upper part of the chest on the affected side. Some- 
 times the diminished resonance is tympanitic in quality 
 (tympanitic dulness) without the existence of cavities, the 
 resonance being conducted from the primary and second- 
 ary bronchial tubes. The respiration is either bronchial, 
 or broncho-vesicular, approximating more or less to the 
 bronchial. Occasionally, however, the respiratory sounds 
 are too feeble for their characters to be appreciated. There 
 is either bronchophony, or the vocal resonance is notably 
 increased without the bronchophonic characters. The 
 whisper is either distinctly bronchophonic or it is notably 
 increased in intensity, high in pitch, and tubular in 
 quality. Vocal fremitus is often increased. Moist 
 bronchial rales, coarse or fine, are generally present. 
 With these diagnostic signs on one side, the signs of a 
 smaller amount of disease are generally present on tiie 
 other side. 
 
 In some cases of a moderate phthisical affection, the 
 judgment may be confused by the resonance on percus- 
 sion being increased or vesiculo-tympaniticon theaffected 
 side. This sign denotes the coexistence of emphysema- 
 tous lobules (vicarious em})hysema) developed in the pro- 
 gress of phthisis. The diagnosis of the latter affection 
 is then to be based on the signs obtained by auscultation. 
 
 In advanced ])hthisis the physical diagnosis of the 
 disease is sufffciently easy. The signs distinctive of this 
 stage of the disease are tliose which denote pulmonary 
 cavities, namely, tympanitic resonance on percussion 
 within a circumscribed space; cracked-metal or amphoric 
 resonance; cavernous respiration; cavernous whisper and 
 sometimes pectoriloquy ; amphoric respiration and voice, 
 
FIBROID PHTHISIS, ETC. 179 
 
 and gurgling [vide Chapter V. for description of these 
 signs). 
 
 The cavernous signs are generally associated with the 
 signs of solidification. In somecases, however, in which 
 the disease has been non-progressive and retrogressive, 
 the cavernous signs are present without the signs which 
 denote solidification of lung. 
 
 Fibroid Phthisis— Interstitial Pneumonia, or Cirrhosis 
 
 of Lung. 
 
 In this affection the physical conditions are, solidifica- 
 tion from hyperplasia of the interstitial pulmonary tissue, 
 dilatation of bronchial tubes (bronchiectasis) and dimin- 
 ished volume of the lung affected. The affection, as a 
 rule, is either limited to or especially marked on one 
 side. The whole of a lung, or only a portion of it, may 
 be affected. Bronchitis always coexists. 
 
 There is notable dulness on percussion, the diminished 
 resonance being sometimes tympanitic. The degree of 
 resonance may vary at different examinations, owing to 
 differences in the amount of morbid products within the 
 bronchial tubes. The respiration is bronchial, or bron- 
 cho-vesicular. At times, from obstruction of bronchial 
 tubes, it may be suppressed. Bronchophony and in- 
 creased vocal resonance are the vocal signs, together with 
 the corresponding whispering signs. The side of the chest 
 wdiioh is chiefly or exclusively affected becomes contracted 
 either entirely or in part, resembling in this respect the 
 appearances after chronic pleurisy. 
 
 With these signs the affection is to be differentiated 
 from the ordinary form of phthisis, by reference to points 
 pertaining to the symptoms and history. 
 
180 PHYSICAL DIAGNOSIS. 
 
 Diaphragmatic Hernia. 
 
 The presence of more or less of the abdominal viscera 
 within the thoracic cavity in consequence of a congenital 
 deficiency of a portion of the diaphragm, or perforation 
 from accidents, or enlargement of the natural openings, 
 gives rise to certain anomalous signs, namely, a tympa- 
 nitic resonance, variable at different times owing to differ- 
 ences as regards the quantity of gas within the viscera; 
 absence of the respiratory murmur from the base of the 
 chest upward, the height proportional to the space occu- 
 pied by the abdominal organs, and the intestinal sounds 
 emanating from within the chest, not conducted from 
 below. 
 
 This extremely rare affection can only be confounded 
 with pneumothorax. The latter affection is to be ex- 
 cluded by the absence of its diagnostic signs, irrespec- 
 tive of the tympanitic resonance on percussion. 
 
THE UEAllT. 181 
 
 CHAPTER VII. 
 
 THE PHYSICAL CONDITIONS OF THE IIEAKT IN 
 HEALTH AND DISEASE. THE HEAKT-SOUNDS AND 
 CAKDIAC MURMURS. 
 
 Pliysical conditions of the heart in health : — Bounflaries of the prse- 
 cordia — Normal situation of the apex-beat — Boundaries of the deep 
 and of the superficial cardiac space — Relations of the aorta and the 
 pulmonary artery to the walls of the chest — The heart-sounds— Char- 
 acters distinguisliing the first and the second sound — Mechanism of 
 the xn'oduction of the heart-sounds — Auscultation of the pulmonic 
 and the aortic second sound separately — Movements of the auricles 
 and ventricles in relation to each other — Physical conditions of the 
 heart in disease ; Enlargement of the heart — Hypertrophy and di- 
 latation — Abnormal imputees of the heart, and modifications of the 
 apex -beat — Valvular lesions — Roughness of the pericardial surfaces 
 — Liquid within the pericardial sac — Abnormal modifications of the 
 heart-sounds — Reduplication of heart-sounds — Cardiac murmurs — 
 Normal and abnormal blood-currents within the heart, and their re- 
 lations with the heart-sounds — Mitral direct murmur — Mitral regur- 
 gitant murmur — Mitral systolic non-regurgitant, or intra-ventricu- 
 lar murmur — Aortic direct murmur — Aortic regurgitant murmur, 
 and an Aortic diastolic non-regurgitant murmur — Coexisting endo- 
 cardial murmurs — Tricuspid direct murmur — Tricuspid regurgitant 
 murmur — Pulmonic direct murmur — Pulmonic regurgitant murmur 
 — Facts of practical importance in relation to endocardial murmurs 
 — Pericardial or friction murmur. 
 
 Before entering upon the study of the physical diag- 
 nosis of the diseases of the heart, the student must be 
 familiar with its anatomy and physiology. For a de- 
 scription of the structure and functions of this organ, he 
 is referred to anatomical and physiological treatises. 
 The plan of this work embraces the anatomical relations 
 of the heart and the space which it occupies within the 
 
 16 
 
182 THE HEART. 
 
 chest, as physical conditions of health determinable by 
 normal signs, together with the heart-sounds. Having 
 briefly stated these conditions of health, the morbid phys- 
 ical conditions which may be ascertained by percussion, 
 auscultation, and other methods of physical exploration, 
 will be considered. The latter heading will inckule an 
 account of the cardiac murmurs. 
 
 The Physical Conditions of the Heart in Health. 
 
 The Prcecordia — The Superficial and the Deep Cardiac 
 Space. — The area on the surface of the chest correspond- 
 ing to the space which the heart occupies within the 
 chest, is the prsecordial region, or the prsecordia. The 
 upper, lower, and two lateral boundaries of this region 
 must be memorized. The upper boundary is the third rib, 
 the lower is a horizontal line passing through the fifth in- 
 tercostal space ; the left lateral boundary is at, or a little 
 within, a vertical line passing through the nipple, the 
 linea mammillarisj and the right lateral boundary is rep- 
 resented by a vertical line situated about a finger's breadth 
 to the right of the right margin of the sternum. As 
 the volume of the heart varies, within certain limits, in 
 different healthy persons, the boundaries of the prse- 
 cordia are, of course, not always exactly the same. The 
 foregoing statements are sufficiently accurate for practical 
 purposes. 
 
 The horizontal line representing the lower boundary 
 of the praecordia intersects the point where the apex- 
 beat of the heart is felt. The normal situation of the 
 apex-beat must be recollected. In most healthy persons 
 the apex-beat is felt in the fifth intercostal space, a little 
 within the linea mammillaris. This is assuming the 
 persons to be sitting or standing; in recumbency on the 
 
CONDITIONS OF HEART IN HEALTH. 183 
 
 back tlie beat sonietinies rises to the fourth intercostal 
 space, and it is sometimes found in the fourth space in 
 the sitting or standing position of the body. The dis- 
 tance from the linea mammillaris vjiries in different 
 healthy persons; it is sufficiently accurate to say it is a 
 little within that line. The force of the apex-beat varies 
 much in different healthy persons, owing to other causes 
 than the power of the heart's action, such as the amount 
 of muscular substance and fat in that situation, the width 
 of the intercostal space, the convexity of the chest, the 
 relation to the left luno^ etc. Allowance is to be made 
 for these variations in determining the abnormal modifi- 
 cations of the force of the beat, which belong among 
 the physical signs of disease. 
 
 Within a portion of the }3r?ecordia the heart is un- 
 covered of lung, and in the remaining portion lung in- 
 tervenes between the heart and the walls of the chest. 
 The former of these portions is called the superficial, and 
 the latter is called the deep cardiac space. The deep 
 cardiac space on the right side extends to the median 
 lino. On the left side the lung recedes at a point on the 
 median line on a level with the cartilage of the fourth 
 rib, and the anterior border of the upper lobe makes an 
 outward curve, returning inward at or near the apex of 
 the heart. This leaves the heart uncovered within an 
 area which, for practical purposes, may. be represented 
 by a right-angled triangle, the hypothenuse extending 
 from the median line on a level with the costal cartilage 
 of the fourth rib to the apex of the heart ; the right 
 angle formed by the median line and the horizontal line 
 which forms the lower boundary of the prsecordia. 
 
 The limits of the superficial cardiac space may be easily 
 defined by percussion. It is only necessary to ascertain 
 
184 THE HEART. 
 
 the curved line formed by the receding anterior border 
 of the upper lobe of the left lung. A distinct, although 
 not great, dulness on percussion marks this border of 
 the lung. The border of the lung is as distinctly marked 
 by the abrupt diminution of the vocal resonance, if aus- 
 cultation be made with the stethoscope. The outer 
 boundaries of the deep cardiac space may also be deter- 
 mined by percussion ; distinct, although slight dulness 
 marks the limits of the prsecordia. Defining thus the 
 boundaries of the prsecordia and of the superficial car- 
 diac space in healthy persons, makes a good practical 
 exercise in percussion. 
 
 Relations of the Aorta and Pulmonary Artery to the 
 Walls of the Chest. — The base of the heart, especially in 
 connection with auscultatory signs, is generally consid- 
 ered to be at the second intercostal space near the ster- 
 num, this situation being, in reality, just above the base. 
 In this situation sounds produced at the aortic and the 
 pulmonic orifice are best studied, either in health or 
 disease. With reference to these sounds, the anatomical 
 relations of the aorta and the pulmonary artery to the 
 right and the left second intercostal space are of im- 
 portance. If the stethoscope be applied in the second 
 intercostal space on the right side, close to the sternum , 
 it is very near the aorta, and sounds produced at the 
 aortic orifice are best heard in this situation. If the 
 stethoscope be applied in the second intercostal space on 
 the left side, it is very near the pulmonary artery, and 
 the sounds produced at the pulmonic orifice are best 
 heard in this situation. Reference will be made to these 
 two situations in giving an account of the heart-sounds 
 in health and disease, and of adventitious sounds or 
 murmurs. 
 
CONDITIONS OP HEART IN HEALTH. 185 
 
 The Heart-sounds. — Tho characters wliich distinguish 
 respectively the first and the second sound of the heart, 
 are to be studied preparatory to the study of the abnor- 
 mal modifications which are important physical signs of 
 disease. It is essential also to be able always to make the 
 distinction practically between the first and the second 
 sound in order to connect with each sound separately 
 cardiac murmurs. The conventional sense of the term 
 heart-sounds, as distinguished from cardiac murmurs, 
 must be borne in mind. The cardiac murmurs are ad- 
 ventitious sounds ; they are never merely abnormal 
 modifications of the heart-sounds, but they are new 
 sounds added to these. 
 
 The two heart-sounds follow in a certain rhvthmical 
 order, and, in health, this suffices for the recognition of 
 each. It answers all practical purposes to say that the 
 first and the second sound follow each other after an in- 
 terval which is just appreciable, this interval being the 
 short pause of the heart. After the two sounds, an in- 
 terval is readily a])preciable, called the long pause of 
 the heart. It is not necessary to carry in the memory 
 the exact relative duration of each of the sounds and 
 each of the intervals. The fractions of a unit, in fact, 
 do not express the length of the sounds and intervals as 
 correctly as less definite expressions, inasmuch as the 
 figures represent only the mean of variations within the 
 limits of health. It is sufficiently definite to say that, 
 with the ear or stethoscope applied over the situation of 
 the apex-beat, the first sound is longer than the second, 
 louder, lower in pitch, and has a quality which may be 
 called booming. Per conbrt, the second sound is shorter, 
 weaker, higher in pitch, and has a quality which may 
 be called valvular or clicking. Aside from the relative 
 
186 THE HEART. 
 
 lengtli of tlie two sounds, tlie other characters are more 
 or less marked in different healthy persons. 
 
 These distinctive cliaracters of the heart-sounds are 
 apparent when the ear or stethoscope is applied over 
 the apex. At the base of the heart, that is, in the 
 second intercostal space near the sternum, the characters 
 of the first sound are not the same. The second sound 
 in this situation is louder than the first. This sound is 
 said to be accentuated at the base, the first sound being 
 accentuated at the apex. Moreover the first sound at 
 the base may not be longer than the second ; it loses 
 more or less of its booming quality, the pitch remaining 
 lower than that of the second sound. Removing the ear 
 or the stethoscope a certain distance from the apex in 
 any direction, occasions ^milar changes in the characters 
 of the first sound. The interposition of several thick- 
 nesses of a napkin has the same effect. 
 
 From the differential characters over the apex, and 
 the rhythm in other situations, there is no difficulty in 
 distinocuishino; the first from the second sound in health. 
 In cases of disease, however, owing to disturbance of the 
 rhythm, modifications of the characters of the first sound, 
 and the absence sometimes of one of the sounds, other 
 means of recognition must be resorted to. If the apex- 
 beat can be felt, this offers a ready way for recognizing 
 the first sound — the sound which is synchronous with 
 the apex-beat is, of course, the first sound. This mode 
 is not always available, inasmuch as the apex-beat can- 
 not always be felt. Another mode is always available, 
 namely, feeling the carotid pulse. The carotid pulse 
 is synchronous with the first sound, whereas there is a 
 slight interval between this sound and the radial pulse. 
 
 The student is aided in comprehending certain physi- 
 
CONDITIONS OF UEART IN HEALTH. 187 
 
 cal signs by taking into view the mechanism of the pro- 
 duction of the heart-sounds. The second sound is pro- 
 duced by the sudden forcible closure of the aortic and 
 the pulmonic valves. This closure is caused by a retro- 
 grade movement of the columns of blood in the aorta 
 and pulmonary artery, directly the ventricular systole is 
 ended. The retrograde movement is due to the recoil of 
 the coats of the arteries which have been dilated by the 
 column of blood moving onward during the ventricular 
 systole. This recoil causes regurgitation into the ven- 
 tricle when either the aortic or the pulmonic valve is 
 rendered incompetent by lesions. The mechanism of the 
 first sound is less simple. This sound is in part due to 
 the forcible tension of the auriculo- ventricular valves, 
 caused by the systole of the veptricles. In this way is 
 produced a valvular element of the first sound. That 
 the impulsion of the heart against the walls of the chest 
 furnishes another element, seems demonstrable. To this 
 element of impulsion the first sound is indebted for its 
 greater intensity, as compared with the second sound, its 
 length, and its booming quality. This is shown by the 
 fact, already stated, that when auscultation is made at a 
 certain distance from the apex, these characters are 
 eliminated, and by the fact that diseases which diminish 
 or arrest the Impulsion movements of the heart produce 
 the same modifications. The valvular element of the 
 first sound Is weaker than the second sound, a fact which 
 at first occasions surprise when the difference in size 
 between the aortic and pulmonic and the auriculo-ven- 
 tricular valves is considered. The explanation of this 
 apparent incongruity is as follows: the aortic and pul- 
 monic sejyments at the end of the ventricular svstole are 
 in contact with the arterial walls, and are expanded when 
 
188 THE HEART. 
 
 the recoil of the latter follows. On the other hand, 
 when the ventricular systole takes place in health, the 
 auriculo-ventricular valves are not in contact with the 
 walls of the ventricles, but they are floated out, and the 
 orifices are nearly or quite closed ; the movement of the 
 blood, therefore, in the systole only renders these valves 
 tense. The second sound, in other words, is due to the 
 expansion of the sigmoid valves of the aorta and pulmo- 
 nary artery, whereas, the valvular element of the first 
 sound is due to the tension of the auriculo-ventricular 
 valves. The foregoing points relating to the heart-sounds 
 were contained in my prize essay " On the Clinical 
 Study of the Heart-Sounds in Health and Disease,'^ 
 published in the Transactions of the American Medical 
 Association in 1858.^ 
 
 A point in relation to the second sound of the heart 
 has an interesting and important bearing on auscultation 
 in disease, namely, the study of this sound as produced 
 at the aortic and the pulmonic orifices separately. Re- 
 calling the anatomical relations of the aorta and the 
 pulmonary artery to the walls of the chest, if the stetho- 
 scope be applied in the second intercostal space on the 
 right side close to the sternum, the characters of the 
 second sound are derived chiefly from the aortic valve, 
 and if the stethoscope be applied in the second intercos- 
 tal space on the left side close to the sternum, the char- 
 acters of the second sound are derived chiefly from the 
 pulmonic valve. The correctness of this statement is 
 proved by differences in the characters of the sound on 
 two sides in health, and by the modifications in cases of 
 disease. These morbid modifications will enter into the 
 
 1 Vide, also, " Treatise on Diseases of the Heart," first edition, 
 1860; second edition, 1870. 
 
CONDITIONS OF HEART IN UEALTH. 189 
 
 physical diagnosis of cardiac affections. In health the 
 aortic second sound is somewhat louder, higher in jjitch, 
 and the valv^ilar quality more marked than the pulmonic 
 second sound. The student should verify these points of 
 difference by the study of the second sound in the two 
 situations just named. In order for the comparison to 
 be a fair one in health, and available in the diagnosis of 
 disease, the normal anatomical relations to the walls of 
 the chest, of tiie aorta, and pulmonary artery must be 
 preserved. These relations are affected by changes in 
 the symmetry of the chest, and sometimes by enlarge- 
 ment of the heart. The lungs must also be free from 
 disease; otherwise, the conduction of the sounds wmU be 
 abnormal. 
 
 The movements of the auricles and the ventricles are 
 to be kept in mind with reference to the comprehension 
 of certain physical signs of disease. Points of especial 
 importance are the contraction of the auricles in the 
 latter part of the long pause of the heart, preceding the 
 ventricular systole, and the twisting of the heart from 
 left to right in the systole, this movement being reversed 
 in the diastole. In these systolic and diastolic twisting 
 movements, tlie pericardial surfaces move upon each, 
 but in health noiselesslv owino^ to their smoothness and 
 moisture. The movements occasion an auscultatory 
 sound when the surfaces are roughened by the presence 
 of lymph. Other points are the size of the pericardial 
 sac, that is, its capability of holding when filled, but not 
 dilated, from fifteen to twenty ounces of liquid, and its 
 attachment, not to the base of the heart, but to the 
 vessels above the base. 
 
190 THE HEART. 
 
 Physical Conditions of the Heart in Disease. 
 
 The physical conditions of the heart in disease, which 
 are determinable by physical exploration, are, 1st, en- 
 largement of the heart; 2d, abnormal impulses and 
 modifications of the apex-beat; 3d, valvular lesions; 
 4th, roughness of the pericardial surfaces ; and, 5th, 
 liquid within the pericardial sac. Having considered 
 tiiese conditions, an account of abnormal modifications 
 of the heart-sounds and cardiac murmurs will conclude 
 this chapter. 
 
 Enlargement of the Heart. — Enlargement of the heart 
 may be slight, moderate, great, or very great, these terms 
 expressing different degrees of enlargement with suffi- 
 cient precision for clinical, purposes. In cases of very 
 great enlargement, the space within the chest which the 
 heart occupies may be from four to five times larger than 
 in health. The situation of the base of the heart re- 
 mains but little, or not at all, changed in cases of en- 
 largement ; the increased space which the heart occupies 
 is therefore downward. The increased space extends 
 much more to the left than to the right; the left border 
 of the heart, in proportion to the enlargement, is carried 
 beyond the mammary line on the left side, whereas, the 
 right border is carried comparatively but little beyond 
 the normal right lateral boundary of the praecordiaeven 
 when the enlargement is very great. The superficial 
 cardiac space is enlarged in proportion to the enlarge- 
 ment of the heart ; the organ pushes to the left the re- 
 ceding anterior border of the upper lobe of the left 
 lung, and is proportionately in contact, uncovered of lung, 
 with the walls of the chest. The apex of the heart is 
 lowered in proportion to the enlargement, and it is car- 
 ried more or less to the left of its normal situation. It 
 
CONDITIONS OF HEART IN DISEASE. 191 
 
 may be lowered to the sixtli, seventli, eighth, or ninth 
 intercostal space. The enlargement of the heart is rarely 
 equal in all its parts. The ventricular enlargement may 
 be entirely or chiefly of either the right or the left ven- 
 tricle. Enlargement of the right ventricle tends to carry 
 the right side of the heart more to the right than when 
 the left ventricle is enlarged. The situation of the apex 
 is also affected by the parts of the heart in which the 
 enlargement predominates. The apex is carried further 
 to the left of its normal situation, other things being 
 equal, when the enlargement predominates on the right 
 side of the heart ; and it is lowered without being carried 
 far to the left when the enlargement of the left ventricle 
 predominates. The apex of the organ in cases of con- 
 siderable or of great enlargement becomes changed in 
 form ; it is rounded or blunted. This change is most 
 marked when enlargement of the right ventricle pre- 
 dominates. All these points are of importance with 
 reference to the comprehension of the physical signs of 
 enlargement of the heart. 
 
 Enlargement of the heart may be entirely due either 
 to hypertrophy or to dilatation (simple hypertrophy and 
 simple dilatation). If, however, the enlargement be 
 sufficient to occasion notable disturbance of the circu- 
 lation, both these forms of enlargement are combined, 
 but, as a rule, one or the other form predominating, so 
 that, of the cases of diseases of the heart which come 
 under medical treatment, the majority are cases of either 
 enlargement with predominant hypertrophy or enlarge- 
 ment with predominant dilatation. 
 
 These widely different physical conditions are con- 
 cerned especially in the abnormal impulses and modi- 
 
192 THE HEART. 
 
 fications of the apex-beat, as well as, also, the heart- 
 sounds. 
 
 Abnormal Im.puhes of the Heart, and Modifications 
 of the Apex-beat. — The abnormal situation of the apex 
 of the heart when enlarged has been stated. Generally 
 the situation is determinable by the apex-beat. It has 
 been seen that in health the beat is sometimes not appre- 
 ciable by the touch, owing to the thickness of the soft 
 parts, and the conformation of the thorax, and, for these 
 reasons, the force of the beat varies much in different 
 healthy persons. Exclusive of normal variations, the 
 beat is generally strong and prolonged in proportion as 
 the heart is enlarged by hypertrophy. There are excep- 
 tions to this statement, which are to be explained by the 
 altered form of the apex ; when it loses its pointed form 
 it does not so readily come into contact with the walls of 
 the chest in an intercostal space, and, hence, the beat 
 may be weak although the ventricular systole be abnor- 
 mally strong. On the other hand, the apex-beat is 
 weakened by dilatation, and it may be wanting as a re- 
 sult of diminished strength of the systole of the ven- 
 tricles. The apex-beat is also abnormally weak in fatty 
 degeneration and softening of the heart, as well as in 
 functional debility of the organ incident to other diseases 
 than those of the heart. 
 
 If there be considerable or great enlargement, tiie 
 heart being in contact with the walls of the chest over a 
 larger area than in health, impulses other than the apex- 
 beat are generally apparent to the eye and touch. Not 
 infrequently impulses are appreciable in each intercostal 
 space between the situation of the apex and the base of 
 tiie heart. These abnormal impulses are felt to be strong 
 in proportion as the enlargement is due to hypertrophy, 
 
CONDITIONS OP HEART IN DISEASE. 193 
 
 and weak in proportion as dilatation predominates. En- 
 largement seated in the right ventricle causes an impulse 
 in the e])igastrium which is stronger weak in proportion 
 as hypertrophy ordilitation predominates. Cardiac im- 
 pulses are felt and seen in abnormal situations when the 
 heart is removed from its normal situation by the pres- 
 sure of an aneurism, or other tumor, by pleuritic effu- 
 sion, hydroperitoneum, etc. The error of mistaking for 
 a cardiac impulse the pulsation of an aneurismal tumor 
 is to be avoided. Another error is to be avoided, namely, 
 mistaking abnormal impulses due to the heart being un- 
 covered of lung, from shrinking of the latter in certain 
 pulmonary affections, for impulses denoting enlargement 
 of the heart. In cases of enlargement by hypertrophy 
 a heaving movement of the whole prsecordia is some- 
 times felt when the hand is applied to the chest. A 
 violent shock is sometimes felt by the hand applied to 
 the prsecordia, but without a sense of increased mus- 
 cular power, in cases of purely functional disorders of 
 the heart. 
 
 Valvular .Lesions. — The lesions affecting the valves of 
 the heart are of a varied character, for an account of 
 which the student is referred to treatises on cardiac dis- 
 eases, or on pathological anatomy. It suffices here to 
 consider that, with reference to physical signs and patho- 
 logical effects they may be distributed into three groups, 
 as follows: 1st, lesions which diminish more or less the 
 size of the orifices, or obstructive lesions; 2d, lesions 
 which render the valves more or less incompetent and 
 permit regurgitation, or regurgitative lesions ; and 3d, 
 lesions which roughen the surface over which the blood 
 moves without occasioning either obstruction or regurgi- 
 tation. The latter may be distinguished as innocuous 
 
194 TUE HEART. 
 
 lesions, giving rise to no pathological effects although 
 represented by cardiac murmurs. 
 
 It is to be borne in mind that in the great majority 
 of cases valvular lesions are seated in the left side of 
 the heart, that is, they are either mitral or aortic. Tri- 
 cuspid and pulmonic lesions are comparatively rare, and 
 they are generally congenital. Not infrequently mitral 
 and aortic lesions coexist, and there may be coexisting 
 lesions at all the orifices of the heart. 
 
 Valvular lesions are represented by cardiac murmurs. 
 By means of tlie murmuj's the existence of lesions is 
 known, their situation at the different orifices may be 
 ascertained, and, generally, it is practicable to determine 
 whether they occasion obstruction or regurgitation, or 
 both. These several points of inquiry will be consid- 
 ered presently under the heading Cardiac i\Ji|irmurs, and 
 in connection with the lesions of the different valves re- 
 spectively in the next chapter. 
 
 Roughness of the Pericardial Surfaces. — In place of 
 the smoothness of the pericardial surfaces in health, 
 which permits their movements upon each other noise- 
 lessly, the presence of the inflammatory product lymph, 
 and, in some rare instances morbid growths, occasion an 
 adventitious sound or murmurs, which will be noticed 
 in connection with other murmurs, and as entering into 
 the ])hysical diagnosis of pericarditis. 
 
 Liquid icithin the Pericardial Sac. — More or less 
 liquid transudes into the pericardial sac in cases of 
 general dropsy or anasarca, but rarely in very large 
 quantity. Liquid effusion occurs in acute pericarditis, 
 and in this affection the sac may become filled with 
 liquid. In some cases of chronic pericarditis the sac is 
 
ABNORMAL MODIFICATIONS OF SOUNDS. 195 
 
 greatly dilated by liquid, the quantity amounting to four 
 pounds, or even more. 
 
 When the pericardial sac is filled with liquid, without 
 being dilated, it forms, virtually, a pyrlform tumor 
 within the chest, the base of which is at the sixth or 
 seventh intercostal space ; the apex rises nearly to the 
 sternal notch ; the left lateral border is considerably 
 beyond the nipple, and the right lateral border is more 
 or less beyond the right margin of the prsecordia. The 
 anterior portion of the filled pericardium is mostly un- 
 covered of lung and in contact with the walls of the 
 chest. Within this area there is either notable dulness 
 or flatness on percussion, together with absence of respi- 
 ratory murmur and of vocal resonance. By means of 
 these signs, the boundaries of the pyriform tumor may 
 be readily delineated on the surface of the chest. 
 
 When the pericardial sac is partially filled with liquid, 
 the same signs are present, but within an area of less 
 extent, and the configuration of the pyriform tumor is 
 want in o;. 
 
 In cases of chronic pericarditis with a large accumu- 
 lation of liquid, the pericardial sac is dilated so that Its 
 lateral boundaries may extend nearly to the axillary and 
 infra-axillary regions. Under these circumstances, flat- 
 ness on percussion, absence of respiratory murmur and 
 of vocal resonance, are present over the greater part of 
 the anterior aspect of the chest. 
 
 Abnormal Modification of the Heart-sounds. 
 
 In order to appreciate the abnormal modifications of 
 the heart-sounds, their normal characters are to be kept 
 in mind (fic/e page 185), and the student must be prac- 
 tically familiar with them. The modifications relate 
 especially to the intensity and quality of the first and the 
 
196 THE HEART. 
 
 second sound. Either of the two sounds may be sup- 
 pressed . 
 
 The first sound has all its normal characters intensified 
 when the power of the ventricular systole is increased 
 by hypertrophy. The sound is louder than in health ; 
 it is longer, and the booming quality is more marked. 
 If obstructive or regurgitant valvular lesions do not exist, 
 the second sound is also intensified, without change in 
 other respects. The first sound, when much intensified, 
 sometimes has a ringing tone or tinnitus. This is also 
 sometimes observed in health when the power of the 
 heart's action from any cause is increased. 
 
 In some cases of violent palpitation the first sound is 
 notably intense, but short and valvular in quality. I 
 suppose the explanation of this to be as follows : the ven- 
 tricles contract with a kind of spasmodic action upon a 
 small quantity of blood ; and, under these circumstances, 
 the auriclo-ventricular valves, not being floated out as 
 they are when the ventricles are well filled, expand with 
 force in the ventricular systole, instead of being merely 
 made tense as in health. Hence, the valvular element of 
 the first sound is much intensified, while those characters 
 of the first sound which are due to the impulsion of the 
 heart against the walls of the chest, may be feeble or 
 wanting. 
 
 Weakening or suppression of the first sound over the 
 apex is an effect of those affections of the heart which 
 diminish the power of the ventricular systole. These 
 affections are enlargement from dilatation, atrophy, fatty 
 degeneration, myocarditis, obstruction of the coronary 
 arteries, and softening. If the sound be notably weak- 
 ened, it becomes short and valvular like the second 
 sound. These changes sliow that the characters depend- 
 
ABNORMAL MODIFICATIONS OF SOUNDS. 197 
 
 cnf/ on the element of impulsion are affected more than 
 the valvular element. Liquid effusion within the peri- 
 cardium renders the first sound more or less weak and 
 valvular, the characters derived from impulsion being 
 under these circumstances wanting. Diminished power 
 of the heart's action from other than cardiac diseases, in- 
 volves weakness of both the heart-sounds, but more 
 especially of the first sound. 
 
 The abnormal modifications of the second sound, which 
 are chiefly of interest and importance, relate to the 
 aortic and pulmonic sound considered separately. Bear- 
 ins: in mind the mode of interroo-atino; the aortic and the 
 pulmonic orifice with reference to the valvular sound de- 
 rived from each independently of the other (vide page 
 188), a comparison of the two sounds in diseases of the 
 heart affords often useful information. Whenever, from 
 mitral obstruction or regurgitant lesions, or both com- 
 bined, the blood propelled by the left ventricle into the 
 aorta is diminished, the recoil of the arterial coats, after 
 the ventricular systole, is lessened ; consequently, the 
 aortic segments expand with less force, and the valvular 
 sound is weakened. Diminished intensity of the aortic 
 sound thus represents an abnormal diminution of thequan- 
 tity of blood propelled into the systemic arteries in the 
 systole of the left ventricle, and this diminished intensity 
 is, in a measure, a criterion of the amount of mitral ob- 
 struction or mitral regurgitation, or both combined. In 
 some cases of extreme obstruction or regurgitation, the 
 aortic sound is completely suppressed. How is weaken- 
 ing of this sound to be determined and measured ? By 
 comparison with the })ulmonic sound. Now, as will 
 presently appear, the pulmonic sound is apt to be in- 
 tensified when the aortic sound is weakened. Hence, 
 
 17 
 
198 THE HEART. 
 
 the former is not an accurate standard for this com- 
 parison ; but it suffices for an approximation to accuracy. 
 In cases of hypertrophy of the left ventricle without 
 obstructive or regurgitant valvular lesions, the aortic 
 sound is abnormally intensified. These cases occur 
 chiefly in connection with fibroid or atrophic lesions of 
 the kidneys. 
 
 A simpler cause of weakening or suppression of the 
 aortic sound, is damage from lesions of the aortic valve. 
 In proportion as the function of this valve is impaired 
 by lesions, the intensity of the sound is diminished, and 
 if the function of the valve be lost, the sound is wanting. 
 In these cases, the pulmonic sound being but little or 
 not at all affected, it is an accurate standard for the 
 comparison. 
 
 The pulmonic sound is weakened in the rare instances 
 of lesions affecting the pulmonic valve. This sound is 
 oftener intensified than weakened. It is notably inten- 
 sified when the right ventricle is hypertrophied, and 
 especially when this hypertrophy is associated with dila- 
 tation of the left auricle resulting from mitral obstruc- 
 tion or regurgitation. These lesions weakening, as has 
 just been seen, the aortic sound, the contrast between 
 the aortic and the pulmonic sound in some cases of 
 mitral lesions is very marked. The pulmonic sound is 
 sometimes loud while the aortic sound is suppressed. 
 
 In comparing the aortic and the pulmonic sound in 
 disease, as in health, it is to be assumed that the anatom- 
 ical relations of the aortic and the pulmonary artery to 
 the second intercostal space on either side, close to the 
 sternum, are not materially altered, and that the lungs 
 are free from lesions in consequence of which the con- 
 duction of the sound on either side is abnormal. 
 
ABNORMAL MODIFICATIONS OF SOUNDS. 199 
 
 Keturnlng to the first sound of the heart, the mitral 
 and the tricuspid part of the valvular element of this 
 sound may be studied separately. With the stethoscope 
 applied at or a little to the left of the apex, the valvular 
 element of the first sound, which is heard, is derived 
 chiefly from the mitral valve. On the other hand, if 
 the stethoscope be applied at or near the right lower 
 border of the heart, the valvular element is derived 
 chiefly from the tricuspid valve. Notable weakness or 
 suppression of the mitral valvular sound, as compared 
 with the tricuspid, represents impairment of the function 
 of the mitral valve, and, per contra, notable weakness 
 or suppression of the tricuspid valvular sound denotes 
 impairment of the function of the tricuspid valve. 
 Allowance in this comparison is to be made for a nor- 
 mal disparity, the mitral valvular sound being louder 
 than the tricuspid in health. 
 
 RedupliGcdion of Heart-sounds. — The sounds of the 
 heart are said to be reduplicated wdien either the first or 
 the second sound is repeated, or when each sound occurs 
 twice before the long pause or interval. Considering 
 the heart-sounds as represented by the whispered words 
 Lub-dup, reduplication of the first sound is expressed 
 by Lublub-dup, of the second by Lub-dupdup, and of 
 both sounds by Lublub-dupdup. 
 
 Clinically, reduplication of the second sound is much 
 more frequent than reduplication of either the first sound, 
 or of both sounds. Yet, accepting the explanation which 
 seems most reasonable of this anomaly, both sounds 
 should always be reduplicated, that is, neither should 
 be reduplicated separately. It is probable that both 
 sounds are always reduplicated, but the reduplication of 
 
200 THE HEART. 
 
 one of them (generally the first sound) from its feeble- 
 ness is not appreciable. 
 
 There is a form of disorder which maybe confounded 
 with reduplication of both sounds of the heart. In this 
 disorder, with every alternate revolution of the heart, 
 the sounds are weak, and the ventricular systole is not 
 represented by a radial pulse, the force of the contraction 
 of the ventricle being insufficient to cause an appreciable 
 pulsation in the remote arteries; hence, the heart-sounds 
 occur twice for each pulse at the wrist. Under these 
 circumstances, however, the carotid pulse may generally, 
 if not always, be felt with the weak, as well as with the 
 stronger, ventricular contraction, and in this way the 
 error of confounding the disorder with reduplication 
 may be avoided. 
 
 The explanation of reduplication is, that instead of the 
 two ventricles contracting in unison, as in health, one 
 contracts a little before the other. This explanation 
 accounts satisfactorily for the anomaly. 
 
 Reduplication of the heart-sounds may occur in con- 
 nection with cardiac lesions, or there may be no evidence 
 of any organic affection. In the latter case the anomaly 
 falls properly among the varied forms of functional dis- 
 order of the heart. Whether, or not, it be connected 
 with lesions, it has no important pathological significance. 
 It is usually of temporary duration. 
 
 Cardiac Murmurs. 
 
 All adventitious, abnormal sounds which are added 
 to the heart-sounds, are embraced by the term cardiac 
 murmurs. Let it be borne in mind that, conventionally, 
 the murmurs are never abnormal modifications of the 
 heart-sounds, but always newly produced sounds, and 
 
CARDIAC MURMURS. 201 
 
 they always represent morbid conditions of either the 
 heart or the blood. When due to morbid conditions of 
 the blood, they are called inorganic, anaemic, hamic 
 murmurs, and when they represent valvular lesions or 
 changes within the heart, they are distinguished as or- 
 ganic murmurs. 
 
 The organic murmurs may be distributed into three 
 groups after differences in quality, namely; 1st, soft, 
 2d, rough, and 3d, musical murmurs. The soft mur- 
 murs resemble the sound produced by air from the 
 nozzle of a pair of bellows, and, hence, are often called 
 bellows murmurs. Murmurs are said to be rough when 
 their qualities may be expressed by such terms as rasp- 
 ing, grating, creaking, croaking, etc. They are called 
 musical when the sound is a musical note. The bellows 
 murmurs are of most frequent occurrence, and the musi- 
 cal are much more rare than the rough murmurs. The 
 quality of a murmur does not in general invest it with 
 any special pathological or diagnostic significance. The 
 murmurs vary in pitch, being either relatively high or 
 low. The variations in pitch are useful in aiding to dis- 
 criminate different coexisting murmurs. 
 
 This account of organic murmurs applies to those pro- 
 duced at the orifices or within the cavities of the heart. 
 They are distinguished as endocardial murmurs. Ad- 
 ventitious sounds, are, however, produced upon the ex- 
 ternal surface of the heart. These constitute what is 
 called exocardial, pericardial, or friction murmurs. 
 
 Endocardial murmurs are produced by blood-currents 
 pursuing either a normal or an abnormal direction. 
 With a familiar knowledge of these currents, and of 
 their relations with the heart-sounds, the several endo- 
 cardial murmurs are very easily understood, as regards 
 
202 THE HEART. 
 
 points involved in their differentiation from each other. 
 The student is, therefore, advised first to become ac- 
 quainted with the blood-currents in health and in dis- 
 ease. Directing the attention to the left side of the heart, 
 there are two normal blood-currents, namely, the current 
 from the left auricle to the left ventricle, and the current 
 from the left ventricle into the aorta. These may be 
 distino-uished as the direct currents. The first is the 
 mitral direct current, and the second is the aortic direct 
 current. Two abnormal currents may occur in the left 
 side of the heart. These currents can only take place 
 when the valves are rendered incompetent by lesions. 
 The incompetency of the valves allows of regurgitation, 
 and these abnormal currents may be distinguished as 
 the regurgitant currents. One of these is a current back- 
 ward from the left ventricle into the left auricle, owing 
 to incompetency of the mitral valve; this is the mitral 
 regurgitant current. The other is a current backwards 
 from the aorta into the left ventricle, arising from in- 
 competency of the aortic valve ; this is the aortic regur- 
 gitant current. 
 
 What are the relations of these four currents in the 
 left side of the heart with the heart sounds? The mi- 
 tral direct current takes place when the auricles contract. 
 The contraction of the auricles precedes the ventricular 
 systole. The ventricular systole is synchronous with 
 the first sound of the heart. The mitral direct current, 
 therefore, takes place just before the first sound of the 
 heart. It begins after the second sound, and continues 
 until it is suddenly and completely arrested by the con- 
 traction of the ventricle. It is obvious that the current 
 cannot continue during the ventricular contraction, that 
 is, when the first sound of the heart is produced. The 
 
CARDIAC MURMURS. 203 
 
 mitral regurgitant current is caused by the contraction 
 of the ventricle; the current, therefore, must take phice 
 with the first sound of tlie heart. This current is sys- 
 tolic in the time of its occurrence. The aortic direct 
 current, being caused by the contraction of the left ven- 
 tricle, takes place with the first sound of the heart. It 
 is, therefore, coincident with the mitral regurgitant cur- 
 rent. The aortic regurgitant current is caused by the 
 recoil of the arterial coats upon the column of blood 
 within the aorta directly after the ventricular systole, 
 and as this recoil causes the second sound of the heart, 
 the current and this sound must be coincident. 
 
 Recapitulating the relations of the four currents with 
 the heart-sounds, the aortic direct and the mitral regur- 
 gitant take place with the first sound — they are systolic 
 currents ; the mitral direct current precedes the first 
 sound— it is presystolic; and the aortic regurgitant cur- 
 rent takes place with the second sound — it is diastolic. 
 
 Analogous blood-currents take place in the right side 
 of the heart, and have corresponding relations with the 
 heart-sounds. These currents are the tricuspid direct, 
 the tricuspid regurgitant, the pulmonic direct, and the 
 pulmonic regurgitant. The pulmonic regurgitant is ex- 
 ceedingly rare in consequence of the infrequency of 
 pulmonic lesions; but the tricuspid regurgitant is not 
 uncommon, and probably occurs without valvular lesions 
 or enlargement of the heart when the right ventricle is 
 distended with blood, constituting what has been called 
 the "safety valve function " of the tricuspid orifice. 
 
 Organic endocardial murmurs are produced by the 
 foregoing direct and regurgitant blood-currents, and they 
 are designated by the same names, that is, they are either 
 direct or regurgitant. Thus, there are produced in the 
 
204 THE HEART. 
 
 left side of the heart — the side in which valvular lesions 
 are seated in the great majority of cases — a mitral direct 
 murmur, a mitral regurgitant murmur, an aortic direct 
 murmur, and an aortic regurgitant murmur. In the 
 right side of the heart there may be produced correspond- 
 ing murmurs, namely, a tricuspid direct, a tricuspid re- 
 gurgitant, a pulmonic direct, and a pulmonic regurgi- 
 tant. It remains to point out the means of diiferentia- 
 ting these several murmurs aside from their relations 
 with the heart-sounds. 
 
 Mitral Dived Murmur. — This murmur is presystolic. 
 It begins after the second sound and ends abruptly with 
 the first sound. Almost invariably, this murmur is 
 rough in quality ; occasionally, it is a soft bellows murmur. 
 When rough, it is often quite loud. The rough qual- 
 ity is peculiar ; it is suggestive of vibration, and may be 
 imitated by causing the lips or the tongue to vibrate 
 with the breath in expiration. I state the mechanism 
 of this murmur, inasmuch as the explanation is origi- 
 nal with me, and has not been as yet generally accepted. 
 It is caused by the vibrations of the mitral curtains, and 
 takes place especially when these curtains are united at 
 their sides, leaving a narrow orifice through which the 
 mitral direct current of blood flows. Throwing the lips 
 into vibration with the breath, re[)rcsents not only the 
 quality of the murmur, but the mode of its production. 
 The physical conditions which are requisite generally for 
 its production are a narrowed mitral orifice, and flac- 
 cidity of the mitral curtains. The latter of these condi- 
 tions does not always exist in cases of mitral obstructive 
 lesions, and, hence, the murmur by no means always ac- 
 companies these lesions. When it is considered how loud 
 a blubbering sound may be produced by the vibration 
 
CARDIAC MURMURS. 205 
 
 of the lips with a feeble current of air, it is not difficult 
 to uuderstand that an intense murmur may be caused 
 by a current of blood propelled by the comparatively 
 weak contraction of the auricle. 
 
 A mitral direct murmur may be produced without 
 mitral lesions, the murmur having the same rough qual- 
 ity as when lesions exist, and being also quite loud. 
 This statement, based on clinical proof, was made by me 
 many years since, together with the explanation. It 
 occurs when there are aortic lesions which permit regur- 
 gitation. Under these circumstances, at the time when 
 the auricular contraction takes place, the left ventricle 
 is already tilled with blood, the mitral curtains are 
 floated out so as to be in contact with each other, and 
 the mitral direct current passing between the curtains 
 throws them into vibration precisely as when the ori- 
 fice is narrowed. Tlie vibration of the lips when lightly 
 in contact, caused by the ex})ired breath, illustrates the 
 manner in which a mitral direct murmur takes place 
 without mitral lesions. The murmur thus occurring 
 without mitral lesions is not constant ; it is now pres- 
 ent and now absent, depending, as it does, on the quan- 
 tity of blood within the left ventricle at the time of the 
 contraction of the auricle. It follows from what has 
 just been stated, that a mitral direct murmur is not al- 
 ways a sign of mitral obstructive lesions when there is 
 free aortic re2;ur2:itation. 
 
 This murmur is limited to a circumscribed space around 
 the apex of the heart. However loud the murmur may 
 be in this situation, it is lost within a short distance from 
 the apex.^ 
 
 ^ Professor Janeway states that in rare instances he has heard this 
 murmur over the knver part of the scapula. 
 
 18 
 
206 THE HEART. 
 
 A mitral direct murmur is never due to a morbid con- 
 dition of the blood. Although it occurs without mitral 
 lesions, yet, inasmuch as its occurrence then requires the 
 existence of aortic regurgitant lesions, it cannot be said 
 to be an inorganic murmur. 
 
 Mitral Begurgitant 3Iurmur — Ilitral Systolie Non- 
 regurgitant, or Intra-ventricular Murmur. — The mitral 
 regurgitant murmur, synchronous with the first sound, 
 that is, a systolic murmur, may be soft, rough, or musical 
 in quality, its intensity and pitch being variable. Aside 
 from its relation with the first sound of the heart, it is 
 distinguished by having its maximum of intensity at or 
 near the situation of the a})ex-beat. It may be limited 
 to a circumscribed area, and if heard at a distance from 
 the apex it is best transmitted laterally around the left 
 side of the chest. It is often heard on the posterior as- 
 pect of the chest on the left side near the lower angle of 
 the scapula, and not infrequently in the corresponding 
 situation on the right side. 
 
 A murmur with the first sound heard within a limited 
 area at the apex, may be due to roughness of the endo- 
 cardial membrane without mitral incompetency, and, 
 consequently, without a mitral regurgitant current. This 
 is a mitral systolic non-regurgitant murmur. It may, 
 also, be called an intra-ventricular murmur, being pro- 
 duced, not at the mitral orifice, but within the ventricle. 
 This murmur cannot always be discriminated from a 
 feeble mitral regurgitant murmur. If, however, a mitral 
 murmur be conducted laterally for some distance to the 
 left of the apex, and if it be heard on the back, it may 
 be considered to represent mitral regurgitation. A mitral 
 systolic, non-regurgitant, or intra-ventricular murmur is 
 the murmur present in endocarditis. It may be caused 
 
CARDIAC MURMURS. 207 
 
 by a tendinous cord extending from the inner wall on 
 one side to the opposite side of the ventricular cavity. 
 This occurs as a congenital anomaly. Aneurism of the 
 heart may be so situated as to give rise to a murmur 
 simulating a mitral systolic murmur. Cardiac aneurism, 
 however, is exceedingly rare. Aneurism of the thoracic 
 aorta may cause a murmur which, transmitted through 
 the heart, simulates a mitral systolic murmur. 
 
 The impulse of the apex of the heart against the ad- 
 jacent portion of the lung sometimes forces the air from 
 the air-vesicles sufficiently to give rise to a blowing 
 sound occurring with each ventricular systole. This 
 is liable to be confounded with an endocardial mur- 
 mur. Produced in the way just stated it may be heard 
 only during the act of inspiration, and especially at the 
 end of this act. 
 
 A mitral systolic murmur is rarely, if ever, due to an 
 abnormal condition of the blood, without any anatomi- 
 cal change in the valve or endocardial membrane. Con- 
 ditions of the blood, however, which are favorable for 
 the production of inorganic murmur may intensify this 
 murmur as well as any of the organic murmurs. 
 
 Aortic Direct Murmur. — This murmur, like the mitral 
 systolic murmurs, occurs with the first sound of the 
 heart, that is, it is systolic. Of the organic murmurs 
 on the left side of the heart, the mitral systolic mur- 
 murs and the aortic direct murmur, are synchronous, 
 the others having different relations with the heart- 
 sounds. The aortic direct murmur differs from the mi- 
 tral systolic murmurs in having its maximum of inten- 
 sity at the base of the heart. It is loudest in the sec- 
 ond intercostal space near the sternum. As a rule, it is 
 louder in this intercostal space on the right than on the 
 
208 THE HEART. 
 
 left side ; tliis rule, however, has frequent exceptions. 
 It is transmitted better and further upward than down- 
 ward. It is always heard over the carotid artery ; and 
 it is sometimes louder over this artery than at the base 
 of the heart. As a murmur may be produced within 
 the carotid artery, it is desirable to determine, when a 
 systolic murmur is heard at the base, whether the carotid 
 murmur is a transmitted murmur or not. This point is 
 to be settled by comparing the murmur over the carotid 
 with the murmur at the base, as regards quality and 
 pitch. If the quality and pitch of the murmur in the 
 two situations be the same, it is fair to consider the mur- 
 mur in the carotid as not produced within the artery, 
 but conducted by the blood-current from the aortic ori- 
 fice. 
 
 An aortic direct murmur is frequently inorganic. It 
 is to be considered as such when it is not associated with 
 an aortic regurgitant murmur ; when the heart is not 
 enlarged ; when anaemia is shown by the presence of 
 murmurs in tlie large arteries ; and when there is the 
 venous hum in the neck — these physical evidences of 
 anaemia being associated, generally, not invariably, with 
 pallor, and with symptoms pointing to impoverishment 
 of the blood. Moreover, an inorganic murmur is very 
 rarely rough, and it is variable in its occurrence, being 
 at onetime present and at another time absent, whereas, 
 an organic murmur is, in general, constant. Associated 
 with other evidence of anaemia, an aortic direct murmur 
 may, nevertheless, be organic, but, under the differen- 
 tiating circumstances just stated, the lesion represented 
 by the murmur, if the murmur be organic, must be in- 
 nocuous, so that it is not of great practical importance to 
 determine whether the murmur be or be not inorganic. 
 
CARDIAC MURMURS. 209 
 
 Like the other organic murmurs, an aortic direct mur- 
 mur varies in different cases in its intensity, quality, and 
 pitch. An organic aortic direct murmur, per se, does 
 not denote always aortic obstruction. It may be due 
 simply to roughness of the membrane at or above the 
 aortic orifice. 
 
 Aortic Regwgitant Murmur — Aortic Diastolic Non- 
 regurgitant Murmur, — An aortic regurgitant murmur 
 occurs with the second sound of the heart, and it is the 
 only one of the organic murmurs produced in the left 
 side of the heart which has this relation with the heart- 
 sounds. It is, therefore, readily enough discriminated 
 from the other murmurs. It is almost always heard at 
 the base of the heart, but, in some instances, when not 
 appreciable at the base, it is heard a little below the 
 base, namely, near the sternum on the left side on a 
 level with the fourth costal cartilage. In the latter sit- 
 uation it has generally its maximum of intensity. It is 
 transmitted best in a downward direction, being often 
 heard at the apex, and sometimes considerably below 
 this point. It is never inorganic. It is usually not in- 
 tense, low in pitch, and soft; but it may be loud, high, 
 rough, or musical. 
 
 A short murmur is sometimes produced by the retro- 
 grade movement of the blood-current within the aorta, 
 the aortic valve being sufficient, and regurgitation not, 
 therefore, taking place. This murmur is due to rough- 
 ening of the lining membrane of the aorta by atheroma or 
 calcareous deposit, and it is always preceded by an aortic 
 direct murmur. It occurs directly after the systole, and 
 ends with the second sound. Although of such brief 
 duration, it is distinctly recognizable and distinguished 
 from the preceding aortic direct murmur. I have long 
 
210 THE HEART. 
 
 been accustomed to demonstrate this murmur in private 
 teaching, and have called it an aortic diastolic non-re- 
 gurgitant murmur. It cannot be said to have practical 
 importance, inasmuch as the lesion giving rise to it is 
 represented by the aortic direct murmur which pre- 
 cedes it. 
 
 Coexisting Endocardial Murmurs. — The murmurs 
 referable to the left side of the heart, which have been 
 considered, are often found in combination ; two or three 
 may coexist, or all of them may be present. Moreover, 
 with more or less of these murmurs may be associated 
 murmurs referable to the right side of the heart. 
 Havins: become familiar with their relations with the 
 heart-sounds, and other points involved in their differ- 
 entiation, it is not difficult to recognize them in combi- 
 nation. The mitral murmurs are not infrequently asso- 
 ciated. The mitral direct, being presystolic, ends with 
 the first sound, and the mitral systolic or regurgitant 
 begins with this sound ; the first sound, as it w^ere, 
 divides these two murmurs. The murmurs almost in- 
 variably difiPer from each other in pitch and quality. 
 The presence of both, in fact, assists, rather than ob- 
 structs, the recognition of each. The aortic direct and 
 the aortic regurgitant murmur, also, are often associated. 
 A murmur then accompanies the first and the second 
 sound of the heart ; the two murmurs follow in the same 
 rhythmical order as the heart-sounds. These murmurs, 
 when associated, can only be confounded with pericar- 
 dial friction-sounds. 
 
 The combination of the aortic direct and the mitral 
 systolic murmur alone offers any difficulty. These two 
 murmurs have the same relation with the heart-sounds; 
 they are both systolic. How is it to be determined, 
 
CARDIAC MURMURS. 211 
 
 wlieii a systolic murmur is heard both at the base and 
 apex, that either a mitral murmur is transmitted to the 
 base, or an aortic murmur is transmitted to the apex ; 
 in other words, how is it to be decided whether two 
 murmurs are present or only one murmur? If these 
 two murmurs coexist, generally the circumstances which 
 distinguish each separately can be ascertained. Thus, 
 the aortic murmur is transmitted into the carotid arterv, 
 and the presence of that murmur is then established ; 
 the mitral regurgitant murmur is often transmitted 
 laterally around the chest or heard at the lower antrle of 
 the scapula, and then the presence of that murmur is 
 established. But there are additional points, namely, 
 the murmur at the base and that at the apex generally 
 differ sufficiently in pitch or quality to render it evident 
 that there are two murmurs; and generally at a situ- 
 ation in the prsecordia between the base and apex, both 
 murmurs may be either lost or become notably w^eakened. 
 Attention to these points in most instances divests the 
 problem of difficulty. 
 
 Mitral and aortic lesions are often of a character to 
 give rise to only one murmur at either of these orifices. 
 A mitral direct murmur not infrequently is present with- 
 out the mitral regurgitant, and the reverse of this is fre- 
 quent. So, either an aortic direct or an aortic regurgi- 
 tant murmur may exist without the other. 
 
 Tricuspid Direct Murmur. — The lesions which are 
 requisite for this murmur very rarely occur at the tri- 
 cuspid orifice ; hence, this murmur is exceedinor:ly rare. 
 It is to be distinguished from the mitral direct murmur 
 by its localization being, not at the apex, but at the right 
 border of the heart. The mitral direct and the tricuspid 
 
212 THE HEART. 
 
 direct murmur may coexist; an instance of this kind 
 has fallen under ray observation. In that instance a 
 pre-systolic murmur, Avith the characteristic blubbering 
 quality, was heard both at the apex and at the right side 
 of the heart. 
 
 Tricuspid JRegw-gitant Murmui\ — This murmur is not 
 of very infrequent occurrence. Tricuspid regurgitation 
 occurs often when the right ventricle is considerably di- 
 lated, without the existence of lesions of the valve. A 
 tricuspid regurgitation current, however, does not inva- 
 riably give rise to an appreciable murmur. This fact is 
 shown by the occurrence of a venous pulse in the neck, 
 due to tricuspid regurgitation, when no murmur can be 
 heard. 
 
 The tricuspid regurgitant murmur, of course, occurs 
 with the first sound, being systolic like the mitral re- 
 gurgitant murmur, and the latter generally coexists. 
 It is distinguished from the mitral regurgitant by its 
 localization at the right inferior margin of the heart, and 
 its transmission to the right rather than to the left. The 
 coexistence of the mitral and the tricuspid regurgitant 
 murmur is determined by the differences in pitch and 
 quality between a systolic murmur at the apex and at 
 the right margin of the heart. A venous pulse, syn- 
 chronous with the first sound of the heart, points to tri- 
 cuspid regurgitation, and, although sometimes present 
 without a tricuspid regurgitant murmur, when present 
 it is corroborative evidence of the latter. 
 
 Pulmonic Direct Murmur. — A pulmonic direct mur- 
 mur, if organic, is generally connected with congenital 
 lesions. The ])ulmonic direct and the aoi'tic direct cur- 
 rent of blood taking place at the same instant, the mur- 
 
CARDIAC MURMURS. 213 
 
 nuirs representing botli, are, of course, systolic. How is 
 the pulmonic to be distinguished from the aortic direct 
 murmur? The pulmonic murmur is heard in the left 
 second intercostal space close to tlie sternum ; but this is 
 not very distinctive, inasmuch as, not infrequently, the 
 aortic murmur is loudest in that situation. The essen- 
 tial point of distinction is this: the pulmonic direct 
 murmur is not transmitted into the carotid artery, 
 whereas, the aortic direct murmur is always thus trans- 
 mitted. If an aortic direct and a pulmonic direct mur- 
 mur coexist, both being organic, the combination is to 
 be ascertained by finding that the murmur in the second 
 intercostal space on the right side differs from that on 
 the left side in pitch or quality sufficiently to show the 
 presence of these murmurs, the one on the right side be- 
 ing transmitted to the carotid artery. 
 
 An inorganic pulmonic direct murmur is of frequent 
 occurrence. It is generally associated with an inorganic 
 aortic direct murmur, the presence of the two murmurs 
 being evidenced by a difference in pitch. 
 
 Pulmonic Regurgitant Murmm\ — This murmur must 
 be exceedingly rare. It occurs, of course, like the aortic 
 regurgitant, with the second sound. Its presence can 
 only be determined when other signs go to show the 
 existence of pulmonic and the absence of aortic lesions. 
 This murmur, as well as the aortic regurgitant, can 
 never be inorganic, its presence being proof of a re- 
 gurgitant current of blood from incompetency of the 
 pulmonic valve. 
 
 Facts of practical importance in relation to the endo- 
 cardial murmurs, are embraced in the following state- 
 ments : 
 
214 THE HEART. 
 
 The question as to a murmur being organic or inor- 
 ganic, relates cliiefly, if not entirely, to the aortic direct 
 and the pulmonic direct murmur, other murmurs being 
 almost invariably, if not invariably, organic. 
 
 Associated signs and symptoms generally warrant a 
 definite conclusion whether an aortic direct or a pul- 
 monic direct murmur be, or be not, organic, and under 
 the circumstances which render it difficult to decide this 
 question positively, a positive decision is not of much 
 immediate practical consequence. 
 
 Valvular lesions, whether obstructive, regurgitant, or 
 innocuous, are so uniformly represented by murmur, 
 that, as a rule, absence of lesions may be predicated on 
 the absence of murmur. 
 
 With a practical knowledge of the different organic 
 murmurs, the situation of lesions at either of the orifices 
 of the heart, or their existence at two or more of these 
 orifices, may be demonstratively determined. 
 
 By means of the murmurs, with other signs, it may be 
 determined demonstratively whether the lesions involve 
 obstruction or regurgitation, or both, or, on the other 
 hand, that they are, as regards immediate pathological 
 effects, innocuous. 
 
 The murmurs do not afford definite information as to 
 the amount of obstruction or regurgitation, in other 
 words as to the pathological importance or gravity of 
 lesions when they are not innocuous. No positive con- 
 clusions on this point of view are to be drawn from the 
 intensity of murmurs, their pitch, or their quality. As 
 a rule, murmurs which are weak, more than those which 
 are loud, represent grave lesions. 
 
 Pericardial or Friction Murmur. — A pericardial or 
 friction murmur is produced by the rubbing together of 
 
CARDIAC MURMURS. 215 
 
 the surfaces of the pericardium in the systolic and dias- 
 tolic movements of the heart. In the vast majority of 
 the cases in which this murmur occurs, it denotes either 
 the presence of recent lympli which renders the surfaces 
 more or less adhesive, or roughening from lymph which 
 has become dense and adherent; its diagnostic signifi- 
 cance, therefore, relates almost exclusively to pericar- 
 ditis. In this relation it is of great practical importance. 
 This murmur is to be discriminated from the endocar- 
 dial murmurs. The points involved in the discrimination 
 are as follows: The murmur is double, that is, a mur- 
 mur accompanies both the ventricular systole and diastole. 
 It can, therefore, only be confounded with an aortic di- 
 rect and an aortic resfurp-itant murmur in combination. 
 The quality of the murmur is suggestive of rubbing or 
 friction. It is sometimes a feeble, grazing sound; in 
 other instances it is loud and rough. When rough, the 
 quality is expressed by such terms as rasping, grating, 
 creaking, etc. Although accompanying both sounds of 
 the heart, it has not that uniform, fixed relation to these 
 sounds which characterizes the aortic direct and the 
 aortic regurgitant murmur; it is not in definite accord 
 with the heart-sounds. Moreover, in intensity it varies 
 with the successive movements of the heart, being louder 
 with some revolutions than with others, in this regard 
 differing notably from the endocardial murmurs. It is 
 not heard without the prsecordia, as a rule, and is often 
 limited to a part of the prttcordial region, whereas, cer- 
 tain of the endocardial murmurs, namely, the mitral re- 
 gurgitant and the aortic direct, are often heard at a 
 considerable distance from the heart. Firm pressure 
 with the stethoscope and often a forced expiration in- 
 tensify the murmur. Its source seems very near the 
 
21G THE HEART. 
 
 surface of the chest. In this respect it differs notably 
 from endocardial murmurs, the latter appearing to come 
 from a certain distance within the chest. This point of 
 distinction is very appreciable, especially if, as often 
 happens, a friction murmur be associated with an endo- 
 cardial murmur. 
 
ENLARGEMENT OF THE HEART. 217 
 
 CHAPTER VIII. 
 
 THE PHYSICAL DIAGNOSIS OF DISEASES OF THE 
 HEAKT AND OF THORACIC ANEURISM. 
 
 Enlargement of the heart by hypertrophy and dilatation — Valvular 
 lesions, mitral, aortic, tricuspid, and pulmonic — Fatly degeneration 
 and softening of the heart — Endocarditis — Pericarditis — Functional 
 disorders — Thoracic aneurism. 
 
 The morbid physical conditions incident to the different 
 diseases of the heart, and the signs representing these 
 conditions, have been considered in the preceding chapter. 
 The diseases are now to be considered with reference to 
 the assemblage of signs on which the physical diagnosis 
 of each is to be based. Most of the diseases of the heart 
 may be diagnosticated by means of physical signs. A 
 few cardiac lesions do not admit of a physical diagnosis, 
 and they do not, therefore, claim consideration in this 
 w^ork. The following are the affections which will form 
 separate headino|;s in this chapter : Enlargement of the 
 Heart by Hypertrophy and by Dilatation, Valvular 
 Lesions, Fatty Degeneration and Softening of the Heart, 
 Endocarditis, Pericarditis, and Functional Disorders. 
 Having considered these affections, the physical diag- 
 nosis of thoracic aneurism will be the concluding topic. 
 
 Enlargement of the Heart by Hypertrophy and by 
 Dilatation. — Physical exploration to determine the size 
 of the heart has three objects, namely to determine, 
 first, that the size of the heart is normal ; second, that 
 the heart is enlarged ; and third, the degree of enlarge- 
 
218 DISEASES OF THE HEART. 
 
 meiit. Tliese objects are attainable by means of percus- 
 sion and auscultation. 
 
 The heart is of normal size when the apex -beat is in 
 its normal situation, that is, in the fifth intercostal space, 
 a little within a vertical line passing through the nipple 
 (the linea mammillaris); when the superficial cardiac 
 space is not enlarged, as shown by percussion and by aus- 
 cultation of the voice {vide page 183) and when percus- 
 sion shows the lateral borders of the heart to be situated 
 normally, namely, on the left side a little within the line 
 of the nipple, and on the right side of a finger's breadth 
 to the right of the right margin of the sternum. These 
 points of evidence warrant a positive conclusion that the 
 heart is not enlarged. 
 
 The fact of an enlargement and its degree are deter- 
 minable by an abnormal situation of the apex, together 
 with an increase of the superficial cardiac space and ex- 
 tension of the lateral boundaries of the deep cardiac space 
 especially on the left side. 
 
 In cases of slight or very moderate enlargement, the 
 apex is situated a little without the linea mammillaris, 
 but not below the fifth intercostal space. A somewhat 
 greater enlargement lowers the apex to the sixth inter- 
 costal space, and removes it further without the line of 
 the nipple. In greater degrees of enlargement the apex 
 is lowered to the seventh, eighth, or ninth intercostal 
 space, and generally further removed to the left. The 
 lowering of the apex and the removal to the left, are not 
 uniformly proportionate to each other. As a rule, if the 
 right side of the heart be more enlarged than the left, the 
 apex is removed without the liuea mammillaris further 
 than when the enlargement of the left side of the heart 
 predominates, and when the latter is the case, the apex 
 
ENLARGEMENT OF THE HEART. 219 
 
 is lowered out of proportion to its removal without that 
 line. The relatively abnormal situation downward and 
 to the left, thus, is evidence of the enlargement predomi- 
 nating in either the right or the left side of the heart. 
 Generally the situation of the apex is apparent to the 
 touch and frequently to the eye. In some instances, 
 however, the impulse can neither be seen nor felt. How 
 is its S-ituation to be then ascertained? Auscultation 
 furnishes a ready and reliable mode of determining this 
 point. The situation in which the first sound of the 
 heart has its maximum of intensity, as ascertained by 
 means of the stethoscope, corresponds to the situation of 
 the apex. This is hardly less definite than the presence 
 of an aj)preciable impulse. 
 
 In determining the fact of enlargement and its degree 
 by the abnormal situation of the apex, causes of the lat- 
 ter which are extrinsic to the heart are to be eliminated. 
 The apex is removed to the left of its normal situation 
 by enlargement of the left lobe of the liver, abdominal 
 tumors, hydroperitoneum, the pregnant uterus, and gas- 
 tric tympanites. These extrinsic conditions are to be 
 excluded or due allowance made for them. In some 
 cases in which one or more of these extrinsic causes of 
 displacement may exist, the apex is carried into the ax- 
 illary region. It is to be borne in mind that these causes 
 of displacement may exist when there is more or less en- 
 largement of the heart. All these causes, while they 
 displace the apex to the left, do not lower, but tend to 
 raise it above, its normal situation. On the other hand, 
 an aneurismal or other tumor, situated above the heart, 
 may press downward the organ, and in this way the 
 apex is more or less lowered.^ 
 
 ^ Professor Janeway states tl)at he lias known tlie apex lowered 
 by an unusually long first portion of the aortic arch. 
 
220 DISEASES OF THE HEART. 
 
 The superficial cardiac sj3ace is increased in proportion 
 as tiie heart is enlarged. The extent of this increase is 
 easily determined by percussion and auscultation. Within 
 this space there is notable dulness on percussion. The 
 degree of dulness is greater than within the superficial 
 cardiac space in health, and this degree of dulness is pro- 
 portionate to the greater area in which the heart is un- 
 covered of lung. It is easy to delineate by percussion 
 on the chest the boundary of the anterior border of the 
 upper lobe of the left lung, in other words, of the oblique 
 line which is the hypothenuse of the right-angled tri- 
 angle representing the superficial cardiac space in health 
 and in disease. The area of the superficial cardiac space 
 is also not less readily and precisely ascertained by auscul- 
 tation of the voice; the limits of the lung within the 
 praecordia are denoted by an abrupt cessation or notable 
 diminution of the vocal resonance. In women, with 
 large mammae, auscultation is more available for this 
 object than percussion. The extent to which the super- 
 ficial cardiac space is enlarged is a good criterion of the 
 degree of the enlargement of the heart. 
 
 In proportion as the heart is enlarged, the situation 
 of the left border is without the linea mammillaris. Its 
 situation is determined by percussion. Dulness, although 
 not great, is sufficiently distinct within the deep cardiac 
 space, and the line which denotes the left border of the 
 heart is easily delineated on the chest. This statement 
 holds true with respect to the right border of the heart ; 
 but this border, even when the enlargement of the heart 
 is great, is removed comj)aratively little to the right of 
 its normal situation. By means of percussion the bound- 
 aries of the pr?ecordia as enlarged by the increased size 
 of the heart may be determined and measured. In 
 making this statement, it is assumed that the lungs are 
 
ENLARGEMENT OF THE HEART. 221 
 
 not diseased, and that the chest is not deformed. Shrink- 
 age of the upper lobe of the left lung may enlarge the 
 superficial cardiac space, and cause displacement of the 
 heart. The latter is an effect of the presence of pleu- 
 ritic effusion, and it may follow its removal. In cases 
 of deformity from spinal curvature, to determine the fact 
 of enlargement of the heart, or its degree, is not always 
 an easy problem. 
 
 There is a liability to error in localizing the apex in 
 some cases of enlargement. Owing to the blunted form 
 of the apex, especially when the enlargement is chiefly of 
 the right side of the heart, the apex-beat may be feeble. 
 It is liable to be overlooked, and a stronger impulse in 
 the intercostal space above the apex, mistaken for the 
 apex-beat. Of course, the lowest impulse is the apex- 
 beat. Careful palpation, and finding by auscultation 
 the spot where the first sound has its maximum of inten- 
 sity, will prevent this error. 
 
 Enlarorement of the heart, and the de2:ree of enlarfje- 
 ment having been ascertained, it is to be determined 
 whether hypertrophy or dilatation predominate. If the 
 enlargement be slight or moderate, it may be a question 
 whether hypertrophy or dilatation exist alone. As a 
 rule, if either of these two forms of enlargement exist 
 without the other, it is hypertrophy, for, with rare ex- 
 ceptions, hypertrophy precedes dilatation. If the en- 
 largement be very great, as a rule, dilatation predomi- 
 nates, for the capability of hypertrophic increase of size 
 has its limit, and an increase of size beyond this limit must 
 be due to dilatation. The signs, denoting on the one 
 hand hypertroi)hy, and on the other hand dilatation, re- 
 late to the impulses of the heart and to the heart-sounds. 
 
 19 
 
222 DISEASES OF THE HEART. 
 
 With a moderate enlargement, hypertrophy is to be 
 inferred from an abnormal force of the apex-beat, and 
 an intensification of the characters of the first sound over 
 the apex. With a considerable or great enlargement, if 
 hypertrophy predominate, the apex- beat may be abnor- 
 mally strong and prolonged, but, as already stated, owing 
 to its blunted form, the beat is sometimes weak and 
 scarcely appreciable. The increased power of the ven- 
 tricular contractions, representing the hypertrophy, is 
 then to be determined by impulses in the intercostal 
 spaces above the apex. These impulses are sometimes 
 present in each intercostal space between the apex and 
 the base, and they are abnormally strong in proportion 
 as hypertrophy predominates. Still more marked evi- 
 dence of hypertrophy is sometimes obtained when the 
 hand is placed over the prsecordia ; a powerful heaving 
 movement is felt. The increased power of the ventricu- 
 lar contractions may, in some cases, be in this way ap- 
 preciated somewhat, as if the heart were held in the 
 hand. In cases of considerable or great enlargement, 
 the intensity of the first sound over the apex is more or 
 less increased ; it is prolonged, and its booming quality 
 is more marked than in health. Not infrequently it is 
 accompanied by a metallic ringing sound, or tinnitus. 
 
 Moderate enlargement by dilatation is characterized 
 by abnormal weakness of the apex-beat, and of the first 
 sound over the apex. Cases, however, of simple dilata- 
 tion are rare. If the enlargement be considerable or 
 great, and dilatation predominate, all the impulses are 
 weak, as compared with the cases in which hypertrophy 
 predominates, and tiie first sound over the apex is more 
 or less divested of the characters derived from impulsion ; 
 that is, the sound is feeble, short, and valvular. These 
 
VALVULAR LESIONS. 223 
 
 points of distinction are marked in proportion as dilata- 
 tion predominates. 
 
 In the great majority of the cases of enlargement of 
 the heart, valvular lesions coexist. These coexisting 
 valvular lesions are represented by endocardial murmurs, 
 and they are excluded by the absence of the latter. In 
 most of the cases in which enlargement exists without 
 valvular lesions, it is associated with either pulmonary 
 emphysema or chronic Bright's disease. 
 
 Valvular Lesions. 
 
 The physical diagnosis of valvular lesions embraces 
 their localization at the different orifices within the 
 heart, and the determination of their character as giving 
 rise to obstruction and regurgitation, or of their innocu- 
 ousness in these respects. These objects of diagnosis 
 involve the endocardial murmurs, and the abnormal 
 modifications of the heart-sounds which were considered 
 in the preceding chapter. Lesions at the different ori- 
 fices, namely, the mitral, aortic, tricuspid, and pulmonic, 
 will be considered separately. 
 
 Mitral Lesions. — The lesions at the mitral orifice are 
 represented by the mitral murmurs — the mitral direct 
 murmur, the mitral regurgitant, and the mitral systolic 
 non-regurgitant or intra-ventricular murmur. Mitral 
 obstructive lesions exist whenever the mitral direct mur- 
 mur is present, with an exception already stated and 
 explained {vide p. 205), namely, this murmur is present 
 in some cases in which the mitral valve is intact, aortic 
 lesions, giving rise to free regurgitation, existing in 
 these cases. These exceptional instances are rare, and I am 
 not aware that any have been reported except by m^'self. 
 
224 DISEASES OF THE HEART. 
 
 Mitral regurgitant lesions exist whenever a mitral 
 murmur which is truly regurgitant is present. A sys- 
 tolic murmur having its maxim of intensity at or near 
 the apex, transmitted laterally for a certain distance 
 beyond the apex on the left side of the chest, and heard 
 on the back near the lower angle of the scapula, denotes 
 a regurgitant current ; but a systolic murmur limited to 
 a small area around the apex, or to the superficial car- 
 diac space, is not proof of regurgitation. A truly regur- 
 gitant murmur, however, may be too feeble to be trans- 
 mitted beyond the apex ; the proof of regurgitation must 
 then be based on other evidence associated with the 
 murmur, namely, on enlargement of the heart and ab- 
 normal modifications of the heart-sounds. 
 
 Mitral obstruction may exist without incompetency 
 of the mitral valve, as shown by the presence of a mitral 
 direct, without a mitral regurgitant, murmur. The con- 
 verse of this is of more frequent occurrence, that is, re- 
 gurgitation may exist without obstruction. The absence, 
 however, of a mitral direct murmur is not positive proof 
 against mitral obstruction, for, as has been seen, the 
 production of a characteristic mitral direct murmur re- 
 quires the obstruction to be caused by an adherence of 
 the mitral curtains at their sides, the curtains being 
 sufficiently flexible to vibrate with the passage of the 
 mitral direct current of blood. Mitral obstruction and 
 regurgitation not infrequently coexist, as shown by the 
 presence of both the mitral direct and the mitral regur- 
 gitant murmur. 
 
 The mitral murmurs do not, j^ei' sc, denote the amount 
 of obstruction or regurgitation, or of both combined. 
 Information with reference to these i)oInts may be de- 
 rived from a comparison of the aortic with the pulmonic 
 
VALVULAR LESIONS. 225 
 
 second sound. The amount of obstruction or regurgi- 
 tation, or both, is great in proportion as the aortic sound 
 is weakened. Per contra, there can be but little ob- 
 struction or regurgitation if the aortic and the pulmonic 
 second sound preserve completely or nearly their normal 
 relation to each other in respect of intensity. Infor- 
 mation may also be obtained by analyzing the first sound 
 as heard at the apex. In proportion as the function of the 
 mitral valve is compromised by lesions, the valvular 
 element of the first sound at the apex will be found 
 deficient. In some cases the first sound in this situation 
 has no valvular element, presenting only the characters 
 of impulsion. 
 
 Enlargement of the right side of the heart, which 
 results from mitral obstructive, and regurgitant lesions, 
 is a criterion of the amount of obstruction and regurgi- 
 tation taken in connection with the length of time in 
 which they have existed. Hypertrophic enlargement 
 of the right ventricle intensifies the pulmonic second 
 sound, and allowance must be made for this modifi- 
 cation in determining, by a comparison of the pulmonic 
 and the aortic sound, the degree in which the latter is 
 weakened. 
 
 Aortic Lesions. — Lesions are localized at the aortic 
 orifice by the aortic murmurs, namely, the aortic direct 
 and the aortic regurgitant murmur. Aortic obstructive 
 lesions give rise to an aortic direct murmur; but it 
 must be considered, in the first place, that an aortic di- 
 rect murmur may be inorganic, and, in the second place, 
 that, if the murmur be organic, it may be produced by 
 lesions which occasion no obstruction, and are conse- 
 quently innocuous. The existence of obstructive lesions 
 must be determined by evidence added to the presence 
 
226 DISEASES OF THE HEART. 
 
 of the murmur. This ev^idence is either impairment or 
 suppression of the aortic second sound, and enkirgement 
 of the left ventricle. If the lesions which occasion ob- 
 struction are of a character to diminish or arrest the 
 movements of the aortic valve, the aortic second sound 
 will be either weakened or lost. If v^alvular lesions be 
 limited to the aortic orifice, the degree of enlargement of 
 the heart is a criterion of their pathological importance. 
 
 Regurgitant lesions at the aortic orifice give rise to 
 an aortic regurgitant murmur. This murmur, of course, 
 is always proof of regurgitation; but the murmur gives 
 no definite information concerning the amount of incom- 
 petency of the aortic valve. A loud murmur may be 
 produced by a regurgitant stream so small as to be, for 
 the time, insignificant; and, on the other hand, a large 
 regurgitant current may give rise to a feeble murmur. 
 The extent to which the valve is damaged by the lesions, 
 is to be determined, first, by either weakness or suppres- 
 sion of the aortic sound, and, second, by the degree of 
 enlargement of the left ventricle. 
 
 Aortic obstructive and regurgitant lesions are often 
 associated. An aortic direct and an aortic regurgitant 
 murmur are then both present, with a weakened aortic 
 sound or its suppression, and enlargement of the left 
 ventricle according to the amount of the obstruction 
 and regurgitation, togetlier with the length of time 
 during which the latter have existed. These effects, 
 and not the intensity, nor the pitch, nor the quality of 
 the murmurs, are indicative of their pathological impor- 
 tance. 
 
 Mitral and aortic lesions often coexist, giving rise to 
 two, three, or four of the obstructive and regurgitant 
 murmurs in the left side of the heart. In addition to 
 
TRICUSPID AND PULMONIC LESIONS. 227 
 
 the murmurs in these cases, tlie effects of tlie combined 
 lesions are shown in the modification of the heart-sounds, 
 and enlargement of both sides of the heart. 
 
 Tricuspid Lesions. — Tricuspid obstructiv^e lesions are 
 exceed in 2:1 y rare. A few instances of the kind of ob- 
 struction which is represented by a presystolic or a tri- 
 cuspid direct murmur, haye been reported. One instance 
 has fallen under my observation. In this case, as in the 
 other instances which have been reported, the tricuspid 
 were associated with mitral lesions : hence, in localizing 
 an obstructive lesion at the tricuspid orifice, the presence 
 of the presystolic murmur on each side of the heart, 
 that is, the coexistence of mitral and the tricuspid direct 
 murmur is to be determined. This point has already 
 been considered [vide page 212). 
 
 Tricuspid regurgitation is not uncommon. Generally 
 the insufficiency is caused by dilatation of the right ven- 
 tricle occurring as an effect of mitral regurgitant or ob- 
 structive lesions. Tricuspid regurgitation is not always 
 represented by murmur ; and when a tricuspid regurgi- 
 tant murmur is present, it is to be discriminated from a 
 coexisting mitral regurgitant murmur. This point has 
 been considered (vide page 212). 
 
 Pulmonic Lesions. — As compared with aortic lesions, 
 these are of extremely infrequent occurrence, and they 
 are generally congenital. Lesions giving rise to a pul- 
 monic direct murmur may be localized by differentiating 
 this murmur from the aortic direct murmur (vide page 
 213). It is to be considered that an inorganic pulmonic 
 direct murmur is not infrequent. Pulmonic regurgi- 
 tant lesions can only be diagnosticated by determining 
 that a murmur occurring with the second sound of the 
 
228 DISEASES OF THE HEART. 
 
 heart is produced at the pulmonic and not at the aortic 
 orifice (vide page 213). 
 
 Faifi/ Degeneration y 3Iyocarditis, and Softening of the 
 Heart. — Fatty degeneration of the heart is not repre- 
 sented by any distinctive signs, but, nevertheless, the 
 physical diagnosis, taking into account the clinical his- 
 tory, may be quite positive. The signs are those whicli 
 denote persistent muscular weakness of the heart. The 
 apex-beat, if appreciable, is feeble. The intensity of 
 the heart-sounds is diminished, and especially the inten- 
 sity of the first sound. The first sound may be even 
 suppressed over the apex, the second sound being heard 
 in this situation. The characters of the first sound 
 which belong to the element of impulsion are especially 
 impaired or lost, the sound becoming short and valvular, 
 in these respects resembling the second sound. Now 
 these evidences of weakened muscular power occur when 
 the weakness is merely functional, and when the heart is 
 enlarged by predominant dilatation. But functional 
 weakness is generally transient, and is sufficiently ex- 
 plained by the existence of other than cardiac disease. 
 Enlargement by dilatation is readily determined by 
 physical signs. If the heart be but little, or not at all, 
 enlarged, and pathological conditions adequate to ex- 
 plain diminished muscular power irrespective of cardiac 
 disease be excluded, and at the same time the signs 
 being connected with diagnostic symptoms, the existence 
 of fatty degeneration may be determined with much con- 
 fidence. 
 
 Fattv deijeneratiou mav coexist with valvular lesions 
 and enlargement of the heart. The physical diagnosis 
 of fatty degeneration under these circumstances is not a 
 simi)le problem. A probable diagnosis may be made 
 
ENDOCARDITIS. 229 
 
 wlien the amount of enlargement seems insufficient to 
 account for the signs denoting muscular weakness of the 
 heart, and when symptoms belonging to the clinical his- 
 tory point to fatty degeneration. 
 
 Softening of the muscular structure of the heart, oc- 
 curring in myocarditis, in continued fever, and other 
 general diseases, is denoted by the same signs which are 
 embraced in the physical diagnosis of fatty degeneration, 
 the most marked evidence being notable weakness, with 
 valvular quality, or suppression, of the first sound over 
 the apex of the heart. 
 
 Endocarditis. — The physical diagnosis of endocarditis 
 relates especially to its occurrence in connection with 
 articular rheumatism. The diagnostic sign is a mitral 
 systolic non-regurgitant murmur (vide page 205). The 
 presence of this murmur, howev^er, in a case of rheuma- 
 tism, is not positive proof of an existing endocarditis, 
 more especially if the patient have previously had artic- 
 ular rheumatism, because an endocarditis developed in 
 a previous attack may have left a permanent murmur. 
 If the murmur be a mitral regurgitant murmur, and the 
 heart be enlarged, it is quite certain that endocarditis has 
 previously occurred. The positive proof is the produc- 
 tion of the murmur during an attack of rheumatism, 
 when previous examinations made after the commence- 
 ment of the rheumatic attack, had shown that there was 
 no mitral murmur. An aortic direct murmur, in cases 
 of rheumatism, is not evidence of endocarditis, because 
 in many cases of rheumatism this murmur occurs, and 
 is to be regarded as inorganic. 
 
 In the variety of endocarditis, known as ulcerative, 
 occurring in the course of infectious or septic diseases, 
 and sometimes without any known pathological connec- 
 
 20 
 
230 DISEASES OF THE HEART. 
 
 tion, an aortic murmur may be developed, with or with- 
 out a coexisting mitral murmur, owing to the soft masses 
 present on the valves. 
 
 Endocarditis is probably of frequent occurrence as 
 secondary to mitral and aortic valvular lesions ; but, un- 
 der these circumstances, a physical diagnosis is imprac- 
 ticable. 
 
 Pericarditis. — The physical diagnosis of pericarditis 
 in the first stage, that is, prior to the effusion of liquid^ 
 is to be based on a pericardial friction murmur. For- 
 tunately for diagnosis, this murmur is uniformly present. 
 Its characters as contrasted with endocardial murmurs 
 have been stated (vide page 214). The presence of a 
 pericardial friction murmur, in connection with symp- 
 toms denoting pericarditis, renders the diagnosis quite 
 positive. There is, however, one liability to error. In 
 some cases of pleurisy or pneumonia with pleuritic in- 
 flammation, the movements of the heart occasion a rub- 
 bing together of the roughened pleural surfaces, and in 
 tills way a cardiac pleural friction murmur is produced. 
 This may be single or double, and when double, it sim- 
 ulates the murmur produced within the pericardial sac. 
 It is limited to the border of the heart, and is neither 
 accompanied nor followe'd by pericardial effusion. Of 
 course, the error of mistaking a cardiac pleural friction 
 murmur for one produced within the pericardium, can 
 only occur when pleurisy exists, either as a primary 
 affection or as secondary to pneumonia. 
 
 In the second stage of pericarditis, that is, after the 
 effusion of liquid has taken place, the pericardial friction 
 murmur often, but not always, disappears. The l)hysi- 
 cal diagnosis in this stage is then to be based on the 
 signs which show the presence of a greater or less quan- 
 
PERICARDITIS. 231 
 
 tity of liquid within the pericardial sac. The signs 
 which denote pericardial effusion, and its amount have 
 been stated {vide page 194). With a moderate effusion, 
 the apex of the heart is raised, and the apex-beat may- 
 be felt in the fourth intercostal space, and removed to 
 the left of its normal situation. With considerable or 
 large effusion, the apex-beat is lost, and the sounds of 
 the heart are feeble and distant. The first sound loses 
 the characters which belong to the element of impulsion, 
 becoming: short and valvular like the second sound. 
 
 Increase or diminution of liquid in the second stage 
 of pericarditis is readily determined by signs obtained 
 by percussion and auscultation. W^hen the quantity is 
 much diminished, the friction murmur, if it have been 
 suppressed, returns, and persists until the pericardial 
 surflices become agglutinated. Not infrequently, by aus- 
 cultating when the body of the patient is inclined for- 
 ward, a friction murmur may be heard, notwithstand- 
 ing the pericardial sac contains a large quantity of 
 liquid. 
 
 In cases of chronic pericarditis with very large effu- 
 sion, dilatation of the pericardial sac is shown by signs 
 obtained by percussion and auscultation. There is no 
 apex impulse, the heart-sounds are feeble and distant, 
 the first sound being short and valvular, and the prse- 
 cordia may be notably projecting. 
 
 A malignant morbid growth filling the pericardial 
 sac, and inclosing within it the heart, may give rise to 
 all the signs of pericardial effusion. A case of this kind, 
 in a young subject, has fallen under my observation. 
 
 AVith reference to diagnosis, the etiological relations 
 of pericarditis should be kept in mind. These are acute 
 articular rheumatism, Bright's disease, and either pleu- 
 
232 DISEASES OF THE HEART. 
 
 risy or pneumonia. It rarely occurs in other connec- 
 tions, and, as an idiopathic affection, it is extremely rare. 
 
 The presence of air and liquid within the pericardial 
 sac gives rise to loud splashing sounds, which, occurring 
 when respiration is suspended, and when pneumo-hy- 
 drothorax is excluded, are at once diagnostic of pneu- 
 mo-hydropericardium. 
 
 Functional Disorders. — Of the varied forms of func- 
 tional disorder of the heart, some are rare, and others 
 are of frequent occurrence. A rare form is persistent 
 frequency of the heart's action, the pulse being from 100 
 to 120 or more per minute, for weeks, months, and even 
 years. This form of disorder exists in the affection 
 known as exophthalmic goitre, Graves's or Basedow's 
 disease. It occurs, also, without being associated with 
 either prominence of the eyes or enlargement of the thy- 
 roid body. In a rare form, the opposite of this, the ac- 
 tion of the heart is abnormally infrequent, the pulse 
 falling to 50, 40, 30,or less, per minute, the infrequency 
 not being an idiosyncrasy, either congenital or acquired, 
 and continuing for a limited period. The occurrence 
 with every alternate revolution of the heart of a ven- 
 tricular systole so feeble as not to be represented by a 
 radial pulse, is another rare form, and another is a want 
 of synchronism in the contraction of the two ventricles, 
 giving rise to reduplication of the heart-sounds. In the 
 more common forms the disorder occurs in paroxysms, 
 which are variable in duration and in the frequency of 
 their occurrence, the heart, in the paroxysms, beating 
 irregularly, and often with intermissions, the action in 
 some instances being violent, and in other instances feeble 
 or fluttering. These common forms are embraced under 
 the name palpitation. 
 
FUNCTIONAL DISORDERS. 233 
 
 As regards the physical diagnosis, all the forms of dis- 
 order are in the same category; in all the functional 
 character of the affection is determined by exclnsion, in- 
 flammatory affections and lesions being excluded by the 
 absence of their diagnostic signs. In whatever way the 
 action of the heart is disturbed, however great may be 
 the disturbance, and let it be attended with ever so much 
 distress or anxiety, if physical exploration furnish no 
 evidence of endocarditis, pericarditis, valvular lesions, 
 enlargement of the heart, fatty degeneration, or heart- 
 clot, the affection is to be considered as functional, if 
 purely functional, the affection is unattended by danger, 
 and is generally remediable, at least in the common 
 forms. Hence, the very great importance of a })ositive 
 diagnosis. 
 
 In one point of view, the physical diagnosis in func- 
 tional disorders may be said to rest, not on negative, but 
 on positive evidence. Percussion and auscultation afford 
 the means, not only of excluding inflammatory affections 
 and lesions, but of demonstrating the fact that the organ 
 is sound, at least as regards freedom from ordinary 
 lesions. That its size is normal, is shown by the situa- 
 tion of the apex-beat ; by ascertaining the lateral bound- 
 aries of the prsecordia and the area of the superficial 
 cardiac space. That the valves are unaffected, is shown 
 by the normal characters of the heart-sounds. These 
 positive facts, taken in connection with the absence 
 of morbid signs, render the diagnosis certain. More- 
 over, the evidence, positive and negative, is readily and 
 quickly obtained. Indeed, the time required for reach- 
 ing a conclusion is so brief, that it is often politic to pro- 
 long unnecessarily the examination in order that a posi- 
 tive assurance of the soundness of the organ may have 
 
 21 
 
234 DISEASES OF THE HEART. 
 
 in the mind of the patient the weight which is desirable 
 in order to secure relief from anxiety and apprehension. 
 Functional disorders are not infrequently associated 
 with lesions with which they have no essential patholog- 
 ical connection. A patient with lesions which are 
 either innocuous or attended with little, if any, inconve- 
 nience, may suffer from disturbance of the action of the 
 heart produced by causes which are wholly independent 
 of the lesions. There is a liability, in these cases, to 
 the error of attributing the disorders to the lesions, and 
 thus forming an exaggerated estimate of the importance 
 of the latter. To decide how much of tlie disturbed 
 action of the heart is due to a superadded functional 
 affection, is not as easy as to determine that lesions do 
 not exist. The decision must be based on the character, 
 degree, or extent of the lesions, as evidenced by the 
 physical signs. In this connection may be stated a 
 practical maxim, which it is well to bear in mind, whether 
 functional disorders exist or not, namely, valvular lesions 
 rarely give rise to much inconvenience until they have 
 led to enlargement of the heart ; and enlargement, either 
 with or without valvular lesions, as a rule, does not lead 
 to the serious effects which are characteristic of cardiac 
 disease, so long as the enlargement is due to hypertrophy 
 and not to dilatation. 
 
 Thoracic Aneurism. 
 
 The physical conditions incident to thoracic aneurism, 
 which are concerned in the production of signs, are, the 
 presence of a tumor within the chest, of variable size, 
 formed by the aneurismal sac ; the passage of blood into 
 the sac with each ventricular systole, and the expulsion 
 of blood in the diastole by the recoil of the coats of 
 
THORACIC ANEURISM. 235 
 
 tlie aneurism ; the size of the o[)etiing into the sac as 
 affecting the quantity of blood which it receives with 
 each systole; the quantity of stratified fibrin which the 
 sac contains; the point of connection with the aorta of 
 the aneurismal tumor, and the direction from this point 
 in which the tumor extends, together with its relations 
 to the lungs, the trachea, and the primary bronchi. 
 
 With reference to diagnosis, it is well to bear in mind 
 that, in the great majority of cases, an aortic aneurism 
 is connected with either the ascending portion, or the 
 junction of the ascending and the transverse portion of 
 the arch, and that the tumor generally extends to the 
 right in a lateral or antero-lateral direction. The physi- 
 cal diagnosis is more easily made when the aneurismal 
 tumor is thus connected. The signs are less available 
 if the aneurism arise from the transverse or descending 
 aorta, and especially if the tumor extends in a direction 
 downward or backward. 
 
 An aneurismal tumor which has made its way through 
 the walls of the chest, or which, without perforation, 
 causes a circumscribed bulging obvious to the eye and 
 touch, presents the following diagnostic signs: An im- 
 pulse is seen and felt which is synchronous with the 
 ventricular systole. The force of the impulse is varia- 
 ble, depending, aside from the force with which the 
 left ventricle contracts, upon the size of the orifice be- 
 tween the sac and the artery, and the quantity of fibrin 
 which the sac contains. A vibration or thrill \vith each 
 impulse is sometimes a marked sign, but is often wanting. 
 Frequently, but by no means constantly, a systolic murmur 
 is heard over the tumor, and there may be also a dias- 
 tolic murmur produced by the passage of blood from the 
 sac. The heart-sounds over the tumor are more or less 
 
236 DISEASES OF THE HEART. 
 
 intense. There is notable clulness on percussion over an 
 area corresponding to the space witliin the chest which 
 the tumor occupies. If tlie tumor be of considerable size, 
 it may produce condensation of lung around it ; the area 
 of dulness on percussion will be in this way extended 
 beyond the limits of the tumor. Under these circum- 
 stances, bronchial respiration and bronchophony may be 
 produced. If the aneurismal sac be beneath the integu- 
 ment, there may be to the touch a sense of fluctuation. 
 
 With the foregoing signs, the physical diagnosis 
 scarcely admits of doubt. Some of the signs may be 
 l)roduced by a tumor, not aneurismal, which is so situated 
 as to receive and conduct the aortic impulse. The 
 chances of a tumor beino^ so situated as to simulate the 
 signs of an aneurism are very few. I have met with a 
 case of empyema in which perforation of the chest took 
 place in the second intercostal space on the right side of 
 the sternum, giving rise in this situation to a fluctuating 
 tumor which had a strong pulsation. On a superficial 
 examination the case seemed clearly one of aneurism ; 
 but an examination of the chest showed the right pleural 
 cavity to be filled with liquid, and a puncture in the 
 axillary region gave exit to a large quantity of pus, tlie 
 pulsating tumor disappearing after a certain quantity of 
 the purulent liquid had escaped. 
 
 When, from its small size or its situation, an aneurismal 
 tumor does not come into contact with the thoracic wall, 
 and when it is situated beneath the sternum, signs ob- 
 tained by palpation and inspection being absent, the 
 physical diagnosis is less easy. Important signs are, 
 dulness within a circumscribed space situated in the 
 course of the aorta; an abnormal transmission of the 
 heart-sounds within this space, and the presence of mur- 
 
TnORACIC ANEURISM. 237 
 
 murs. These signs are not always available, and when 
 present they are not sufficient for a positive diagnosis. 
 Other physical evidence and the presence of certain 
 symptoms render the existence of aneurism highly prob- 
 able either with or without the foregoing signs. If an 
 aneurismal tumor press upon the trachea, it occasions a 
 tracheal sound, or stridor, together with weakness of the 
 respiratory murmur on both sides of the chest. If the 
 tumor press upon a primary bronchus, it occasions dimin- 
 ished or suppressed respiratory murmur on one side, and 
 increased respiratory murmur on the other side of the 
 chest. These physical signs should always lead to a 
 suspicion of aneurism in a person forty years of age. 
 Symptoms which should excite this suspicion and lead to 
 careful physical exploration for the physical signs of 
 aneurism, are dyspnoea from spasm of the glottis, and 
 aphonia or impairment of the voice without evidence of 
 laryngitis, these symptoms denoting either excitation or 
 pressure of the recurrent laryngeal nerve; dysphagia 
 from obstruction of the oesophagus ; congestion of the 
 face, neck, and upper extremities from obstruction of the 
 vena cava or the vense innominatse ; inequality of the 
 radial, carotid, and subclavian pulsation on the two sides, 
 or the absence of pulsation on one side, and contraction 
 of one of the pupils. These symptoms not only render 
 probable the existence of aneurism, but indicate its situa- 
 tion as regards the aorta and the direction in which the 
 aneurismal tumor extends. 
 
 An aneurism may be suspected when, owing to shrink- 
 age of the lung, or deformity of the chest, either the 
 aorta or the pulmonary artery, just above the heart, is 
 removed laterally from its normal situation and brought 
 into contact with the walls of the chest in the second 
 
 22 
 
238 DISEASES OF THE HEART. 
 
 intercostal space, so as to give rise to an appreciable im- 
 pulse. A murmur may also be present at the point of 
 impulse. An error of diagnosis under these circum- 
 stances is avoided by finding an adequate explanation of 
 the signs just noted, and by the absence of other signs 
 and of symptoms which are diagnostic of aneurism. 
 
 In conclusion, an aortic murmur, however intense or 
 routrh, is never evidence of aortic aneurism. 
 
INDEX. 
 
 Adventitious respiratory sounds 
 or rales, 106 
 
 ^Egophony, 125 
 
 Amphoric resouance on percussion, 
 61 
 respiration, 100 
 
 Amplioric voice, 130 
 
 Aneurism, thoracic, 232 
 
 Aortic direct murmur, 207 
 lesions, diagnosis of, 223 
 regurgitant murmur, 209 
 diastolic non-regurgitant mur- 
 mur, 209 
 
 Apex-beat of heart, modification of, 
 1S2 
 
 Apoplexy, pulmonary, 165 
 
 Artery, pulmonic, and aorta, rela- 
 tion of. to walls of chest, 184 
 
 Asthma, 144 
 
 Auscultation, definition of, 14 
 in disease, 85 
 in health, 65 
 
 mediate and immediate, 66 
 rules in practice of, 68. 
 
 Bronchial rales, dry, 112 
 moist, 107 
 respiration, 92 
 "whisper increased, 128 
 Bronchitis seated in large bi-on- 
 chial tubes, 139' 
 in small bronchial tubes 
 (capillary), 141 
 Broncho-cavernous respiration, 99 
 Bronchophony, 123 | 
 
 whispering, 124 , 
 
 Broncho-vesicuiar respiration, 94 
 
 Carcinoma of lung, 168 
 Cardiac space, superficial and deep, 
 182 
 
 Cavernous rale, 117 
 respiration, 97 
 Chest, anatomy and physiology of, 
 16 
 regional divisions of, 33 
 Cirrhosis of lung, 179 
 Conditions, morbid physical, inci- 
 dent to different dis- 
 eases of the respiratory 
 system, 19 
 summary of, 25 
 physical, of the heart in dis- 
 ease, 190 
 in health, 182 
 represented by amphoric reso- 
 nance, 61 
 by cracked - metal reso- 
 nance, 63 
 by dulness, 57 
 by flatness on percussion, 
 
 55 
 by tympanitic resonance, 
 
 58 
 by vesicnlo-tymi)anitic re- 
 sonance, 60 
 Coughing, signs obtained by, 133 
 Cracked-metal resouance on per- 
 cussion, 63 
 Crepitant rale, 114 
 
 Diaphragmatic hernia, 180 
 Diseases of the respiratory system, 
 
 phvsical conditions incident to, 
 
 19,' 135 
 Dulness on percussion, 57 
 
 Echo, amphoric, 130 
 Emphvsema, pulmonary or vesicu- 
 lar, 145 
 Empyema, 150 
 Endocarditis, diagnosis of, 228 
 
240 
 
 INDEX. 
 
 Exocardial murmur. 214 
 Expiratory sound, prolonged, 102 
 Exploration, physical, dilicreut 
 methods of, 13 
 
 Flatness on percussion. 55 
 Fremitus, normal, vocal, 77 
 
 in different regions. 80 
 Friction murmur, i)ericaitlial, 214 
 
 pleuritic, rales, 118 
 
 Gangrene, puhnonary, 166 
 
 Ha?morrhagic infarctus, 165 
 Heart, abnormal impiilses of, 192 
 diagnosis of diseases of, 217 
 enlargement of, 190, 217 
 fattv degeneration and soften- 
 ing of. 228 
 first sound of, intensified, 196 
 
 weakened, 196 
 functional disorders of, 230 
 murmurs of, 201 
 physical conditions of, in dis- 
 ease, 190 
 in health, 182 
 diagnosis of diseases of, 217 
 second sound, aortic, weak- 
 ened, 197 
 pulmonic, weakened, 
 198 
 sounds of, 185 
 valvular lesions of, 193 
 diagnosis of, 223 
 Heart-sounds, abnormal modifica- 
 tions of, 195 
 reduplication of, 199 
 Hernia, diaphragmatic, 180 
 Hydrothorax, 150 
 
 Indeterminate rales. 121 
 Infarctus, luemorrhagic, 165 
 Inspiratory sound shortened, 101 
 Intensity of normal and abnormal 
 
 sounds, differences of, 27 
 Interrupted respiration, 104 
 
 Laryngeal and tracheal respira- 
 tion, 70 
 rales, 106 
 
 Larvnx and trachea, affections of, 
 
 137 
 Lesions, valvular, of heart, 193, 223 
 
 diagnosis of, 223 
 Lobular pneumonia, 141 
 Lobules, pulmonary, collapse of, 
 
 141 
 
 Metallic tinkling, 118, 133 
 Mitral lesions, diagnosis of, 223 
 Murmur, aortic direct, 207 
 
 diastolic or non-regurgi- 
 
 tant, 209 
 regurgitant, 209 
 cardiac, 200 
 mitral direct, 204 
 
 regurgitant, 206 
 normal vesicular, 72 
 pericardial or friction, 214 
 pulmonic direct, 212 
 regurgitant, 213 
 systolic non-regurgitant or 
 
 intra-veutricular. 206 
 tricuspid direct. 211 
 regurgitant. 212 
 vesicular diminished, 87 
 increased, 87 
 Murmurs, endocardial coexisting, 
 210 
 facts of importance relating to, 
 213 
 
 CE^ema, pulmonary, 16'! 
 
 Pectoriloquy, 129 
 Percussion, definition of, 13 
 
 in health, 38 
 
 in disease. 54 
 
 modes of performing, 3-S 
 
 objects of, 39 
 
 respiratory, 51 
 
 rules in practice of, 51 
 
 signs of disease furnished bv, 
 54 
 
 sense of resistance in, 63 
 Pericardial or friction murmur, 
 214 
 
 sac. liquid within, 194 
 
 surfaces, roughness of, 194 
 Pericarditis, diagnosis of, 228 
 Phthisis, 172 
 
 fibroid, 179 
 
INDEX. 
 
 241 
 
 Pitcli of nonuiil and abnormal 
 
 Kounds, 27 
 ricnnil rales, 118 
 IMcurisy, aculc and chronic, 150 
 I'ncunioiiia, acntc; lobar, 150 
 
 circumscribed, 1()5 
 
 embolic, 1()5 
 
 interstitial, 17J) 
 
 lobular, 111 
 Pncumo-bydrothorax, 157 
 l*iieumo-pyotiiorax, 157 
 rneumotborax, 157 
 rrau-.ordia, 1S2 
 Pulmonary ai)oi)lcxy, 105 
 
 gangrene, KiG 
 
 (cibMua, 1()7 
 Pulmonic direct murmur, 212 
 
 lesions, dia,t;'nosis of, 227 
 
 regurgitant murmur, 213 
 
 Quality of normal and abnormal 
 sounds, 28 
 terms denoting, 30 
 
 Eale, cavernous or gurgling, 117 
 crepitant or vesicular, 114 
 indeterminate, 121 
 metallic tinkling, 120 
 splashing or succussion, 121 
 Ealcs, 10(5 
 
 fine bubbling or subcrcpitant, 
 
 109 
 dry bronchial, 112 
 laryngeal and tx'acheal. lOG 
 moist bronchial, 107 
 pleural or friction, 118 
 Regions, division of chest into, 33 
 sections of chest corresponding 
 to, 34 
 Res(mancc, amphoric, 61 
 crack(xl-metal, (J3 
 diminished, or dulness, 57 
 in dillercnt regions, 80 
 normal, vesicular, on percus- 
 sion, 40 
 vocal over laiynx and 
 trachea, 76 
 on percussion, absence of, or 
 
 flatness, 55 
 over chest, 78 
 tympanitic, 58 
 variations in different regions 
 
 of chest, 43 
 vesiculo-tympanitic, 60 
 
 Respiration, iibiKniual modifica- 
 tions of, H() 
 amphoric, 100 
 bronchial or tubular, 92 
 l)roncho-caveriious, 99 
 broncho-vesicular, 94 
 cavernous, 97 
 diminislu;d, 87 
 in difi'erent regions, 74 
 interrupted, 101 
 normal, laryngi'al, and tra- 
 cheal, 70 
 vesicular murmur of, 72 
 srippressed, 90 
 
 vesicular murmur of, in- 
 creased, 87 
 Respiratory organs, anatomy and 
 physiologj'' of, 16 
 physical conditions inci- 
 dent to diseases of, 19, 
 25 
 
 Signs, arrangement of, 105 
 
 by percussion in disease, 54 
 
 in health, 39 
 healthy and morbid, distinc- 
 tive characters of, 26 
 obtained by coughing, 133 
 physical definition of, 14 
 respiratory, in disease, 86 
 
 in health, 69 
 significance of, 32 
 
 as representing physi- 
 cal conditions, 32 
 vocal, in health, 76 
 of disease, 122 
 Sounds, differences of intensity in, 
 27 
 in pitch, 27 
 in quality, 28 
 normal and abnormal, 14 
 Splashing or succussion sounds, 
 
 121 
 Stethoscope, advantages of, 66 
 binaural, 66 
 
 Tricuspid, direct murmur, 211 
 lesions, diagnosis of, 227 
 regurgitant murmur, 212 
 
 Tuberculosis, acute, 171 
 
 Tumor within the chest, 168 
 
 Tussive signs, 133 
 
 Tympanitic resonance on percus- 
 sion, 58 
 
242 
 
 INDEX. 
 
 Vesiculo-tympanitic resonance on 
 
 percussion, 60 
 Vocal fremitus, diminished or sup- 
 pressed, 133 
 increased, 125 
 resonance, diminished and 
 suppressed, 131 
 increased, 125 
 signs of disease, 122 
 
 Voice, amphoric, 130 
 
 Whisper, hronchial, increased, 128 
 cavernous, 129 
 in different regions, 83 
 normal bronchial, 82 
 
 Whispering pectoriloquy, 129 
 
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