COLLEGE OF OSTEOPATHIC PHYSICIANS
AND SURGEONS LOS ANGELES, CALIFORNIA

Radiograph of a Healthy Child's Chest.

^PHYSICAL DIAGNOSIS

DISEASES OF THE CHEST

RICHARD C. CBOT, M.D.

PHYSICIAN TO OUT-PATIENTS, MASSACHUSETTS GENERAL HOSPITAL ; ASSISTANT IN
CLINICAL MEDICINE, HABVABD MEDICAL SCHOOL

WITH ONE HUNDRED AND
FORTY-TWO ILLUSTRATIONS

NEW YORK

WILLIAM WOOD AND COMPANY

M DCCCCI

FREDERICK C. SHATTUCK, M.D.

Jackson Professor of Clinical Medicine
in Harvard University

IN* EVIDENCE OF MY APPRECIATION OF

THE EXAMPLE OF SINCERITY, COMMON SENSE, AND ENTHUSIASM

ESTABLISHED BY HIM IN THE TEACHING AND

THE PRACTICE OF MEDICINE

PREFACE.

THIS book is intended for students and, so far as I am aware,
contains nothing original. I have written it because I have not
been able to find any small work upon the subject which does not
contain glaring errors. The correct books are too large ; the small
books are out of date and repeat such well-worn myths as that the
aortic second sound is normally louder than the pulmonic second,
that aortic regurgitant murmurs are usually best heard in the sec-
ond right interspace, that a hypertrophied left auricle can produce
dulness and pulsation near the left sternal border, that systolic re-
traction at the cardiac apex means adherent pericardium, that epi-
gastric pulsation denotes hypertrophy of the right ventricle, etc.
Further, none of the smaller text-books contains any adequate ac-
count of muscle sounds, of pulmonary atelectasis, or of adherent
pericardium. To record the well-known but often forgotten truth
on such matters as these has seemed to me of importance in small
books as well as in encyclopaedic treatises.

The diagrams illustrating respiratory types are modifications of
those used by Wylie and Sahli.

I am indebted to Mr. Eliot Alden, of the Harvard Medical
School, for his kind assistance in the preparation of the illustra-
tions and to Drs. E. C. Bradford and R. W. Lovett for permission
to use three cuts from their well-known work on orthopedic sur-
gery.

I am also indebted to the editor of the Archives of the Rontyen
Ray for permission to use two radiographs from that journal.

ERRATA.

1. Page 35, line 7, for "expiration" read "inspiration".

2. Page 81, last line, first word, for "of" read "or".

3. Page 120, in the legend underneath Fig. 78, for "pulmonic"

read "aortic".

4. Page 125, last line but one, for "found" read "sound".

5. Page 261, line 11, for "aphonic" read "aphonia".

6. Page 299, third paragraph, for "three" read "two".

TABLE OF CONTENTS.

PAGE

INTRODUCTION, ............ 1

I. Methods of Examining the Thoracic Organs, ..... 1

II. Regional Anatomy of the Chest, 2

PAKT I.

TECHNIQUE AND GENEEAL DIAGNOSIS.

CHAPTER I.
INSPECTION.

I. SIZE, 5

II. SHAPE, 6

(a) The Rachitic Chest, 7

(b) The Paralytic Chest, 8

III. DEFORMITIES, ........... 12

(a) Curvature of the Spine, . .12

(b) Flattening of One Side of the Chest, 14

(d) Local Prominences, 15

IV. RESPIRATORY MOVEMENTS, ........ 16

(a) Normal Respiration, 16

(b) Anomalies of Expansion, 16

1. Diminished Expansion, 17

2. Increased Expansion, 18

V. THE RESPIRATORY RHYTHM, .21

(a) Asthmatic Breathing, . . . . ^ . . . .21

(b) Cheyne-Stokes Breathing, ....... 21

(d) Shallow and Irregular Breathing, 22

(e) Stridulous Breathing, ........ 23

Viii TABLE OF CONTENTS.

PAGE

VI. DIAPHRAGMATIC MOVEMENTS (LitterTs Phenomenon), . . .23

VII. THE CARDIAC MOVEMENTS, ........ 26

1. Normal Cardiac Impulse, ....... 26

2. Displacement of the Cardiac Impulse, 29

3. Apex Retraction, .... .... 31

4. Epigastric Pulsation 32

5. Uncovering of the Heart, ....... 32

VIII. ANEUIUSM AND OTHEK CAUSES OF ABNORMAL PULSATIONS OF THE

CHEST WALL, 33

IX. THE PERIPHERAL VESSELS, ........ 34

(a) Venous Phenomena, 35

(6) Arterial Phenomena, . . . . . . .36

X. THE SKIN AND Mucous MEMBRANES, 39

1. Cyanosis, 39

2. (Edema 40

3. Pallor, . . 40

4. Jaundice, 40

5. Scars and Eruptions 41

XI. ENLARGED GLANDS, ......... 41

CHAPTER II.
PALPATION AND THE STUDY OF THE PULSE.

I. PALPATION, ............ 42

1. The Cardiac Impulse 42

2. Thrills, 43

3. Tactile Fremitus, 44

4. Friction. Pleural or Pericardial, 4fc'

5. Palpable Rales .47

6. Tender Points, 48

7. Abnormal Pulsations ......... 48

8. Tumors 48

9. Temperature and Quality of the Skin. ..... 49

II. THE PULSE, 49

1. The Rate 51

2. Rhythm, 51

3. Compressibility, .......... 52

4. Size and Shape of Pulse Wave, 52

6. Tension, ........... 53

6. Size and Position of Artery. 55

7. Condition of Artery Walls, 55

TABLE OF CONTENTS. IX

CHAPTER III.
PERCUSSION.

PAGE

I. TECHNIQUE, ....... . . . .58

^ Mediate Percussion, ......... 58

'' ( Immediate Percussion, ........ 58

(6) Auscultatory Percussion, ...... . 65

II. PERCUSSION-RESONANCE OF THE NORMAL CHEST, . . . .67

(a) Vesicular Resonance, . . . . . . . .68

(b) Dulness and Flatness, ......... 68

(d) Cracked-pot Resonance, ........ 74

(e) Amphoric Resonance. ......... 75

(/) The Lung Reflex, ......... 76

III. SENSE OF RESISTANCE, ......... 76

CHAPTER IV.

AUSCULTATION.

1. MEDIATE AND IMMEDIATE AUSCULTATION, . . 77

2. SELECTION OF A STETHOSCOPE, ........ 78

3. THE USE OF THE STETHOSCOPE, ........ 83

A. Selective Attention and What to Disregard, ... .84

B. Muscle Sounds, .......... 86

C. Other Sources of Error, ......... 88

4. AUSCULTATION OF THE LUNGS, ........ 91

I. Respiratory Types, ......... 92

(a) Vesicular Breathing, ........ 93

(b) Tubular Breathing, ...... . 95

(d) Emphysematous Breathing, ....... 97

(e) Asthmatic Breathing ......... 97

(/) Cog-wheel Breathing, ........ 98

(g) Amphoric Breathing, ........ 98

(h) Metamorphosing Breathing, ....... 98

II. Differences between the Right and the Left Chest, . . .99

III. Pathological Modifications of Vesicular Breathing, . . .99

(a) Exaggerated Vesicular Breathing, . . . . . 99
(6) Diminished Vesicular Breathing. ..... 100

IV. Bronchial Breathing in Disease, ....... 102

PAGE

V. Amphoric Breathing, 103

VI. Rales, .... 103

(a) Moist, 103

(b) Dry, 104

VII. Cough. Effects ou Respiratory Sounds, ..... 107

VIII. Pleural Friction, 107

IX. Auscultation of the Voice Sound, 109

(a) The Whispered Voice, 109

(b) The Spoken Voice, 110

X. Phenomena Peculiar to Pneumo-Hydrothorax, . . . .111

(a) Succussion, . . . . . . . . . .111

(b) Metallic Tinkle, .112

CHAPTER V.

AUSCULTATION OF THE HEART.

1. THE VALVE AREAS, 113

2. NORMAL HEART SOUNDS, . . . . . . . . .114

3. MODIFICATIONS IN THE INTENSITY OF THE HEART SOUNDS, . . . 116

(a) Mitral First Sound, 117

1. Shortening, 117

2. Doubling, 118

(b) The Second Sounds at the Base of the Heart, . . ... 118

1. Physiological Variations, 118

2. Pathological Variations, . . . . . . . 120

(a) Accentuation of Pulmonic Second Sound, . . . 120

(b) Weakening of Pulmonic Second Sound, . . . 121

(c) Accentuation of the Aortic Second Sound, . . .121
C/) Weakening of the Aortic Second Sound, . . . 121
(e) Accentuation of Both Second Sounds, . . . .122
(/) Summary, . . . . . . . . .122

ond Sounds. . . . . . . . . . .123

(d) Metallic Quality of the Heart Sounds 124

(ei "Muffled "Heart Sounds, 124

4. SOUNDS AUDIBLE OVER THE PERIPHERAL VESSELS, .... 124

(a) Arterial Sounds, 124

(b) Venous Sounds, 125

TABLE OF CONTENTS. Xl

CHAPTEK VI.

(AUSCULTATION OF THE HEART CONTINUED.)
CARDIAC MURMURS.

PAGE

I. TERMINOLOGY, 126

1. Mode of Production 126

2. Place of Murmurs in the Cardiac Cycle, 128

3. Point of Maximum Intensity, 129

4. Area of Transmission, ......... 130

5. Effects of Respiration, Exertion, and Position, .... 135

6. Intensity, Quality, and Length, 132-135

7. Relation to Heart Sounds,. 135

8. Metamorphosis of Murmurs, . 136

II. FUNCTIONAL MURMURS, ......... 136

III. CARDIO-RESPIRATORY MURMURS, ....... 138

IV. VENOUS MURMURS, 139

V. ARTERIAL MURMURS, . 140

PART II.

DISEASES OF THE HEAKT.
CHAPTER VII.

VALVULAR LESIONS.

1. VALVULAR AND PARIETAL DISEASE, 141

2. THE ESTABLISHMENT AND FAILURE OF COMPENSATION, . . . 144

3. HYPERTROPHY AND DILATATION, 146

4. VALVULAR DISEASE, .......... 151

I. Mitral Regurgitation, 151

(a) Pre-compensatory Stage, 153

(b) Stage of Compensation 154

(d) Differential Diagnosis 159

II. Mitral Stenosis, 161

1. First Stage, 163

2. Second Stage, 165

3. Third Stage, 166

4. Differential Diagnosis 167

III. Aortic Regurgitation, . 170

1. Inspection, .171

xii TABLE OF CONTENTS.

PAGE

(a) Arterial Jerking, . ....... 172

(6) Capillary Pulsation . . 17o

2. Palpation, 174

3. Percussion, 175

4. Auscultation, .......... 175

5. Summary and Differential Diagnosis, .... 178

6. Prognosis ... 179

7. Complications, ......... 179

IV. Aortic Stenosis 180

1. (a) The Murmur, 181

(6) The Pulse 183

(d) Feeble Aortic Second Sound, 184

2. Differential Diagnosis, ........ 184

V. Tricuspid Regurgitation, ........ 187

1. (a) The Murmur, 188

(6) Venous Pulsation, 188

(d) Feeble Pulmonic Second Sound 189

2. Differential Diagnosis, 190

VI. Tricuspid Stenosis, 191

VII. Pulmonary Regurgitation. . . . . . . . . 192

VIII. Pulmonary Stenosis, 193

IX. Combined Valvular Lesions 194

(a) Double Mitral Disease. ........ 195

(6) Aortic and Mitral Regurgitation 196

CHAPTER VIII.

PARIETAL DISEASE AND CARDIAC NEUROSES.

I. ACUTE MYOCARDITIS, .......... 198

1 Acute Moycarditis 198

2. Chronic Myocarditis 199

3. Fatty Overgrowth 201

4. Fatty Degeneration. ......... 201

II. CARDIAC NECROSES, .......... 202

1. Tachycardia 202

2. Bradycardia 203

3. Arrhythmia, .......... 204

4. Palpitation 205

5. Congenital Heart Disease, 206

TABLE OF CONTENTS. xin

CHAPTER IX.

DISEASES OF THE PERICARDIUM.

> PAGE

I. PERICARDITIS, 209

(a) Dry or Fibrinous, 209

(6) Pericardial Effusion, 212

1. The Area of Dulness, 213

2. The Cardiac Impulse and the Pulse, 214

3. Pressure Signs, . . . . . . . . .215

1. Retraction of Interspaces, 217

2. Limitation of Respiratory Movements, .... 217

3. Absence of Cardiac Displacement with Change of Position, 217

4. Hypertrophy and Dilatation not otherwise Explained, . 217

5. Capsular Cirrhosis of the Liver, 218

II. HYDROPKRICARDIUM AND PNEUMOPERICAUI>IUM, ..... 219

CHAPTER X.
THORACIC ANEURISM.

1. Abnormal Pulsation, 220

2. Tumor, 221

3. Thrill 222

4. Diastolic Shock, 222

5. Tracheal Tug, 223

6. Pressure Signs 224

7. Percussion Dulness, 224

8. Auscultation, 225

(a) Murmurs, 225

(6) Diastolic Shock Sound, 226

9. Radioscopy, 227

10. Summary 227

11. Diagnosis 229

PART III.

DISEASES OF THE LUNGS AND PLEURA.
CHAPTER XI.

BRONCHITIS, PNEUMONIA, TUBERCULOSIS.

1. TRACHEITIS, 233

2. BRONCHITIS, 233

xiv TABLE OF CONTENTS.

PAGE

(a) Physical Signs, 234

(6) Differential Diagnosis. ......... 235

3. CROUPOUS PNEUMONIA, .......... 237

(a) Inspection, 237

(6) Palpation 238

(d) Auscultation, 239

(e) Summary, 242

(/) Differential Diagnosis, 242

4. BRONCHO-PNEUMONIA, .......... 244

5. POI.MONARY TUBERCULOSIS, ......... 245

(a) Incipient Tuberculosis, ........ 245

(6) Moderately Advanced Cases, 249

(d) Anomalous Forms of Pulmonary Tuberculosis 256

CHAPTER XII.

(DISEASES OF THE LUNGS, CONTINUED.)

1. EMPHYSEMA, 258

(a) Small-Lunged Emphysema, 258

(6) Large-Lunged Emphysema ........ 258

(d) Interstitial Emphysema, 262

(e) Complementary Emphysema, ....... 262

(/) Acute Pulmonary Tympanites 262

2. BRONCHIAL ASTHMA, 263

3. SYPHILIS OF THK LUNG, . . . . . . . . . 264

4. BRONCHIECTASIS, .... ....... 264

5. CIRRHOSIS OF THE LUNG, 265

CHAPTER XIII.
DISEASES AFFECTING THE PLEURAL CAVITY.

I. Hydrothorax 266

II. Pneumothorax, 260

III. Pneumohydrothorax and Pneumopyothorax, 268

Differential Diagnosis of Pneumothorax and Pneumohydrothorax. . 270

IV. Pleurisy 271

1. Dry Pleurisy 271

TABLE OF CONTENTS. xv

PACK

2. Pleuritic Effusion, 273

(a) Percussion, 273

(b) Auscultation 279

3. Pleural Thickening, 283

4. Encapsulated Pleural Effusions, 283

5. Pulsating Pleurisy and EnipyemaNecessitatis, ..... 284

6. Differential Diagnosis of Pleural Effusions, 284

CHAPTER XIV.

ABSCESS, GANGRENE AND CANCER OF THE LUNG, PULMONARY
ATELECTASIS, (EDEMA AND HYPOSTATIC CONGESTION.

1. Abscess and Gangrene of the Lung, ....... 290

2. Cancer of the Lung, . . . . . . . . . 291

3. Atelectasis 292

4. CEdema and Hypostatic Congestion, ....... 293

APPENDICES.

APPENDIX A. DISEASES OF THE MEDIASTINUM 293

1. Mediastinal Tumors, ......... 293

2. Mediastinitis, .......... 295

3. Tuberculosis of Mediastinal Glands, 296

APPENDIX B. ACUTK ENDOCARDITIS. ....... 296

APPENDIX C. EXAMINATION OF INFANT'S CHESTS, ..... 297

APPENDIX D. RADIOSCOPY OF THE CHEST, 298

APPENDIX E. THE SPHYGMOGRAPH, ........ 305

PHYSICAL DIAGNOSIS

DISEASES OF THE CHEST.

INTRODUCTION.

I. METHODS OF EXAMINING THE THORACIC ORGANS.

To carry out a thorough examination of the chest we do five
things: 1. We look at it; technically called "inspection." 2. We
feel of it; technically called "palpation." 3. We listen to the
sounds produced by striking it; technically called "percussion."
4. We listen to the sounds produced within it by physiological or
pathological processes; technically called "auscultation." 5. We
study pictures thrown on the fluoroscopic screen or on a photo-
graphic plate by the Roentgen rays as they traverse the chest;
technically called "radioscopy."

Measuring the dimensions or the movements of the chest (" men-
suration ") is often mentioned as co-ordinate with the above meth-
ods, but it yields very little information of practical value, and is
at present very little used.

The data obtained by examining the sputa, blood, and urine are
frequently of great value in helping us to interpret the signs re-
vealed by examination of the chest, but do not fall within the
scope of this book. Accordingly, I shall confine myself in the
first part of this book to a description of the methods of inspect-
ing, palpating, percussing, and auscultating the chest, with a brief
account of the physical signs which we have learned to appreciate
by the use of these methods. (For radioscopy, see Appendix.)
1

PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Without some knowledge of the regional anatomy of the chest
no intelligent investigation of the condition of the thoracic organs
can be carried on. Accordingly, I shall begin by recalling very
briefly some of the most essential anatomical relations.

II. REGIONAL ANATOMY OF THE CHEST.

It seems to me a mistake to divide the chest into arbitrary por-
tions and to describe physical signs Avith reference to such division.
The seat of any lesion can best be described
by giving its relation to the clavicle, ster-
num, or ribs on the front and sides of the
chest, and to the scapulae and ribs behind.
Thus we may speak of rales as heard " above
the left clavicle in front, " " below the right
scapula behind, " "between the seventh and
ninth ribs in the axilla," and so on. When
we want to state more exactly what part of
the axilla anteroposteriorly is affected, we
may refer to the " mid-axillary line " (see
Fig. 1) ; or better, we may place the lesion
by measuring the number of centimetres cl-
inches from the median line of the sternum.
In a similar way the place of the apex im-
pulse of the heart (whether in the normal
situation or farther toward the axilla) can be
determined by measuring from the median
line of the sternum. Measurements refer-
ring to the nipple are entirely useless in
women and not very reliable in men. It is
better to measure as above.

If, then, we confine ourselves chiefly to
the bones of the. chest as landmarks, and

fix, with reference to them, the position of any portion of the in-
ternal organs which we desire to study, it becomes unnecessary to
memorize any technical terms or to learn the position of any arbi-
trary lines and divisions such as are frequently forced upon the

FIG. l.-The Mid-Axillary
Line.

INTRODUCTION.

student. The only points which it is necessary to memorize once
for all are :

1. The position of the heart, lungs, liver, and spleen with ref-
erence to the bones of the chest.

2. The position of certain points which experience has taught
us have a certain value in physical diagnosis. I mean (a) the
so-called " valve areas " of the heart, which do not correspond to
the actual position of the valves, for reasons to be explained later

Upper lobe of left
lung.

Right lung. .
Right auricle.

Liver. - -

. I _ I Left ventricle.

Lower lobe of left
lung.

~ Stomach.

FIG. 2. Position of the Heart, Lungs, Liver, and Stomach. The dotted lines correspond to the
outlines of the lung ; the heavy continuous line represents the heart ; while the position of
the liver and of the lower border of the stomach is indicated by light continuous lines. The
ribs are numbered.

on, and (6) the percussion outlines of the heart, liver, and spleen.
These outlines do not correspond in size with the actual dimensions
of the organs within, yet there is a definite relation between the two
which remains relatively constant, so that we can infer the size of
the organ itself from the outlines which we determine by percus-
sion. The position of the organs themselves is shown in Figs. 2,
3, and 4. It will be noticed in Fig. 2 that the lungs extend up
above the clavicles and overlap the liver and the heart facts of
considerable importance in the physical examination of these or-
gans, as will be later seen. It is also to be noticed how small

PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

a portion of the stomach is directly accessible to physical examina-
tion, the larger part of it lying behind the ribs and covered by the

^ f * Upper lobe.

, Lower lobe.

Spleen.

Lower lobe.

Upper
lobe.

Middle
lobe.

_ Liver

FIG. 3. Position of the Left Lung from tbe
Sides and of the Spleen.

FIG. 4. Position of the Right Lung from the
Side, and of the Liver.

liver. The normal pancreas and kidneys are practically inacces-
sible to physical examination.

The percussion outlines corresponding to those portions of
the heart, liver, and spleen which lie immediately beneath the
chest walls will be illustrated in the section on Percussion (see
page 58).

PART I.

TECHNIQUE AND GENERAL DIAGNOSIS.

INSPECTION.

MUCH may be learned by a careful inspection of all parts of the
chest, but only in case the clothes are wholly removed. A good
light is essential, and this does not always mean a direct light ; for
example, when examining the front of the chest it is often better
to have the patient stand with his side to the window so that the
light strikes obliquely across the chest, accenting every depression
and making every pulsation a moving shadow. In searching for
abnormal pulsations, this oblique light is especially important.

In examining the thorax we look for the following points :

1. The size.

2. The general shape and nutrition.

3. Local deformities or tumors.

4. The respiratory movements of the chest walls.

5. The respiratory movements of the diaphragm.

6. The normal cardiac movements.

7. Abnormal pulsations (arterial, venous, or capillary).

8. The peripheral vessels.

9. The color and condition of the skin and mucous membranes.

10. The presence or absence of glandular enlargement.

I. SIZE.

Small chests are seen in patients who have been long in bed
from whatever cause ; also in those who have suffered in infancy
from rickets, adenoid growths in the naso-pharynx, or a combina-
tion of the two diseases. Abnormally large chests are seen chiefly
in emphysema. Of course the chests of healthy individuals vary

6 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

a great deal in size at any given age, and I have been referring in
the last sentences only to variations greater than those normally
found.

II. SHAPE.

There are marked differences in shape between the child's and
the adult's chest in health. A child's trunk, as compared with

FIG. 5. Funnel Breast.

that of an adult, is far more nearly cylindrical; that is, the antero-
posterior diameter is nearly as great as the lateral. The adult's
chest is distinctly flattened from before backward, although indi-
vidual variations in this respect are considerable, as Woods Hutch-
inson has shown.

In childhood the commonest pathological modifications are due

INSPECTION. I

to rickets ; in middle and later life to emphysema, phthisis, or old
pleuritic disease.

(a) The Hachitic Chest.

The sternum generally projects ("pigeon breast"}, but in some
cases, especially when rickets is combined with adenoid hyper-
trophy, there may be a depression at the root of the sternum re-
sulting in the condition known as "funnel breast " ' (Figs. 5 and 6).

FIG. 6. Funnel Breast.

The sides of the chest are compressed laterally and slope in to meet
the sternum as the sides of a ship slope down to meet the keel
(pectus carinatum) (Figs. 8, 9 and 10). From the origin of the eiisi-
form cartilage a depression or groove is to be seen running down-
ward and outward to the axilla and corresponding nearly to the
attachment of the diaphragm. This is sometimes spoken of as
" Harrison's groove " (Figs. 11 and 12). The lower margin of the ribs
1 In some cases this condition appears to be congenital.

PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

in front often flares out, owing to the enlargement of the liver and
spleen below and the pull of the diaphragm, above. Along the line
of the chondro-costal articulation there is to be felt, and sometimes

FIG. 7. Acquired Depression at the Root of the Ensifonn Cartilage. The patient is a shoe-
maker of seventy, who has all his life pressed against his breast bone the shoe on which
he worked.

seen, a line of eminences or swellings, to which the name of " ra-
chitic rosary " has been given (see Fig. 13).

(ft) The "Paralytic Thorax."

Fig. 14 conveys a better idea of this form of chest than any
description. The normal anteroposterior flattening is exaggerated
so that such persons are often spoken of as "flat-chested." The
clavicles are very prominent, owing to falling in of the tissues

INSPECTION. 9

above and below them; the shoulders are stooping, the scapulae
prominent, and the neck is generally long. The angle where the
ribs meet at the ensif orm cartilage, the so-called " costal angle, " is in
such cases very sharp. This type of chest has often been supposed
to be characteristic of phthisis, but may be found in persons with
perfectly healthy lungs. On the other hand, phthisis frequently

FIG. 8. Pigeon Breast.

exists in persons with normally shaped chests or with abnormally
deep chests (Woods Hutchinson). (See Fig. 128, page 251.)

Nothing is less like a barrel than the " barrel chest. " Its most
striking characteristic is its greatly increased anteroposterior diam-
eter, so that it approaches the form of the infant's chest. The
costal angle is very obtuse, the shoulders are high, and the neck
is short. The respiratory movements of the barrel chest will be
spoken of later (see Figs. 15 and 16).

10 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Nutrition of the Chest Walls.

Emaciation is readily appreciated by inspection. The ribs are
unusually prominent, the scapulae stand out, and the clavicles pro-
ject. All this may be seen independently of any change in the

FIG. 9. Pigeon Breast.

shape of the chest such as was described above under the title of
Paralytic Thorax. Tuberculosis of the apices of the lungs may
produce a marked falling in of the tissues above and below the
clavicle independent of any emaciation of the chest itself.

INSPECTION.

FIG. 10. Pigeon Breast.

12 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

III. DEFORMITIES.

The abnormalities just enumerated are symmetrical and affect
the whole thorax. Under the head of Deformities, I shall consider
chiefly such abnormalities as affect particular portions of the chest
and not the thorax as a whole.

(<t) Spinal Curvatures end Tirists.

A good view of the patient's back brings out best the lesser de-
grees of lateral curvature, which are not at all infrequent in persons

;::::.'..

Fio. 11. Harrison's Groove.

who are not aware of them. Slight degrees of deformity are best
seen by marking with a skin-pencil the position of the spinous proc-
esses (see Fig. 18). The more marked cases of lateral curvature,
which are usually accompanied by a certain amount of twistiny,
give rise to considerable displacement of the thoracic organs and
render unreliable the usual bony landmarks, with reference to
which we judge of the position of the intrathoracic organs. By
such deformities the apex of the heart may be pushed up into the

INSPECTION.

FIG. 12. Harrison's Groove.

fourth space or out into the axilla, or portions of the lungs may
be compressed and made atelectatic.

I. The bulging on the convex side of the curve may simulate
an aneurismal tumor.

II. Pott's disease of the spine should be looked for as apart

FIG. 13. Remains of Racbitic Rosary in a Boy of Seventeen.

14 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

of the routine inspection of the chest. It is sometimes better felt
than seen.

III. Abnormal rigidity of the spine, due to spondylitis defor-
mans, is to be recognized by watching the movements of the spinal
column as the patient bends forward and back. Where the verte-
brae are locked together, as occurs in moderately advanced cases of

this disease, the spine is
maintained rigidly stiff, in-
dependent of muscular sup-
port. A similar stiffness of
the spine may also be seen
in early Pott's disease. It
is here due mostly to mus-
cular spasm.

(ft) Flattening of One Side
of the Chest.

In chronic phthisis, cir-
rhosis of the lung, or long-
standing pleuritic effusion,
marked falling in of one
side of the chest is often to
be seen. This may be ap-
parent in the upper and
front portion, beneath the
clavicle, or in the axilla, or
in both situations (see Figs.

14 and 20). The shrinkage of the affected side is made more ob-
vious by contrast with the compensatory hypertrophy of the sound
lung, which makes the sound side unusually full and prominent.

Fi. 14. The Paralytic Thorax.

In pneumothorax or pleural effusions, and sometimes in malig-
nant disease of the lung or pleura, there is a marked increase in the
size of the affected side of the chest. Very rarely emphysema

INSPECTION.

may affect one lung predominantly. In pneumothorax or pleuritic

effusion we usually see, in addition to the above enlargement of the

affected side, a smoothing out of

the intercostal depressions so that

the surface of that side is much

more uniform than the other side.

Bulging of the interspaces from

great pressure within the chest is

said to occur. I have never seen

it and am somewhat sceptical as

to its occurrence.

(d) Local Prominences.

In nearly one -quarter of all
healthy chests that part of the
thoracic wall which overlies the
heart (the so-called "precordial
region ") is abnormally promi-
nent. The cause of this condi-
tion is much disputed. A similar
prominence may be brought about
in children, whose thoracic bones
are very flexible (and occasionally
in older patients) , by the outward
pressure of an enlarged heart or
of an effusion in the pericardial
sac. The prominences due to
spinal curvature have been al-
ready mentioned. Less common
causes of local prominence are :

1. Aneurism of the arch of
the aorta.

2. Tumor of the chest wall

(lipoma, sarcoma, gumina) or of the lung, mediastinum, or of the
thoracic glands pressing their way outward.

FIG. 15. Barrel Chest in a Case of Bron-
chial Asthma (set. 13).

16 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

3. " Cold abscess " (tuberculosis) of a rib or of the sternum.

4. A'///////'-//"*, perforating the chest wall, the so-called " empyema
necessitatis."

IV. THE RESPIRATORY MOVEMENTS.

(a) Normal Resjtu-iit'nni.

During normal respiration, one sees the ribs move outward and
upward with inspiration, and downward and inward with expira-
tion. Possibly one catches some
hint of the movements of the
diaphragm at the epigastrium.
In men, diaphragmatic breath-
ing is more marked, while in
women breathing is mostly of
the " costal type " ; that is, is
done by the intercostal muscles.
In certain diseases an exaggera-
tion of the costal or of the dia-
phragmatic type of breathing
may be seen. In emphysema,
for example, and in some cases
of asthma, the ribs move very
little, and most of the work of
respiration is performed by the
diaphragm, whose pull upon the

lower ribs can sometimes be distinctly seen during inspiration. On
the other hand, when the movements of the diaphragm are impeded
by the presence of fluid or a solid tumor, as in cirrhosis of the
liver or leukaemia, the breathing has largely to be performed by the
ribs, and becomes, as we say, costal in type (see below, p. 19).

FIG. 16. Barrel Chest. Chronic bronchitis
and emphysema.

(b) Anomalies of Expansion.

If we watch the patient while he takes a full breath, we may
notice certain variations from the normal type of respiratory move-

INSPECTION.

ments, We may see: (1) Diminished expansion of one side (as a
whole, or at the apex). (2) Increased expansion of one side.

(1) If diminished expansion of one side is due to pleuritic effusion,
pneumothorax, or solid tumor of the lung or pleura, the affected-
side is usually distended as well as immobile. When, on the other

FIG. 17. Severe Lateral Curvature (Un-
treated).

FIG. 18. Lateral Curvature Three Weeks
After Correction.

hand, the lung is retracted or bound down by adhesions, as in
phthisis, old pleurisy, occlusion of the bronchus, or from the pres-
sure of an aneurism, we have immobility combined with a retraction
of the affected side. In tuberculous disease at the apex of the
lungs, we may see one side or both sides fail to expand at the top.
Restriction of the motion of one side of the chest may also be due
2

18 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

to pressure from below the diaphragm. An enlarged liver or spleen
and tumors of the hepatic or splenic region may in this way prevent
the normal expansion of one or the other side of the thorax. Oc-
casionally a hemiplegia or a unilat-
ral paralysis of the diaphragm
results in diminished movement of
one side of the chest.

(2) Increased expansion of one
side of the chest is observed princi-
pally as a compensatory or vicarious
overfunctioning of that side when
the other side of the chest is thrown
out of use by a large pleuritic effu-
sion, by pneumothorax, long-stand-
ing pleurisy with contraction, or
other causes.

This term is often used rather
loosely to include : (1) Difficult
breathing, whether rapid or slow.
(2) Unusually deep breathing,
whether difficult or not. (3) Rapid
breathing.

True dyspnoea or difficult breath-
ing is almost always rapid as well,
and does not differ at all from the

well-known phenomenon of being " out of breath " after a hard run
or any violent exertion. Conceive these conditions as persisting
over hours or days, and we have the phenomenon known as dysp-
noea. The breathing is not only thick but labored; that is, per-
formed with difficulty, and unusual muscles, not ordinarily called
upon for respiration, come into play and are seen working above
the clavicle and elsewhere. More or less distress is generally ex-
pressed in the face, and there is often a blueness of the lips or a
dusky color throughout the face. The commonest causes of dysp-

FIG. 19. Lateral Curvature Before Cor-
rection.

INSPECTION.

ncea are the various forms of heart disease, pneumonia, large
pleuritic effusion, emphysema, asthma, and phthisis.

Dyspnoea may affect especially inspiration, as, for example,
when a foreign body lodges in the larynx, or in ordinary "croup."
In such cases we speak of "inspiratory dyspnoea," distinguishing it
from "expiratory dyspnoea " such as occurs in asthma and emphy-
sema. In the latter condition the breath seems to enter the chest
readily, but the difficulty is to get it out again. Expiration is
greatly prolonged and often noisy.

Combined types also occur in which both respiratory acts are
difficult.

Abnormally deep and full respiration, without any appearance of
difficulty in the process, is sometimes seen near the fatal termina-
tion of cases of diabetes,
the so - called diabetic
dyspnoea.

Simple rapidity of
Ireathiny should be dis-
tinguished from dyspnoea
of any type. In adults
the normal rate of respi-
ration is about 22 per
minute. In children, it is
considerably quicker and
more irregular. It is not
desirable to attempt here
to enumerate all the
causes which may lead to
a quickening of the respi-
ration. Among the com-
moner are muscular exer-
tion, emotional disturb-
ance, diseases of the heart and lungs, and fluid or solid accumula-
tions below the diaphragm, which push up that muscle and cause it
to encroach abnormally upon the thoracic cavity. Most of the in-
fectious fevers are also apt to be accompanied by quickened breath-

FIG. 20. Contraction of Left Chest. Empyema.

20 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

ing, especially but not exclusively when the fever is associated with
a disease of the heart, lung, pleura, or pericardium.

Sucking-in of the interspaces in the lower axillary regions or

below the clavicles may

^"t--- .'^J be seen in connection

with dyspnrea when-
ever the lungs are pre-
vented by some cause
from properly expand-
ing during inspiration.
Negative pressure i s
thus produced within
t the chest, and the at-
mospheric pressure
without pushes in the
more elastic parts of
the thorax. This phe-
nomenon is seen in col-
lapse or atelectasis of
a portion or the whole
of a lung, such as may
occur in obstruction at
the glottis (in which
case both sides are
equally retracted) o r
FIG. 21. Prominence of Right Side. Pleural Effusion. from occlusion of a

bronchus. In the lat-
ter event, the sucking-in of the interspaces during inspiration oc-
curs only on the affected side. 1

1 Slight retraction of the lower interspaces in the axilla during inspiration
is often seen in health. In disease this phenomenon is greatly exaggerated.

INSPECTION. 21

V. CHANGES ix THE RESPIRATORY RHYTHM.

(a) Asthmatic Breathing.

In asthma the normal rhythm is reversed and the expiration
becomes longer, instead of shorter, than inspiration. Inspiration
may be represented only by a short gasp, while expiration becomes
a prolonged wheeze lasting several times as long as inspiration.
Dyspnoea is usually very marked. In emphysema we get very
much the same type of breathing so far as rhythm is concerned,
but the dyspnoea is not usually so extreme and the auxiliary mus-
cles of respiration are not so apt to be called into use. In many
cases of emphysema one sees the thorax move all as one piece, " en
cuirasse," owing to a senile fixation of the bones of the thorax from
ossification of the cartilaginous portions. In hereditary syphilis
this fixation may occur in youth or early middle age.

(b) Cheyne- Stokes Breath in <j.

An anomaly of respiratory rhythm in which short, recurrent
paroxysms of dyspnoea are preceded and followed by periods in
which no respiration occurs (apnoea). If we represent the normal
respiratory movement by an up-and-down line, as seen in Fig. 22,

vwwvww

FIG. 22. Diagram to Represent Normal Breathing-Rhythm.

the Cheyne-Stokes type of breathing would appear as in Fig 23.
The period of apnoea may last from one to ten seconds ; then short,
shallow respirations begin and increase rapidly, both in volume and
in rate, until a maximum of marked dyspnoea is reached, when a
diminution in the rate and depth of the act begins, and the patient
gradually returns to the apnceic state The length of the whole
paroxysm may be from 30 to 70 seconds During the apnoeic
period the patient is apt to drop asleep for a few seconds and the
pupils may become contracted When the paroxysm of dyspnoea

22 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

is -at its height, he is apt to cough and shift his position restlessly,
or in case the whole phenomenon occurs during sleep he moves un-
easily in his sleep at this period. Modified types of the phenome-
non also occur, in which there is a rhythmic increase and decrease
in the depth and rapidity of respiration but without any interven-
ing period of apncea. This type of breathing is most often seen in
severe cases of cardiac, renal, or cerebral disease. It is generally
more marked at night and may occur only at that time. In chil-
dren it appears sometimes to be physiological during sleep. As a

FIG. 23. Cheyue-Stokes Respiration.

rule, it is a sign of grave prognostic significance, but patients have
been known to recover completely after weeks or even months of
Cheyne-Stokes breathing.

When the patient has a " stitch in the side," due to dry pleu-
risy, intercostal neuralgia, or to other causes, the inspiration may
be suddenly interrupted in the middle, owing to a seizure of pain
which makes the patient stop breathing as quickly as he can. The
same conditions may produce very shallow breathing as the patient
tries to avoid the pain which a fall inspiration will cause. This
type of restrained breathing is c Iten seen in pleurisy and pneumo-
nia, and in the latter disease expiration is often accompanied by
a little moan or grunt of discomfort

(fZ) Shallow a in] ii-i'i't/iiJar /ir<'<ifltin>j is often seen in states of pro-
found unconsciousness from any cause, such as apoplexy or poison-
ing. A few deep respirations may be followed by a number of
shallow and irregular ones. When death is imminent in any dis-
ease, the respiration may become very irregular and gasping, and
it is apt to be accompanied by a peculiar nodding movement of the

INSPECTION. 23

head, the chin being thrown quickly upward during inspiration, and
falling slowly during expiration. I have known but one patient to
recover after this type of breathing had set in.

After severe hemorrhage the breathing may be of a aighing type
as Avell as very shallow.

(e) Stridulous Breathing.

A high-pitched, crowing or barking sound is heard during inspi-
ration when there is obstruction of the entrance of air at or near
the glottis. This type of breathing occurs in spasm or oedema of
the glottis, " croup," laryngismus stridulus, and forms the "whoop "
in the paroxysms of whooping-cough. Laryngeal or tracheal ob-
structions due to foreign bodies, or tumors within or pressure from
without the air-tubes, may cause a similar type of respiration. It
is in these cases especially that we see the sucking-in of the inter-
spaces mentioned above (see p. 20).

VI. DIAPHRAGMATIC MOVEMENTS.

Litten's Phenomenon.

The normal movements of the diaphragm may be rendered vis-
ible by the following procedure, suggested by Litten in 1892 : The
patient lies upon his back with the chest bared and the feet pointed
directly toward a window. Cross lights must be altogether ex-
cluded by darkening any other windows which the room may con-
tain 1 (see Fig. 24). The observer stands at the patient's side
and asks him to take a full breath. As the ribs rise with the
movement of inspiration, a short, narrow shadow moves doAvn along
the axilla from about the seventh to about the ninth or tenth rib.
During the expiration the shadow rises again to the point from
which it started, but is less easily seen. This phenomenon is to be
seen on both sides of the chest and sometimes in the epigastrium.

1 If it is inconvenient to move the patient's bed into the proper position
with relation to the window, or if the foot-board interferes, or if the observa-
tion has to be made after dark, a dark lantern or other strong light held at the
foot of the bed answers very well. All other light must, of course, be ex-
cluded.

24 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

It is best seen in spare, muscular young persons of either sex, and
is never absent in health except in those who are very fat, or who
cannot or will not breathe deeply. The latter condition occurs in

FIG. 24. Litten's Diaphragm Shadow. Proper position of patient and of observer. The
shadow is best seen near L.

hysteria and in some very stupid persons who cannot be made to
understand what is meant by a full breath. In the observation of
several thousand cases, I have never known it absent in health
except under these conditions.

In normal chests, the excursion of the shadow is about two and
a half inches; with very forced breathing three and a half inches.
The mechanism of this phenomenon is best understood by imagin-
ing a coronal section of the thorax as seen from the front or buck
(see Fig. 25). At the end of expiration, the diaphragm lies
flat against the thorax from its attachment up to about the sixth
rib. During inspiration it "peels off" as it descends and allows
the edge of the lung to come down into the chink between the dia-
phragm and thorax. This "peeling off" of the diaphragm and the
descent of the lung during inspiration give rise to the moving
shadow above described.

By thus observing the excursion of the diaphragm we can obtain
a good deal of information of clinical value.

INSPECTION.

In pneumonia of the lower lobe, pleuritic effusion, extensive pleu-
ritic adhesions, or in advanced cases of emphysema, the shadow is
absent. This is explained by the fact that in pneumonia, pleuritic
effusion, and emphysema the diaphragm is held off from the chest
wall so that its movements communicate no shadow. In pleuritic
adhesions the movements of the diaphragm are prevented. In
early phthisis I have generally found the excursion of the dia-
phragm diminished upon the affected side, owing to a loss of
elasticity in the affected lung and in part probably to pleuritic
adhesions. On the other hand, fluid or solid tumors below the dia-
phragm, unless very large, do not prevent the descent of that muscle,
and so do not abolish the diaphragm shadow. In cases in which
the diagnosis is in doubt between fluid in the right pleural cavity
and an enlargement of the liver upward or a subdiaphragmatic ab-
seess, the preservation of the Litten's phenomenon in the latter two
affections may be of great value in diagnosis. Very large accumu-
lations of ascitic fluid may so far restrain the diaphragmatic move-
ments that no shadow can be seen. Great muscular weakness or
debility may greatly diminish, but rarely if ever prevent, the excur-

FIG. 25. Excursion of the Diaphragm during Forced Respiration. R, Ribs ; E, position of
the diaphragm at end of expiration ; J, position of diaphragm at end of inspiration.

sion of the shadow. In persons who cannot be made to breathe
deeply enough to bring it out, a hard cough will frequently render
it visible.

The use of this method of examination tends, to a certain ex-
tent, to free us from the necessity of using the arrays, inasmuch as

26 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

it furnishes us with the means of observing the diaphragmatic
movements, on the importance of which so much stress has been
laid by F. H. Williams and others, much more easily and cheaply
than with the ic-rays, and upon the left side, more plainly as well.

It also frees us to a considerable extent from the need of using
the spirometer to determine the capacity of the lungs.

By measuring the excursion of the phrenic shadow and taking
account of the thoracic movement, we obtain a very fair idea of the
respiratory capacity of the individual.

VII. OBSERVATION OF THE CARDIAC MOVEMENTS.
(1) The Normal Cardiac, Impulse.

With each systole of the heart there may be seen in the great
majority of normal chests an outward movement of a small portion
of the chest wall just inside and below the left nipple. This phe-
nomenon is known as the cardiac impulse. 1 It is now generally
admitted that the " apex impulse " is caused by the impact of a
portion of the right ventricle against the chest wall and not by the
apex of the heart itself. [The bearings of this fact, which have
not, I think, been generally appreciated, will be discussed pres-
ently.] The position of the maximum impulse in adults is usually
in the fifth intercostal space just inside the nipple line. In chil-
dren under the age of six it is often in the fourth interspace or
behind the fifth rib; while in persons of advanced age it often de-
scends as low as the sixth interspace. In adults it is occasionally
absent even in perfect health and under certain pathological condi-
tions to be later mentioned.

(a) The position of the impulse varies to a certain extent ac-
cording to the position of the body. If the patient lies upon the
left side, the heart's apex swings out toward the axilla, so that
the visible impulse shifts from one to two and one-half inches to
the left (see Fig. 26). A slight shift to the right can also be
brought about by lying upon the right side, and, as a rule, the im-

1 For a more detailed description of the normal position of the cardiac
impulse, see next page.

INSPECTION.

pulse is. less visible in the recumbent than in the upright position.
Since the heart is lifted with each expiration by the rise of the dia-
phragm and falls during inspiration, a corresponding change can be
observed in the apex beat, which, in forced breathing, may shift as
much as one interspace. Of the changes in the position of the im-
pulse brought about by disease, I shall speak in a later paragraph.

FIG. 2. Showing Amount of Shifting of the Apex Impulse with Change of Position. The in-
ner dot represents the position of the impulse when the patient lies on his back ; the outer
dot corresponds to the position of the apex with patient on left side.

(i) Relation of the maximum cardiac impulse to the apex of the
heart. I mentioned above that the maximum cardiac impulse is not
due to the striking of the apex of the heart against the chest wall,
but to the impact of a portion of the right ventricle. The practical
importance of this fact is this: When we are trying to localize the

28 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

apex of the heart in order to determine how far the organ extends
to the left and downward, it will not do to be guided by the posi-
tion of the maximum impulse, for the apex of the heart is almost
always to be found three-fourths of an inch or more farther to the
left (see Fig. 27). This may be proved by percussion (vide infra,

FIG. 27, The Inner Dot is the Maximum Cardiac Impulse. That to the right is the true apex
of the heart, as obtained by percussion. The ribs are numbered.

p. 58). The true position of the cardiac apex thus determined cor-
responds usually not with the moy'innim impulse, but with the point
farthest out and farthest down at which any rise and full syn-
chronous with the heart beat can be felt (for further discussion of
this point see below, p. 213).

INSPECTION. 29

been described, it is often possible to see that a considerable section
of the chest wall in the precordial region is lifted " en masse. "
The phenomenon is the " Herzenstoss " of the Germans, with which
the ' : Spitzenstoss " or apex impulse is contrasted. A variable
amount of " Herzenstoss " can be seen and felt over any normal
heart when it is acting rapidly and forcibly, and in thin, nervous
subjects or in children even when the heart is beating quietly. It
is more marked in cardiac neuroses or in cases in which the heart
is hypertrophied and in which there is more or less stiffening of the
ribs with loss of their natural elasticity. At times it may be
impossible to localize any one point to which we can give the
name of apex impulse, and what we see is the rhythmical rise and
fall of a section of the chest as large as the palm of the hand or
larger.

((/) Character of the cardiac impulse. Palpation is considerably
more effective than inspection in giving us information as to the na-
ture of the cardiac movements which give rise to the "apex beat,"
but even inspection sometimes suffices to show that the impulse has
a heaving character or is of the nature of a short tap, a peristaltic
wave, or a diffuse slap against the chest wall. In some cases a dis-
tinct undulation can be seen passing from the apex region upward
toward the base of the heart, or less often in the opposite direction.

(2.) Displacement of the Cardiac Impulse.

To one familiar with the position, extent, and character of the
normal cardiac impulse, any displacement of this impulse from its
normal site or any superadded pulsation in another part of the chest
is apparent at a glance. I will consider first the commonest forms
of dislocation of the apex impulse.

(a) Displacement of the cardiac impulse due to hypertrophy and
dilatation of the heart. By far the most common directions of dis-
placement are toward the left axilla, or downward. As a rule, it
is displaced in both these directions at once. I shall return to this
subject more in detail under the heading Cardiac Hypertrophy, but
here I may say that enlargements of the left ventricle tend espe-
cially to displace the apex impulse downward, while enlargements of

30 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

the right ventricle are more commonly associated with displacement
of the impulse toward the axilla.

(ft) Next to hypertrophy and dilatation of the heart perhaps the
commonest cause of dislocation of the cardiac impulse is pressure
from below the diaphragm. When the diaphragm is raised by a
large accumulation of gas or fluid or by solid tumors of large size,
we may see the apex beat in the fourth interspace and often an inch
or more inside the nipple line.

AYhen a considerable amount of air or fluid accumulates in the
left pleural cavity, the apex of the heart is displaced to the right
so that it may be concealed behind the sternum or be visible beyond
it to the right ; in extreme cases it may be dislocated as far as the
right nipple. Eight pleuritic effusions have far less effect upon
the position of the cardiac impulse, but when a very large amount
of fluid accumulates we may see the impulse displaced considerably
toward the left axilla.

(cT) I have mentioned causes tending to push the heart to the
ri'/ltt, to the left, or upward. Occasionally the heart is pushed
<lnirnii-<ird by an aneurismal tumor or a neoplasm of the mediasti-
num. In these cases there is usually more or less displacement to
the left as well. In old age the aorta sags or stretches a little,
and hence the apex beat may descend to the sixth interspace. A
similar stretching of the aorta may be produced by the weight of
a hypertrophied heart

(e) Displacement of the cardiac impulse resulting from adhesions
of the pericardium, or of the pleura, with subsequent contraction,
occurs m fibroid jththisis and in some cases of long-standing disease
of the pleura. Through the effect of negative pressure the heart
may be sucked into the space formerly occupied by a portion of the
lung, when the latter has become contracted by disease. It seems
likely, however, that in the majority of cases adhesions between
the pleura and pericardium play a part in such displacement. By
these means the heart may be displaced to the right of the sternum,
as it is by left-sided pleuritic effusion. It is often drawn upward

INSPECTION. 31

as well as to the right in such cases by the contraction which takes
place in the upper part of the lung. More rarely we may see the
heart drawn toward the left clavicle in fibroid phthisis of the left
apex.

(f) Distortion of the thorax due to spinal curvature or other
causes may bring about a considerable displacement of the heart
from its normal position.

(</} Dexti-ocardta and Situs Inversus. In rare cases a displace-
ment of the apex impulse to the right of the sternum may be due
either to a transjjosition of all viscera [the liver being found upon
the left, the spleen upon the right, etc.], or to dextrocardia , in which
the heart alone is transposed while the other viscera retain their
normal places (see Fig. 138, p. 302).

Summary.

The apex impulse is displaced by

(a) Hypertrophy and dilatation of the heart.

(l>) Pressure from below the diaphragm.

(d) Aneurism, mediastinal growths, and sagging of the aorta.

(e) Fibroid phthisis.
(/) Spinal curvatiire.

(<7) Transposition of the heart or of all the viscera.

(3) Apex Retraction.

Before leaving the subject of the cardiac impulse it seems best
to speak of those cases in which during systole we see a retraction
of one or more interspaces at or near the point where the cardiac
impulse normally appears.

(a] In by far the greater number of instances such retraction is
due to negative pressure produced within the chest by the vigorous
contraction of a more or less hypertrophied and dilated heart. In
these cases the retraction is usually to be seen in several inter-
spaces. Such retraction is not at all uncommon and usually at-
tracts no attention.

(b) In rarer cases several interspaces, both in the precordial

32 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

region and in the left lower axilla and back, may be drawn in as
a result of adhesions between the pericardium and the chest wall,
such as form in cases of adherent pericardium and fibrous medias-
tinitis (see below, pages 216 and 295).

(4) Epigastric Pulsation.

In a considerable portion of healthy adults a piilsation at the
epigastrium synchronous with the systole of the heart is to be seen
from time to time. Such pulsation has often been treated as evi-
dence of hypertrophy of the right ventricle of the heart, but this I
believe to be an error. It is not at all uncommon to find, post mor-
tem, considerable hypertrophy of the right ventricle in cases in
which during life no epigastric pulsation has been visible, while, on
the other hand, the heart is frequently found normal at autopsy in
cases in vhich during life there has been marked epigastric pulsa-
tion. In some cases such pulsation is to be explained as the trans-
mission of the heart's impulse through the liver, or as a lifting of
that organ by the movements of the abdominal aorta. In other
cases it is more difficult to "explain.

(5) Visible Pulsations due to Uncovering of J'ortlons of the Jfi >/i'f
Normally Covered \j the Linn/s.

One of the commonest causes of visible pulsations in parts of
the chest where normally none is to be seen is retract I on <>f the
Ininj.

(a) It is in chlorosis, perhaps, that we most frequently see
such pulsations. In that disease, as in other' debilitated states, the
lungs are often not adequately expanded owing to the superficiality
of the respiration, and accordingly their margins do not cover as
much of the surface of the heart as they do in healthy adults.
This results in rendering visible, in the second, third, or fourth left
interspace near the sternum, pulsations transmitted from the conus
arteriosus or from the right ventricle. Less commonly, similar pul-
sations may be seen on the right side of the sternum.

(l>) A rarer cause of retraction of the lungs is fibroid phthisis
or chronic interstitial pneumonia. In these diseases a very large

INSPECTION.

area of pulsation may be seen in the precordial region owing to the
entire uncovering of the heart by the retracted lung, even when the
heart is not drawn out of its normal position.

VIII. ANEURISM AND OTHER CAUSES OF ABNORMAL THORACIC

PULSATION.

So far I have spoken altogether of pulsations transmitted di-
rectly to the thorax by the heart itself, but we have also to bear in

FIG. ~'S. Position When Looking forSlight Aneurisinal Pulsation.

mind that a dilated aorta may transmit to the chest wall pulsations
which it is exceedingly important for us to recognize and properly to
interpret. No disease is easier to recognize than aneurism when the
groAvth has perforated the chest wall and appears as a tumor exter-
nally, but it is much more important as well as much more difficult
to recognize the disease w r hile it is confined within the thorax. In
such cases, the movements transmitted from the aorta to the chest
wall may be so slight that only the keenest and most thorough in-
spection controlled by palpation will detect them. When slight
pulsations are searched for, the patient should be put in a position
3

34 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

shown in Fig. 28, and the observer should place himself so that his
eye is as nearly as possible on a level with the chest and looks
across it so that he sees it in profile. In this position he can make
out pulsations which are totally invisible if the patient sits facing
the light.

Pulsations due to aneurism are most apt to be seen in the first
or second right interspace near the sternum, and not infrequently
the clavicle and the adjacent parts may be seen to rise slightly with
every beat of the heart, but in any part of the chest wall pulsa-
tions due to an aneurism are occasionally to be seen, and should be
looked for scrupulously Avhenever the symptoms of the case suggest
the possibility of this disease (see below, p. 221).

Pulsating Pleurisy.

In cases of purulent pleurisy in which the pus has worked its
way out betwen the ribs so that it is covered only by the skin and
subcutaneous tissues, a pulsation transmitted from the heart may
become visible, and the resemblance to the pulsation seen in aneu-
rism may be confusing. Such pulsation is apt to be seen in the
upper and front portions of the chest. Very rarely a pleuritic effu-
sion which has not burrowed into the chest wall may transmit to
the latter a wavy movement corresponding to the motions set up
in the fluid by the cardiac contractions.

IX. INSPECTION OF THE PERIPHERAL VESSELS.

In a work dealing with diseases of the heart and lungs it is im-
possible to avoid reference to vascular phenomena apparent in the
neck or in the extremities, since such phenomena have a very direct
bearing upon the interpretation of the conditions obtaining within
the chest. Inspection plays a very large part in the study of these
vascular phenomena. We should look for :

() Venous phenomena.

() Arterial phenomena.

INSPECTION. 35

(a) Inspection of the Veins.

1. The condition of the veins of the neck is of considerable im-
portance in the diagnosis of diseases of the heart and lungs. Where
the tissues of the neck are more or less wasted the veins may be
quite prominent even when no disease exists within the chest, and
in such cases they may be more or less distended during each expi-
ration, especially if dyspnoea or cough is present. If the veins
are completely emptied during each expiration and on both sides of
the neck, we can usually infer that there is an overdistention of the
right side of the heart. When a similar phenomenon occurs on
one side only, it may mean pressure upon one innominate vein. So
far I have spoken of venous changes synchronous with respiration,
but we may have also

2. A presystolic pulsation or undulation seen either in the ex-
ternal jugular vein or in the bulbus jugularis between the two
attachments of the stern oniastoid muscles. Such pulsation or
undulation, which is to be seen just before each systole of the
heart, is not necessarily anything abnormal and must be carefully
distinguished from

3. Systolic venous pulsation, such as occurs in one of the most
serious valvular diseases of the heart tricuspid re gurgitation. '
Systolic venous pulsation is more often seen upon the right side
than upon the left side of the neck. There may be a wave during
the systole of the auricle and another during the systole of the ven-
tricle, the latter closely following the former. In any case in
which a doubt arises whether a pulsation in the veins of the neck
is due to tricuspid regurgitation, it is well to try the experiment of
emptying the vein by stroking it from below upward. If it imme-
diately fills from below, we may be practically certain that tricus-
pid regurgitation is present. In the vast majority of cases of ve-
nous pulsation due to other causes or occurring in healthy persons

1 A pulsating carotid may transmit an up-and-down motion to the veins
overlying it. In such cases, if the veins be emptied by "milking" them up-
ward, they will not refill from below.

36 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

a vein will not refill from below if emptied in the manner above
described.

4. Rarely, superficial veins may be seen to pulsate in other parts
of the body, especially in aortic regurgitation, and occasionally
large and tortuous veins may be seen pulsating upon the chest wall,

FIG. 29. Tortuous Veins on Chest and Abdomen.

representing an attempt at collateral circulation when one or the
other vena cava is compressed (Fig. 29).

(&) Arterial Phenomena.

1. In thin or nervous persons pulsations are not infrequently to
be seen in the carotids independent of any abnormal condition of
the heart.

2. Very violent throbbing of the carotids, more noticeable than

INSPECTION.

that seen in health, occurs in many cases of aortic regurgitation
and occasionally in simple hypertrophy of the heart without any
valvular disease. From the same causes, visible pulsation may
occur in the subclavian, axillary, brachial, and radial arteries, as
well as in. the large arterial trunks of the lower extremity.

I lately examined a blacksmith whose heart was considerably
enlarged by hard work, but without any valvular disease. Pulsa-

FIG. 30. Enlarged Tortuous Brachial Arteries (Arterio-sclerosis).

tion was violent in all the peripheral arteries which I have just
named.

3. In arterio-sclerosis occurring in spare, elderly men, with or
without aortic regurgitation, one often notices a lateral excursion of
the tortuous brachial arteries synchronous with every heart beat.
An up-and-down pulsation may occur at the same time. Not infre-
quently the arteries which are stiffened by deposition of lime salts
(see below, page 55) stand out visibly as enlarged, tortuous cords
upon the temple and along the inner side of the biceps muscle,
(see Figs. 30 and 31) and occasionally the course of the radial artery

38 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

may be traced over a considerable distance in the forearm. In rare
cases inequalities produced in the arterial wall by deposition of
lime salts may be visible as well as palpable.

If a microscopic slide is placed against the mucous membrane of
the lower lip so as partially to blanch its surface, one may see, with

FIG. 31. Enlarged and Tortuous Brachial Artery (Arteriosclerosis) .

each beat of the heart (in cases of aortic re gurgitation and sometimes
in other conditions), a delicate flushing of the blanched surface be-
neath the glass slide. The same pulsation is sometimes to be ob-
served under the finger nails, or may be still better brought out by
drawing a pencil or other hard substance across the forehead so as
to cause a line of hypersemia, at the edge of which the systolic flush-
ing occurs. This phenomenon will be referred to again when we
come to speak of aortic regurgitation. Here it suffices to say that
it is not in any way peculiar to that disease, and occurs occasion-

INSPECTION. 39

ally in health or in conditions associated with low tension in the
peripheral arteries, as well as in any area of inflammatory hyper-
semia (jumping toothache, throbbing felon, etc.).

X. INSPECTION OF THE SKIX AND Mucous MEMBRANES.

Light may be thrown upon the diagnosis of diseases of the chest
by observing the color and condition of the cutaneous surfaces as
well as of the mucous membranes. We should look for the follow-
ing conditions :

(1) Cyanosis.

(2) (Edema.

(3) Pallor.
t (4) Jaundice.

(o) Scars and eruptions.

(1) Cyanosis.

By cyanosis we mean a purplish or grayish-blue tint notice-
able especially in the face, in the lips, and under the nails. There
are many degrees of cyanosis, from the slight purplish tinge of the
lips, which a little overexertion or slight exposure to cold may bring
out, up to the gray -blue color seen in advanced cases of pulmonary or
cardiac disease, or the dark reddish-blue seen in congenital malfor-
mations of the heart. Cyanosis makes a very different impression
upon us when it is combined with pallor on the one hand or with
jaundice on the other. When combined with pallor, one gets vari-
ous ashy-gray tints, while the admixture of cyanosis and jaundice
results in a color very difficult to describe, sometimes approaching
a greenish hue. The commonest causes of cyanosis are :

(a) Valvular or parietal disease of the heart.

(l>~) Emphysema.

(il) Pneumonia.

(e) Phthisis.

(/) In some persons a certain degree of cyanosis of the lips
exists despite perfect health. This is especially true of weather-
beaten faces and those of the so-called "full-blooded" type.

40 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

A rare but very striking type of cyanosis is that seen in cases
of congenital heart disease, in which the lips may be indigo blue
in color or almost black while yet no dyspnoea is present.

(2) (Edema.

CEdema, or the accumulation of serous fluid in the subcutaneous
spaces, is usually appreciated by palpation rather than by inspec-
tion, but sometimes makes the face look very puffy, especially
under the eyes This is not a common occurrence in diseases of
the chest, in connection with which such oedema as takes place is
usually to be found in the lower extremities and is appreciable
rather by palpation than by inspection. If we are not familiar with
a patient's face, we often do not perceive in it the changes of out-
line due to oedema which a friend would notice at once. Clothing
is apt to leave grooves and marks wherever it presses tightly upon
the oedematous tissues, as around the waist or over the shoulders.
In the legs, the presence of oedema may be suggested by an unnatu-
rally smooth, glossy appearance of the skin Such impressions,
however, may be false unless controlled by palpation, for simple
obesity may produce very similar appearances.

(3) Pallor.

Pallor suggests, though it does not in any way prove, anaemia,
and anaemia is a characteristic of the commonest of all diseases of
the chest phthisis. It is also seen in certain varieties of cardiac
disease. Pallor of the mucous membranes, as seen in the lips and
conjunctive, is much more apt to be a sign of real anaemia than is
pallor of the skin. At best, pallor is only a sign which suggests to
us to look further into the case in one or another direction, and of
itself proves nothing of importance.

(4) Jaundice.

The yellowish tint which appears in the skin, and especially in
the conjunctivae. when the escape of bile from the liver is hindered,
is sometimes to be seen in connection with unconipensated heart

INSPECTION. 41

disease when the liver is greatly distended by passive congestion
Pneumonia is occasionally complicated by jaundice; but beyond
this I know of no special connection between this symptom and
diseases of the chest.

(5) Scars and Eruptions.

In cases of suspected syphilis of the lung or bronchi the pres-
ence of scars and eruptions suggestive of syphilis may be useful in
diagnosis.

XI. ENLARGED G LANDS.

Routine inspection of the chest may reveal the presence of en-
larged glands in the neck or axillae, and may thereby give us a clew
to the nature of some intrathoracic disease ; for example, the pres-
ence of enlarged glands in the neck, especially if there are any
scars, sinuses, or other evidence that suppuration is going on or
has formerly taken place in them, suggests the possibility of pul-
monary tuberculosis or of an enlargement of the bronchial and nie-
diastinal glands. Again, malignant disease of the chest is some-
times associated with the metastatic nodules over the clavicle, and
a microscopic examination of them may thus reveal the nature of
the intrathoracic disease to which they are secondary. Very large
and matted masses of glands above the clavicle, which have never
suppurated and have been painless and slow in their growth, sug-
gest the presence of similar deposits in the mediastinum as a part
of the symptom complex known as "Hodgkin's disease." The
presence of a goitre or enlargement of the thyroid gland may ac-
count for a well-marked dyspnoea.

Syphilis produces general glandular enlargement ; the posterior
cervical and the epitrochlear glands are often involved, but this is
also the case in many diseases other than syphilis.

CHAPTER II.

PALPATION AND THE STUDY OF THE PULSE.

I PALPATION.

THE most important points to be determined by palpation that
is, by laying the hand upon the surface of the chest are :

(1) The position and character of the apex beat of the heart.

(2) The presence of a " thrill " (see below) .

(3) The vibrations of the spoken voice ( u tactile Jreinitus").

(4) The presence of pleuritic or pericardial friction.

Other less important data furnished by palpation will be men-
tioned later.

(1) The Afjex Seat.

(a) In feeling for the apex impulse of the heart, one should
first lay the palm of the hand lightly upon the chest just below the
left nipple. In this way we can appreciate a good deal about the
movements of the heart, and confirm or modify what we have
learned by inspection. One learns, in the first place, whether the
heart beat is regular or not, and in case it is irregular, whether the
beats are unequal in force or whether some are skipped ; further,
one gets a more accurate idea than can be obtained through inspec-
tion regarding the character of the cardiac movements. The power-
ful heaving impulse suggesting a hypertrophied heart, the diffuse
slap often felt in dilatation of the right ventricle, the sudden tap
characteristic of mitral stenosis, the deliberate thrust occasionally
met with in aortic stenosis, may be thus appreciated.

(b) After this, it is best to lay the tips of two or three fingers
over the point where the maximum impulse is to be seen, and fol-
low it outward and downward until one arrives at the point farthest
to the left and farthest down at which it is still possible to feel

PALPATION AND THE STUDY OF THE PULSE. 43

any up-and-down movement. This point usually corresponds with
the apex of the heart, as determined by percussion. It does not
correspond with the maximum cardiac impulse, but is often to be
found at least an inch farther to the left and downward (see above,
Fig. 27).

Sometimes one can localize by palpation a cardiac impulse
which is not visible ; on the other hand, in some cases we can see
pulsations that Ave cannot feel. Both methods must be used in
every case.

The results obtained by palpation and inspection of the apex
region give us the most reliable data that we have regarding the
size of the heart. Percussion may be interfered with by the pres-
ence of gas in the stomach, of fluid or adhesions in the pleural cav-
ity, or by the ineptness of the observer, but it is almost always pos-
sible with a little care to make out by a combination of palpation
and inspection the position of the apex of the heart. When we
can neither feel it nor see it, we may have to fall back upon auscul-
tation, considsring the apex of the heart to be at or near the point
at which the heart sounds are heard loudest. When endeavoring
to find the apex of the heart, we must not forget that the position
of the patient influences considerably the relation of the heart to
the chest walls If the patient is leaning toward the left or lying
on the left side, the apex will swing out several centimetres toward
the left axilla.

(2) "Thrills."

When feeling for the cardiac impulse with the palm of the
hand, we are in a good position to notice the presence or absence
of a very important physical sign to which we give the name of
"thrill." The feeling imparted to the fingers by the throat of
a purring cat is very much like the palpable " thrill " over the pre-
cordia in certain diseases of the heart to be mentioned later. It is
a vibration of the chest wall, usually confined to a small area in the
region of the apex impulse, but sometimes felt in the second right
intercostal space or elsewhere in the precordial region. This vibra-
tion or thrill almost always occurs intermittently, i.e., only during

44 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

a portion of the cardiac cycle, When felt in the apex region, it
usually occurs just before the cardiac impulse ; this fact we express
by calling it a "presystolic tin-ill"; but occasionally we may feel a
systolic thrill at the apex one, that is, which accompanies the car-
diac impulse. The word thrill should be used to denote only a
purring, vibrating sensation communicated to the fingers by the
chest wall. It is incorrect to speak of a thrill as if it were some-
thing audible.

We must also distinguish a purring thrill from the slight shud-
der or jarring which often accompanies the cardiac impulse in func-
tional neuroses of the heart or in conditions of mental excitement.

As a rule we can appreciate a thrill more easily if we lay the
fingers very lightly upon the chest, iising as little pressure as pos-
sible. Firm pressure may prevent the occurrence of the vibrations
which we desire to investigate. Of the thrills felt over the base of
the heart, more will be said in Chapter VII.

(3) Vibrations Communicated to the Chest Wall by the Voice.

" Tactile fremitus " is the name given to the sense of vibration
communicated to the hand if the latter is laid upon the chest while
the patient repeats some short phrase of words. The classical
method of testing tactile fremitus is to ask the patient to count
"one, two, three," or to repeat the words "ninety-nine " w r hile the
palm of the hand is laid flat upon the chest. The amount of fre-
mitus to be obtained over a given part of the thorax varies, of course,
according to the loudness of the words spoken, and is influenced
also by the vowels contained in them. A certain uniformity is ob-
tained by getting the patient to repeat always the same formula.
Thus, he is likely to use the same amount of force each time he re-
peats them and to use approximately the same pitch of voice.

Other things being equal, the fremitus is greater in men than
in women, in adults than in children, and is more marked in those
whose voices are low pitched than in those whose voices are rela-
tively shrill The amount of fremitus also varies widely in differ-
ent parts of the healthy chest A glance at Fig 32 will help us to
realize this The parts shaded darkest communicate to the fingers

PALPATION AND THE STUDY OF THE PULSE. 45

the most marked fremitus, while in the parts not shaded at all, lit-
tle or no fremitus is felt. Intermediate degrees of vibration are
represented by intermediate tints of shading. From this diagram
we see at once (a) that the maximum of fremitus is to be obtained
over the apex of the right lung in front, (b) that it is greater in the
upper part of the chest than in the lower, and somewhat greater
throughout the right chest than in corresponding parts of the left.

FIG. 32. Distribution of Tactile Fremitus.

This natural inequality of the two sides of the chest cannot be too
strongly emphasized.

Comparatively little fremitus is to be felt over the scapulae be-
hind, and still less in the precordial region in front. The outlines
of the lungs can be quite accurately mapped out by means of the
tactile fremitus in adults of low-pitched voice. In children, as has
been already mentioned, fremitus is usually very slight and may be
entirely absent, and in many women it is too slight to be of any
considerable diagnostic value. Again, some very fat persons and
those with thick chest walls transmit but little vibration to their
chest walls when they speak. On the other hand, in emaciated
patients or in those ivith thin-walled, flexible chests, the amount
of fremitus is relatively great.

46 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Bearing in mind all these disparities disparities both between
persons of different age and different sex, and between the two

sides of the chest in any one
person we are in a position to
appreciate the modifications to
which disease gives rise and
which may be of great impor-
tance in diagnosis. These vari-
ations are :

() Diminution or absence
of fremitus.

(i) Increase or absence of
fremitus.

(a) If the lung is pushed
away from the chest wall by the
presence of air or fluid in the
pleural cavity, we get a diminu-
tion or absence of tactile fremi-
tus diminution where the layer
of fluid or air is very thin, ab-
sence where it is of considerable
thickness.

(//) Solidification of the lung
due to phthisis or pneumonia is
the commonest cause of an ///-

FIG. 33. Showing Point (F) at Whk-b Pleunil . ,., ., --,

Friction is Most often Heard. crease in tactile f remitus.

ther details as to the variations

in amount of fremitus in different diseases may be found in later
chapters of this book.

(4) friction, PImral or 7V/vV<7/v//W.

In many cases of inflammatory roughening of the pleural sur-
faces (" dry pleurisy ") a grating or rubbing of the two surfaces
upon each other may be felt as Avell as heard during the movements
of respiration, and especially at the end of inspiration. Such fric-
tion is most often felt at the bottom of the axilla, on one side or

PALPATION AND THE STUDY OF THE PULSE.

the other, where the diaphragmatic pleura is in close apposition
with the costal layer (see Fig. 33, p. 46).

Similarly, in roughening of the pericardia! surfaces ("dry" or
" plastic " pericarditis) it is occasionally possible to feel a grating
or rubbing in the precordial region more or less synchronous with
the heart's movements. Such friction is most often to be felt in
the region of the fourth left costal cartilage (see Fig. 34).

Palpable friction is of great value in diagnosis because it is a
sign about which we can feel no doubt ; as such it frequently con-

FIG. 34. Showing Point (P) at Which Perieardial Friction is Most Often Heard.

firms our judgment in cases in which the auscultatory signs are less
clear. Friction sounds heard with the stethoscope may be closely
sinmlated by the rubbing of the stethoscope upon the skin, but pal-
pable friction is simulated by nothing else, unless occasionally by

(5) Palpable Rales.

Occasionally coarse, dry rales communicate a sensation to the
hand placed upon the chest in the region beneath which the rales
are produced ; to the practised hand this sensation is quite differ-
ent from that produced by pleural friction, although the difference
is hard to describe.

48 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(6) Tender points upon the thorax.

In intercostal neuralgia, dry pleurisy, necrosis of a rib, and
sometimes in phthisis, one finds areas of marked tenderness in
different parts of the chest. The position of the tender points in
intercostal neuralgia generally corresponds with the point of exit
of the intercostal nerves. These points are shown in Fig. 35.

The tenderness in phthisis is most apt to be in the upper and
front portions of the chest. In neurotic individuals we sometimes
find a very superficial tenderness over parts of the thorax ; in such

FIG. 35. Showing Points of Exit of the Intercostal Nerves.

cases pain is produced by very light pressure, but not by firm press-
ure at the same point.

(7) The presence of pulsations in parts of the chest where nor-
mally there should be none is suggested by inspection and con-
firmed by palpation. It is not necessary to repeat what was said
above as to the commonest causes of such abnormal pulsations.
When searching for slight, deep-seated pulsation (>.</., from an
aortic aneurism), it is well to use bimanual palpation, keeping one
hand on the front of the chest and the other over a corresponding
area in the back.

(8) Fluctuation or elasticity in any tumor or projection from

PALPATION AND THE STUDY OF THE PULSE. 49

the chest is a very important piece of information which palpation
may give us.

(9) The ' temperature and quality of the skin are often brought
to our attention during palpation. After a little practice one can
usually judge the temperature within a degree or two simply from
the feeling of the skin. Any roughness or dryness of the skin
(myxcedema, diabetes) is easily appreciated as we pass the hand over
the surface of the thorax or down the arms. The same manipula-
tion often brings to our attention in cases of alcoholism an unusu-
ally smooth and satiny quality of the cutaneous surface.

II. THE PULSE.

Fifty years ago the study of the pulse furnished the physician
with most of the available evidence regarding the condition of the
heart. At present this is not the case. With the increase of our
knowledge of the direct physical examination of the heart, the
amount of information furnished exclusively by the pulse has pro-
portionately decreased, until to-day, I think, it is a fact that there
is but little to be learned by studying the pulse which could not be
as well or better ascertained by examining the heart itself.

Nevertheless, the radial pulse is still an important factor in
diagnosis, prognosis, and treatment, and will remain so, because it
gives us quickly, succinctly, and in almost every case a great deal
of valuable information which it would take more time and trouble
to obtain by examining the heart itself. As we feel the pulse, we
get at once a fact of central importance in the case ; by the pulse
the steps of our subsequent examination are guided. In emergen-
cies or accidents the pulse gives us our bearings and tells us whether
or not the patient's condition is one demanding immediate succor
e.g., hypodermic stimulation and whether the outlook is bright or
dark. To gather this same information by examining the heart
itself would involve losing valuable time.

Again, when one has to see a large number of patients in a
short time, as in visiting a hospital ward or on the crowded days
of private practice, the pulse is an invaluable short cut to some of
the most important data.
4

50 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Moreover, there are some important inferences which the pulse
and only the pulse enables us to make. They are not numerous, but
their value may be great. Delay in one radial pulse when taken in
connection with other signs may furnish decisive evidence of aneu-
rism of the aortic arch ; aortic stenosis is a lesion which cannot be
diagnosed unless the pulse shows certain characteristic features;
arterial degeneration may betray its presence chiefly in the periph-
eral arteries.

Since, then, the condition of the pulse furnishes information of
crucial importance in a few diseases, and is a quick, reliable, and
convenient indication of the general condition of the circulation in
all cases, it is essential that we should study it most carefully both
in health and in disease.

How to Feel the Pulse.

(a) We usually feel for the pulse in the radial artery because
this is the most superficial vessel which is readily available. Oc-
casionally, as when the wrists are swathed in surgical dressings or
tied up in a straight-jacket, we make use of the temporal, facial,
or carotid arteries.

(b) Both radials should always be felt at the same time. By
making this a routine practice many mistakes are avoided and any
difference in the two pulses is appreciated.

1. The rate of the pulse.

2. The rhythm of the pulse (regular or irregular).

3. The amount of force necessary to obliterate it (compressi-
Ulity}.

4. The size and shape of the pulse wave.

5. The extent to which the artery collapses between beats
(tension) .

6. The size and position of the artery.
1. The condition of the artery walls.

Each of these points will now be considered in detail.

PALPATION AND THE STUDY OF THE PULSE. 51

1. The Rate of the Pulse.

In the adult male the pulse averages 72 to the minute, in the
female 80. In children it is considerably more frequent. At birth
it averages about 130, and until the third year it is usually above
100. In some families as low pulse, 60 or less, is hereditary ; on the
other hand, it is not very rare to observe a permanent pulse rate of
110 or more in a normal adult (see below, p. 202). Exercise or emo-
tion quickens the pulse very markedly, and after food it is somewhat
accelerated. Some account of the causes of pathological quicken-
ing or slowing of the pulse will be found 011 pages 202 and 203.

2. Rhythm.

The pulse may be irregular in force, in rhythm, or (as most
commonly happens) in both respects. As a rule, irregularities in
force are the more serious. Interinittence or irregularity in rhythm
alone, means that the heart skips one or more beats at regular or
irregular intervals. This may be a mere idiosyncrasy not associ-
ated with any evidence of disease. I have known several instances
in which a perfectly sound person has been aware of such an irregu-
larity throughout life the heart dropping regularly every third or
fourth beat. Such rhythmical intermittence in health is not un-
common.

When beats are dropped, not at fixed intervals, but irregularly,
the pulse waves usually vary in force as well. This combination
of irregular cardiac rhythm with variations in the strength of the
individual beats is very rarely seen in health and usually points to
functional or structural disease of the heart.

Special types of irregularity will be discussed later.

In general it may be said (a) that irregularity in the force of
the pulse beats is a serious sign, if overexertion and temporary
toxic influences (tobacco, tea, etc.) can be ruled out; (b] that it is
far more serious when occurring in connection with diseases of the
aortic valve than in mitral disease ; and (c) that it often occurs in
connection with sclerosis of the coronary arteries and myocarditis.

1 t-i I C

52 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

3. Compressibility.

There is no single datum concerning the pulse more important
than the amount of force needed to obliterate its beat. We have
110 more accurate method of measuring the compressibility of the
pulse than the following : Let the tips of three fingers rest as usual
on the radial artery Then gradually increase the pressure made
upon the vessel with the finger nearest the patient's heart until the
pulse wave is arrested and cannot be felt by the other fingers which
rest loosely on the artery. The degree of force necessary to arrest
the wave varies a great deal in different cases and at different times
of day, but by trying the above manoeuvre day after day in as many
cases as possible one conies to possess a fairly accurate mental
standard or picture of the compressibility of the average pulse, and
is then able to estimate in any given case whether it is more or
less compressible than usual.

The compressibility of the pulse is a rough measure of the mus-
cular power of the heart's beat, and therefore gives us direct infor-
mation about this important element in the patient's condition.

4- The Size and Shape of tlii Pulse War/'.

Of the use of the sphygniograph for representing pulse waves I
shall speak later. The points discussed in this section are appre-
ciable to the fingers.

I. The size of the pulse wave the height to w r hich it lifts the
finger depends on two factors :

(a) The force of the cardiac contractions.

(b) The tightness or looseness of the artery (tension).

If the arteries are contracted and small, the pulse wave corre-
sponds, while if they are large and relaxed, it needs only a moder-
ate degree of power in the heart to produce a high pulse wave. If
the tension remains constant the size of the pulse wave depends on
the force of the heart's contraction. If the heart power remains
Constant, the size of the pulse wave depends on the degree of vas-
cular tension. Vascular tension is estimated in ways to be de-
scribed presently, and after allowing for it, we are enabled to esti-

PALPATION AND THE STUDY OF THE PULSE. 53

mate the power of the heart's contractions from the height of the
pulse wave.

II. The shape of the pulse wave is also of importance.

(a) It may have a very sharp summit, rising and falling back
again suddenly; this is known as an ill-sustained pulse, and may
be due to a lack of sustained propulsive power in the contracting
heart muscle, to low vascular tension, or to a combination of the
two causes. A weak heart when stimulated by alcohol often pro-
duces such a pulse wave deceptively high and giving at first an
impression of power in the heart wall, but ill sustained and easily
compressible. An exaggeration of this type of pulse is to be felt
in aortic re gurgitation (see Fig. 102).

(7) In sharp contrast with the above is the pulse wave which
lifts the finger gradually and slowly, sustains it for a relatively
long period, and then sinks gradually down again. Such a pulse
Avith a " long plateau " instead of a sharp peak is to be felt most
distinctly in aortic stenosis, less often in mitral stenosis and other
conditions (see Fig. 107).

(c) The dicrotic pulse Avave is one in Avhich the secondary Avave,
which the sphygmograph shoAvs to be present in the normal pulse,
is much exaggerated, so that a distinct " echo " of the primary
Avave is felt after each beat. If the heart is acting rapidly, this
dicrotic wave does not have time to fall before it is interrupted by
the primary wave of the next beat, and so appears in the sphygrno-
graphic tracing as a part of the up-stroke of the primary wave.
This is known as the " ana erotic pulse."

(d) The shape of the hiyh-temlnn pulse ware will be described
in the next paragraph.

5. Tension.

The degree of contraction of the vascular muscles determines
the size of the artery and (to a great extent) the tension of the
blood Avithin it. But if the heart is acting feebly, there may be so
little blood in the arteries that even when tightly contracted they
do not subject the blood within them to any considerable degree of
tension. To produce high tension, then, we need tAvo factors: a

54 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

certain degree of power in the heart muscle, and contracted arteries.
To produce low tension we need only relaxation of the arteries, and
the heart rnay be either strong or weak.

The pulse of low tension collapses between beats, so that the ar-
tery is less palpable than usual or cannot be felt at all. Normally,

FIG. 36. Sphygmographic Tracing of Low Tension Pulse.

the artery can just be made out between beats, and any consider-
able lowering of arterial tension makes it altogether impalpable
except during the period of the primary wave and of the dicrotic
wave, which is often very well marked in pulses of low tension.
The shape of the wave under these conditions has already been
described (see Fig. 36).

The pulse of high tension is perceptible between beats as a dis-
tinct cord which can be rolled between the fingers, like one of the ten-

FIG. 37. Sphygmographic Tracing of High Tension Pulse.

dons of the wrist. It is also difficult to compress in most cases, but
this may depend rather on the heart's power than on the degree
of vascular tension. The pulse wave is usually of moderate height
or low, and falls away slowly with little or no dicrotic wave (see
Fig. 37).

PALPATION AND THE STUDY OF THE PULSE. 55

6. The Size and Position of the Artery.

I have often known errors to occur because a small artery is
mistaken for a small pulse u-ave. The size of the branches of the
arterial tree varies a great deal in different individuals of the same
weight and height, and if the radial is unusually small and a hur-
ried observation gives us the impression (true, so far as it goes) that
there is very little in the way of a pulse to be felt, we are apt to
conclude (wrongly, perhaps) that the heart's work is not being
properly performed. The effort to obliterate such a pulse, how-
ever, may set us right by showing that despite the small size of the
vessel (and consequently of the pulse wave) it takes as much force
as it normally does to obliterate it. Thus, a small pulse wave (in a
congenitally small artery) may be distinguished from a weak pulse.
From the contracted artery of high vascular tension we distinguish
the conyenitally small artery because the latter is not to be rolled
beneath the fingers, and is not more than normally palpable between
the pulse beats.

Not inf requently the nurse reports in alarm that the patient has
no pulse, when in reality the pulse is excellent but the artery mis-
placed so as to be impalpable in the ordinary situation. It may be
simply more deeply set than normal, so that the fingers cannot get
at it, or it may run superficially over the end of the radius toward
the "anatomical snuff box." Other anomalies are less common.
As a rule, the other radial artery is normally placed and can be used
as a standard, but occasionally both radials are anomalous and we
may be compelled to use the temporal or facial instead.

7. The Condition of the Artery Walls.

Arterio-sclerosis is manifested in the peripheral arteries in the
following forms :

(a) Simple stiffening of the arteries without calcification.

(6) Tortuosity of the arteries.

(c] Calcification.

Simple stiffening without calcification is due to fibrous thicken-

56 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

ing of the intima and produces a condition of the arteries not al-
ways to be distinguished from high tension. The artery can be
rolled under the fingers, stands out visibly between the heart's
beats, but is not incompressible, has a smooth surface, and is not
always tortuous. If it is tortuous as well as stiff, we may con-
clude that there is endarteritis at any rate, whether or not there is
increased tension as well. In the vast majority of cases the two
conditions are asssociated and do not need to be distinguished.

The normal radial artery is straight; hence any deviation is
evidence of changes in its walls and is easily, recognized as we run
our fingers up and down the vessel.

Calcification of the radial produces usually a leading of its sur-
face. As we move the fingers along the artery, quickly and with
very slight pressure, a series of transverse ridges or beads can be
felt. The qualities of the pulse wave within can usually be appre-
ciated fairly well, in this type of artery, but in very advanced cases
the calcification is diffuse and converts the radial into a rigid "pipe
stern " absolutely incompressible unless we break the calcified
coat and easily mistaken for a tendon. In such an artery no
pulse can be felt.

Such are the points to be observed in feeling the pulse. To
enumerate the characteristics of the pulse in the many diseases in
which it affords us valuable information is beyond the scope of this
book. The qualities to be expected in the pulse in connection with
the different diseases of the heart are described in the sections on
those diseases. Here it will suffice to enumerate some of the con-
ditions in which vascular tension is usually increased or diminished.

Low tension is produced by moderate exercise, by warmth (e.g.,
a warm bath), by food. Among pathological conditions we may
mention especially debilitated states, mental worry, and fever.

High tension is produced by cold (e.g., cold bathing, malarial
chills), and by constipation (in some cases). As a rule, the tension
of the pulse increases with age and is high after the fiftieth year.
Hysteria and migraine are often associated with increased vascular
tension. Most frequent among pathological conditions as causes

PALPATION AND THE STUDY OF THE PULSE. 57

of high tension are chronic nephritis and arterio-sclerosis with the
various diseases in which arterio-sclerosis is a factor (gout, alcohol-
ism, lead poisoning, diabetes of fat old people, chronic bronchitis
with emphysema).

Among valvular heart lesions, aortic and mitral stenosis are espe-
cially apt to be associated with increased vascular tension.

CHAPTER III.

PERCUSSION

I. TECHNIQUE.

THERE is no other method of physical examination which needs
so much practice as percussion, and none that is so seldom thor-
oughly learned. Many physicians never succeed in acquiring a
facility in the use of it sufficient to make them rely upon their
results. Undoubtedly one of the greatest difficulties arises from
the necessity of being at once active and passive at once the per-
cussor and the one who listens to the percussion. Students half
unconsciously get to treat the percussion as an end in itself, and
hammer away industriously without realizing that two-thirds of the
attention must be given to listening, while the percussion itself
should become semi-automatic.

It is undoubtedly an advantage to possess a musical ear, but this
is by no means a necessity. Some of the most accurate percussors
that I know possess absolutely no musical ear no ear, that is, for
pitch and form their judgments in percussing upon the quality or
intensity of the note, and upon the sense of resistance.

In this country practically all percussion is done with the rin-
gers ; in Germany instruments are still used to a considerable ex-
tent (see Appendix).

('?) Mediate and Im ni]<nte Percussion.

Percussion may be either " mediate " or " immediate, " the lat-
ter term referring to blows struck directly upon the chest with the
flat of the hand, or upon the clavicles with the tip of the second
finger.

PERCUSSION.

(It) Methods.

Mediate percussion (which is iised ninety-nine hundredths of
the time) is performed as follows :

The patient should either lie down or sit with his back against
some support. The reason of this is that for good percussion one

FIG. 38. Position of the Hands When Percussing the Right Apex.

needs to press very firmly with th'e middle finger of the left hand
upon the surface of the chest, so firmly that if the patient is sitting
upon a stool without support for his back, it will need considerable
exertion upon his part to avoid losing his balance.

60 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

In percussing the front of the chest it is important to have the
patient sitting or lying in a symmetrical position that is, without
any twist or tilting to one side. His head should point straight
forward and his muscles must be thoroughly relaxed. Many pa-
tients, when stripped for examination, swell out their chests and

FIG. 39. Position of the Hands When Percussing the Left Apex.

sit up with a military erectness. The muscular tension thus pro-
duced modifies the percussion note and causes an embarrassing
multitude of muscle sounds which greatly disturb auscultation.

Having placed the patient in an easy and symmetrical position,
our percussion should proceed according to the following rules :

(1) Always press as firmly as possible upon the surface of the

PERCUSSION.

chest with the second finger of the left hand ' on the dorsum of
which the blow is to be struck. Kaise the other fingers of the left
hand from the chest so as not to interfere with its vibrations.

(2) Strike a quick, perpendicular, rebounding blow with the tip
of the second finger 2 of the right hand upon the second finger of the
left just behind the nail, imitating as far as possible with the right
hand the action of a piano-hammer. The quicker the percussing

FIG. 40. The Right Way to Percuss i. e.. From the Wrist.

finger gets away again after striking, the clearer will be the note
obtained.

(3) Let all the blows struck in any one part of the chest be
uniform in force.

^eft-handed percussors will, of course, keep the right hand upon the
chest and strike with the left.

'- When percussing the right apex I prefer to strike upon the thumb (see
Figs. 38 and 39) as it is almost impossible when standing directly in front
of the patient to fit any of the fingers comfortably into the right supraclavicular
fossa.

62 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(4) Strike from the wrist and not from the elbow (see Figs. 40
and 41). The wrist must be held perfectly loose.

(5) Keep the percussing finger bent at a right angle as in Fig.
42.

The force to be used in percussion depends upon the purpose

FIG. 41. The Wrong Way to Percuss f. e., From the Elbow.

for which the percussion is used that is, upon what organ we are
percussing and also upon the thickness of the muscles covering
that part of the chest. For example, it is necessary to percuss
very strongly when examining the back of a muscular man, where
an inch or two of muscle intervenes between the finger on which

PERCUSSION.

we strike and the lung from which we desire to elicit a sound.
Over the front of the chest and in the axillae the muscular covering
is much thinner, and hence a lighter blow suffices. In children or
emaciated patients, or in any case in which the muscular develop-
ment is slight, percussion should be as light as is sufficient to elicit a
clear sound. Heavy percussion is sometimes necessary but always
unsatisfactory, in that the sound which it elicits comes from a rela-
tively large area of the chest and does not therefore give us infor-

Fio. 42. Proper Position of the Right Hand During Percussion.

rnation about the condition of any sharply localized area. If a car-
penter, in tapping the wall to find the position of the studs, strikes
too hard, he will fail to find the beam, because the blow delivered
over the spot behind which the beam is situated is so forcible as to
bring out the resonance of the hollow parts around. It is the same
with medical percussion. Heavy percussion is always inaccurate.'
It may be necessary where the muscles are very thick, but its value

1 See also below, page 76, the lung reflex.

64 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

is then proportionately diminished. On the other hand, it is pos-
sible to strike so lightly that no recognizable sound is elicited at
all. The best percussion, therefore, is that which is just forcible
enough to elicit a clear sound without setting a large area of chest
wall in vibration.

The position of the patient above described applies to percus-
sion of the front. AVhen we desire to percuss the back, it is im-

FIG. 43. Proper Position of the Patient During Percussion of the Back.

portant to get the scapulae out of the way as far as possible, since
we cannot get an accurate idea of sounds transmitted through them.
To accomplish this, we put the patient in the position shown in
Fig. 43, the arms crossed upon the chest and each hand upon the
opposite shoulder. The patient should be made to bend forward ;
otherwise the left hand of the percussor will be uncomfortably bent
backward and his attention thereby distracted (see Fig. 44).

When the axillae are to be percussed, the patient should put the
hands upon the top of the head.

PERCUSSION.

(I) Auscultatory Percussion.

If while percussing one auscults at the same time, letting the
chest piece of the stethoscope rest upon the chest, or getting the
patient or an assistant to hold it there, the sounds produced by
percussion are greatly intensified, and changes in their volume,
pitch, or quality are very readily appreciated. The blows must be

FIG. 44. Wrong Position for Percussing the Back. The patient should be bent forward.

very lightly struck, either upon the chest itself or upon the finger
used as a pleximeter in the ordinary way. Some observers use a
short stroking or scratching touch upon the chest itself without
employing any pleximeter.

This method is used especially in attempting to map out the
borders of the heart and in marking the outlines of the stomach.
In the hands of skilled observers it often yields valuable results,
5

66 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

but one source of error must be especially guarded against. T/tf
line alonrj which we percuss, when approaching n organ whose bor-
ders ive desire to mark out, must neither (ijij/t'nuch the chest jiiece of
the stethoscope nor recede from it. In other words, the line along
which we percuss must always describe a segment of a circle whose
centre is the chest piece of the stethoscope (see Fig. 45). If we
percuss, as we ordinarily do, in straight lines toward or away from
the border of an organ, our results are wholly unreliable since
every straight line must bring the point percussed either closer to

Percussion arc.

Chest-piece of

Stethoscope.

FIG. 45. Auscultatory Percussion, Showing the Arc along -which such Percussion should be

made.

the stethoscope or farther from it, and the intensity and quality
of the sounds conducted through the instrument to our ears vary
directly with its distance from the point percussed.

It will be readily seen that the usefulness of auscultatory per-
cussion is limited by this source of error, and that considerable
practice is necessary before one can get the best results from this
method. Nevertheless it has, I believe, a place, though not a very
important one, among serviceable methods of physical examination.

PERCUSSION.

Some German observers use a method of percussion in which
attention is fixed directly or primarily on the amount of resistance
offered by the tissues over which percussion is made. Even in or-
dinary percussion the amount of resistance is always noted by
experienced percussors, but the element in sound is usually the
main object of attention. Palpatory percussion is rather a series
of short pushes against various points on the chest wall, but some

Normal dulness

of the right apex. ~~

Liver dulness.

Deep cardiac
dulness.

Superficial cardiac
dulness.

Traube's semilu-
nar tympanitic
space.

FIG. 46. Percussion Outlines in the Normal Chest.

sound is elicited and probably enters into the rather complex judg-
ment which follows.

In this country palpatory percussion is but little employed.

II. PERCUSSION EESONANCE OF THE NORMAL CHEST.

The note obtained by percussing the normal chest varies a great
deal in different areas. In Fig. 46, the parts shaded darkest are
those that normally give least sound when percussed in the manner
described above, while from the lightest areas the loudest and clear-
est sound may be elicited.

68 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

-- Upper lobe.

(____- Splenic area.

(a) The sound elicited in the latter areas is known as normal or
"vesicular" resonance, and is due to the presence of a normal
amount of air in the vesicles of the lung underneath. If this a.ii-
containing lung is replaced by a fluid or solid medium, as in pleu-
ritic effusion or pneumonia, it is much more difficult to elicit a

sound, and such sound as is produced is
short, high pitched, and has a feeble carry-
ing power when compared with the sound
elicited from the normal lung. This
short, feeble, high-pitched sound is
known technically as a "dull" or
-- Lower lobe, "flat " sound, flatness designating
the extreme of the qualities that
characterize dulness. Over the
parts shaded dark in Fig. 46, we
normally get a dull or flat tone, the darkest
portions being flat and the others dull.
The heavy shadow on the right corresponds
to the position occupied by the liver, or
rather by that part of it which is in imme-
diate contact with the chest wall. The up-
per portion of the liver is overlapped by the
right lung (see Fig. 46), and hence at this
point we get a certain amount of resonance
on percussion, although the tone is not so
clear as that to be obtained higher up. Be-
low the sixth rib we find true flatness near
the sternum and for a few inches to the right
of this point. As.-we go toward the axilla,

the line of lung resonance slopes down, as is seen in Fig. 47. In
the back resonance extends to the ninth or tenth ribs.

^on/i"l Dull Areas.

(b) On the left side, the main dull area corresponds to the heart,
which at this point approaches the chest wall, and over the por-
tion shaded darkest is uncovered by the lung. The part here

FIG. 4". Position of the Left
Lung in the Axilla.

PERCUSSION. 69

lightly shaded corresponds to that portion of the heart which is
overlapped by the margin of the right and left lungs.

Over the portion of the heart not overlapped by the lung (see
Fig. 46, p. 67) the percussion note is nearly flat to light percus-
sion, and very dull even when strongly percussed. This little
quadrangular area is known as the "superficial cardiac space," and
the dulness corresponding to it is referred to as the "superficial"
cardiac dulness, Avhile the dulness corresponding to the outlines of
the heart itself beneath the overlapping lung margins is called the
"deep" cardiac dulness.

When the heart becomes enlarged, both of these areas, the deep
and the superficial, are enlarged, the former corresponding to the
increased size of the heart itself, while the superficial cardiac space
is extended because the margins of the lungs are pushed aside and
a larger piece of the heart wall conies in contact with the chest
wall. Accordingly, either the superficial or the deep dulness may
be mapped out as a means of estimating the size of the heart.
Each method has its advantages and its advocates. The superficial
dulness is easier to map out, but varies not only with the size of the
heart, but with the degree to which the lungs are distended with
air, or adherent to the pericardium or chest wall. What we are
percussing is in fact the borders of the lungs at this point.

On the other hand, the deep cardiac dulness is much more satis-
factory as a means of estimating the size of the heart but much
more difficult to map out. It needs a trained ear and long practice
to percuss out correctly the borders of the heart itself, especially
the right and the upper borders, since here we have to percuss
over the sternum where differences of resonance are very deceptive
and difficult to perceive.

It is a disputed point whether light or forcible percussion should
be used when AVC attempt to map out the deep cardiac dtilness.
Heavy percussion is believed by its advocates to penetrate through
the overlapping lung margins and bring out the note corresponding
to the heart beneath, a note which, they say, is missed altogether
by light percussion. On the other hand, those who employ light
percussion contend that heavy percussion sets in vibration so large

70 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

an area of lung superficially that fine distinctions of note are made
impossible (see above, p. 63).

Good observers are to be found 011 each side of this question,
and I have no doubt that either method works well in skilled
hands. Personally I have found light percussion preferable.

Whatever method we use we must percuss successive points
along a line running at right angles to the border of the organ
which we wish to outline until a change of note is perceived.
Thus, if we wish to percuss out the upper border of the liver, we
strike successive points along a line running parallel to the ster-
num and about an inch to the right of it. 1 When a change of note
is perceived, the point should be marked with a skin pencil ; then
we percuss along a line parallel to the first one, and perhaps an
inch farther out, and again mark with a dot the point at which the
note first changes. A line connecting the points so marked upon
the skin represents the border of the organ to be outlined.

If now we look at the upper part of the chest in Fig. 46, we
notice at once that the two sides are not shaded alike : the left apex
is distinctly lighter colored than the right. This is a very impor-
tant point and one not sufficiently appreciated by students. The
apex of the normal right lung is distinctly less resonant than the
apex of the left in a corresponding position.

In percussing at the bottom of the left axilla, we come upon a
small oval area of dulness corresponding to that outlined in Fig. 47.
This is the area of splenic dulness, so called, and corresponds to
that portion of the spleen which is in contact with the chest wall.
This dull area is to be made out only in case the stomach and colon
are not overdistended with air. When these organs are full of gas
as is not infrequently the case, there is no area of splenic dulness
and the whole region gives forth, when percussed, a note of a qual-
ity next to be described, namely, " tympanitic. "

(c) Tympanitic resonance is that obtained over a hollow body,
like the stomach or the colon when distended with air. It is usu-
ally of a higher pitch than the resonance to be obtained over the

1 Or we may reverse the procedure ; percuss first over the liver and then
work toward the lung above until the note becomes more resonant.

PERCUSSION. 71

normal lung, and may be elicited by percussion lighter than that
needed to bring out the lung resonance. It differs also from the
vesicular or pulmonary resonance in quality, in away easy to appre-
ciate but difficult to describe. Tympanitic resonance is usually to
be heard when one percusses over the front of the left chest near
the ensiforrn cartilage and for a few inches to the left of this point
over an area corresponding with that of the stomach more or less
distended with air. This tympanitic area, known as "Traube's
semilunar space," varies a great deal in size according to the contents
of the stomach. It is bounded on the right by the liver flatness,
above by the pulmonary resonance, on the left by the splenic clul-
ness, and below by the resonance of the intestine, which is also
tympanitic, although its pitch is different owing to the different
size and shape of the intestine.

(The right axilla shows normal lung resonance down to the
point at which the liver flatness begins, as shown in Fig. 4. )

In the back, when the scapulae are drawn forward, as shown in
Fig. 43, page 64 percussion elicits a clear vesicular resonance from top
to bottom on each side, although the top of the right lung is always
slightly less resonant than the top of the left, and sometimes the
bottom of the right lung is slightly less resonant than the corre-
sponding portion of the left, on account of the presence of the liver
on the right.

It should be remembered, however, that in the majority of cases
the resonance throughout the back is distinctly less than that ob-
tained over the front, on account of the greater thickness of the
back muscles. Yet in children or emaciated persons, or where the
muscular development is slight, there may be as much resonance
behind as in front.

Importance of Percussing Symmetrical Points. Since we depend
for our standard of resonance upon comparison with a similar spot
on the outside of the chest, it is all-important that in making such
comparisons we should percuss symmetrical points, and not, for
example, compare the resonance over the third rib in the right front
with that over the third interspace on the left, since more resonance
can always be elicited over an interspace than over a rib. This

72 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

comparison of symmetrical points, however, is interfered with by
the presence of the heart on one side and the liver on the other, as
well as by the fact that the apex of the right lung is normally less
resonant than that of the left A resonance which would be patho-
logically feeble if obtained over the left top may be normal over the
right Where both sides are abnormal, as in bilateral disease of
the lung, or where fluid accumulates in both pleural cavities, we
have to make the best comparison we can between the sound in the
given case and an ideal standard carried in the mind.

It must always be remembered that the amount of resonance
obtained at any point by percussion depends upon how hard one
strikes, as well as upon the conditions obtaining within the chest.
A powerful blow over a diseased lung may bring out more reso-
nance than a lighter blow over a normal lung. To strike with per-
fect fairness and with equal force upon each side can be learned only
by considerable practice. Furthermore, the distance from the ear
to each of the two points, the resonance of which we are compar-
ing, must be the same that is, we must stand squarely in front or
squarely behind the patient, otherwise the note coming from the
part farther from the ear will sound duller than that coming from
the nearer side.

The normal resonance of the different parts of the chest can be
considerably modified by the position of the patient, by deep breath-
ing, by muscular exertion, and by other less important conditions.
If, for example, the patient lies upon the left side, the heart swings
out toward the left axilla and its dulness is extended in the same
direction. Deep inspiration pushes forward the margins of the
lungs so that they encroach upon and reduce the area of the heart
dulness and liver dulness. After muscular exertion the lungs be-
come more than ordinarily voluminous, owing to the temporary clis-
tention brought about by the iinusual amount of work thrown upon
them.

The area of cardiac dulness is increased in any condition involv-
ing insufficient lung expansion. Thus, in children, in debility,
chlorosis, or fevers, the space occupied by the lungs is relatively
small and the dull areas corresponding to the heart and liver are

PERCUSSION. 73

proportionately enlarged. In old age, on the other hand, when the
lungs have lost part of their elasticity and sag down over the heart
and liver, the percussion dulness of these organs is reduced.

Conditions Modifying the Percussion Note in Health. The de-
velopment of muscle or fat as well as the thickness of the chest
wall will influence greatly the amount of resonance to be obtained
by percussion. Indeed, we see now and then an individual in no
part of whose chest can any clear percussion tone be elicited. In
women, the amount of development of the breasts has also great
influence upon the percussion note. In children, the note is gener-
ally clearer, and only the lightest percussion is to be used on ac-
count of the thinness of the chest wall. In old people whose lungs
are almost always more or less emphysematous, a shade of tym-
panitic quality is added to the normal vesicular resonance. The
distention of the colon with gas may obliterate the liver dulness by
rotating that organ so that only its edge is in contact with the chest
wall, and if there is wind in the stomach, a variable amount of
tympany is heard on percussing the lower left front and axilla or
even 011 the left back.

If a patient is examined while lying on the side the amount of
resonance over, the lung corresponding to the side on which he
lies is usually less than that of the side which is uppermost, because
there is more air in the latter. Whatever the patient's position,
the amount of resonance is also greater at the end of inspiration
than at the end of expiration, for the reason just given. As the
lungs expand with full inspiration, their borders move so as to
cover a larger portion of the organs which they normally overlap.
Portions of the chest which at the end of expiration are dull or
flat, owing to the close juxtaposition of the heart, liver, or spleen,
become resonant at the end of inspiration. For example, the Lower
margin of the right lung moves down during inspiration so as to
cover a considerably larger portion of the liver.

Percussion as a Means of Ascertaining the Movability of the Lung
Borders. It is often of great importance to determine not merely
the position of the resting lung but its power to expand freely.
This can be ascertained by percussion in the following way : The

74 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

lower border of the lung resonance, say in the axilla, is carefully
marked out. Then percussion is made over a point just lelotr the
level of the resting lung and at the same time the patient is directed
to inspire deeply If the lung expands and its border moves down,
the percussion note will change suddenly from dull to resonant
during the inspiration. An excursion of two or three inches can
often be demonstrated by this method, which is especially impor-
tant for the anterior and posterior margins of the lung. In the
axilla Litten's phrenic shadow will give us the same information.

The mobility of the borders of the lung, as determined by this
method, is of considerable clinical importance, for an absence of
such mobility may indicate pleuritic adhesions. Its amount de-
pends upon various conditions and varies much in different indi-
viduals, but complete absence of mobility is always pathological,

(d) Cracked-Pot Resonance

When percussing the chest of a crying child, we sometimes
notice that the sound elicited has a peculiar "chinking" quality,
like that produced by striking one coin with another, but more
muffled. The sound may be more closely imitated, and the mode
of its production illustrated, by clasping the hands palm to pabn
so as to enclose an air space which communicates with the outer air
through a chink left open, and then striking the back of the under
hand against the knee By the blow, air is forced out through the
chink with a sound like that of metallic coins struck together.

In disease, the cracked-pot sound is iisually produced over the
pulmonary cavity (as in advanced phthisis) from which the air is
suddenly and forcibly expelled by the percussion stroke.

It is much easier to hear this peculiar sound if, while percuss-
ing, one listens with a stethoscope at the patient's open mouth.
The patient himself holds the chest piece of the instrument just in
front of his open mouth, leaving the auscultator's hands free for
percussing.

PERCUSSION. 75

(e) Amphoric Resonance.

A low-pitched hollow sound approximating in quality to tyin-
panitic resonance, and sometimes obtained over pulmonary cavities
or over pneumothorax, has received the name of amphoric reso-
nance It may be imitated by percussing the trachea or the cheek
distended with air

Summary

The varieties of resonance to be obtained by percussing the nor-
mal thorax are :

(1) Vesicular resonance, to be obtained over normal lung tissue.

(2) Tympanitic resonance, to be obtained in Traube's semilunar
space

(3) Diminished resonance or dulness, such as is present over the
scapulae, and

(4) Absence of resonance or flatness, such as is discovered when
we percuss over the lowest ribs in the right front

(5) Cracked-pot resonance, sometimes obtainable over the chest
of a crying child.

(6) Amphoric resonance, obtainable over the trachea.

Any of these sounds may denote disease if obtained in portions
of the chest where they are not normally found. Each has its
place, and becomes pathological if found elsewhere. Tympanitic reso-
nance is normal at the bottom of the left front and axilla, but not
elsewhere. Dulness or flatness is normal over the areas corre-
sponding to the heart, liver, and spleen, and over the scapulae, but
not elsewhere unless the muscular covering of the chest is enor-
mously thick. Vesicular resonance is normal over the areas corre-
sponding to the lungs, but becomes evidence of disease if found
over the cardiac or hepatic areas.

Cracked-pot resonance may be normal if produced while per-
cussing the chest of a child, but under all other conditions, so far
as is known, denotes disease.

Amphoric resonance always means disease, usually pulmonary
cavity or pneumothorax, if found elsewhere than over the trachea.

76 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(/) The LWKJ Reflex.

It must also be remembered, when percussing, that in some cases
every forcible percussion blow increases the resonance to be ob-
tained by subsequent blows. Any one who has demonstrated an
area of percussion dulness to many students in succession must
have noticed occasionally that the more we percuss the dull area,
the more resonant it becomes, so that to those who last listen to
the demonstration the difference which we wish to bring out is much
less obvious than to those who heard the earliest percussion strokes.
Abrams has referred to this fact under the name of the " lung re-
flex," believing, partly on the evidence of fluoroscopic examination,
that if an irritant such as cold or mustard is applied to any part of
the skin covering the thorax, the lung expands so that a localized
temporary emphysema is produced in response to the irritation.
Apparently percussion has a similar effect.

III. SENSE OF RESISTANCE.

While percussing the chest we must be on the lookout not only
for changes in resonance, but for variations in the amount of resist-
ance felt underneath the finger. Normally the elasticity of the
chest walls over the upper fronts is considerably greater and the
sense of resistance considerably less than that felt over the liver.
In the axillae and over those portions of the back not covered by
the scapulas, we feel in normal chests an elastic resistance when
percussing which is in contrast with the dead, woodeny feeling
which is communicated to the finger when the air-containing lung
is replaced by fluid or solid contents (pleuritic effusion, pneu-
monia, phthisis, etc.). In some physicians this sense of resistance
is very highly developed and as much information is obtained
thereby as through the sounds elicited. As a rule, however, it is
only by long practice that the sense of resistance is cultivated to a
point where it becomes of distinct use in diagnosis.

CHAPTER IV.

AUSCULTATION.

AUSCULTATION may be practised by placing one's ear directly
against the patient's chest (immediate auscultation) or with the
help of a stethoscope (mediate auscultation).

Each method has its place. Immediate auscultation is said to
have advantages similar to those of the low power of the micro-
scope, in that it gives us a general idea of the condition of a rela-
tively large area of tissue, while the stethoscope may be used, like
the oil immersion lens, to bring out details at one or another point.

On the other hand, I have heard it said by E. C. Janeway and
other accomplished diagnosticians that the unaided ear can perceive
sounds conducted from the interior of the lung sounds quite inau-
dible with any stethoscope and that in this way deepseated areas
of solidification may be recognized.

Immediate auscultation may be objected to

(a) On grounds of delicacy (when examining persons of the
opposite sex).

(1} On grounds of cleanliness (although the chest may be cov-
ered with a towel so as to protect the auscultator to a certain
extent).

(d] Because it is difficult to localize the different valvular areas
and the sites of cardiac murmurs if immediate auscultation is em-
ployed.

On account of the latter objection the great majority of observ-
ers now use the stethoscope to examine the heart. For the lungs,
both methods are employed by most experienced auscultators.

78 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(Personally, I have never yet learned to hear anything with my
unaided ear Avhich I could not hear better with a stethoscope, and
the Bowles stethoscope seems to me to reach as large an area and
as deep as the unaided ear. Xevertheless the weight of competent
opinion is against me and greater experience will doubtless show
me my mistake.)

"While learning the use of immediate auscultation it is best to
close with the fingers the ear which is not in contact with the chest.
With practice one comes to disregard outer noises and does not
need to stop the ear.

MEDIATE AUSCULTATION.

1. Selection of a Stethoscope.

(1) It is as rash for any one to select a stethoscope without first
trying the fit of the ear pieces in his ears as it would be to buy a
new hat without trying it on. What suits A. very well is quite im-
possible for B. It is true that one can get used to almost any
stethoscope as one can to almost any hat, but it is not necessary to
do so. The ear pieces of the ordinary stethoscope are often too
small and rarely too large. In ease of doubt, therefore, it is better
to err upon the side of getting a stethoscope with too large rather
than too small ends.

(2) The binaural stethoscope, which is now almost exclusively
used in this country, maintains its position in the ears of the aus-
cultator either through the pressure of a rubber strap stretched
around the metal tubes leading to the ears, or by means of a steel
spring connecting the tubes. Either variety is usually satisfactory,
but I prefer a stethoscope made with a steel spring (see Fig. 48)
because such a spring is far less likely to break or lose its elasticity
than a rubber strap. A rubber strap can always be added if this
is desirable. It is important to pick out an instrument possessing
a spring not strong enough to cause pain in the external meatus of
the ear and yet strong enough to hold the ear pieces firmly in place.
Persons with narrow heads need a much more powerful spring or
strap than would be convenient for persons with wide heads.

AUSCULTATION.

(3) The rubber tubing used to join the metallic tubes to the
chest piece of the instrument should be as flexible as possible (see
Fig. 48). Stiff tubing (see
Fig. 49) makes it necessary
for the auscultator to move
his head and body from
place to place as the exam-
ination of the chest pro-
gresses, while if flexible
tubing is used the head need
seldom be moved and a great
deal of time and fatigue is
thus saved. Stiff stetho-
scopes are especially incon-
venient when examining the
axilla.

(4) Jointed stethoscopes
which fold up or take apart
should be scrupulously
avoided. They are a delu-
sion and a snare, apt to
come apart at critical mo-
ments, and to snap and creak
at the joints when in use,
sometimes producing in this way sounds which
may be easily mistaken for rales. Such an in-
strument is no more portable nor compact than
the ordinary form with flexible tubes. It has,
therefore, no advantages over stethoscopes made
in one piece and possesses disadvantages which
are peculiarly annoying.

(5) The Chest Piece. The majority of the
stethoscopes now in use have a chest piece of
hard-rubber or wood with a diameter of about seven-eighths of an
inch. Chest pieces of larger diameter than this are to be avoided
as they are very difficult to maintain in close apposition with thin

FIG. 49. C a m m a n

Stethoscope With Stiff
Tubing and Rubber
Strap.

PIG. 48. stethoscope
Fitted With Long
Flexible Tubes, Espe-
cially Useful When
Examining Children.

80 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

chests. To avoid this difficulty the chest piece is sometimes made
of soft-rubber or its diameter still further reduced.

(6) The Bowles Stethoscope. (See Figs. 50 and 51.) Within
the last year there has been introduced an instrument which, for
most purposes, seems to me far superior to any other form of stetho-
scope with which I am acquainted. Its pe-
culiarity is the chest piece,
which consists of a very shal-
low steel cup (see Fig. 52)
over the mouth of which a
thin metal plate or a bit of
pigskin is fastened. The
metal or pigskin diaphragm
serves simply to prevent the
tissues of the chest from pro-
jecting into the shallow cup
of the chest piece when the
latter is pressed against the
chest, and does not in any
other way contribute to the
sounds which we hear with
the instrument. This is
proved by the fact that we
can hear as well even when
the diaphragm is cracked
across in several directions.

"\\ ith this instrument al-
most all sounds produced
within the chest can be heard
much more distinctly than in
any other variety of stethoscope. Cardiac murmurs which are in-
audible with any other stethoscope maybe distinctly heard with this.
Especially is this true of low-pitched murmurs due to aortic regur-
gitation. Yet it is useful for examination not merely of the heart,
but of the lungs as well. For any one who has difficulty in hearing
the ordinary cardiac or respiratory sounds, or for one who is par-

FIG. 50. Bowies' Stetho-
scope. Front view.

FIG. 51. Bowles 1
Stethoscope.
Back View.

AUSCULTATION.

tially deaf, the instrument is invaluable. Its flat chest piece makes
it very useful in listening to the posterior portions of the lungs in
cases of pneumonia in which the patient is too sick to be turned over
or to sit up. Without moving the patient at all we can work the
chest piece in under the back of the patient by pressing down the
bed-clothes, and in this way can listen to any part of the chest
without moving the patient. A further advantage of the instru-
ment is that it enables us to gain an approximately accurate idea
of the heart sounds without undressing the patient. Respiratory

FIG. 52. Chest Piece of Bowies' Stethoscope. On the right the shallow cup communicating
with the ear tubes. On the left the diaphragm which covers the cup, and the ring which
holds it in place.

sounds cannot well be listened to through the clothes, as the rub-
bing of the latter may simulate rales.

There are two purposes for which I have found the Bowles
stethoscope inferior to the ordinary stethoscope :

(1) For listening over the apex of the lung for fine rales, e.g.,
in incipient phthisis.

(2) For listening for superficial sounds, such as a friction rub
of a presystolic murmur. l When I desire to listen for fine rales at

1 It has frequently been observed, when listening with the ordinary stetho-
scope, that a presystolic murmur can be better heard if only the very lightest
pressure is made with the stethoscope. The fact that a thrill is communicated
to the chest wall, and that that thrill is connected with the audible murmur
explains my calling this murmur a superficial one.

82 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

an apex, for a friction rub, or for a presystolic murmur, I separate
the chest piece of the Bowles stethoscope from, the rubber tube which
connects it with the rest of the instrument and slip on in its place
the hard-rubber bell of an ordinary stethoscope, thereby converting
the instrument into one of the ordinary form. With an extra hard-
rubber bell attached or kept
in the pocket, the instrument
is no more bulky than an
ordinary stethoscope, and
far more efficient. When
used for listening to the res-
piration, the Bowles instru-
ment gives us information
similar in some respects to
that obtained by the use of
the free ear that is, we are
through it enabled to ascer-
tain by listening at one spot
the condition of a much
larger area of the chest than
can in any other way be in-
vestigated.

Owing to the fact that
both cardiac and respiratory
sounds are magnified by the
Bowles stethoscope, this
instrument is especially well
adapted for use with some

sort of an attachment whereby several sets of ear pieces are so
joined by tubing to one chest piece that several persons may listen
at once. Bowies' multiple stethoscope, fitted for six and for twelve
observers, is seen in Figs. 53 and 54, and the method of its use in
Fig. 55. In the teaching of auscultation this instrument is of great
value, saving as it does the time of the instructor and of the stu-
dents and the strength of the patient. The sounds conducted
through any one of the twelve tubes used in this instrument are

FIG. 53. Bowies' Multiple Stethoscope for Six Stu-
dents.

AUSCULTATION.

as loud as those to be heard with a single instrument of the ordi-
nary form, although far fainter than those to be heard with a single
Bowles stethoscope.

II. The Use of the Stethoscope.

Having secured an instrument which fits the ears satisfactorily,
the beginner may get a good deal of practice by using it upon him-

FIG. 54. Bowies' Multiple Stethoscope for Twelve Students.

self, especially upon his own heart. The chief point to be learned
is to disregard various irrelevant sounds and to concentrate atten-
tion upon those which are relevant. Almost any one hears enough
with a stethoscope, and most beginners hear too much. No great
keenness of hearing is required, for the sounds which we listen for
are not, as a rule, difficult to hear if attention is concentrated upon
them.

84 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

A. Selective Attention find What to Disregard,

Accordingly, the art of using a stethoscope successfully depends
upon the acquisition of two powers

() A knowledge of Avhat to disregard, (i) A selective atten-

FIG. 55.1-Bowlts' Multiple Stethoscope in Use. Twelve students listening at once

tion or concentration upon those sounds which we know to be of
importance.

Among the sounds which we must learn to disregard are the
following :

(1) Noises produced in the room or its immediate neighborhood,
but not connected with the patient himself. It is, of course, easier

AUSCULTATION. 85

to listen in a perfectly quiet room where there are no external
noises which need to be excluded from attention, but as the greater
part of the student's work must be done in more or less noisy
places, it is for the beginner a practical necessity to learn to with-
draw his attention from the various sounds which reach his ear
from, the street, from other parts of the building, or from the room
in which he is working. This is at first no easy matter, but can
be accomplished with practice.

(2) When the power to disregard external noises has been ac-
quired, a still further selection must be made among the sounds
which come to the ear through the tubes of the stethoscope. Noises
produced by friction of the chest piece of the stethoscope upon the
skin are especially deceptive and may closely simulate a pleural or
pericardial friction sound. It is well for the student to experiment
upon the nature and extent of such " skin rubs " by deliberately
moving the chest piece of the stethoscope upon the skin and listen-
ing to the sounds so produced. Mistakes can be avoided in the
majority of cases by holding the chest piece of the stethoscope very
firmly against the chest. This can be easily done when the patient
is in the ivoumbt'iit position, but when the patient is sitting up it
may be necessary to press so hard with the chest piece of the
stethoscope as to throw the patient off his balance unless he is in
some way supported; accordingly, it is niy practice in many cases
to put the left arm around and behind the patient so as to form a
support, against which he can lean when the chest piece of the
stethoscope is pressed strongly against his chest. AVhen listening
to the back of the chest, the manoeuvre is reversed. If the skin
is very dry, the ribs are very prominent, or the chest is thickly
covered with hair, it may be impossible to prevent the occur-
rence of adventitious sounds due to friction of the chest piece
upon the chest, no matter how firmly the instrument is held. In
case of doubt, and in any case in which a diagnosis of pleural or
pericardial friction is in question, the surface of the chest, at the
point where we desire to listen, should be moistened and any hair
that may be present thoroughly wetted with a sponge, so that it
will lie flat upon the chest. Otherwise the friction of the hair

86 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

under the chest piece of the stethoscope may simulate crepitant
rales as closely as " skin rubs " simulate pleural friction.

(3) The friction of the fingers of the auscultator upon the chest
piece or on some other part of the stethoscope frequently gives rise
to sounds closely resembling rales of one or another description.
The nature of these sounds can be easily learned by intentionally
moving the fingers upon the stethoscope. They are to be avoided
by grasping the instrument as firmly as possible, and by touching it
with as few fingers as will suffice to hold it close against the chest.

(4) Noises produced by a shifting of the parts of the stetho-
scope upon each other are especially frequent in stethoscopes made
in several pieces and jointed together. A variety of snapping and
cracking sounds, not at all unlike certain varieties of rales, may
thus be produced, and if we are not upon our guard, may lead to
errors in diagnosis. Stethoscopes which have no hinges and which
do not come apart are far less likely to trouble us in this way.

(5) When a rubber band is used to press the ear pieces more
firmly into the ears, a very peculiar sound may be produced by the
breathing of the auscultator as it strikes upon the rubber strap. It
is a loud musical note, and may be confused with coarse, dry rales.

When one has learned to recognize and to disregard the noises
produced in the ways above indicated, there is still one set of
sounds which are very frequently heard, yet which have no signifi-
cance for physical diagnosis, and must therefore be disregarded ; I
refer to

B. Muscle Sounds.

Patients who hold themselves very erect while being exam-
ined, or who for any reason contract the muscles of that portion of
the chest over which we are listening, produce in these muscles a
very peculiar and characteristic set of sounds. The contraction of
any muscle in the body produces sounds similar in quality to those
heard over the chest, but of less intensity.

Those who have the faculty of contracting the tensor tympani
muscle at will can at any time listen to a typical muscle sound.

A USC ULTA TION. 87

Or close both ears with the fingers and strongly contract the mas-
seter muscle, with the teeth clenched. A high-pitched muscle
sound will be heard.

It is well also to have a patient contract one of the pectorals
and then listen to the sound thus produced. In some cases a con-
tinuous, low-pitched roar or drumming is all that we hear ; in other
cases we hear nothing but the breath sounds during expiration,
while during inspiration the breath sound is obscured by a series of
short, dull, rumbling sounds, following each other at the rate of
from five to ten in a second. Occasionally the sound is like the
puffing of the engine attached to a pile-driver, or like a stream of
water falling upon a sheet of metal just slowly enough to be sepa-
rated into drops and heard at a considerable distance. As already
mentioned, we are especially apt to hear these muscle sounds dur-
ing forced inspiration, owing to the contraction of voluntary mus-
cles during that portion of the respiratory act. They are most
often heard over the upper portion of the chest (over the pectorals
in front and over the trapezius behind), but in some persons no
part of the chest is free from them. It is a curious fact that we
are not always able to detect by sight or touch the muscular con-
tractions which give rise to these sounds, and the patient himself
may be wholly unaware of them. Under such circumstances they
are not infrequently mistaken for rales, and I am inclined to think
that many of the sounds recorded as "crumpling," "obscure,"
"muffled," "distant," or "indeterminate" rales are in reality due
to muscular contractions. The adjectives " muffled " and " distant "
give us an inkling as to the qualities which distinguish muscular
sounds from rales. Kales are more clean cut, have a more distinct
beginning and end, seem nearer to the ear, and possess more of a
crackling or bubbling quality than muscle sounds.

I have made no attempt exhaustively to describe all the sounds
due to muscular contractions and conducted to the ear by the steth-
oscope, but have intended simply to call attention to the importance
of studying them carefully.

88 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

C. Other Sources of Error.

Another source of confusion, which for beginners is very trouble-
some, especially if they are using the ordinary form of stethoscope
with a bell-shaped chest piece, arises in case the chest piece is not

FIG. 56. Showing an Accident to be Avoided. (Stethoscope disconnected.)

held perfectly in apposition with the skin. If, for example, the
stethoscope is slightly tilted to one side so that the bell is lifted
from the skin at some point, or if one endeavors to listen ovef
a very uneven part of the chest on which the bell of the stethoscope
cannot be made to rest closely, a roar of external noises reaches the
ear through the chink left between the chest piece and the chest.

AUSCULTATION. 89

After a little practice one learns instantly to detect this condition
of things and so to shift the position of the chest piece that exter-
nal noises are totally excluded ; but by the beginner, the peculiar
babel of external noises which is heard whenever the stethoscope
fails to fit closely against the chest is not easily recognized, and

FIG. 57. Accident to be Avoided. CStethoscope kinked.)

hence he tends to attribute some of these external sounds to diseased
conditions within the chest.

Again, it is not until we have had considerable practice that our
sense of hearing comes instantly to tell us when something is wrong
about the stethoscope itself ; when, for example, one of the tubes
is blocked, kinked, or disconnected (see Figs. 56 and 57), or when
we are holding the stethoscope upside down, so that the ear pieces
point downward instead of upward (see Figs. 58 and 59). It is only
when we have learned through long practice about how much we

90 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

ought to hear at a given point in the normal chest that we recognize
at once the fact that we are not hearing as much as we should,, in

FIG. 58. Stethoscope Held Ilipht Side Up.

case some one of the above accidents has happened. Many begin-
ners do not listen long enough in any one place, but move the chest
piece of the stethoscope about rapidly from point to point, as they
have seen experienced auscultators do; but it is remarkable how
much more one can hear at a given point by simply persevering and
listening to beat after beat, or breath after breath. It is sometimes

FIG. 59. Stethoscope Held Wrong Side Up.

difficult to avoid the impression that the sounds themselves have
grown louder as we continue to listen, especially if we are in any

AUSCULTATION. 91

doubt as to what we hear. Therefore, if we hear indistinctly, it is
important to keep on listening, and to fix the attention successively
upon each of the different elements in the sounds under consideration.
In difficult cases we should use every possible aid toward concen-
tration of the attention, and where it is possible, all sources of dis-
traction should be eliminated. Thus, in any case of doubt, I think
it is important for the auscultator to get himself into as comfort-
able a position as he can, so that his attention is not distracted by
his own physical discomforts. Many auscultators shut their eyes
when listening in a difficult case so as to avoid the distraction of
impressions coming through the sense of sight. It goes without
saying that if quiet can be secured in the room where we are work-
ing, and outside it as well, we shall be enabled to listen much more
profitably.

AUSCULTATION OF THE LUNGS.

In the majority of cases ordinary quiet breathing is not forcible
enough to bring out the sounds on which we depend for the diag-
nosis of the condition of the lungs. Deep or forced breathing is
what we need.

As a rule, the patient must be taught how to breathe deeply,
which is best accomplished by personally demonstrating the act of
deep breathing and then asking him to do the same. Two difficul-
ties are encountered:

(a) The patient may blow out his breath forcibly and with a
noise, since that is what he is used to doing whenever he takes a
long breath under ordinary circumstances ; or

(&) It may be that he cannot be made to take a deep breath at
all. The first of these mistakes alters the sounds to be heard with
the stethoscope in any part of the chest by disturbing both the
rhythm and the pitch of the respiratory sounds. In this way the
breathing may be made to sound tubular or asthmatic throughout a
sound chest. This difficulty can sometimes be overcome by demon-
strating to the patient that what you desire is to have him take a
full breath and then simply let it go, but not blow it forcibly out.
In some cases the patient cannot be taught this, and we have to get

92 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

on the best we caii despite his mistakes. "\Yhen he cannot be made
to take a full breath at all, we can often accomplish the desired re-
sult by getting him to cough. The breath just before and after a
cough is often of the type we desire. The use of voluntary cough
in order to bring out rales will be discussed later on. Another use-
ful manoeuvre is to make the patient count aloud as long as he can
with a single breath. The deep inspiration which he is forced to
take after this task is of the type which we desire.

I. RESPIRATORY TYPES.

In the normal chest two types of breathing are to be heard :

(1) Tracheal, bronchial, or tubular breathing.

(2) Vesicular breathing.

Tracheal, bronchial, or tubular breathing is to be heard in normal
cases if the stethoscope is pressed against the trachea, and as a rule

FIG. 60. Situation of the Trachea and Primary Bronchi.

it can also be heard over the situation of the primary bronchi, in
front or behind (see Figs. 60 and 61) .

Vesicular breath in y is to be heard over the remaining portions of
the lung that is, in the front of the thorax except where the heart

AUSCULTATION.

and the liver come against the chest wall, in the back except where
the presence of the scapulae obscures it, and throughout both axillae.

(1) Characteristics of Vesicular Breathing.

Vesicular breathing that heard over the air vesicles or paren-
chyma of the lung has certain characteristics which I shall try to
describe in terms of intensity, duration, and pitch.

FIG. 61. Situation of the Trachea and Primary Bronchi.

Of the quality of the sounds heard over this portion of the lung
there is little can be said ; it sounds something like the swish of the
wind in a grove of trees some distance off, and hence is sometimes
spoken of as " breezy. "

The intensity, duration, and pitch of the inspiration as compared
with that of the expiration may be represented as in Fig. 62. In
this figure, as in all those to be used in description of respiratory
sounds

(1) I represent the inspiration by an up-stroke and the expira-
tion by a down-stroke (see the direction of the arrows in Fig. 62).

(2) The length of the up-stroke as compared with that of the
down-stroke corresponds to the length of inspiration conipaj-ed with
expiration.

94 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(3) The thickness of the tip-stroke as compared with the down-
stroke represents the intensity of the inspiration as compared with
the expiration.

(4) The pitch of inspiration as compared with that of expi-
ation is represented by the sharpness of the angle which the up-

FIG. 62. Vesicular Breath-
ing.

FIG. 63. Distant Vesicular
Breathing.

FIG. 64. -Exaggerated Ve-
sicular Breathing.

stroke makes with the perpendicular as compared with that which
the down-stroke makes with the perpendicular. The pitch of a
rorfm&y be thought of in this connection to remind us of the mean-
ing of these symbols.

If now we look again at Fig. 62 we see that when compared
with expiration (the down-stroke), the inspiration is

() More intense.

(b) Longer.

Our comparison is invariably made between inspiration and ex-
piration, and not with any other sound as a standard.

Now, this type of breathing (which, as I have said, is to be
heard over every portion of the lung except those portions imme-
diately adjacent to the primary bronchi), is not heard everywhere
with equal intensity. It is best heard below the clavicles in front,
in the axillae, and below the scapulae behind, but over the thin,
lower edges of the lung, whether behind or at the sides, it is
feebler, though still retaining its characteristic type as revealed in
the inspiration and expiration in respect to intensity, duration, and
pitch. To represent distant vesicular breathing graphically we
have only to draw its symbol on a smaller scale (see Fig. 63). On

AUSCULTATION. 95

the other hand, when one listens to the lungs of a person who has
been exerting himself strongly, one hears the same type of respira-
tion, but on a larger scale, which may then be represented as in
Fig. 64. This last symbol may also be used to represent the respi-
ration which we hear over normal but thin-walled chests ; for ex-
ample, in children or in emaciated persons. It is sometimes known
as "exaggerated" or "puerile" respiration. When one lung is
thrown out of use by disease so that increased work is brought
upon the other, the breath sounds heard over the latter are increased
and seem to be produced on a larger scale. Such breathing is some-
times spoken of as " rough " breathing.

It is very important to distinguish at the outset between the
different types of breathing, one of which I have just described, and
the different degrees of Fondness with which any one type of breath-
ing may be heard.

(2) Bronchial or Tracheal Breathing in Health.

Bronchial breathing may be symbolically represented as in Fig.
65, in which the increased length of the down stroke corresponds
to the increased duration of expiration, and the greater thickness

FIG. 65. Bronchial Breath- FIG. 66. Distant Bronchial FIG. 67. Very Loud Bron-

ing of Moderate Intensity. Breathing. chial Breathing.

of both lines corresponds to the greater intensity of both sounds,
expiratory and inspiratory, while the sharp pitch of the " gable " on
both sides of the perpendicular corresponds to the high pitch of
both sounds. Expiration, it will be noticed, slightly exceeds inspi-
ration both in intensity and pitch, and considerably exceeds it in
duration, while as compared with vesicular breathing almost all the

96 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

relations are reversed. Bronchial breathing has also a peculiar
qxiality which can be better appreciated than described.

In the healthy chest this type of breathing is to be heard if one
listens over the trachea or primary bronchi (see above, Fig. 60),
but practically one hardly ever listens over the trachea and bronchi
except by mistake, and the importance of familiarizing one's self
with the type of respiration heard over these portions of the chest
is due to the fact that in certain diseases, especially in pneumonia
and phthisis, we may hear bronchial breathing over the parenchyma
of the lung where normally vesicular breathing should be heard.

The student should familiarize himself with each of these types
of breathing, the vesicular and the bronchial, concentrating his at-
tention as he listens first upon the inspiration and then upon the
expiration, and comparing them with each other, first in duration,
next in intensity, and lastly in pitch. To those who have not a
musical ear, high-pitched sounds convey the general impression of
being shrill, while low-pitched sounds sound hollow and empty, but
the distinction between intensity and pitch is one comparatively
difficult to master. Distant bronchial breathing may be repre-
sented in Fig. 66, and is to be heard over the back of the neck
opposite the position of the trachea and bronchi. Fig. 67 repre-
sents very loud bronchial breathing such as is sometimes heard in
pneumonia.

(3) Broncho- Vesicular Breathing in Health.

As indicated by its name, this type of breathing is intermediate
between the two just described, hence the terms " mixed breath-
ing, " or " atypical breathing " (" unbestimint ") . Its characteristics
may be symbolized as in Fig. 68. In the normal chest one can be-
come familiar with broncho-vesicular breathing, by examining the
apex of the right lung, or by listening over the trachea or one of the
primary bronchi, and then moving the stethoscope half an inch at
a time toward one of the nipples. In the course of this journey
one passes over points at which the breathing has, in varying de-
grees, the characteristics intermediate between the bronchial type
from which we started and the vesicular type toward which we are

AUSCULTATION.

moving. Expiration is a little longer, intenser, or higher pitched
than in vesicular breathing, and inspiration a little shorter, feebler,

FIG. 68. Two Common Types of Broncbo-
Vesicular Breathing.

FIG. 69. Distant Broncho-Vesicular Breath-
ing.

or lower pitched ; but since these characteristics are variously com-
bined, there are many subvarieties of broncho-vesicular breathing.
Fig. 69 represents two types of distant broncho-vesicular breath-
ing.

(4) Emphysematous Breathing.

A glance at Fig. 70 will call up the most important features of
this type of respiration. The inspiration is short and somewhat
feeble, but not otherwise remarkable. The expiration is long,
feeble, and low pitched. This type of breathing is the rule in
elderly persons, particularly those of the male sex.

(5) Asthmatic Breathing.

Fig. 71 differs from emphysematous only in the greater intensity
of the expiration. In this type of breathing, however, both sounds

FIG. 70. Emphysematous Breathing.

FIG.

ft. Asthmatic Breathing,
squeaking (musical) rales.

are usually obscured to a great extent by the presence of piping and
squeaking rales (see below).

98 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(6) Interrupted or " Cogwheel " Breathing.

As a rule, only the inspiration is interrupted, being transformed
into a series of short, jerky puffs as shown in Fig. 72. Very rarely
the expiration is also divided into segments. When heard over the
entire chest, cogwheel breathing is usually the result of nervous-
ness, fatigue, or chilliness on the patient's part. "With the removal
of these causes this type of respiration then disappears. If, on the
other hand, cogwheel respiration is confined to a relatively small
portion of the chest, and remains present despite the exclusion of

FIG. 72. Cogwheel Breathing.

FIG. 73. Metamorphosing Breathing.

fatigue, nervousness, or cold, it points to a local catarrh in the finer
bronchi such as to render difficult the entrance of air into the alve-
oli. As such, it has a certain significance in the diagnosis of early
phthisis, a significance similar to that of rales or other signs of
localized bronchitis (see below) .

(7) Amphoric or Cavernous Breathing (see below, p. 103).

(8) Metamorphosing Breathing.

Occasionally, while we are listening to an inspiration of normal
pitch, intensity, and quality, a sudden metamorphosis occurs and the
type of breathing changes from vesicular to bronchial or amphoric
(see Fig. 73), or the intensity of the breath sounds may suddenly
be increased without other change. These metamorphoses are usu-
ally owing to the fact that a plugged bronchus is suddenly opened
by the force of the inspired air, so that the sounds conducted
through it become audible.

AUSCULTATION. 99

II. DIFFERENCES BETWEEN THE Two SIDES OF THE CHEST.

Over the apex of the right lung that is, above the right clavi-
cle in front, and above the spine of the scapula behind one hears
in the great majority of normal chests a distinctly broncho- vesicu-
lar type of breathing. In a smaller number of cases this same
type of breathing may be heard just below the right clavicle.
These facts cannot be too strongly insisted upon, since it is only
by bearing them in mind that we can avoid the mistake of diagnos-
ing a beginning consolidation of the right apex where none exists.
Breath sounds which are perfectly normal over the right apex would
mean serious disease if heard over similar portions of the left lung.
It will be remembered that the apex of the right lung is also duller
on percussion than the corresponding portion of the left, and that
the voice sounds and tactile fremitus are normally more intense on
the right (see Fig. 32).

Occasionally one finds at the base of the right lung posteriorly
a slightly feebler or more broncho-vesicular type of breathing than
in the corresponding portion of the left lung.

III. PATHOLOGICAL MODIFICATIONS OF VESICULAR BREATHING.

Having now distinguished the different types of breathing and
described their distribution in the normal chest, we must return to
the normal or vesicular breathing in order to enumerate certain of
its modifications which are important in diagnosis.

(1) Exaggerated Vesicular Breathing (" Compensatory " Breathing).

(a) It has already been mentioned that in children or in adults
with very thin and flexible chests the normal breath sounds are
heard with relatively great distinctness ; also that after any exer-
tion which leads to abnormally deep and forcible breathing a simi-
lar increase in the intensity of the respiratory sounds naturally
occurs.

(b) The term "compensatory breathing," or " vicarious " breath-
ing, refers to vesicular breathing of an exaggerated type, such as is
heard, for example, over the whole of one lung when the other lung

100 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

is thrown out of use by the pressure of an accumulation of air or
fluid in the pleural cavity. A similar exaggeration of the breathing
upon the sound side takes place when the other lung is solidified,
as by tuberculosis, pneumonia, or malignant disease, or when it is
compressed by the adhesions following pleuritic effusion, or by
a contraction of the bones of that side of the chest such as occurs
in spinal curvature.

(2) Diminished Vesicular

The causes of a diminution in the intensity of the breath sounds
without any change in their type are very numerous. I shall men-
tion them in an order corresponding as nearly as possible to the
relative frequency of their occurrence.

(a) Fluid, Air, or Solid in the Pleural Cavity. Probably the
commonest cause for a diminution or total abolition of normal
breath sounds is an accumulation of fluid in, the pleural cavity such
as occurs .in inflammation of the pleura or by transudation (hydro-
thorax). In such cases the layer of fluid intervening between the
lung and the stethoscope of the auscultator causes retraction of the
lung so that little or no vesicular murmur is produced in it, and
hence none is transmitted to the ear of the auscultator. An ac-
cumulation of air in the pleural cavity (pneumothorax) may dimin-
ish or abolish the breath sounds precisely as a layer of fluid does ;
in a somewhat different way a thickening of the costal or pulmo-
nary pleura or a malignant growth of the chest wall may render
the breath sounds feeble or prevent their being heard because the
vibrations of the thoracic sounding-board are thus deadened. Which-
ever of these causes, fluid or air or solid, intervenes between the lung
and the ear of the auscultator, the breath sounds are deadened or
diminished without, as a rule, any modification of their type. The
amount of such diminution depends roughly on the thickness of the
layer of extraneous substance, whether fluid, air, or solid.

Total absence of breath sounds may therefore be due to any one
of these causes, provided the layer intervening between the lung and
chest wall is of sufficient thickness to produce complete atelectasis
of the lung or to deaden the vibrations of the chest wall.

AUSCULTATIOX. 101

(b) Emphysema of the lung, by destroying its elasticity and re-
ducing the extent of its movements, makes the breath sounds rela-
tively feeble, but seldom, if ever, abolishes them altogether.

(c) In bronchitis the breath sounds are usually considerably di-
minished owing to the filling up of the bronchi with secretion.
This diminution, however, usually attracts but little attention,
owing to the fact that the bubbling and squeaking sounds, which
result from the passage of air through the bronchial secretions, dis-
tract our notice to such an extent that we find it difficult to con-
centrate attention upon the breath sounds, even if we do not forget
altogether to listen to them. When, however, we succeed in listen-
ing through the rules to the breath sounds themselves, we usually
notice that they are very feeble, especially over the lower two-
thirds of the chest. (E'lfma of the Jung may diminish the breath
sounds in a similar way.

(d) Pain in the thorn x, such as is produced by dry pleurisy or
intercostal neuralgia, diminishes the breath sounds because it leads
the patient to restrain, so far as possible, the movements of his
chest, and so of his lungs. If, for any other reason, the full ex-
pansion of the lung does not take place, whether on account of the
feebleness of the respiratory movements or because the lung is me-
chanically hindered by the presence of pleuritic adhesions, the
breath sounds are proportionately feeble.

(e) Occlusion of the upper air passages t as by spasm or oedema
of the glottis, renders the breathing very feeble on both sides of
the chest. If one of the primary bronchi is occluded, as by a .for-
eign body or by pressure of a tumor or enlarged gland from without,
we get a unilateral enfeeblement of the breathing over the corre-
sponding lung.

(/) Occasionally a paralysis of the muscles of respiration on one
or both sides is found to result in a unilateral or bilateral enfeeble-
ment of the breathing.

It should be remembered, when estimating the intensity of the
breathing, that the sounds heard over the right lung are, as a rule,
slightly more feeble than those heard over the left lung in the
normal chest.

102 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

IV. BRONCHIAL OB TUBULAR BREATHING IN DISEASE.

(a) I have already described the occurrence of bronchial breath-
ing in parts of the normal chest, namely, over the trachea and pri-
mary bronchi. In disease, bronchial breathing may be heard else-
where in the chest, and usually points to solidification of that portion
of lung from which it is conducted. It is heard most commonly in
phthisis (see below, p. 249).

(li) Croupous pneumonia is probably the next most frequent
cause of bronchial breathing, although by no means every case of
croupous pneumonia shows this sign. For a more detailed account
of the conditions under which it does or does not occur in croupous
pneumonia, see below, p 239. Lobular pneumonia is rarely mani-
fested by tubular breathing.

(c) In about one-third of the cases of pleuritic effusion distant
bronchial breathing is to be heard over the fluid. On account of
the feebleness of the breath sounds in such cases they are often
put down as absent, as we are so accustomed to associate intensity
with the bronchial type of breathing. One should be always on
the watch for any degree of intensity of bronchial breathing from
the feeblest to the most distinct.

(fZ) Rarer causes of bronchial breathing are hemorrhagic infarc-
tion of the lung, syphilis, or malignant disease, any one of which
may cause a solidification of a portion of the lung.

V. BRONCHO. VESICULAR BREATHING IN DISEASE.

Respiration of this type should be carefully distinguished from
puerile or exaggerated breathing, in which we hear the normal vesic-
ular respiration upon a large scale. I have already mentioned
that broncho-vesicular breathing is normally to be heard over the
apex of the right lung. In disease, broncho- vesicular breathing is
heard in other portions of the lung, and usually denotes a moderate
degree of solidification of the lung, such as occurs in early phthisis
or in the earliest and latest stages of croupous pneumonia. In cases
of pleuritic effusion, one can usually hear broncho-vesicular breath-

AUSCULTATION. 103

ing over the upper portion of the affected side, owing to the retrac-
tion of the lung at that point.

VI. AMPHOKIC BREATHING (Amphora = A Jar').

Respirations having a hollow, empty sound like that produced
by blowing across the top of a bottle, are occasionally heard in dis-
ease over pulmonary cavities (e.y., in phthisis) or in pneumothorax,
i.e., under conditions in which the air passes in and out of a large
empty cavity vdthin the chest. Amphoric breathing never occurs
in health. The pitch of both sounds is low, but that of expiration
lower than that of inspiration. The intensity and duration of the
sounds vary, and the distinguishing mark is their quality which
resembles that of a whispered "who."

VII. HALES.

The term " rales " is applied to sounds produced by the passage
of air through bronchi which contain mucus or pus, or which are
narrowed by swelling of their walls.' Rales are best classified as
follows :

(1) Moist or bubbling rales, including (a) coarse, (&) medium,
and (c) fine rales.

(2) Dry or crackling rales (large, medium, or tine) .

The smallest varieties of this type are known as " crepitant " or
" subcrepitant " rales.

(3) Musical rales (high or low pitched).

Each of these varieties will now be described more in detail.

(1) Moist or Bubbling Rales.

The nature of these is sufficiently indicated by their name.
The coarsest or largest bubbles are those produced in the trachea,
and ordinarily known as the "death rattle." Tracheal rales occur

1 Rales are of all auscultatory phenomena the easiest to appreciate, pro-
vided we exclude various accidental sounds which may be transmitted to the
ear as a result of friction of the stethoscope against the skin or against th6
fingers of the observer. (See above, page 86.)

104 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

in any condition involving either profound unconsciousness or very
great weakness, so that the secretions which accumulate in the
trachea are not coughed out. Tracheal rales are by no means a
sure precursor of death, although they are very common in the
moribund state. They can usually be heard at some distance from
the patient and without a stethoscope. In catarrh of the larger
bronchi large bubbling rales are occasionally to be
heard. In phthisical cavities one sometimes hears
coarse, bubbling rales of a very metallic and gurgling
quality (see below, p. 252). The finer grades of moist
rales correspond to the finer bronchi.

In the majority of cases moist rales are most nunier-

FIG 74 Expio- ous during inspiration and especially during the latter

sion of Fine part of this act. Their relation to respiration may be

Rales at End Ll i-n TK m i ij_

of inspiration, represented graphically as in Fig. <4, using large dots
for coarse rales and small dots for fine rales. Musical
rales can be symbolized by the letter S (squeaks).

(2) Crackling liaJes.

These differ from the preceding variety merely by the absence
of any distinct bubbling quality. They are usually to be heard in
cases of bronchitis in which the secretions are unusually tenacious
and viscid. They are especially apt to come at the end of inspira-
tion, a large number being evolved in a very short space of time, so
that one often speaks of an " explosion of fine crackling rales " at
the end of inspiration. Crackling rales are to be heard in any one
of the conditions in Avhich bubbling rales occur, but are more fre-
quent in tuberculosis than in simple bronchitis.

Crepitant rdlrs, which represent the finest sounds of this type,
are very much like the noise which is heard when one takes a lock
of hair between the thumb and first finger and rubs the hairs upon
each other while holding them close to the ear. A very large num-
ber of minute crackling sounds is heard following each other in
rapid succession. To the inexperienced ear they may seem to blend
into a continuous sound, but with practice the component parts may

AUSCULTATION. 105

be distinguished. This type of rales is especially apt to occur dur-
ing inspiration alone, but not very infrequently they are heard
during expiration as well. From subcrepitant rales they are dis-
tinguished merely by their being still finer than the latter. ' Sub-
crepitant rales are often mixed with sounds of a somewhat coarser
type, while crepitant rales are usually all of a size. If the
chest is covered with hair, sounds precisely like these two varieties
of rales may be heard when the stethoscope is placed upon the hairy
portions. To avoid mistaking these sounds for rales one must
thoroughly wet or grease the hair.

Crepitant Rales in Atelectasis.

Crepitant and subcrepitant rales are very often to be heard along
the thin margins of the lungs at the base of the axillae and in the
back, especially when a patient who is breathing superficially first
begins to take deep breaths. In such cases, they usually disappear
after the few first respirations, and are then to be explained by the
tearing apart of the slightly agglutinated surfaces of the finer bron-
chioles.

It is by no means invariably the case, however, that such sub-
crepitant rales are merely transitory in their occurrence. In a large
number of cases they persist despite deep breathing. The fre-
quency of subcrepitant rales, persistent or transitory, heard over
the inferior margin of the normal lung at the bottom of the axilla,
is shown by the following figures : Out of 356 normal chests to
which I have listened especially for these rales, I found 228, or 61
per cent, which showed them on one or both sides. They are very
rarely to be heard in persons under twenty years of age. After
forty-five, on the other hand, it is unusual to find them absent.
In my experience they are considerably more frequent in the situa-
tion shown in Fig. 124 than in any other part of the lung, but they
may be occasionally heard in the back or elsewhere. In .view of

1 A distinction was formerly drawn between crepitant and subcrepitant
rales, on the ground that the latter were heard during both respiratory sounds
and the former only during inspiration, but this distinction cannot be main-
tained and is gradually being given up.

106 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

these facts, it seems to me that we must recognize that it is almost
if not quite physiological to find the finer varieties of crackling
rales at the base of the axillae in persons over forty years old. I
have supposed these rales to be due to a partial atelectasis result-
ing from disease in the thin lower margin of the lungs. Such por-
tions of the lung are ordinarily not expanded unless the respirations
are forced and deep. This explanation would agree with the obser-
vations of Abrams, to which I shall refer later (see below, p. 290).

(b) Crepitant or subcrepitant rales are also to be heard in a
certain portion of cases of pneumonia, in the very earliest stages
and when resolution is taking place ("crepitans redux"). More
rarely this type of rale may be heard in connection with tubercu-
losis, infarction, or oedema of the lung.

In certain cases of dry pleurisy there occur fine crackling
sounds which can scarcely be differentiated from subcrepitant rales.
I shall return to the description of them in speaking of pleural
friction (see below, p. 271).

(3) Musical Rales.

The passage of air through bronchial tubes narrowed by in-
flammatory swelling of their lining membrane (bronchitis), gives
rise not infrequently to a multitude of musical sounds. Such a
stenosis occurring in relatively large bronchial tubes produces a
deep-toned yroaniny sound, while narrowing of the finer tubes re-
sults in pij'iiny, squeaking, whistling noises of various qualities.
Such sounds are often known as " dry rales " in contradistinction
to the " ImUAlnrj rules " above described, but as many iion-umsical
crackling rales have also a very dry sound, it seems to me best to
apply the more distinctive term " musical rales " to all adventitious
sounds of distinctly musical quality which are produced in the
bronchi. Musical rales are of all adventitious sounds the easiest
to recognize but also the most fugitive and changeable. They ap-
pear now here, now there, shifting from minute to minute, and may
totally disappear from the chest and reappear again within a very
short time. This is to some extent true of all varieties of rales,
but especially of the squeaking and groaning varieties.

A USC ULTA TION. 107

Musical rales are heard, as a rule, more distinctly during expira-
tion, especially when they occur in connection with asthma or em-
physema. In these diseases one may hear quite complicated chords
from the combinations of rales which vary in pitch.

VII. THE EFFECTS OF COUGH.

The influence of coughing upon rales is usually very marked.
Its effect may be either to intensify them and bring them out where
they have not previously been heard, or to clear them, away alto-
gether. Other effects of coughing upon physical signs will be
mentioned later on in the chapters on Pneumonia and Phthisis.

VIII. PLEUKAL FRICTIOX.

The surfaces of the healthy pleural cavity are lubricated with
sufficient serum to make them pass noiselessly over each other dur-
ing the movements of respiration. But when the tissues become
abnormally dry, as in Asiatic cholera, or when the serous surfaces
are roughened by the presence of a iibrinous exudation, as in ordi-
nary pleurisy, the rubbing of the two pleural surfaces against one
another produces peculiar and very characteristic sounds known as
"pleural friction sounds." The favorite seat of pleural friction
sounds is at the bottom of the axilla, i.e., where the lung makes
the widest excursion and where the costal and diaphragmatic pleura
are in close apposition (see Fig. 33). In some cases pleural fric-
tion sounds are to be heard altogether below the level of the lung.
In others they may extend up several inches above its lower mar-
gin, and occasionally it happens that friction may be appreciated
over the whole lung from the top to the bottom. Very rarely
friction sounds are heard only at the apex of the lung in early
tuberculosis.

The sound of pleural friction may be closely imitated by hold-
ing the thumb and forefinger close to the ear, and rubbing them
past each other with strong pressure, or by pressing the palm of
one hand over the ear and rubbing upon the back of this hand with

108 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

the fingers of the other. Pleural friction is usually a catchy,
jerky, interrupted, irregular sound, and is apt to occur during in-
spiration only, and particularly at the end of this act. It may,
however, be heard with both respiratory acts, but rarely if ever
occurs during expiration alone. The intensity and quality of the
sounds vary a great deal, so that, they niay be compared to gmziny,
rulibiny, rfisjiiny, and /-m/ /.-///// sounds. They are sometimes spoken
of as " leathery." As a rule, they seem very near to the ear, and are
sometimes startlingly loud. In many cases they cannot be heard
after the patient has taken a few full breaths, probably because the
rough pleural surfaces are smoothed down temporarily by the fric-
tion which deep breathing produces. After a short rest, however,
and a period of superficial breathing, pleural friction sounds often
return and can be heard for a short time with all their former in-
tensity. They are increased by pressure exerted upon the outside
of the chest Avail. Such pressure had best be made with the hand
or with the Bowles stethoscope, since the sharp edges of the chest-
piece of the ordinary stethoscope may give rise to considerable
pain; but if such pressure is made with the hand, one must be
careful not to let the hand shift its position upon the skin, else
rubbing sounds may thus be produced which perfectly sinmlate
pleural friction. In well-marked cases pleuritic friction can be
frit if the palm of the hand is laid over the suspected area; occa-
sionally the sound is so loud that it can be heard by the patient
himself or by those around him.

In doubtful cases, or when a friction sound appears to have
disappeared, and when one wishes to bring it out again, there are
several rnano3uvres suggested by Abrarns for obtaining this end.

(a) The Arm Manoeuvre.

The patient suspends respiration altogether, and the arm upon
the affected side is raised over the head by the patient himself or
by the physician, as in performing Sylvester's method of artificial
respiration. During this movement we listen over the suspected area.
" By this manoeuvre the movement of the parietal against the vis-
ceral pleura is opposite in direction to that occurring during the

AUSCULTATION. 109

respiratory act, and for this reason the pleuritic sound may often
be elicited after it has been exhausted in the ordinary act of breath-

ing."

The Decubital Manoeuvre.

"Let the patient lie upon the affected side for a minute or two,
then let him rise quickly and suspend respiration. Now listen over
the affected area, at the same time directing the patient to take a
deep breath."

Pleuritic friction sounds are distinguished from rales by their
greater superficiality, by their jerky, interrupted character, by the
fact that they are but little influenced by cough, and that they are
increased by pressure. It has already been mentioned, however,
that there is one variety of sounds which we have every reason to
think originate in the pleura, which cannot be distinguished from
certain varieties of crackling bronchial rales. Such sounds occur
chiefly in connection with phthisical processes, in which both pleu-
risy and bronchitis are almost invariably present, and it is seldom
of importance to distinguish the two.

IX. AUSCULTATION OF THE SPOKEN OK WHISPERED VOICE SOUNDS.
The more important of these is :

(a) The Whispered Voice.

The patient is directed to whisper "one, two, three," or
"ninety -nine," while the auscultator listens over different portions
of the chest to see to what degree the whispered syllables are trans-
mitted. In the great majority of normal chests the whispered
voice is to be heard only over the trachea and primary bronchi in
front and behind, while over the remaining portions of the lung
little or no sound is to be heard. When, on the other hand, solidi-
fication of the lung is present, the whispered voice may be dis-
tinctly heard over portions of the lung relatively distant from the
trachea and bronchi ; for example, over the lower lobes of the lung
behind. The usefulness of the whispered voice in the search for
small areas of solidification or for the exact boundaries of a solidi-

110 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

fied area is very great, especially when we desire to save the patient
the pain and fatigue of taking deep breaths. Whispered voice
sounds are practically equivalent to a forced expiration and can be
obtained with very little exertion on the patient's part. The in-
creased transmission of the whispered voice is, in niy opinion, a
more delicate test for solidification than tubular breathing. The
latter sign is present only Avhen a considerable area of lung tissue
is solidified, Avhile the increase of the whispered voice may be ob-
tained over much smaller areas. Ketraction of the lung above the
level of a pleural effusion causes a moderate increase in the trans-
mission of the whispered voice, and at times this increased or bron-
chial whisper is to be heard over the fluid itself, probably by trans-
mission from the compressed lung above.

\\liere the lung is completely solidified the whispered words
may be clearly distinguished over the affected area. In lesser de-
grees of solidification the syllables are more or less blurred.

(b) The Spoken Voice.

The evidence given us by listening for the spoken voice in vari-
ous parts of the chest is considerably less in value than that obtained
through the whispered voice. As a rule, it corresponds with the
tactile fremitus, being increased in intensity by the same causes
which increase tactile fremitus, viz., solidification or condensation
of the lung, and decreased by the same causes which decrease tac-
tile fremitus namely, by the presence of air or water in the pleu-
ral cavity, by the thickening of the pleura itself, or by an ob-
struction of the bronchus leading to the part over which we are
listening. In some cases the presence of solidification of the lung
gives rise not merely to an increase in transmission of the spoken
voice, but to a change in its quality, so that it sounds abnormally
concentrated, nasal, and near to the listener's ear. The latter
change may be heard over areas where tactile fremitus is not in-
creased, and even where it is diminished. Where this change in
the quality of the voice occurs, the actual words spoken can often
be distinguished in a way not usually possible over either normal
or solidified lung. "Broiichophony," or the distinct transmission

AUSCULTATION.

of audible words, and not merely of diffuse, unrecognizable voice
sounds, is considerably commoner in the solidification s due to pneu-
monia than in those due to phthisis; it occurs in some cases of
pneumothorax and pulmonary cavity.

Among the least important of the classical physical signs is a
nasal or squeaky quality of the sounds which reach the observer's
ear when the patient speaks in a natural voice. To this peculiar
quality of voice the name of "egophony" has been given. It is
most frequently heard in cases of moderate-sized pleuritic effusion
just about the level of the lower angle of the scapula and in the
vicinity of that point. Less often it is heard at the same level in
front. It is very rarely heard in the upper portion of the chest
and is by no means constant either in pleuritic effusion or in any
other condition. A point at which it is heard corresponds not, as
a rule, with the upper level of the accumulated fluid, as has been
frequently supposed, but often with a point about an inch farther
down. The presence of egophony is in no way distinctive of pleu-
ritic effusions and may be heard occasionally over solidified lung.

X. PHENOMENA PECULIAR TO PXEUMOHYDROTHORAX AXD PXEU-

MOPTOTHORAX.

Now and then a patient consults a physician, complaining that
he hears noises inside him as if water were being shaken about.
One such patient expressed himself to me to the effect that he felt
"like a half -empty bottle." In the chest of such a patient, if one
presses the ear against any portion of the thorax and then shakes
the whole patient strongly, one may hear loud splashing sounds
known technically as "suct-tuss'c^t.^ Such sounds are absolutely
diagnostic of the presence of both o'tr <m<l jfla'd in the cavity over
which they are heard. Very frequently they may be detected by
the physician when the patient is not aware of their presence. Oc-

112 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

casionally the splashing of the fluid within may be felt as well as
heard. It is essential, of course, to distinguish succession due to
the presence of air and fluid in the pleural cavity from similar
sounds produced in the stomach, but this is not at all difficult in
the majority of cases. It is a bare possibility that succussion
sounds may be due to the presence of air and fluid in the pericar-
dial cavity.

It is important to remember that succussion is never to be
heard in simple pleuritic effusion or hydrothorax. The presence of
air, as Avell as liquid, in the pleural cavity is absolutely essential to
the production of succussion sounds. 1

(2) Metallic Tinkle or F<tHlii(j-Drop Sound.

When listening over a pleural cavity which contains both air
and fluid, one occasionally hears a liquid, tinkling sound, due pos-
sibly to the impact of a drop of liquid falling from the relaxed
lung above into the accumulated fluid at the bottom of the pleural
cavity, and possibly to rales produced in the tissues around the
cavity. It is stated that this physical sign may in rare cases be
observed in large-sized phthisical cavities as well as in pneuruohy-
drothorax and pneumopyothorax.

(3) The Luny-Fistula Sound.

When a perforation of the lung occurs below the level of the
fluid accumulated in the pleural cavity, bubbles of air may be forced
out from the lung and up through the fluid with a sound reminding
one of that made by children when blowing soap-bubbles.

1 It is well for the student to try for himself the following experiment,
which I have found useful in impressing these facts upon the attention of
classes in physical diagnosis: Fill an ordinary rubber hot-water bag to the
brim with water. Invert it and squeeze out forcibly a certain amount (per-
haps half) of the contents, by grasping the upper end of the bag and compress-
ing it. While the water is thus being forced out, screw in the nozzle of the
bag. Now shake the whole bag, and it will be found impossible to produce
any splashing sounds owing to the fact that there is no air in the bag. Un-
screw the nozzle, admit air, and then screw it in again. Now shake the bag
again and loud splashing will be easily heard.

CHAPTER V.

AUSCULTATION OF THE HEAET.

I. ''VALVE AREAS."

IN the routine examination of the heart, most observers listen
in four places :

(1) At the apex of the heart in the fifth intercostal space neai
the nipple, the "mitral area."

Aortic area. *f r'i

Tricuspid area.

Pulmonic area.

........ Mitral area.

FIG. 75. The Valve Areas.

(2) In the second left intercostal space near the sternum, the
"pulmonic area. "

(3) In the second right intercostal space near the sternum, the
"aortic area."

(4) At the bottom of the sternum near the ensiform cartilage,
the "tricuspid area."

These points are represented in Fig. 75 and are known as
8

114 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

"valve areas." They do not correspond to the anatomical position
of any one of the four valves, but experience has shown that sounds
heard best at the apex can be proved (by post-mortem examination
or otherwise) to be produced at the mitral orifice. Similarly sounds
heard best in the second left intercostal space are proved to be
produced at the pulmonary orifice ; those which are loudest at the
second right intercostal space to be produced at the aortic orifice ; '
while those which' are most distinct near the origin of the ensiforin
cartilage are produced at the tricuspid orifice.

II. THE NORMAL HEART SOUXDS.

A glance at Fig. 75, which represents the anatomical positions
of the four valves above referred to, illustrates what I said above ;
namely, that the traditional valve areas do not correspond at all
with the anatomical position of the valves. If now we listen in
the "mitral area," that is, in the region of the apex impulse of the
heart, keeping at the same time one finger on some point at which
the cardiac impulse is palpable, one hears with each outward thrust
of the heart a low, dull sound, and in the period between the heart
beats a second sound, shorter and sharper in quality. 2

That which occurs with the cardiac impulse is known as the
first sound ; that which occurs between each two beats of the heart
is known as the second sound. The second sound is generally ad-
mitted to be due to the closure of the semilunar valves The cause
of the first sound has been a most fruitful source of discussion, and
no one explanation of it can be said to be generally received. Per-
haps the most commonly accepted view attributes the first or
systolic sound of the heart to a combination of two elements

(a} The contraction of the heart muscle itself.

(b) The sudden tautening of the mitral curtains.

Following the second sound there is a pause corresponding to

1 For exceptions to this rule, see below, page 176.

2 The first sound of the heart, as heard at the apex, may be imitated by
holding a linen handkerchief by the corners and suddenly tautening one of the
borders. To imitate the second sound, use one-half the length of the border
instead of the whole.

AUSCULTATION OF THE HEART. 115

the diastole of the heart. Normally this pause occupies a little
more time than the first and second sounds of the heart taken to-
gether. In disease it may be much shortened.

The first sound of the heart is not only longer and duller than
the second (it is often spoken of as " booming " in contrast with the
" snapping " quality of the second sound) but is also considerably
more intense, so that it gives us the impression of being accented
like the first syllable of a trochaic rhythm. After a little practice
one grows so accustomed to this rhythm that one is apt to rely upon

^ Aortic valve.
. Pulmonic valve.

Tricuspid valve. -- " " "^- -^ ~- '"' ' - Mitral valve.

FIG. 76. Anatomical Position of the Cardiac Valves.

his appreciation of the rhythm alone for the identification of the
systolic sound. This is, however, an unsafe practice and leads to
many errors. Our impression as to which of the two sounds of each
cardiac cycle corresponds to systole should always be verified either
by sight or touch. We must either see or feel the cardiac impulse
and assure ourselves that it is synchronous with the heart sound
which we take to be systolic. 1 This point is of especial importance
in the recognition and identification of cardiac murmurs, as will be
seen presently.

1 When the cardiac impulse can be neither seen nor felt, the pulsation of
the carotid will generally guide us. The radial pulse is not a safe guide.

116 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

So far, I have been describing the normal heart sounds heard
in the "mitral area," that is, at the apex of the heart. If now we
listen over the pulmonary area (in the second left intercostal
space), we find that the rhythm of the heart sounds has changed
and that here the stress seems to fall upon the "second sound,"
i.e., that corresponding to the beginning of diastole; in other
words, the first sound of the heart is here heard more feebly and
the second sound more distinctly. The sharp, snapping quality of
the latter is here even more marked than at the apex, and despite
the feebleness of the first sound in this area we can usually recog-
nize its relatively dull and prolonged quality

Over the aortic area (i.e., in the second right interspace) the
rhythm is the same as in the pulmonary area, although the second
sound may be either stronger or weaker than the corresponding
sound on the other side of the sternum (see below, p. 118).

Over the tricuspid area one hears sounds practically indistin-
guishable in quality and in rhythm from those heard at the apex.

When the chest walls are thick and the cardiac sounds feeble,
it may be difficult to hear them at all. In such cases the heart
sounds may be heard much more distinctly if the patient leans for-
ward and toward his own left so as to bring the heart closer to the
front of the chest. Such a. position of the body also renders it
easier to map out the outlines of the cardiac dulness by percussion.

In cardiac neuroses and during conditions of excitement or emo-
tional strain, the first sound at the apex is not only very loud but
has often a curious metallic reverberation (" cliquetis metallique")
corresponding to the trembling, jarring cardiac impulse (often mis-
taken for a thrill) which palpation reveals.

III. MODIFICATIONS IN THE INTENSITY OF THE HEART SOUNDS.

It has already been mentioned that in young persons with thin,
elastic chests, the heart sounds are heard with greater intensity
than in older persons whose chest walls are thicker and stiffer.
In obese, indolent adults it is sometimes difficult to hear any heart
sounds at all, while in young persons of excitable temperament the
sounds may have a very intense and ringing quality. Under dis-

AUSCULTATION OF THE HEART. 117

eased conditions either of the heart sounds may be increased or
diminished in intensity. I shall consider

(1) The First Sound at the Apex (sometimes Called the Mitral First

Sound)

(a) Increase in the length or intensity of the first sound at the
apex of the heart occurs in any condition which causes the heart
to act with unusual degree of force, such as bodily or mental exer-
tion, or excitement. In the earlier stages of infectious fevers a
similar increase in the intensity of this sound may sometimes be
noted. Hypertrophy of the left ventricle sometimes has a similar
effect upon the sound, but less often than one would suppose, while
dilatation of the left ventricle, contrary to what one would suppose,
is not infrequently associated with a loud, forcible first sound at
the apex. In mitral stenosis the first sound is usually very intense
and is often spoken of as a " thumping first sound " or as a " sharp
slap."

(b) Shortening and weakening of the first sound at the apex.
In the course of continued fevers and especially in typhoid fever

the granular degeneration which takes place in the heart muscle is
manifested by a shortening and weakening of the first sound at the
apex, so that the two heart sounds come to seem much more alike
than usual. In the later stages of typhoid, the first sound may
become almost inaudible. The sharp "valvular " quality, which
one notices in the first apex sound under these conditions, has been
attributed to the fact that weakening of the myocardium has caused
a suppression of one of the two elements which go to make up the
first sound, namely, the muscular element, so that we hear only the
short, sharp sound due to the tautening of the mitral curtains.
Chronic myocarditis, or any other change in the heart wall which
tends to enfeeble it, produces a weakening and shortening of the
first sound similar to that just described. Simple weakness in the
mitral first sound without any change in its duration or pitch may
be due to fatty overgrowth of the heart, to emphysema or pericar-
dial effusion in case the heart is covered by the distended lung or
by the accumulated fluid. Among valvular diseases of the heart

|L18 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

the one most likely to be associated with a diminution in intensity
of the first apex sound is mitral regurgitation.

It is not uncommon in healthy hearts to hear in the region of
the apex impulse a doubling of the first sound so that it may be
suggested by pronouncing the syllables "turrupp " or "trupp." In
health this is especially apt to occur at the end of expiration. In
disease it is associated with many different conditions involving an
increase in the work of one or the other side of the heart. It
seems, however, to be unusually frequent in myocarditis.

(2) Modifications in the Second Sounds as Heard at the Base of the

Heart.

Physiological Variations. The relative intensity of the pul-
monic second sound, when compared with the second sound heard
in the conventional aortic area, varies a great deal at different pe-
riods of life. Attention was first called to this by Vierordt, 1 and
it has of late years been recognized by the best authorities on dis-
eases of the heart, though the majority of current text-books still
repeat the mistaken statement that the aortic second sound is always
louder than the pulmonic second in health.

The work of Dr. Sarah R. Creighton, done in my clinic during
the summer of 1899, showed that in 90 per cent of healthy chil-
dren under ten years of age, the pulmonic second sound is loxider
than the aortic. In the next decade (from the tenth to the twen-
tieth year) the pulmonie second sound is louder in two-thirds of
the cases. About half of 207 cases, between the ages of twenty and
twenty-nine, shoAved an accentuation of the pulmonic second, Avhile
after the thirtieth year the number of cases showing such accentua-
tion became smaller with each decade, until after the sixtieth year
we found an accentuation of the aortic second in sixty-six out of sixty-
eight case-s examined. These facts are exhibited in tabular form in

'Vierordt: "Die Messung der Intensitat der Herztone" (Tubingen,
1885). See also Hochsinger, "Die Auscultation des kindlichen Herzens";
Gibson, "Diseases of the Heart" (1898) ; Kosenbach, "Diseases of the Heart"
(1900) ; Allbutt, "System of Medicine."

AUSCULTATION OF THE HEART.

119,

Figs. 77 and 78, and appear to show that the relative intensity of
the two sounds in the aortic and pulmonic arteries depends pri-
marily upon the age of the individual, the pulmonic sound predomi-
nating in youth and the aortic in old age, while in the period of
middle life there is relatively little discrepancy between the two.

DECADES.

] 0-9 | 10-19 J20-29I 30-39 | 40-49J 50-59 j 60-69 j 70-79 1

iuu/0 -

90 *y

- -iuu/

rn O/

TCl/'

x' !

- PERCEN

50%
-40%
30%

O
m
b)

QO?/

20%-
10 9/-

-~\

- in n /

^^.

FIG. 77. Showing the Per Cent of Accentuated Pulmonic Second Sound in Each Decade

Based on 1,000 cases.

It is, therefore, far from true to suppose that we can obtain evi-
dence of a pathological increase in the intensity of either of the
second sounds at the base of the heart simply by comparing it with
the other. Pathological accentuation of the pulmonic second
sound must mean a greater loudness of this sound than should
be expected at the age of the patient in question, and not simply a
greater intensity than that of the aortic second sound. The same

120 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

observation obviously applies to accentuation of the aortic second
sound.

Both the aortic and the pulrnonic second sounds are sometimes

' 0-9

DECADES.

50-59

60-69 70-79

-100%
SO X

10-19 ! 20-29 ] 30-39 1 40-49

Oft OX.

eno/

? * I

R PERCENTAGES

70%
60%
vi X

- -40 V

30%

qn OX

20%-

/
'

20%

10%-

FIG. 78. Showing the Per Cent of Accentuated Pulmonic Second Sound in Each Decade.

Based on 1,000 cases.

very intense during great emotional excitement or after muscular
exertion, and sometimes without any obvious cause.

Pathological V<trl<itions.

A. Accentuation of the Pulmonic Second SowxL

Pathological accentuation of the second sound occurs especially
in conditions involving a backing up of blood in the lungs, such as
occurs in stenosis or insufficiency of the mitral valve, or in obstruc-

AUSCULTATION OF THE HEART. 121

tive disease of the lungs (emphysema, bronchitis, phthisis, chronic
interstitial pneumonia). Indirectly accentuation of the pulmonic
second sound points to hypertrophy of the right ventricle, since
without such hypertrophy the work of driving the blood through
the obstructed lung could not long be performed. If the right ven-
tricle becomes weakened, the accentuation of the pulmonic second
sound is no longer heard.

B. Weakening of the Pulmonic Second Sound.

Weakening of the pulmonic second sound is a very serious symp-
tom, sometimes to be observed in cases of pneumonia or cardiac
disease near the fatal termination. It is thus a very important
indication for prognosis, and is to be watched for with the greatest
attention in such cases.

C. Accentuation of the Aortic Second Sound.

I have already shown that the aortic second sound is louder
than the corresponding sound in the pulmonary area in almost every
individual over sixty years of age and in most of those over forty.
A still greater intensity of the aortic second sound occurs

(.) In interstitial nephritis or any other condition which in-
creases arterial tension and so throws an increased amount of work
upon the left ventricle. Indirectly, therefore, a pathologically loud
aortic sound points directly to increased tension in the peripheral
arteries and indirectly to hypertrophy of the left ventricle.

(&) A similar increase in the intensity of the aortic second
sound occurs in aneurism or diffuse dilatation of the aortic arch.

D. Diminution in the Intensity of the Aortic Second Sound.

Whenever the amount of blood thrown into the aorta by the
contraction of the left ventricle is diminished, as is the case espe-
cially in mitral stenosis and to a lesser degree in mitral regurgita-
tion, the aortic second sound is weakened so that at the apex it
may be inaudible. A similar effect is produced by any disease
which weakens the walls of the left ventricle, such as fibrous myo-

122 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

carclitis, fatty degeneration, arid cloudy swelling. Relaxation of
the peripheral arteries has the same effect. In conditions of col-
lapse the aortic second sound may be almost or quite inaudible.

In persons past middle life the second sounds are often louder
in the third or fourth interspace than in the second, so that if we
listen only in the second space we may gain the false impression that
the second sounds are feeble.

Accentuation of both the second sounds at the base of the
heart may occur in health from nervous causes or when the lungs
are retracted by disease so as to uncover the conus arteriosus and
the aortic arch. Under these conditions the second sound may be
seen and felt as well as heard. In a similar way, an apparent in-
crease in the intensity of either one of the second sounds at the
base of the heart may be produced by a retraction of one or the
other lung,

Summary. (1) The mitral first sound is increased by hyper-
trophy or dilatation of the left ventricle, and among valvular dis-
eases especially by mitral stenosis. It is weakened or reduplicated
by parietal disease of the heart. Any of these changes may occur
temporarily from physiological causes.

(2) The pulmonic second sound is usually more intense than
the aortic in children and up to early adult life. Later the aortic
second sound predominates. Pathological accentuation of the sec-
ond pulmonic sound usually points to obstruction in the pulmonary
circulation (mitral disease, emphysema, etc.). Weakening of the
pulmonic second means failure of the right ventricle and is serious.

(3) The aortic second sound is increased pathologically by any
cause which increases the work of the left ventricle (arteriosclero-
sis, chronic nephritis). It is diminished Avhen the blood stream,
thrown into the aorta by the left ventricle, is abnormally small
(mitral disease, cardiac failure).

(4) Changes in the tricuspid sounds are rarely recognizable,
while changes in the first aortic and pulmonic sounds have little
practical significance.

AUSCULTATION OF THE HEART. 123

Modifications in the Rhythm of the Cardiac Sounds.

(1) Whenever the walls of the heart are greatly weakened by
disease, for example, in the later weeks of a case of typhoid
fever, the diastolic pause of the heart is shortened so that the car-
diac sounds follow each other almost as regularly as the ticking of
a clock; hence the term ""tick-tack heart." As this rhythm is not
unlike that heard in the foetal heart, the name of " embryocardia *'
is sometimes applied to it. The " tick-tack " rhythm may be heard
in any form of cardiac disease after compensation has failed, or in
any condition leading to collapse.

(2) A less common change of rhythm is that produced by a
shortening of the interval between the two heart sounds owing to
an incompleteness of the contraction of the ventricle. This change
may occur in any disease of the heart when compensation fails.

(3) The " Gallop Rhythm." Shortening of the diastolic pause
together with doubling of one or another of the cardiac sounds re-
sults in our hearing at the apex of the heart three sounds instead
of two, which follow each other in a rhythm suggesting the hoof
beats of a galloping horse. Such a rhythm may occur temporarily in
any heart which is excited or overworked from any cause, but when
permanent is usually a sign of grave cardiac weakness. The rhythms
so produced are usually anapaestic, ^ ^ ', ^ ^ ', ^^ ', or of
this type : ^ _' ^, ^ _' ^, ^ -

DoiMing of the Second Sounds at the Base of the Heart. At
the end of a long inspiration this change may be observed in al-
most any healthy person if one listens at the base of the heart. It
is still better brought out after muscular exertion or by holding the
breath. In such cases it probably expresses the non-synchronous
closure of the aortic and pulmonic valves, owing to increased press-
ure in the pulmonary circulation. Similarly in diseased condi-
tions, anything which increases the pressure either in the periph-
eral arteries or in the pulmonary circulation, and thus throws
increased work upon one or the other ventricle, will cause a doub-
ling of the second sound as heard at the base of the heart.

In mitral stenosis a double diastolic sound is usually to be

124 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

heard at the apex, and in the diagnosis of this disease this " double
shock sound " during diastole may be an important piece of evi-
dence, and may sometimes be felt as well as heard. The " double
shock sound " of mitral stenosis is not generally believed to repre-
sent a doubling of the ordinary second sound, although it corre-
sponds with diastole. Just what its mechanism is, is disputed.

I have said nothing about modifications in the second sound at
the apex, since this sound is now generally agreed to represent the
aortic second sound transmitted by the left ventricle to the apex.
The first sounds at the base of the heart have also not been dwelt
upon, since they have no special importance in diagnosis.

Metallic Heart Sounds.

The presence of air in the immediate vicinity of the heart,
as, for example, in pneuniothorax or in gaseous distention of the
stomach or intestine, may impart to the heart sounds a curious
metallic quality such as is not heard under any other conditions.

"Muffling," "Prolongation," or " Unclearness" of the Heart Sounds.

These terms are not infrequently met with in literature, but
their use should, I think, be discontinued. The facts to which
they refer should be explained either as faintness of the heart
sounds, due to the causes above assigned, or as faint, short mur-
murs. In their present usage such terms as " muffled " or " unclear "
heart sounds represent chiefly an unclearness in the mind of the
observer as to just what it is that he hears, and not any one recog-
nized pathological condition in the heart.

IV. SOUNDS AUDIBLE OVER THE PERIPHERAL, VESSELS.

(1) The normal heart sounds are in adults audible over the
carotids and over the subclavian arteries. In childhood and youth
only the second heart sound is thus audible.

(2) In about 7 per cent of normal persons a systolic sound can
be heard over the femoral artery. This sound is obviously not

AUSCULTATION OF THE HEART. 125

transmitted from the heart, and is usually explained as a result of
the sudden systolic tautening of the arterial wall.

In aortic regurgitation this arterial sound is almost always
audible not only in the femoral but in the brachial and even in the
radial, and its intensity over the femoral becomes so great that the
term "pistol-shot" sound has been applied to it. In fevers,
exophthalmic goitre, lead poisoning, and other diseases, a similar
arterial sound is to be heard much more frequently than in health.

Venous Sounds.

The violent closure of the venous valves in the jugular is some-
times audible in cases of insufficiency of the tricuspid valve. The
found has no clinical importance, and is difficult to distinguish owing
to the presence of the carotid first sound mentioned above.

CHAPTER VI.

AUSCULTATION OF THE HEART: CONTINUED.

CARDIAC MURMURS.

(a) Terminology.

THE word " murmur " is one of the most unfortunate of all the
terms used in the description of physical signs. No one of the
various blowing, whistling, rolling, rumbling, or piping noises to
which the term refers, sounds anything like a " murmur " in the
ordinary sense of the word. Nevertheless, it does not seem, best
to try to replace it by any other term. The French word "souffle "
is much more accurate and has become to some extent Anglicized.
Under the head of cardiac murmurs are included all abnormal
sounds produced within the heart itself. Pericardia! friction
sounds and those produced in that portion of the lung or pleura
which overlies the heart are not considered "murmurs."

(b) Mode of Production.

With rare exceptions all cardiac murmurs are produced at or
near one of the valve orifices, either by disease of the valves them-
selves resulting in shrivelling, thickening, stiffening, and narrowing
of the valve curtains, or by a stretching of the orifice into which
the valves are inserted.

Diseases of the valves themselves may lead to the production of
murmurs :

(a) When the valves fail to close at the proper time (incompe-
tence, insufficiency, or regurgitation).

(b) When the valves fail to open at the proper time (stenosis
or obstruction) .

AUSCULTATION OF THE HEART. 127

(c) When the surfaces of the valves or of the parts immedi-
ately adjacent are roughened so as to prevent the smooth flow of the
blood over them.

((/) When the orifice which the valves are meant to close is di-
lated as a result of dilatation of the heart chamber of which it forms

FIG. 79. Diagram to Illustrate the Production of a Cardiac Murmur Through Regurgitation
from the Aorta or in an Aneurismal Sac. The arrow shows the direction of the blood cur-
rent and the curled lines the audible blood eddies.

the entrance or exit. The valves themselves cannot enlarge to
keep pace with the enlargement of the orifice, and hence no longer
suffice to reach across it.

The presence of any one of these lesions gives rise to eddies
in the blood current and thereby to the abnormal sounds to which
we give the name murmurs. 1 (See Figs. 79, 80, and 81). When

Q .

FIG. 80. Diagram to Illustrate the Production of a Cardiac Murmur Through Stenosis of a

Valve-Oriflce.

valves fail to close and so allow the blood to pass back through
them, we speak of the lesion as reyurgitation, insufficiency, or in-
competence ; if, for example, the aortic valves fail to close after
the left ventricle has thrown a column of blood into the aorta,
some of this blood regurgitates through these valves into the ven-

1 The method by which functional murmurs are produced will be discussed
later. (See page 130.)

128 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

tricle from which it has just been expelled, and we speak of the
lesion as "aortic regurgitation," and of the murmur so produced as
an aortic regurgitant murmur or a murmur of aortic regurgitation.
A similar regurgitation from the left ventricle into the left auricle
takes place in case the mitral valve fails to close at the beginning
of systole. If, on the other hand, the mitral valve fails to open
properly to admit the blood which should flow during diastole from
the left auricle into the left ventricle, we speak of the condition as
mitral stenosis or mitral obstruction. A similar narrowing of the
aortic valves such as to hinder the egress of blood during the systole
of the left ventricle is known as aortic stenosis or obstruction. Val-

Fin. 81. Diagram to Illustrate the Production of Cardiac Murmurs Through Roughening of a

Valve.

vular lesions of the right side of the heart (tricuspid and pulmonic
valves) are comparatively rare, but are produced and named in a
way similar to those just described.

The facts most important to know about a murmur are :

(1) Its place in the cardiac cycle.

(2) Its point of maximum intensity.

(3) The area over which it can be heard.

(4) The effects of exertion, respiration, or position upon it.
Less important than the above are :

(5) Its intensity.

(6) Its quality.

(7) Its length.

(8) Its relation to the normal sounds of the heart.
Each of these points will now be taken up in detail :

(1) Time of Murmurs. The first and most important thing to
ascertain regarding a murmur is its relation to the normal cardiac
cycle ; that is, whether it occurs during systole or during diastole,
or in case it does not fill the whole of one of those periods, in what

AUSCULTATION OF THE HEART. 129

part of systole or diastole it occurs. It must be borne in mind that
the period of systole is considered as lasting from the beginning of
the first sound of the heart up to the occurrence of the second
sound, while diastole lasts from the beginning of the second sound
until the beginning of the first sound in the next cycle. Any mur-
mur occurring with the first sound of the heart, or at the time when
the first sound should take place, or in any part of the period inter-
vening between the first sound and the second, is held to be systolic.
Murmurs which distinctly follow the first sound or do not begin
until the first sound is ended are known as late systolic murmurs.

On the other hand, it seems best, for reasons to be discussed
more in detail later on, not to give the name of diastolic to all
murmurs which occur within the diastolic period as above defined.
Murmurs which occur during the last part of diastole and which
run up to the first sound of the next cycle are usually known as
"jiri'syst otic " murmurs. All other murmurs occurring during dias-
tole are known as diastolic.

The commonest of all the errors in the diagnosis of disease of
the heart is to mistake systole for diastole, and thereby to misin-
terpret the significance of a murmur heard during those periods.
This mistake would never happen if we were always careful to
make sure, by means of sight or touch, just when the systole of
the heart occurs. This may be done by keeping one finger upon
the apex impulse of the heart or upon the carotid artery while
listening for murmurs, or, in case the apex impulse or the pulsa-
tions of the carotid are better seen than felt, we can control by the
eye the impressions gained by listening. It is never safe to trust
our appreciation of the cardiac rhythm to tell us which is the first
heart sound and which the second. The proof of this statement
is given by the numberless mistakes made through disregarding it.
Equally untrustworthy as a guide to the time of systole and dias-
tole is the radial pulse, which follows the cardiac systole at an
interval just long enough to mar our calculations.

(2) Localizations of Murmurs. To localize a murmur is to find
its point of maximum intensity, and this is of the greatest impor-
tance in diagnosis. Long experience has shown that murmurs
9

130 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

heard loudest in the region of the apex beat (whether this is in the
normal situation or displaced), are in the vast majority of cases pro-
duced at the mitral valve. In about five per cent of the cases mitral
murmurs may be best heard at a point midway between the position
of the normal cardiac impulse and the ensiform cartilage, or (very
rarely) an inch or two above this situation.

Murmurs heard most loudly in the second left intercostal space
are almost invariably produced at the pulmonic orifice or just above
it in the conus arteriosus.

Murmurs whose maximum intensity is at the root of the ensi-
form cartilage or within a radius of an inch and a half from this
point are usually produced at the tricuspid orifice. Murmurs pro-
duced at the aortic orifice may be heard best in the aortic area, but
in a large proportion of cases are loudest on the other side of the
sternum at or about the situation of the fourth left costal cartilage.
Occasionally they are best heard at the apex of the heart or over
the lower part of the sternum (see above, Fig. 103).

(3) Transmission of Murmurs. If a murmur is audible over sev-
eral valve areas, the questions naturally arise : " How are we to
know whether we are dealing with a single valve lesion or with
several? Is this one murmur or two or three murmurs? " Obvi-
ously the question can be asked only in case the murmur which we
find audible in various places occupies everywhere the same time
in the cardiac cycle. It must, for example, be everywhere systolic
or everywhere diastolic. A systolic murmur at the apex cannot
be supposed to point to the same lesion as a diastolic murmur, no
matter where the latter is heard. But if we hear a systolic mur-
mur in various parts of the chest, say over the aortic, mitral, and
tricuspid regions, how are we to know whether the sound is simple
or compound, whether produced at one valve orifice or at several?

This question is sometimes difficult to answer, and in a given
case skilled observers may differ in their verdict, but, as a rule, the
difficulty may be overcome as follows :

(1) Experience and post-mortem examination have shown that
the murmur produced by each of the valvular lesions has its own
characteristic area of propagation, over which it is heard with an in-

AUSCULTATION OF THE HEART. 131

tensity which regularly diminishes as we recede from, a maximum
whose seat corresponds with some one of the valve areas just de-
scribed. These areas of propagation are shown in Figs. 91, 92, 95,
and 100. Any murmur whose distribution does not extend beyond
one of these areas, and which steadily and progressively diminishes
in intensity as we move away from the valve area over which it is
loudest, may be assumed to be due to a single valve lesion and no

FIG. 82. Mitral and Tricuspid Regurgitation. The intensity of the systolic murmur is least at
the " waist " of the shaded area and increases as one approaches either end of it.

more. Provided but one valve is diseased, this course of procedure
gives satisfactory results.

(2) When several valves are diseased and several murmurs may
be expected, it is best to start at some one valve area, say in the
mitral or apex region, and move the stethoscope one-half an inch
at a time toward one of the other valve areas, noting the intensity
of any murmur we may hear at each of the different points passed
over. As we move toward the tricuspid area, we may get an im-
pression best expressed by Fig. 82. That is, a systolic murmur
heard loudly at the apex may fade away as we move toward the
ensiform, until at the point x (Fig. 82) it is almost inaudible. But
as we go on in the same direction the murmur may begin to grow

132 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

louder (and perhaps to change in pitch and quality as well) until a
maximum is reached at the tricuspid area, beyond which the mur-
mur again fades out.

These facts justify us in suspecting that we are dealing with two
murmurs, one produced at the tricuspid and one at the mitral ori-
fice. The suspicion is more likely to be correct if there has been
a change in the pitch and quality of the murmur as we neared the
tricuspid orifice, and may be confirmed by the discovery of other
evidences of a double lesion, ^o diagnosis is satisfactory wliirh
rests on the evidence of murmurs alone. Changes in the size of
the heart's chambers or in the pulmonary or peripheral circulations
are the most important facts in the case. Nevertheless the effort
to ascertain and graphically to represent the intensity of cardiac
murmurs as one listens along the line connecting the valve areas
has its value. An "hour-glass" murmur, such as that represented
in Fig. 82, generally means two-valve lesions. A similar "hour-
glass " may be found to represent the auditory facts as we move
from the mitral to the pulmonic or to the aortic areas (see Fig.
83), and, as in the previous case, arouses our suspicion that more
than one valve is diseased.

It must not be forgotten, however, that " a murmur may travel
some distance underground and emerge with a change of quality "
(Allbutt). This is especially true of aortic murmurs, which are often
heard well at the apex and at the aortic area, and faintly in the in-
tervening space, probably owing to the interposition of the right
ventricle.

In such cases we must fall back xipon the condition of the heart
itself, as shown by inspection, palpation, and percussion, and upon
the condition of the pulmonary and peripheral circulation, as
shown in the other symptoms and signs of the cases (dropsy, cough,
etc.).

(4) Intensity of 3furn/urs. Sometimes murmurs are so loud
that they are audible to the patient himself or even at some dis-
tance from the chest. In one case I was able to hear a murmur
eight feet from the patient. Such cases are rare and usually not
serious, for the gravity of the lesion is not at all proportional to

AUSCULTATION OF THE HEART. 133

the loudness of the murmur; indeed, other things being equal,
loud murmurs are less serious than faint ones, provided we are sure
we are dealing with organic lesions. (On the distinction between
the organic and functional murmurs, see below, p. 138.)

A loud murmur means a powerful heart driving the blood
strongly over the diseased valve. When the heart begins to fail,
the intensity of the murmur proportionately decreases because the
blood does not flow swiftly enough over the diseased valve to pro-

Fio. 83. Mitral Regurgitation and Aortic Stenosis. The systolic murmur is loudest at the ex-
tremities of the shaded area and faintest at its "waist."

duce as loud a sound as formerly. The gradual disappearance of
a murmur known to be due to a valvular lesion is, therefore, a very
grave sign, and its reappearance revives hope. Patients are not
infrequently admitted to a hospital with valvular heart trouble
which has gone on so long that the muscle of the heart is no longer
strong enough to produce a murmur as it pumps the blood over the
diseased valve. In such a case, under the influence of rest and
cardiac tonics, one may observe the development of a murmur as
the heart wall regains its power, and the louder the murmur be-
comes the better the condition of the patient. On the other hand,
when the existence of a valvular lesion has been definitely deter-

134 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

mined, and yet the compensation remains perfectly good (for exam-
ple, in the endocarditis occurring in children in connection with
chorea) , an increase in the loudness of the murmur may run paral-
lel with the advance in the valvular lesion.

In general the most important point about the intensity of a
murmur is its increase or decrease -while under observation, and not
its loudness at any one time.

(5) Quality of Heart Murmurs. It has been already mentioned
that the quality of a heart murmur is never anything like the
sound which we ordinarily designate by the word " murmur. " The
commonest type of heart murmur has a blowing quality, whence the
old name of "bellows sound." The sound of the letter "f" pro-
longed is not unlike the quality of certain murmurs. Blowing
murmurs may be low-pitched like the sound of air passing through
a large tube, or high-pitched approaching the sound of a whistle.
This last type merges into that known as the musical murmur, in
which there is a definite musical sound whose pitch can be identi-
fied. Rasping or tearing sounds often characterize the louder
varieties of murmurs.

Finally, there is one type of sound which, though included
under the general name murmur, differs entirely from any of the
other sounds just described. This is the "presystolic roll, " which
has a rumbling or blubbering quality or may remind one of a short
drum-roll. This murmur is always presystolic in time and usually
associated with obstruction at the mitral or tricuspid valves. Not
infrequently some part of a cardiac murmur will have a musical
quality while the rest is simply blowing or rasping in character.
Musical murmurs do not give us evidence either of an especially
serious or especially mild type of disease. Their chief importance
consists in the fact that they rarely exist without some valve
lesion, 1 and are, therefore, of use in excluding the type of mur-
mur known as "functional," presently to be discussed, and not
due to valve disease. Very often rasping murmurs are associated
either with the calcareous deposit upon a valve or very marked
narrowing of the valve orifice.

1 Rosenbach holds that they may be produced by adhesive pericarditis.

AUSCULTATION OF THE HEART, 135

Murmurs may be accented at the beginning or the end ; that is,
they may be of the crescendo type, growing louder toward the end,
or of the decrescendo type with their maximum intensity at the
beginning. Almost all murmurs are of the latter type except those
associated with mitral or tricuspid obstruction.

(6) Length of Murmurs. Murmurs may occupy the whole
of systole, the whole of diastole, or only a portion of one of
these periods, but no conclusions can be drawn as to the severity
of the valve lesion from the length of the murmur. A short mur-
nmr, especially if diastolic, may be of very serious prognostic im-
port.

(7) Relations to the Normal Sounds of the Heart. Cardiac mur-
murs may or may not replace the normal heart sounds. They may
occur simultaneously with one or both sounds or between the
sounds. These facts have a certain amount of significance in prog-
nosis. Murmurs which entirely replace cardiac sounds usually mean
a severer disease of the affected valve than murmurs which accom-
pany, but do not replace, the normal heart sounds. Post-systolic
or late systolic murmurs, which occur between the first and the
second sound, are usually associated with a relatively slight degree
of valvular disease. Late diastolic murmurs, on the other hand,
have no such favorable significance.

(8) Effects of Position, Exercise, and Respiration upon Cardiac
Murmurs. Almost all cardiac murmurs are affected to a greater
or less extent by the position which the patient assumes while he
is examined. Systolic murmurs which are inaudible while the
patient is in a sitting or standing position may be quite easily
heard when the patient lies down. On the other hand, a pre-
systolic roll which is easily heard when the patient is sitting up
may entirely disappear when he lies down. Diastolic murmurs
are relatively little affected by the position of the patient, but
in the majority of cases are somewhat louder in the upright posi-
tion.

The effects of exercise may perhaps be fitly mentioned here.
Feeble murmurs may altogether disappear when the patient is at
rest, and under such circumstances may be made easily audible by

136 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

getting the patient to walk briskly up and clown the room a few
times. Such lesions are usually comparatively slight. 1 On the
other hand, murmurs which become more marked as a result of rest
are generally of the severest type (see above, p. 132).

Organic murmurs are usually better heard at the end of expira-
tion and become fainter during inspiration as the expanding lung
covers the heart. This is especially true of those produced at the
mitral valve, and is in marked contrast with the variations of func-
tional murmurs which are heard chiefly or exclusively at the end of
inspiration.

(9) Sudden Metamorphosis of Murmurs. In acute endocarditis,
when vegetations are rapidly forming and changing their shape
upon the valves, murmurs may appear and disappear very sud-
denly. This metamorphosing character of cardiac murmurs, when
taken in connection with other physical signs, may be a very im-
portant factor in the diagnosis of acute endocarditis. In a similar
way relaxation or rupture of one of the tendinous cords, occurring
in the course of acute endocarditis, may effect a very sudden change
in the auscultatory phenomena.

" Functional Murmurs."

Not every murmur which is to be heard over the heart points to
disease either in the valves or in the orifices of the heart. Perhaps
the majority of all murmurs are thus unassociated with val vular
disease, and to such the name of "accidental," ''functional," or
" hsemic " murmurs has been given. The origin of these " functional "
murmurs has given rise to an immense amount of controversy, and
it cannot be said that any one explanation is now generally agreed
upon. To me the most plausible view is that which regards most
of them as due either to a temporary or permanent dilatation of
the conus arteriosus, or to pressure or suction exerted upon the
overlapping lung margins by the cardiac contractions. This ex-
plains only the systolic functional murmurs, which make up ninety-
nine per cent, of all functional murmurs. The diastolic functional
murmurs, which undoubtedly occur, although with exceeding rarity,
1 For exception to this see below, page 161.

AUSCULTATION OF THE HEART. 137

are probably due to sounds produced in the veins of the neck and
transmitted to the innominate or vena cava.

Characteristics of functional Murmurs. (1) Almost all func-
tional murmurs are systolic, as has before been mentioned.

(2) The vast majority of them are heard best over the puluionic
valve in the second left intercostal space. From this point they
are transmitted in all directions, and are frequently to be heard, al-
though with less intensity, in the aortic and mitral areas. Occa-
sionally they may have their maximum, intensity in one of the latter
positions.

(3) As a rule, they are very soft and blowing in quality, though
exceptionally they may be loud and rough.

(4) They are not associated with any evidence of enlargement
of the heart nor with accentuation of the pulmonic second sound. ]

(5) They are usually louder at the end of inspiration.

(6) They are usually heard over a very limited area and not
transmitted to the left axilla or to the back.

(7) They are especially evanescent in character ; for example,
they may appear at the end of a hard run or boat race or during
an attack of fever, and disappear within a few days or hours. Ees-
piration, position, and exercise produce greater variations in them
than in " organic " murmurs.

(8) They are especially apt to be associated with anaemia,
although the connection between anaemia and functional heart mur-
murs is by no means as close as has often been supposed. The
severest types of anaemia, for example pernicious anaemia, may not
be accompanied by any murmur, while, on the other hand, typical
functional murmurs are often heard in patients whose blood is nor-
mal, and even in full health. It should not be forgotten that a
real, though temporary, leakage through the mitral or tricuspid
valve may be associated with anaemia or debilitated conditions
owing to weakening of the papillary muscles or of the mitral
sphincter. In such cases we find not the signs of a functional

1 In chlorosis the second pulmonic sound is often very loud (owing to the
retraction of the lungs and uncovering of the conus arteriosus) and associated
with a systolic murmur.

138 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

murmur, as above described, but the evidence of an organic valve
lesion hereafter to be described.

The distinctions between organic and functional heart murmurs
may be summed up as follows :

Organic murmurs may occupy any part of the cardiac cycle; if
systolic, they are usually transmitted either into the axilla and
back or into the great vessels of the neck ; they are usually asso-
ciated with evidences of cardiac enlargement and changes in the sec-
ond sounds at the base of the heart, as well as with signs and symp-
toms of stasis in other organs. Organic murmurs not infrequently
have a musical or rasping quality, although this is by no means al-
ways the case. They are rarely loudest in the pulmonic area and
are relatively uninfluenced by respiration, position, or exercise.

Functional murmurs are almost always systolic in time and
usually heard with maximum intensity in the pulmonic area. They
are rarely transmitted beyond the precordial region and are usually
loudest at the end of inspiration. They are not accompanied by
evidences of cardiac enlargement or pathological accentuation of
the second sounds at the base of the heart, nor by signs of venous
stasis or dropsy. They are very apt to be associated with anaemia
or with some special attack upon the resources of the body (e.y.,
physical overstrain or fever), and to disappear when such forces are
removed. They are usually soft in quality ; never musical. The
very rare diastolic functional murmur occurs exclusively, so far as
I am aware, in conditions of profound anaemia; i.e., when the haemo-
globin is twenty-five per cent or less. It can be abolished by press-
ure upon the bulbus jugularis, and can be observed, if followed up
into the neck, to pass over gradually into a continuous venous hum
with a diastolic accent.

Cardio- Respiratory Mummrs.

When a portion of the free margin of the lung is fixed by ad-
hesions in a position overlapping the heart, the cardiac movements
may rhythmically displace the air in such piece of lung so as to
give rise to sounds which at times closely simulate cardiac mur-
murs. These conditions are most often to be found in the tongue-

AUSCULTATION OF THE HEART. 139

like projection of the left lung, which normally overlaps the heart,
but it is probably the case that cardio-respiratory murmurs may be
produced without any adhesion of the lung to the pericardium
under conditions not at present understood. Such murmurs may
be heard under the left clavicle or below the angle of the left scap-
ula, as well as near the apex of the heart, less often in other parts
of the chest.

Cardio-respiratory murmurs may be either systolic or diastolic,
but the vast majority of cases are systolic. The area over which
they are audible is usually a very limited one. They are greatly
affected by position and by respiration, and are heard most distinctly
if not exclusively during inspiration, especially at the end of that
act. (This fact is an important aid in distinguishing them from
true cardiac murmurs, which are almost always fainter at the end
of inspiration.) They are also greatly affected by cough or forced
respiration or by holding the breath, whereas cardiac murmurs
are relatively little changed thereby. Pressure on the outside
of the thorax and in their vicinity may greatly modify their in-
tensity or quality, while organic cardiac murmurs are but little
influenced by pressure. As a rule, they have the quality of nor-
mal respiratory murmur, and sound like an inspiration interrupted
by each diastole of the heart.

In case the effect of the cardiac movements is exerted upon a
piece of lung in which a catarrhal process is going on, we may have
systolic or diastolic explosions of rales, or any type of respiratory
murmur except the bronchial type, since this is produced in solid lung
which could not be emptied or filled under the influence of the car-
diac movements. Cardio-respiratory murmurs have no special diag-
nostic significance, and are mentioned here only on account of the im-
portance of not confusing them with true cardiac murmurs. They
were formerly thought to indicate phthisis, but such is not the case.

Murmurs of Venous Origin.

I have already mentioned that the venous hum so often heard
in the neck in cases of anaemia may be transmitted to the region of
the base of the heart and heard there as a diastolic murmur owing

140 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

to the acceleration of the venous current by the aspiration of the
right ventricle during diastole. Such murmurs are very rare and
may usually be obliterated by pressure upon the bulbus jugularis,
or even by the compression brought to bear upon the veins of the
neck when the head is sharply turned to one side. They are heard
better in the upright position and during inspiration.

Arterial Murmurs.

(1) Roughening of the arch of the aorta, due to chronic endo-
carditis, is a frequent cause in elderly men of a systolic murmur,
heard best at the base of the heart and transmitted into the vessels
of the neck. Such a murmur is sometimes accompanied by a pal-
pable thrill. From cardiac murmurs it is distinguished by the lack
of any other evidence of cardiac disease and the presence of marked
arterio-sclerosis in the peripheral vessels (see further discussion
under Aortic Stenosis, p. 180, and under Aneurism, p. 220) .

(2) A narrowing of the lumen of the left subclavian artery, due
to some abnormality in its course, may give rise to a systolic mur-
mur heard close below the left clavicle at its outer end. The mur-
mur is greatly influenced by movements of the arm and especially
by respiratory movements. During inspiration it is much louder,
and at the end of a forced expiration it may disappear altogether.
Occasionally such murmurs are transmitted through the clavicle so
as to be audible above it.

(3) Pressure exerted upon any of the superficial arteries (carot-
id, femoral, etc.) produces a systolic murmur (see below, p. 178).
Diastolic arterial murmurs are peculiar to aortic regurgitation.

(4) Over the anterior fontanelle in infants and over the gravid
uterus systolic murmurs are to be heard which are probably arterial
in origin.

PART II.

DISEASES OF THE HEART.

CHAPTER VII.

VALVULAK LESIONS.

CLINICALLY it is convenient to divide the ills which befall the
heart into three classes :

(1) Those which deform the cardiac valves (valvular lesions).

(2) Those which weaken the heart wall (parietal disease).

(3) Congenital malformations.

Lesions which affect the cardiac valves without deforming them
are not often recognizable during life. The vegetations of acute
endocarditis 1 do not usually produce any peculiar physical signs
until they have so far deformed or obstructed the valves as to pre-
vent their opening or closing properly.

The murmurs which are often heard over the heart in cases of
acute articular rheumatism cannot be considered as evidence of
vegetative endocarditis unless valvular deformities, and their re-
sults in valvular obstruction or incompetency, ensue. The chordae
tendinese may be ruptured or shortened, thickened, and welded to-
gether into shapeless masses, but if these deformities do not affect
the action of the valves we have no means of recognizing them dur-
ing life. Congenital malformations are practically unrecognizable
as such. If they do not affect the valves, we cannot with any cer-
tainty make out what is wrong.

For physical diagnosis, then, heart disease means either de-
formed valves or weakened walls. Whatever else may exist, we
are none the wiser for it unless the autopsy enlightens us.

1 See Appendix.

142 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

In this chapter I shall confine myself to the discussion of valvu-
lar lesions and their results.

Valvular lesions are of two types :

(a) Those which produce partial obstruction of a valve orifice
or prevent its opening fully ("stenosis").

ily

FIG. 84. The Base of the Contracted Heart Showing Spliincteric Action of the Muscular Fibres
Surrounding the Mitral and Tricuspid Valves. The outer dotted line is the outline of the
relaxed heart. The inner dotted circles show the size of the mitral and tricuspid valves
during diastole, a, Outline of the heart when relaxed ; b, outline of the relaxed tricuspid
valve ; c, outline of the mitral orifice during diastole.

(&) Those which produce leakage through a valve orifice or
prevent its closing effectively (" reyuryitation," "insufficiency,"
" incompetencij ").

Stenosis results always from the stiffening, thickening, and con-
traction of a valve.

Kegurgitation, on the other hand, may be the result either of

VALVULAR LESIONS.

143

Mitral curtains.
I

Chordea
tendinea?.

Papillary
muscle.

Endocardium.

(rt) Deformity of a valve, or

(&) Weakening of the heart muscle.

The mitral and tricuspid orifices are closed not simply by the
shutting of their valves, but also in part by the sphincter-like ac-
tion of the circular fibres of the heart wall (see Fig. 84) and the
contraction of the papillary muscles (Fig. 85).

In birds the tricuspid orifice has no valve and is closed wholly
by the muscular sphincter of
the heart wall.

In conditions of acute car-
diac failure, such as may oc-
cur after a hard run, the
papillary muscles are in all
probability relaxed,
so that the valve-flaps
swing back into the
auricle and permit re-
gurgitation of blood
from the ventricle.

Valvular incom-
petence, then, differs from
valvular obstruction in that
the latter always involves
deformity and stiffening of
valves, while incompetence
or leakage is often the result
of deficient muscular action

on the part of the heart wall. An obstructed valve is almost always
leaky as well, since the same deformities which prevent a valve
from opening usually prevent its closure; Intt this rule does not
work backward. A leaky valve is often not obstructed. It is leaky
but not obstructed if the valve curtain has been practically de-
stroyed by endocarditis; or, again, it is leaky but not obstructed if
the leak represents muscular weakening of the mitral sphincter ^or
of the papillary muscles. Pure stenosis is very rare. Pure regur-
gitation is very common.

Myocardium.

Pericardium.

FIG. 85. -The Mitral Valve Closed, Showing the
Action of the Papillary Muscles.

144 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

When valves are so deformed that their orifice is loth leaky and
obstructed, we have what is known as a " combined " or " double "
valve lesion.

Since valvular lesions are recognized largely by their results,
first upon the walls of the heart itself and then upon the other
organs of the body, it seems best to give some account of these
results before passing on to the description of the individual le-
sions in the heart itself.

The results of valvular lesions are 'first conservative and later
destructive. The conservative results are known as :

The establishment of compensation through hypertrophy.

The destructive or degenerative results are known as :

The failure of compensation through (or icithouf) dilatation.

I shall consider, then,

(a) The establishment and the failure of compensation.

(5) Cardiac hypertrophy.

ESTABLISHMENT AND FAILURE OF COMPENSATION IN
VALVULAR DISEASE OF THE HEART.

We may discriminate three periods in the progress of a case of
valvular heart disease :

(1) The period before the establishment of compensation.

(2) The period of compensation.

(3) The period of failing or ruptured compensation.

(1) Compensation Not Yet Established.

In most cases of acute valvular endocarditis, whether of the
relatively benign or of the malignant type, there is a time when
the lesion is perfectly recognizable despite the fact that compensa-
tory hypertrophy has not yet occurred. In some cases this period
may last for months ; the heart is not enlarged, there is no accentu-
ation of either second sound at the base, there is no venous stasis,
and our diagnosis must rest solely upon the presence and character-
istics of the murmur. For example, in early cases of mitral regur-

VALVULAR LESIONS. 145

gitation due to chorea or rheumatism, the disease may be recog-
nized by the presence of a loud musical murmur heard in the back
as well as at the apex and in the axilla. In the earlier stages of
aortic regurgitation occurring in young people as a complication of
rheumatic fever, there may be absolutely no evidence of the valve
lesion except the characteristic diastolic murmur. In most text-
books of physical diagnosis I think too little attention is given to
this stage of the disease.

(2) The Period of Compensation.

Valvular disease would, however, soon prove fatal were it not
for the occurrence of compensatory hypertrophy of the heart walls.
To a certain extent the heart contracts as a single muscle, and in-
creases the size of all its walls in response to the demand for in-
creased work ; but as a rule the hypertrophy affects especially one
ventricle that ventricle, namely, upon which especially demand is
made for increased power in order to overcome an increased resist-
ance in the vascular circuit which it supplies with blood. What-
ever increases the resistance in the lungs brings increased work
upon the right ventricle ; whatever increases the resistance in the
aorta or peripheral arteries increases the amount of work which the
left ventricle must do.

Now, any disease of the mitral valve, whether obstruction or
leakage, results in engorgement of the lungs with blood, and hence
demands an increased amount of work on the part of the right
ventricle in order to force the blood through the overcrowded pul-
monary vessels ; hence it is in mitral disease that we find the great-
est compensatory hypertrophy of the right ventricle.

On the other hand, it is obvious that obstruction at the aortic
valves or in the peripheral arteries (arterio-sclerosis) demands an
increase in power in the left ventricle, in order that the requisite
amount of blood may be forced through arteries of reduced calibre,
while if the aortic valve is so diseased that a part of the blood
thrown into the aorta by the left ventricle returns into that ven-
tricle, its work is thereby greatly increased, since it has to contract
upon a larger volume of blood.
10

146 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

In response to these demands for increased work, the muscular
wall of the left ventricle increases in thickness, and compensation is
thus established at the cost of an increased amount of work on the
part of the heart.'

(3) Failure of Compensation.

Sooner or later in the vast majority of cases the heart, handi-
capped as it is by a leakage or obstruction of one or more valves,
becomes unable to meet the demands made upon it by the needs of
the circulation. Failure of compensation is sometimes associated
with dilatation of the heart and weakening of its walls, but in
many cases no such change can be found to account for its failure,
and we have to fall back upon changes in the nutrition of the
heart wall or upon some hypothetical derangement of the ner-
vous mechanism of the organ as an explanation. Whatever the
cause may be, the result of ruptured compensation is venous stasis ;
that is, oedema or dropsy of various organs appears. If the
left ventricle is especially weakened, dropsy appears first in the
legs, on account of the influence of gravity, soon after in the geni-
tals, lungs, liver, and the serous cavities. Engorgement of the
lungs is especially marked in cases of mitral disease with weakening
of the right ventricle, and is manifested by dyspnoea, cyanosis,
cough, and haemoptysis. In many cases, however, dropsy is very
irregularly and unaccountably distributed, and does not follow the
rules just given. In pure aortic disease, uncomplicated by leakage
of the mitral valve, dropsy is a relatively late symptom, and dysp-
nosa and precordial pain (angina pectoris) are more prominent.

HYPERTROPHY AXD DILATATION.

Since cardiac hypertrophy or dilatation are not in themselves
diseases, but may occur in any disease of the heart (valvular or
parietal), it seems best to give some account of them and of the
methods by which they may be recognized, before taking up sepa-
rately the different lesions with which they are associated.

1 Rosenbach brings forward evidence to show that the arteries, the lungs.
and other organs actively assist in maintaining compensation.

VALVULAR LESIONS. 147

1. Cardiac Hypertrophy.

Hypertrophy of the heart is usually due to the following causes :

First (aud most frequent) : Valvular disease of the heart itself.
Second: Obstruction of the flow of blood through the arteries
owing to increase of arterial resistance, such as occurs in chronic
nephritis and arterio-sclerosis. Third : Obstruction to the circula-
tion of the blood through the lungs (emphysema, cirrhosis of the
lung, fibroid phthisis). Fourth: Severe and prolonged muscular
exertion (athlete's heart).

In valvular disease the greatest degree of hypertrophy is to be
seen usually in relatively young persons, and especially when the
advance of the lesion is not very rapid.

Hypertrophy of the heart in valvular disease is also influenced
by the amount of muscular work done by the patient, by the de-
gree of vascular tension, and by the treatment. In the great major-
ity of cases of hypertrophy, from whatever cause, both sides of the
heart are affected, but we may distinguish cases in which one or the
other ventricle is predominantly affected.

(1) Cardiac hypertrophy affecting especially the left ventricle.

() The apex impulse is usually lower than normal, often in
the sixth space, occasionally in the seventh. or eighth. 1 It is also
farther to the left than normal, but far less so than in cases in
which the hypertrophy affects especially the right ventricle. The
area of visible pulsation is usually increased, and a considerable por-
tion of the chest wall may be seen to move with each systole of the
heart, while frequently there is a systolic retraction of the inter-
spaces in place of a systolic impulse.

(b) Palpation confirms the results of inspection and shows us
also that the apex impulse is unusually powerful. Percussion
shows in many cases that the cardiac dulness is more intense and
its area increased downward and to a lesser extent toward the left. 2

1 This is due partly to a stretching of the aorta, produced by the increased
weight of the heart.

-Post mortem hypertrophy of the left ventricle is often found despite the
absence of the above signs in life.

148 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(c) If we listen in the region of the maximum cardiac impulse,
we generally hear an unusually long and low-pitched first sound,
which may or may not be of a greater intensity than normal. A
very loud first sound is much more characteristic of a cardiac neu-
rosis than of pure hypertrophy of the left ventricle.

The second sound at the apex (the aortic second sound trans-
mitted) is usually much louder and sharper than usual. Ausculta-
tion in the aortic area shows that the second sound at that point is
loud and ringing in character. Not infrequently the peripheral ar-
teries (the subclavians, brachials, carotids, radials, and femorals)
may be seen to pulsate with each systole of the heart. This sign is
most frequently observed in cases of hypertrophy of the left ven-
tricle, which are due to aortic re gurgitation, but is by no means
peculiar to this disease and may be repeatedly observed when the
cardiac hypertrophy is due to nephritis or muscular work. I have
frequently observed it in athletes, blacksmiths, and others whose
muscular work is severe.

The radial pulse wave has no constant characteristics, but de-
pends rather upon the cause which has produced the hypertrophy
than upon the hypertrophy itself.

(2) Cardiac Hypertrophy Affecting Especially the Bight Ventricle.

It is much more difficult to be certain of the existence of en-
largement of the right ventricle than of the left. Practically we
have but two reliable physical signs :

(a) Increase in the transverse diameter of the heart, as shown
by the position of the apex impulse and by percussion of the right
and left borders of the heart ; and

(b) Accentuation of the pulnionic second sound, which is often
palpable as well as audible.

The apex beat is displaced both to the left and downward, lid
especially to the left. In cases of long-standing mitral disease, the
cardiac impulse may be felt in mid-axilla, several inches outside the
nipple, and yet not lower down than the sixth intercostal space.
In a small percentage of cases (i.e., when the right auricle is en-
gorged), an increased area of dulness to the right of the sternum

VALVULAR LESIONS. 149

may be demonstrated. Accentuation of the pulmonic second sound
is almost invariably present in hypertrophy of the right ventricle,
though it is not peculiar to that condition. It may be heard, for
example, in cases of pneumonia when no such hypertrophy is pres-
ent, but in the vast majority of cases of cardiac disease we may
infer the presence and to some extent the amount of hypertrophy
of the right ventricle from the presence of a greater or lesser ac-
centuation of the pulmonic second sound. The radial pulse shows
nothing characteristic of this type of hypertrophy.

Epigastric pulsation gives us no evidence- of the existence of
hypertrophy of the right ventricle, despite contrary statements in
many text-books. Such pulsation is frequently to be seen in per-
sons with normal hearts, and is frequently absent when the right
ventricle is obviously hypertrophied. It is perhaps most often due
to an unusually low position of the whole heart.

DILATATION OF THE HEART.

(1) Acute Dilatation. Immediately after severe muscular exer-
tion, as, for example, at the finish of a boat race, or of a two-mile
run (especially in persons not properly trained), an acute dilatation
of the heart may occur, and in debilitated or poorly nourished sub-
jects such an acute dilatation may be serious or even fatal in its
results.

(2) Chronic dilatation comes on gradually as a result of valvu-
lar disease or other cause, and gives rise to practically the same
physical signs as those of acute dilatation, from which it differs
chiefly as regards the accompanying physical phenomena and the
prognosis. Briefly stated, the signs of dilatation of the heart,
whether acute or chronic, are :

() Feebleness and irregularity of the apex impulse and of the
radial impulse, (&) enlargement of the heart, as indicated by inspec-
tion, palpation, and percussion, and (sometimes) (c) murmurs indi-
cative of stretching of one or another of the valvular orifices.

150 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Dilatation of the Left Ventricle.

Inspection shows little that is not better brought out by palpa-
tion. Palpation reveals a feeble "napping" cardiac impulse, or
a vague shock displaced both downward and to the left and diffused
over an abnormally large area of the chest wall. Percussion veri-
fies the position of the cardiac impulse and sometimes shows an
unusually blunt or rounded outline at the apex of the heart.

On auscultation, the first sound is usually very short and sharp,
but not feeble unless it is accompanied by a murmur. In case the
mitral orifice is so stretched as to render the valve incompetent, or
in case the muscles of the heart are so fatigued and weakened that
they do not assist in closing the mitral orifice, a systolic murmur is
to be heard at the apex of the heart. This murmur is transmitted
to the axilla and back, but does not usually replace the first sound
of the heart. The aortic second sound, as heard in the aortic area
and at the apex, is feeble.

Dilatation of the right ventricle of the heart is manifested by an
increase in the area of cardiac dulness to the light of the sternum
(corresponding to the position of the right auricle), by feebleness of
the pulmonic second sound together with signs of congestion and
engorgement of the lungs, and often by a systolic murmur at the
tricuspid valve; i.e., at or near the root of the eusiform cartilage.
When this latter event occurs, one may have also systolic pulsation
in the jugular veins and in the liver (see below, p. 188).

In cases of acute dilatation, such as occur in infectious fevers
or at the end of well-contested races, there is often to be heard a
systolic murmur loudest in the pulmonary area and due very pos-
sibly to a dilatation of the conus arteriosus.

The diagnosis of dilatation of the heart seldom rests entirely
upon physical signs referable to the heart itself. In acute cases
our diagnosis is materially aided by a knowledge of the cause,
which is often tolerably obvious. In chronic cases the best evi-
dence of dilatation is often that furnished by the venous stasis
which results from it.

VALVULAR LESIONS. 151

(4) CHRONIC VALVULAR DISEASE.
I. MITRAL KEGUEGITATIOX.

The commonest and on the whole the least serious of valvular
lesions is incoinpetency of the mitral. It results in most cases
from the shortening, stiffening, and thickening of the valve pro-
duced by rheumatic endocarditis in early life. It is the lesion
present in most cases of chorea (see Figs. 86 and 87).

Temporary and curable mitral regurgitation may result from
weakening of the heart muscle, which normally assists in closing
the mitral orifice through the sphincter-like contraction of its cir-
cular fibres.

Great muscular fatigue, such as is produced by a hard boat
race, may result in a temporary relaxation of the mitral sphincter
or of the papillary muscles sufficient to allow of genuine but tem-
porary and curable regurgitation through the mitral orifice. In
conditions of profound nervous debility and exhaustion, similar
weakening of the cardiac muscles may allow of a leakage through
the mitral, which ceases Avith the removal of its cause. Stress has
recently been laid upon these points by Arnold and by Morton
Prince.

Mitral insufficiency due to stretching of the ring into which the
valve is inserted occurs not unfrequently as a result of dilatation
of the left ventricle, and is commonly known as relative insufficiency
of the mitral valve. The valve orifice can enlarge, the valve can-
not, and hence its curtains are insufficient to fill up the dilated ori-
fice. This type of mitral insufficiency frequently results from
aortic regurgitation with the dilatation of the left ventricle which
that lesion produces, or from myocarditis, which weakens the heart
wall until it dilates and widens the mitral orifice.

The results of any form of mitral leakage are :

1. Dilatation or hypertrophy of the left auricle, which has to
receive blood both from the lungs and through the leaky mitral
from the left ventricle.

2. The overfilled left auricle cannot receive the blood from the

152 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

lungs as readily as it should; hence the blood "backs up" in the
lungs and thereby increases the work which the right ventricle
must do in order to force the blood through them. Thus result
redeina of the lungs, and

FIG. 86. Normal Heart during Systole. Mitral valve closed ; blood flowing through the open
aortic valves into the aorta.

TIG. 87. Mitral Regurgitation. The heart is in systole and the arrows show the current flowing
back in the left auricle as well as forward into the aorta.

[J ^ rJ

VALVULAR LESIONS. 153

(3) Hypertrophy and dilatation of the right ventricle, which in
turn becomes sooner or later overcrowded so that the tricuspid
valve gives way and tricuspid leakage occurs.

(4) The capacity for hypertrophy possessed by the right auricle
is soon exhausted, and we get then

(5) General venous stasis, which shows itself first as venous
pulsation in the jugulars and in the liver and later in the tissues
drained by the portal and peripheral veins. This venous stasis in-
creases the work of the left ventricle, and so we get

(6) Hypertrophy and dilatation of the left ventricle. Hyper-
trophy of the left ventricle is also produced by the increased work
necessary to maintain some vestige of sphincter action at the leaky
mitral orifice, as well as by the labor of contracting upon the extra
quantity of blood delivered to it by the enlarged left auricle.

At last the circle is complete. Every chamber in the heart is
enlarged, overworked, and failure is imminent.

Returning now to the signs of mitral re gurgitation, we shall find
it most convenient to consider first the type of regurgitation pro-
duced by rheumatism and resulting in thickening, stiffening, and
retraction of the valve.

PHYSICAL SIGNS.

(a) First Stage Prior to the Establishment of Compensation.

We have but one characteristic physical sign :

A systolic murmur heard loudest at the apex of the heart, trans-
mitted to the back (below or inside the left scapula) and to the left
axilla. The murmur is not infrequently musical in character, and
when this is the case diagnosis is much easier. Systolic musical
murmurs so transmitted do not occur without valvular leakage.
Eosenbach believes that adherent pericardium is capable of produc-
ing such a murmur, but only, if I understand him rightly, in case
there is a genuine mitral leakage due to the embarrassing embrace
of the pericardium which prevents the mitral orifice from closing.

"Functional" or "haemic" murmurs are rarely heard in the
back, and very rarely, if ever, have a musical quality.

154 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Cases of mitral regurgitation are not very often seen at this
stage, but in acute endocarditis after the fever and anaemia have
subsided, or in chorea, such a murmur may exist for days or weeks
before any accentuation of the pulmonic second sound or any en-
largement of the heart appears. I have had the opportunity of
verifying the diagnosis at autopsy in two such cases.

(&) Second Staye Compensation

As long as compensation remains perfect, the only evidence of
regurgitation may be that obtained by auscultation, and I shall
accordingly begin with this rather than in the traditional way with
inspection, palpation, and percussion.

The distinguishing auscultatory phenomena in cases of well-
compensated mitral insufficiency are :

() A systolic murmur whose maximum :' 'tensity is at or near
the apex impulse of the heart, but which is also to be heard in the
left axilla and in the back below or inside the angle of the left
scapula (so far the signs are those of the first stage, above de-
scribed).

(I) A pathological accentuation of the pulmonic second sound.

This is the minimum of evidence upon which it is justifiable to
make the diagnosis of compensated mitral regurgitation. In the
vast majority of cases, however, our diagnosis is confirmed by the
following additional data :

((V) Evidence of congestion of the lungs (dyspnoea, orthopnoea,
cough, cyanosis, hemoptysis), as well as of the general venous sys-
tem (engorgement of the liver, oedema of the legs, ascites, etc.).

The pulse in well-compensated cases shows no considerable
abnormality. When compensation begins to fail, or sometimes be-
fore that time, the most characteristic thing about the pulse is its
marked irregularity both in force and rhythm. Such irregularity
is at once more comnm/i <nul less serious in mitral disease than in
that of any other valve ; it may continue for years and be compat-
ible with very tolerable health.

VALVULAR LESIOA 7 S.

155

Returning now to the details of the sketch just given, we will
take \\p first

() The Murmur. In children the murmur of mitral re gurgita-
tion may be among the loudest of all murmurs to be heard in val-

1st

2nd

1st

2nd.

FIG. 88. Diagram to Represent Systolic Mitral Murmur. The heavy lines represent the normal
cardiac sounds and the light lines the murmur, which in this case does not replace the first
sound and '* tapers " off characteristically at the end.

vular disease, but this does not necessarily imply that the lesion is
a very severe one. A murmur which (/rows louder under observa-
tion in a well-compensated valvular lesion may mean an advance of
the disease, but if the case is first seen after compensation has
failed a faint, variable whiff in the mitral area may mean the se-
verest type of lesion. As the patient improves under the influence
of rest and cardiac tonics, such a murmur may grow very much
louder, or a murmur previously inaudible may appear.

The length of the murmur varies a great deal in different cases
and is not of any great practical importance. It rarely ends
abruptly, but usually "tails off" at the end of systole (see Fig. 88).
Musical murmurs are heard more often in mitral regurgitation than
in any other valve lesion, but the musical quality rarely lasts
throughout the whole duration of the murmur, contrasting in this
respect with musical murmurs produced at the aortic valve. The

2nd

FIG. 89. Systolic Mitral Murmur Replacing the First Sound of the Heart.

first sound of the heart may or may not be replaced by the murmur
(see Fig. 89). "When the sound persists and is heard either with
or before the murmur, one can infer that the lesion is relatively
slight in comparison with cases in which the first sound is wholly

156 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

obliterated. Post-systolic or late systolic murmurs, which are occa-
sionally heard in mitral re gurgitation, are said to point to a rela-
tively slight amount of disease in the valve (see Fig. 90). Kosen-

1st

2nd

FIG. 90. Late Systolic Murmur. The first sound Is clear and an interval intervenes between

it and the murmur.

bach claims that the late systolic murmur is always due to organic
disease of the valves and never occurs as a functional murmur.

When compensation fails, the murmur may altogether disappear
for a time, and if the patient is then seen for the first time and
dies without rallying under treatment, it may be impossible to-

Pulmonic second
accented.

Systolic murmur
loudest here.

FIG. 91. Mitral Regurgitation. The murmur is heard over the shaded area as well as in the

back.

make the diagnosis. The very worst cases, then, are those in which
there is no murmur at all.

The murmur of mitral regurgitation is conducted in all directions,
but especially toward the axilla and to the back (not around the
chest, but directly). In the latter situation it is usually louder

VALVULAR LESIONS.

157

than it is in mid-axilla, and occasionally it is heard as loudly in the
back as anywhere else. This is no doubt owing to the position of
the left auricle (see Figs. 91 and 92).

(It) After compensation is established and as long as it lasts an
accentuation, of the pulmonic second sound is almost invariably to
be made out, and may be so marked that we can feel and see it, as
well as hear it. Not infrequently one can also see and feel the
pulsation of the conus arteriosus not the left auricle in the second
and third left intercostal space. (It may be well to mention again

Systolic murmur.

FIG. 92. Mitral Regurgitation. Murmur heard over the shaded area.

here that by accentuation of the pulmonic second sound one does
not mean merely that it is louder or sharper in quality than the
aortic second sound, since this is true in the vast majority of cases
in healthy individuals under thirty years of age. Pathological ac-
centuation of the pulmonic second sound means a greater intensity
of the sound than ive have a right to expect at the age of the individ-
ual in question.') Occasionally the pulmonic second sound is redu-
plicated, but as a rule this points to an accompanying stenosis of
the mitral valve. At the apex the second sound (i.e., the trans-
mitted aortic second) is not infrequently wanting altogether, owing

158 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

to the relatively small amount of blood which recoils upon the
aortic "alves.

(p~) Enlargement of the heart, and more especially of the right
ventricle, is generally to be made out, and in the majority of cases
tnis enlargement is manifested by displacement of the apex impulse
both downward and toward the left, but more especially to the
left. Percussion confirms the results of inspection and palpation
regarding the position of the cardiac impulse. The normal sub-
sternal dulness is increased in intensity, and we can sometimes
demonstrate an enlargement of the heart toward the right (see
Fig. 91).

In children (in whom adhesive pericarditis often complicates
the disease) a systolic THRILL may not infrequently be felt at the
apex, and the precordia may be bulged, and even in adults such a
systolic thrill is not so rare as some writers would have us sup-
pose.

(d) The pulse, as said above, shows nothing characteristic at any
stage of the disease. "\Vhile compensation lasts, there is usually
nothing abnormal about the pulse, although it may be somewhat
irregular in force and rhythm, and may be weak when compared to
the powerful beat at the apex in case the regurgitant stream is a
very large one. Irregularity at this period is less common in pure
mitral regurgitation than in cases complicated by stenosis.

"\Vhen compensation begins to fail, the pulse becomes weak and
irregular, and many heart beats fail to reach the wrist, but there,
is still nothing characteristic about the pulse, which differs in no
respect from that of any case of cardiac weakness of whatever
nature.

(e) Evidence of venous stasis, first in the lungs and later in the
liver, lower extremities, and serous cavities, does not show itself
so long as compensation is sufficient, but when the heart begins to
fail the patient begins to complain not only of palpitation and car-
diac distress, but of dyspnoea, orthopnoea, and cough, and examina-
tion reveals a greater or lesser degree of cyanosis with pulnio-

VALVULAR LESIONS. 159

nary oedema manifested by crackling rales at the base of the lungs
posteriorly, and possibly also by haemoptysis or by evidences of
hydrothorax (see below, p. 266). If compensation is not re-estab-
lished, the right ventricle dilates, the tricuspid becomes incompe-
tent, the liver becomes enlarged and tender, dropsy becomes gen-
eral, the heart and pulse become more and more rapid and irregular,
the heart murmur disappears and is replaced by a confusion of
short valvular sounds, "gallop rhythm" or "delirium cordis," often
considerably obscured by the noisy, labored breathing with numer-
ous moist rales. In a patient seen for the first time in such a con-
dition diagnosis may be impossible, yet mitral disease of some type
may usually be suspected, since murmurs produced at the aortic
valve are not so apt to disappear when compensation fails. The
relative tricuspid insufficiency which often occurs is likely to mani-
fest itself by an enlargement of the right auricle, sometimes demon-
strable by percussion and later by venous pulsation in the neck and
in the liver.

(d) Differential Diagnosis.

The murmur of mitral regurgitation may be confused with

(1) Tricuspid regurgitation.

(2) Functional murmurs.

(3) Stenosis or roughening of the aortic valves.

(1) The post-mortem records of the Massachusetts General
Hospital show that in the presence of a murmur due to mitral re-
gurgitation it is very easy to fail altogether to recognize a tricuspid
regurgitant murmur. Only 5 out of 29 cases of tricuspid regurgi-
tation found at autopsy were recognized during life. Allbutt's
figures from Guy's Hospital are similar. In the majority of these
cases, mitral regurgitation was the lesion on which attention was
concentrated during the patient's life. This is all the more excus-
able because the tricuspid area is so wide and uncertain. Murmurs
produced at the tricuspid orifice are sometimes heard with maxi-
mum intensity just inside the apex impulse, and if we have also a
mitral regurgitant murmur, it may be impossible under such cir-
cumstances to distinguish it from the tricuspid murmur. Some-

160 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

times the two are of different pitch, but more often tricuspid regur-
gitatioii must be recognized indirectly if at all, i.e., through the
evidence given by venous pulsation in the jugular veins and in the
liver. Tricuspid murmurs are not transmitted to the left axilla
and do not cause accentuation of the puluionic second sound, al-
though they are compatible with such accentuation. They are to
be distinguished from the murmurs of mitral regurgitation by their
different seat of maximum intensity, possibly by a difference in
pitch, but most clearly by the concomitant phenomena of venous
pulsation above mentioned.

(2) " Functional " murmurs are usually systolic and may have
their maximum intensity at the apex of the heart, but in the great
majority of cases they are heard best over the puluionic valve or
just inside or outside the apex beat (Potain). They are faint or
inaudible at the end of expiration, and are more influenced by
position than organic murmurs are. In the upright position they
are often very faint. They are rarely transmitted beyond the
precordia and are unaccompanied by any evidences of enlargement
of the heart, by any pathological accentuation of the pulmonic
second sound, 1 or any evidences of engorgement of the lungs or
general venous system.

(3) Roughening or narrowing of the aortic valves may produce
a systolic murmur with maximum intensity in the second right in-
tercostal space, but this murmur is not infrequently heard all over
the precordia and quite plainly at the apex, so that it may simulate
the murmur of mitral regurgitation. The aortic murmur may in-
deed be heard more plainly at the apex than at any other point ex-
cept the second right intercostal space, owing to the fact that the
right ventricle, which occupies most of the precordial region be-
tween the aortic and mitral areas, does not lend itself well to the
propagation of certain types of cardiac murmurs. Under these
circumstances " a loud, rough aortic murmur may be heard at the

1 It must be remembered that in chlorosis, a disease in which functional
murmurs are especially prone to occur, the pulmonic second sound is often
surprisingly loud, owing to a retraction of the left lung, which uncovers the
root of the pulmonic artery.

VALVULAR LESIONS. 161

apex as a smooth murmur of a different tone " (Broadbent) . Such
a murmur is not, however, likely to be conducted to the axilla or
heard beneath the left scapula, nor to be accompanied by accentua-
tion of the pulmonic second sound nor evidences of engorgement
of the lungs and general venous system.

II. MITRAL STENOSIS.

Narrowing or obstruction of the mitral orifice is almost invari-
ably the result of a chronic endocarditis which gradually glues to-
gether the two flaps of the valve until only a funnel-shaped open-
ing or a slit like a buttonhole is left (see Figs. 93 and 94). As we
examine post mortem, the tiny slit which may be all that is left of
the mitral orifice in a case of long standing, it is difficult to con-
ceive how sufficient blood to carry on the needs of the circulation
could be forced through such an insignificant opening.

Usually a slow and gradually developed lesion, mitral stenosis
often represents the later stages of a process which in its earlier
phases produced pure mitral re gurgitation. By some observers the
advent of stenosis is regarded as representing an attempt at com-
pensation for a reduction of the previous mitral leakage. Others
consider that the stenosis simply increases the damage which the
valve has suffered.

A remarkable fact never satisfactorily explained is the predilec-
tion of mitral stenosis for the female sex. A large proportion of
the cases seventy-six per cent in my series occur in women.

It is also curious that so many cases are associated with pul-
monary tuberculosis.

Physical Signs.

Mitral stenosis may exist for many years without giving rise to
any physical signs by which it may be recognized, and even after
signs have begun to show themselves they are more fleeting and
inconstant than in any other valvular lesion of the heart. In the
early stages of the disease the heart may appear to be entirely nor-
mal if the patient is at rest, and especially if examined in the re-
cumbent position, characteristic signs being elicited only by exer-
11

162 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

tion ; or again a murmur which is easily audible with the patient
in the upright position may disappear in the recumbent position ;
or a murmur may be heard at one visit, at the next it may be im-
possible to elicit it by any manoeuvre, while at the third visit it may

FIG. 93. Diagram to Represent the Position of the Valves in the Normal Heart during Diastole,
the Open Mitral Allowing the Blood to Flow Down from the Left Auricle, the Aortic Closed.

FIG. 94. Mitral Stenosis Period of Diastole. The blood flowing from the left auricle is ob-
structed by the thickened and adherent mitral curtains.

VALVULAR LESIONS. 163

be easily heard again. These characteristics explain to a certain
extent the fact that differences bf opinion so often arise regarding
the diagnosis of mitral stenosis, and that out of forty-eight cases in
which this lesion was found at autopsy at the Massachusetts General
Hospital, only twenty-three were recognized during life. No com-
mon lesion (with the exception of tricuspid regurgitation) has been
so frequently overlooked in our records.

I shall follow Broadbent in dividing the symptoms 'into three
stages, according to the extent to which the lesion has progressed.

In the first stage inspection and palpation show that the apex
beat is little if at all displaced, and percussion reveals no increase

Pulmonic second
accented.

" Double-shock '
sound.

Presystolic murmur
heard in limited
area.

FIG. 95. Mitral Stenosis.

in the area of cardiac dulness ; indeed, in rare cases the heart may
be smaller than usual. If one lays the hand lightly over the origin
of the apex beat, one can generally feel the purring presystolie thrill
which is so characteristic of this disease, more common indeed than
in any other. This thrill is more marked in the second stage of
the disease, but can generally be appreciated even in the first. It
runs up to and ceases abruptly with the very sharp first sound,

164 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

the sudden shock of which may be appreciated even by palpation.
The thrill is sometimes palpable even when no murmur can be
heard, and often the thrill is transmitted to the axilla when the
murmur is confined to the apex region. On auscultation one
hears, especially after the patient has been exerting himself, and
particularly if he leans forward and to the left, a short rumble or
roll immediately preceding the systole and increasing in intensity
as it approaches the first sound (see Fig. 9/5). At this stage of
the Disease the second sound can still be heard at the apex. The
first sound is very sharply accented or snapping, and communi-
cates a very decided shock to the ear when a rigid stethoscope
is used. As a rule, the murmur is closely confined to the region
of the apex beat and not transmitted any considerable distance in
any direction. I have seen cases in which it was to be heard only

1st

2nd

1st

2nd

FIG. 96. The Murmur of Mitral Stenosis First Stage. The place of the murmur and its cres-
cendo character are indicated by the position of the light lines just before the first sound
and by their increasing length.

over an area the size of a half-dollar. 1 Very characteristic of mi-
tral stenosis is a prolongation of the diastolic pause so that the inter-
val beween the second sound of one cycle and the first sound of the
next is unduly long. Occasionally the diastolic sound is redupli-
cated (" double-shock sound " Sansom) at this stage of the disease,
but this is much more frequent in the later phases of the lesion. 2

Irregularity of the heart beat both in force and rhythm is very
frequently present even in the early stages of the affection. The
heart may be regular while the patient is at rest, but slight exer-
tion is often sufficient to produce marked irregularity.

1 It may, however, be widely transmitted to the left axilla and audible in
the back or even over the whole of the left chest, especially when the stenosis
is combined with regurgitation.

2 This is the opinion of most observers. Sansom states that the "double-
shock sound" may precede all other evidences of mitral stenosis.

VALVULAR LESIONS.

165

II.

In the second stage the murmur and thrill are usually longer and
may occupy the whole of diastole, beginning with considerable in-
tensity just after the reduplicated second sound, quickly cliinmish-

1st

FIG. 97. Type of Presystolic Murmur Often Heard In the Second Stage of Mitral Stenosis.
Here the murmur fills the whole of diastole, with a gradual increase of intensity as it ap-
proaches the first sound. No second sound is audible at the apex.

ing until it is barely audible, and then again increasing with a
steady crescendo up to the first sound of the next cycle. 1 These
changes may be graphically represented as in Figs. 97 and 98. Dia-
stole is now still more prolonged, so that the characteristic rhythm
of this lesion is even more marked than in the earlier stages of the
disease. In many cases at this stage no second sound is to be heard
at all at the apex, although at the pulmonic orifice it is loud and
almost invariably double. (This is one of the reasons for believing
that the second sound which we usually hear at the apex is the
transmitted aortic second sound. In mitral disease the aortic valves

2nd

FIG. 98. Type of Presystolic Murmur Sometimes Heard in the Second Stage of Mitral Stenosis.
There is a double crescendo. The second sound seems reduplicated.

shut feebly owing to the relatively small amount of blood that is
thrown into the aorta.)

At this stage of the disease enlargement of the heart begins to
make itself manifest. The apex impulse is displaced to the left

1 Rarely one finds a crescendo in the middle of a long presystolic roll with
a diminuendo as it approaches the first sound.

166 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

sometimes as far as the mid-axillary line, and often descends to
the sixth interspace. Occasionally the cardiac dulness is increased
to the right of the sternum.

The instability and fleeting character of the murmur in the ear-
lier stages of the disease are much less marked in this, the second
stage. The first sound at the apex still retains its sharp, thump-
ing quality, and is often audible without the murmur in the back.

The irregularity of the heart is generally greater at this stage
than in the earlier one.

III.

The third stage of the affection is marked by the disappearance
of the characteristic murmur, and is generally synchronous with
the development of tricuspid re gurgitation. The right ventricle
becomes dilated sometimes very markedly. Indeed, it may produce
a visible pulsating tumor below the left costal border and be mis-
taken for cardiac aneurism (Osier). The snapping first sound and
the " double-shock " sound usually remain audible, but the latter
may be absent altogether. Diagnosis in this stage rests largely upon
the peculiar snapping character of the first sound, together with the
prolongation of diastole and the very great irregularity of the heart,
both in force and rhythm. At times a presystolic thrill may be
felt even when no murmur is to be heard.

The pulse shows nothing characteristic in many cases except
that early and persistent irregularity which has been already al-
luded to. In other cases the wave is low, long, easily compressed,
but quite perceptible between beats ; but for the lack of sufficient
power in the cardiac contractions the pulse would be one of high
tension.

As the disease advances the irregularity of the pulse becomes
more and more marked, and sometimes presents an amazing contrast
with the relatively good general condition of the circulation. Even
when not more than a third of the beats reach the Avrist, the patient
may be able to attend to light work and feel very well. Such cases
make us feel as if a pulse were a luxury rather than a necessity.

Under the influence of digitalis the pulse is especially apt to

VALVULAR LESIONS. 167

assume the liyeminal type in mitral stenosis. Every other beat is
then so abortive that it fails to send a wave to the wrist, and the
weak beat is succeeded by a pause. According to Broadbent the
weak beat corresponds to an abortive contraction of the left ven-
tricle accompanied by a normal contraction of the right ventricle,
so that for each two strong beats of the right side of the heart we
have one strong and one weak beat of the left side of the heart.

Mitral stenosis is in the great majority of cases combined with
mitral regurgitation, and it often happens that the signs of regur-
gitation are so much more prominent than those of stenosis that
the latter escape observation altogether, especially in the third
stage of the disease, when the typical presystolic roll has disap-
peared. In such cases combined stenosis and regurgitation is to be
distinguished from pure regurgitation by the sharpness of the first
sound, which would be very unusual at this stage of a case of pure
mitral regurgitation. The presence of reduplicated second sound, a
" double-shock sound " at the outset of the prolonged diastolic pause,
and of great irregularity in force and rhythm, is further suggestive
of mitral stenosis.

Mitral stenosis is apt to be associated with haemoptysis, with en-
gorgement of the liver and ascites, and especially with arterial em-
bolism. No other valve lesion is so frequently found associated
with embolism. The lungs are generally very voluminous, and
may therefore mask an increase in area or intensity of the cardiac
dulness.

Differential Diagnosis.

I have already discussed the difficulty of distinguishing a double
lesion at the mitral valve from a simple mitral regurgitation (see
above, p. 161).

Other murmurs which may be mistaken for the murmur of mi-
tral stenosis are :

() The Austin Flint murmur.

(b) The murmur of tricuspid stenosis.

168 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(a) The Austin Flint murmur.

In 1862 Austin Flint studied two cases in which during life a
typical presystolic roll was audible at the apex of the heart, yet in
which post mortem the mitral valve proved to be perfectly normal,
and the only lesion present was aortic insufficiency. This observation
has since been verified by Osier, Bramwell, Gairdner, and other com-
petent observers. At the Massachusetts General Hospital we have
had seven such cases with autopsy. Yet, despite repeated confir-
mation, Flint's observation has remained for nearly forty years un-
known to physicians at large. Its importance is this : Given a case
of aortic regurgitation a presystolic murmur at the apex does not
necessarily mean stenosis of the mitral valve even though the mur-
mur has the typical rolling quality and is accompanied by a pal-
pable thrill. It may be only one of the by-effects of the aortic
incompetency. How it is that a presystolic murmur can be pro-
duced at the apex in cases of aortic regurgitation has been much
debated. Some believe it is due to the impact of the aortic regur-
gitant stream upon the ventricular side of the mitral valve, floating
it out from the wall of the ventricle so as to bring it into contact
with the stream of blood descending from, the left auricle. Others
suppose that the mingling of the two currents of blood, that from
the mitral and that from the aortic orifice, is sufficient to produce
the murmur.

Between the " Austin Flint murmur " thus defined and the mur-
mur of true mitral stenosis, complicating aortic regurgitation, diag-
nosis may be impossible. If there are no dilatation of the mitral
orifice and no regurgitation, either from this cause or from, deformi-
ties of the mitral valve itself, any evidence of engorgement of the
pulmonary circuit (accentuation of the pulmonic second sound,
oedema of the lungs, haemoptysis, and cough) speaks in favor of an
actual narrowing of the mitral valve, while the absence of such
signs and the presence of a predominating hypertrophy of the left
ventricle tend to convince us that the murmur is of the type de-
scribed by Austin Flint, i.e., that it does not point to any sten-
osis of the mitral valve. The sharp, snapping first sound and
systolic shock so characteristic of mitral stenosis are said to be

VALVULAR LESIONS 169

modified or absent in connection with murmurs of the Austin Flint
type.

(b) Tricuspid obstruction.

Luckily for us as diagnosticians, stenosis of the tricuspid valve
is a very rare lesion. Like mitral stenosis it is manifested by a
presystolic rolling murmur whose point of maximum intensity is
sometimes over the traditional tricuspid area, but may be at a point
so near the mitral area as to be easily confused with stenosis of
the latter valve.

The difficulty of distinguishing tricuspid stenosis from, mitral
stenosis is further increased by the fact that the two lesions almost
invariably occur in conjunction. Hence we have two presystolic
murmurs, perhaps with slightly different points of maximum inten-
sity and possibly with a difference in quality, but often quite un-
distinguishable from each other. In the vast majority of cases,
therefore, tricuspid stenosis is first recognized at the autopsy, and
the diagnosis is at best a very difficult one.

(c) Broadbent, Rosenbach, and others have noticed in children
who have just passed through an attack of pericarditis a rumbling
murmur near the apex of the heart, which suggests the murmur of
mitral stenosis. It is distinguished from the latter, however, by the
absence of any accentuation of the first sound at the apex, as well
as by the conditions of its occurrence and by its transiency. Such
cases are important, since their prognosis is much more favorable
than that of mitral stenosis.

Phear (Lancet) September 21, 1895) investigated 46 cases in
which a presystolic murmur was observed during life and no mitral
lesion found at autopsy. In 17 of these there was aortic regurgi-
tation at autopsy ; in 20 of these there was adherent pericardium
at autopsy ; in 9 nothing more than dilatation of the left ventricle
was found. In none of these cases was the snapping first sound,
so common in mitral stenosis, recorded during life.

It should be remembered that patients suffering from mitral
stenosis are very frequently unaware of any cardiac trouble, and
seek advice for anaemia, wasting, debility, gastric or pulmonary
complaints. This is less often true in other forms of valvular dis-

170 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

ease. We should be especially on our guard in cases of supposed
"nervous arrhythmia" or "tobacco heart," if there has been an at-
tack of rheumatism or chorea previously. Such cases may present
no signs of disease except the irregularity yet may turn out to
be mitral stenosis.

IV. AOKTK; KKGUKGITATIOX.

Rheumatic endocarditis usually occurs in early life and most
often attacks the mitral valve. The commonest cause of aortic dis-
ease on the other hand arterio-sclerosis is a disease of late niid-

FIG. 99. Diastole in Aortic Regurgitation. The blood is flowing back through the stumpy and
incompetent aortic valves.

die life, and attacks men much more often than women. When
we think of aortic re gurgitation, the picture that rises before us is
usually that of a man past middle life and most often from the
classes who live by manual labor. Nevertheless cases occur at all
ages and in both sexes, and rheumatic endocarditis does not spare
the aortic cusps altogether by any means.

Whether produced by arterio-sclerosis extending down from the
aorta, or by rheumatic or septic endocarditis, the lesion which re-
sults in aortic regurgitation is usually a thickening and shortening
of the cusps (see Fig. 99). In rare cases an aortic cusp may be
ruptured as a result of violent muscular effort, and the signs and

VALVULAR LESIONS. 171

symptoms of regurgitation then appear suddenly. But as a rule
the lesion conies on slowly and insidiously, and unless discovered
accidentally or in the course of routine physical examination it may
exist unnoticed for years. Dropsy and cyanosis are relatively late
and rare, and the symptoms which first appear are usually those of
dyspnoea and precordial distress.

It is a disputed point whether relative and temporary aortic
insufficiency due to stretching of the aortic orifice ever occurs. If
it does occur, it is certainly exceedingly rare, as the aortic ring is
very tough and inelastic.

Dilatation of the aortic arch practically diffuse aneurism oc-
curs in almost every case of aortic regurgitation, and produces sev-
eral important physical signs. This complication is a very well-
known one, but has not, I think, been sufficiently insisted on in
text-books of physical diagnosis. It forms part of that general
enlargement of the arterial tree which is so characteristic of the
disease.

"Physical tSiyns.

Inspection reveals more that is important in this disease than
in any other valvular lesion. In extreme cases the patient's face
or hand may blush visibly with every systole. Not infrequently
one can make the diagnosis across the room or in the street by not-
ing the violent throbbing of the carotids, which may be such as to
shake the person's whole head and trunk, and even the bed on
which he lies. No other lesion is so apt to cause a heaving of the
whole chest and a bobbing of the head, and no other lesion so often
causes a bulging of the precordia, for in no other lesion is the en-
largement of the heart so great (cor bovinum or ox-heart). The
throbbing of the dilated aorta can often be felt and sometimes seen
in the suprasternal notch or in the second right interspace. Not
only the carotids but the subclavians, the brachials and radials,
the femoral and anterior tibial, and even the digital and dorsalis
pedis arteries may visibly pulsate, and the characteristic jerking
quality of the pulse may be seen as well as felt. This visible pul-
sation in the peripheral arteries, while very characteristic of aortic

172 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

regurgitation, is occasionally seen in cases of simple hypertrophy of
the heart from hard muscular work (e.g., in athletes). If the ar-
teries are extensively calcified, their pulsation become much less
marked.

The peculiar conditions of the circulation whereby it is " changed
into a series of discontinuous discharges as if from a catapult" (All-
butt) throws a great tensile strain upon all the arteries, and results,
in almost every long-standing case, in increasing both their length

Pulsation at the jugulum.

Dulness and pul-
sation corre-
sponding to the
dilated aortic
arch.

Pulsating car-
otids.

Diastolic murmur.

Displaced cardiac
impulse.

FIG. 100. Aortic Regurgitation, Showing Position of the Diastolic Murmur and Areas of Visible

Pulsation.

and their diameter. The visible arterial trunks become tortuous
and distended, while the arch of the aorta is diffusely dilated and
becomes practically an aneurism (see Fig. 100). With each heart
beat the snaky arteries are often jerked to one side as well as made
to throb.

Inspection of the region of the cardiac impulse almost always
shows a very marked displacement of the apex beat both downward
and outward (but especially the former), corresponding to the hy-
pertrophy of the left ventricle, which is usually very great, and to

VALVULAR LESIONS. 173

the downward sagging of the enlarged aorta. In a small propor-
tion of the cases no enlargement of the heart is to be demonstrated.
This was true of 5 out of the last 67 cases which I have notes of,
and generally denotes an early and slight lesion. Not at all infre-
quently one finds a systolic retraction of the interspaces near the
apex beat instead of a systolic impulse. This is probably due to
the negative pressure produced within the chest by the powerful
contraction of an hypertrophied heart. In the suprasternal notch
one often feels as well as sees a marked systolic pulsation trans-
mitted from the arch of the dilated aorta, and sometimes mistaken
for saccular aneurism.

Arterial pulsation of the liver and spleen are rarely demon-
strable by a combination of sight and touch.

Capillary Pulsation.

If one passes the end of a pencil or other hard substance once
or twice across the patient's forehead, and then Avatches the red
mark so produced, one can often see a systolic flushing of the hyper-
semic area with each beat of the heart. This is by far the best
method of eliciting this phenomenon. It may also be seen if a glass
slide is pressed against the mucous membrane of the lip so as par-
tially to blanch it, or if one presses upon the finger-nail so as par-
tially to drive the blood from under it ; but in both these manoeuvres
error may result from inequality in the pressure made by the ob-
server upon the glass slide or upon the nail. Very slight movements
of the observer's fingers, even such as are caused by his own pulse,
may give rise to changes simulating capillary pulsation. Capillary
pulsation of normal tissues is not often seen in any condition other
than aortic 1 re gurgitation, yet occasionally one meets with it in
diseases which produce very low tension of the pulse, such as
phthisis or typhoid, ansemic and neurasthenic conditions, and I
have twice seen it in perfectly healthy persons. In such cases the
pulsation is usually less marked than in aortic regurgitation.
Rarely pulsation may be detected in the peripheral veins.

1 Jumping toothache and throbbing felon are common examples of capil-
lary pulsation in inflamed areas.

174 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Palpation.

Palpation verifies the position of the cardiac impulse and the
heaving of the whole chest wall suggested by inspection. The
shock of the heart is very powerful and deliberate unless dilatation

FIG. 101. Sphygmographic Tracing from Normal Pulse.

is extreme, when it becomes wavy and diffuse. In the supraclavie-
ular notch a systolic thrill is often to be felt. A diastolic thrill
in the precordia is very rare.

The pulse is important, usually characteristic. The wave rises

FIG. 102. Sphygmographic Tracing of the " Pu1#n* Celer" in Aortic Regurgitation. Its col-
lapsing character is well shown.

very suddenly and to an unusual height, then collapses complete!"
and with great rapidity (pulsus celer) (see Figs. 101, 102).

This type of pulse, which is known as the " Corrigan pulse " or
"water-hammer pulse," is exaggerated if one raises the patient's
arm above the head so as to make the force of gravity aid in emp-
tying the artery. The quality of the pulse in aortic re gurgitation

VALVULAR LESIONS. 175

is due to the fact that a large volume of blood is suddenly and for-
cibly thrown into the aorta by the hypertrophied and dilated left
ventricle, thus causing the characteristically sharp and sudden rise
in the peripheral arteries. The arteries then empty themselves in
two directions at once, forward into the capillaries and backward
into the heart through the incompetent aortic valves ; hence the
sudden collapse in the pulse which, together with its sharp and
sudden rise, are its important characteristics. The arteries are
large and often elongated so as to be thrown into curves.

Not infrequently one can demonstrate that the radial pulse is
delayed or follows the apex impulse after a longer interval than
in normal persons. While compensation lasts, the pulse is usually
regular in force and rhythm. Irregularity is therefore an especially
grave sign, much more so than in any other valvular lesion.

Percussion.

Percussion adds but little to the information obtained by inspec-
tion and palpation, but verifies the results of these methods of in-
vestigation respecting the increased size of the heart, and especially
of the left ventricle, which may reach enormous dimensions, espe-
cially in cases occurring in young persons'. The heart may be
increased to more than four times its normal weight.

Auscultation.

In rare cases there may be absolutely no murmur and the diag-
nosis may be impossible during life, though it may be suspected
by reason of the above-mentioned signs in the peripheral arteries.
But although the murmur is seldom entirely absent, it is often so
faint as to be easily overlooked. This is especially true in cases
occurring in elderly people, and when the patient has been for a
considerable time at rest. The difficulty of recognizing certain
cases of aortic regurgitation during life is shown by the fact that
out of sixty-five cases of aortic regurgitation demonstrated at au-
topsy in the Massachusetts General Hospital, only forty-four were
recognized during life.

176 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

In the majority of cases, however, the characteristic diastolic
in r in nr is easily heard if one listens in the right place, and when
heard it is the most distinctive and trustworthy of all cardiac mur-
murs. It almost invariably points to aortic regurgitation and to
nothing else.

The murmur of aortic regurgitation, as has been already men-
tioned, is diastolic in time. 1 Its innjciniaiii intensity is usually not

FIG. 103. Position of the Point of Maximum Intensity of the Murmur of Aortic Regurgitation.
The dots are most thickly congregated where the murmur is oftenest heard.

in the conventional aortic area (second riff /it interspace), but on the
left side of the sternum about, the level of the fourth left costal carti-
lage. In about one-tenth of the cases, and especially when the
aortic arch is much dilated, the murmur is best heard in the con-
ventional aortic area. Occasionally there are two points at which
it may be loudly heard one in the second right interspace and the
other at or near the apex of the heart, while between these points

1 Another murmur, systolic in time, which almost always accompanies
the diastolic murmur, is usually due to roughening of the edges of the aortic
valves or to dilatation of the aortic arch. This murmur must not be assumed
to mean aortic stenosis (see below, p. 184).

VALVULAR LESIONS. 177

the inurinur is faint. This is probably clue to the fact that the
left ventricle, through which the murmur is conducted, approaches
the surface of the chest only at the apex, while the intermediate space
is occupied by the right ventricle, which often fails readily to trans-
mit murmurs produced at the aortic orifice. Less frequently the
murmur of aortic regurgitation is heard with maximum intensity
at the second or third left costal cartilage or in the region of the
ensiform cartilage (see Fig. 103).

From its seat of maximum intensity (i.e., usually from the
fourth left costal cartilage) the murmur is transmitted in all direc-
tions, but not often beyond the precordia. In about one-third of
the cases it is transmitted to the left axilla or even to the back.
It is sometimes to be heard in the subclavian artery and the
great vessels of the neck; in other c'ases two heart sounds are

1st
2nd

2nd

FIG. 104. Short Diastolic Murmur Not Replacing the Second Sound.

audible in the carotid, but no murmur. The murmur is usually
blowing and relatively high pitched, sometimes musical. Its inten-
sity varies much, but is most marked at the beginning of the mur-
mur, giving the impression of an accent there. It may occupy the
whole of diastole or only a small portion of it usually the earlier
portion (see Fig. 104). Late diastolic murmurs are rare. The mur-
mur may or may not replace the second sound of the heart. Broad-
bent believes that when it does not obliterate the second sound,
the lesion is usually less severe than when only the murmur is to
be heard. Allbutt dissents from this opinion.

In listening for the aortic second sound with a view to gauging
the severity of the lesion, it is best to apply the stethoscope over the
right carotid artery, as here we are less apt to be confused by the
murmur or by the pulmonic second sound.

The position of the patient's body has but little effect upon the
murmur less than upon murmurs produced at the mitral orifice.
12

178 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

The first sound at the apex is generally loud and long. There
is no accentuation of the pulmonic second.

Over the larger peripheral arteries, especially over the femoral
artery, one hears in most cases a sharp, short systolic sound ("pis-
tol-shot sound ") due to the sudden filling of the unusually empty
artery; this sound is merely an exaggeration of what may be heard
in health. Pressure with the stethoscope will usually bring out a
systolic murmur (as also in health), and occasionally a di<nstol.ic
murmur as well (Duroziez's sign). This diastolic murmur in the
peripheral arteries, obtained on pressure with the stethoscope, is
practically never heard except in aortic re gurgitation. It is thought
by some to be due to the regurgitant current in the great vessels
which in very marked cases may extend as far as the femoral ar-
tery. Duroziez's sign is a comparatively rare one, not present in
most cases of aortic regurgitation, and usually disappears when
compensation fails.

Summary and Differential Diagnosis.

A diastolic murmur heard with the maximum intensity about
the fourth left costal cai'tUaf/e (less often in the second right inter-
space or at the apex) gives us almost complete assurance of the
existence of aortic regurgitation. From pulmonary regurgitation,
an exceedingly rare lesion, the disease is distinguished by the pres-
ence of predominating hypertrophy of the left ventricle with a
heaving apex impulse and by the following arterial phenomena :

(a) Visible pulsation in the peripheral arteries.

(b) Capillary pulsation.

(d) " Pistol-shot sound " in the femoral artery.

(e) Duroziez's sign.

The very rare functional diastolic murmur, transmitted from
the veins of the neck and heard over the base of the heart in cases
of grave anaemia, may be obliterated by pressure over the bulbus
jugularis. Such pressure has no effect upon the murmur of aortic
regurgitation. .

It must be remembered that aortic regurgitant murmurs are

VALVULAR LESIONS. 179

often exceedingly faint, and should be listened for with the greatest
care and under the most favorable conditions.

Estimation of the Extent and Gravity of the Lesion.

The extent of the lesion is roughly proportional to

() The amount of hypertrophy of the left ventricle.

(b) The degree to which the pulse collapses during diastole
(provided the radial is not so much calcified as to make collapse
impossible) .

(<) The degree to which the murmur replaces the second sound
as heard over the right carotid artery (Broadbent).

Irregularity of the pulse is a far more serious sign in this dis-
ease than in lesions of the mitral valve, and indicates the beginning
of a serious failure of compensation.

Another grave sign is a diminution in the intensity of the
murmur.

Complications.

(1) Dilatation of the Aorta. Diffuse dilatation of the aortic arch
is usually associated with aortic regurgitation and may produce a
characteristic area of dulness to the right of the sternum (see Fig.
100). Not infrequently this dilatation is the cause of a systolic
murmur to be heard over the region of the aortic arch and in the
great vessels of the neck.

(2) Roughening of the Aortic Valves. In the great majority of
cases of aortic regurgitation the valves are sufficiently roughened
to produce a systolic murmur as the blood flows over them. This
murmur is heard at or near the conventional aortic area, and may
be transmitted into the carotids. (The relation of these murmurs
to the diagnosis of aortic stenosis will be considered with the latter
lesion.)

(3) The return of arterial blood through the aortic valves into
the left ventricle produces in time both hypertrophy and dilatation
of this chamber, and results ultimately in a stretching of the mitral
orifice which renders the mitral curtains imcompetent. The result
is a "relative mitral insufficiency " i.e., one in which the mitral valve

180 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

is intact but too short to reach across the orifice which it is in-
tended to close. Such an insufficiency of the mitral occurs in most
"well-marked cases; it temporarily relieves the overdistention of the
left ventricle and often the accompanying angina, although at the
cost of engorging the lungs. 1

(4) The Austin Flint Murmur. The majority of cases of aortic
regurgitation are accompanied by a presystolic murmur at the apex,
which may be due to a genuine mitral stenosis or may be produced
in the manner suggested by Austin Flint. (For a fuller discussion
of this murmur see above, p. 168.)

(5) Aortic stenosis frequently supervenes in cases of aortic re-
gurgitation, and results in a more or less temporary improvement in
the patient's condition. It has the effect of increasing the intensity
of the diastolic murmur, since the regurgitating stream has to pass
through a smaller opening.

The general visible arterial pulsation becomes much less marked
if stenosis supervenes on regurgitation.

AORTIC STENOSIS.

Uncomplicated aortic stenosis is by far the rarest of the valvu-
lar lesions of the left side of the heart, as well as the most difficult
to recognize. Out of two hundred and fifty-two autopsies made at
the Massachusetts General Hospital in cases of valvular disease
there was not one of uncomplicated aortic stenosis. Twenty-nine
cases occurred in combination with aortic regurgitation. During
life the diagnosis of aortic stenosis is frequently made, but often on
insufficient evidence i.e., upon the evidence of a systolic murmur
heard with maximum intensity in the second right intercostal space
and transmitted into the vessels of the neck. Such a murmur does
indeed occur in aortic stenosis, but is by no means peculiar to this
condition. Of the other diseases which produce a similar murmur
more will be said under Differential Diagnosis.

1 This relative insufficiency of the mitral valve has been termed its " safety -
vahe" action, but the safety is but temporary and dearly bought.

VALVULAR LESIONS. 181

For the diagnosis of aortic stenosis we need the following evi-
dence :

(1) A systolic murmur heard best in the second right intercostal
space and transmitted to the neck.

(2) The characteristic pulse (vide infra) .

(3) A palpable thrill (usually).

(4) Absence or great enfeeblement of the aortic second sound.
Of these signs the characteristic pulse is probably the most im-

FIG. 105. Aortic Stenosis. The heart is in systole and the blood column is obstructed by the
narrowed aortic ring. The mitral is closed (as it should be).

portant, and no diagnosis of aortic stenosis is possible without it.
The heart may or may not be enlarged.

Each of these points will now be described more in detail.

(1) Tlie Murmur.

(a) The maximum intensity of the murmur, as has already been
said, is usually in the second right intercostal space near the ster-
num or a little above that point near the sterno-clavicular articula-
tion, but it is by no means uncommon to find it lower down, i.e.,
in the third, fourth, or fifth right interspace, and occasionally it is
best heard to the left of the sternum in the second or third inter-
costal space, (b) The time of the murmur is late systolic; that is,

182 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

it follows the apex impulse at an appreciable interval, contrasting
in this respect with the systolic murmur usually to be heard in
mitral re gurgitation, (c) The murmur is usually widely transmit-
ted, often being audible over the whole chest and occasionally over
the skull and the arterial trunks of the extremities (see Fig. 106).
It is usually heard less well over that portion of the precordia oc-
cupied by the right ventricle, while, on the other hand, it is rela-
tively loud in the region of the apex impulse, whither it is trans-
mitted through the left ventricle. The same line of transmission

Maximum intensity
of systolic mur- '
mur and thrill.

FIG. 106. Aortic Stenosis. The murmur is audible over the shaded area and sometimes over

the whole chest.

was mentioned above as characteristic of the murmur of aortic re-
gurgitation in many cases. The murmur is also to be heard over
the carotids and subclavians, and can often be traced over the tho-
racic aorta along the spine and down the arms.

Until compensation fails the murmur is apt to be a very loud
one, especially in the recumbent position; it is occasionally au-
dible at some distance from the chest, and is often rough and
vibrating, sometimes musical or croaking. Its length is unusually
great, extending throughout the whole of systole, but to this rule
there are occasional exceptions. The first sound in the aortic re-

VALVULAR LESIONS. 183

gion is altogether obliterated, as a rule, and the second sound is
either absent or very feeble. 1

(2) The Pulse.

Owing to the opposition encountered by the left ventricle in
its attempt to force blood into the aorta, its contraction is apt to
be prolonged ; hence the pulse wave rises gradually and late, and falls
dint i/ skucly. This is shown very well in sphygniographic tracings
(see Fig. 107) . But further, the blood thrown into the aorta by the
left ventricle is prevented, by the narrowing of the aortic valves,
from striking upon and expanding the arteries with its ordinary
force ; hence the pulse wave is not only slow to rise but small in

FIG. 107. Sphygmographic Tracing of the Pulse in Uncomplicated Aortic Stenosis. Compare
with the normal pulse wave and with that of aortic regurgitation (page 174).

t, contrasting strongly with the powerful apex beat ("pulsus
"). Again, the delay in the emptying of the left ventricle,
brought about by the obstruction at the aortic valves, renders the
contractions of the heart relatively infrequent, and hence the pulse
is infrequent (pulsus ranis') as well as small and slow to rise. The
' l>ulsus rants, parvus, tardus" is, therefore, a most constant and
important point in diagnosis, but unfortunately it is to be felt
in perfection only in the very rare cases in which aortic stenosis
occurs uncomplicated. When stenosis is combined with regurgita-
tion, as is almost always the case, the above-described qualities of
the pulse are greatly modified as a result of the regurgitation. It
is also to be remembered that the pulse of aortic stenosis is by no

1 "Occasionally, as noted by W. H. Dickinson, there is a musical murmur
of great intensity in the region of the apex, probably due to a slight regurgita-
tion at high pressure through the mitral valve." OSLEK.

184 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

means unalterable and does not exhibit its typical plateau at all
times.

A less characteristic, but decidedly frequent, variation in the
pulse wave of aortic stenosis is the anacrotic curve. The slow,
long pulse with a long plateau at the summit is seen also in some
cases of mitral stenosis and renal disease, and is not peculiar to
aortic stenosis, but taken in connection with the other signs of the
disease it has great value in diagnosis.

(3) The Thrill.

In the majority of cases an intense purring vibration may be
felt if the hand is laid over the upper portion of the sternum, espe-
cially over the second right intercostal space. This thrill is con-
tinued into the carotids, can occasionally be felt at the apex, and
rarely over a considerable area of the chest. It is a very important
aid in the diagnosis of aortic stenosis, but is by no means pathog-
nomonic, since aneurism may produce a precisely similar vibration
of the chest wall.

The heart is slightly enlarged to the left and downward as a
rule, but the apex impulse is unusually indistinct, " a well-defined
and deliberate push of no great violence" (Broadbent). Corre-
sponding to the protracted sustained systole the first sound at the
apex is dull and long, but not very loud.

Differential Diagnosis.

A systolic murmur heard loudest in the second right intercostal
space is by no means peculiar to aortic stenosis, but may be due to
any of the following conditions :

() Roughening, stiffness, fenestration, or slight congenital mal-
formation of the aortic valves.

(&) Roughening or diffuse dilatation of the arch of the aorta.

(c?) Functional murmurs.

(e) Pulmonary stenosis.

(/) Open ductus arteriosus.

(g} Mitral re gurgitation.

VALVULAR LESIONS. 185

(a and b) The great majority of such systolic murmurs at the
base of the heart, first appearing after middle life, are due to the
causes mentioned above under a, b, and c. In such cases it is usu-
ally combined with accentuation and ringing quality of the aortic
second sound owing to the arterio -sclerosis and high arterial tension
associated with the changes which produce the murmur. This
accentuation of the aortic second sound enables us, except in extraor-
dinarily rare cases, to exclude aortic stenosis, in which the intensity
of the aortic second sound is almost always much reduced.

Diffuse dilatation of the aorta, such as often accompanies aortic
re gurgitation, is a frequent cause of a systolic murmur loudest in
the second right interspace. This may be recognized in certain
cases by the characteristic area of dubiess on percussion and by its
association with aortic regurgitation of long standing (see Fig. 100) .

Roughening of the intima of the aorta (endaortitis) is always to
be suspected in elderly patients with calcified and tortuous periph-
eral arteries, and such a condition of the aorta doubtless favors the
occurrence of a murmur, especially when accompanied by a slight
degree of dilatation. The absence of a thrill and a long, slow
pulse with a low maximum serves to distinguish such murmurs
from those of aortic stenosis.

(c) Aneurism of the ascending arch of the aorta or of the in-
nominate artery may give rise to every sign of aortic stenosis except
the characteristic pulse and the diminution of the aortic second
sound. In aneurism we may have a well-marked tactile thrill and
a loud systolic murmur transmitted into the neck, but there is
usually some pulsation to be felt in the second right intercostal
space and often some difference in the pulses or in the pupils, as
well as a history of pain and symptoms of pressure upon the tra-
chea and bronchi or recurrent laryngeal nerve. In aneurism the
aortic second sound is usually loud and accompanied by a shock,
and the pulse shows none of the characteristics of aortic stenosis.

(d) Functional murmurs, sometimes known as "haemic," are
occasionally best heard in the aortic area instead of in their usual
situation (second left intercostal space). They occur especially in
young, anaemic persons, are not accompanied by any cardiac en-

186 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

largenient, by any palpable thrill, any diminution in the aortic
second sound, or any distinctive abnormalities in the pulse.

(e) Pulmonary stenosis, an exceedingly rare lesion, is mani-
fested by a systolic murmur and by a thrill whose maximum inten-
sity is usually on the left side of the sternum. In the rare cases
in which this murmur is best heard in the aortic area it may be
distinguished from the murmur of aortic stenosis by the fact that
it is not transmitted into the vessels of the neck, has no effect upon
the aortic second sound, and is not accompanied by the character-
istic changes in the pulse.

(/) The murmur due to persistence of the ductus arteriosus
may last through systole and into diastole ; it may be accompanied
by a thrill, but does not affect the aortic second sound nor the
pulse.

(y) The systolic murmur of aortic stenosis may be heard loudly at
the apex, and hence the lesion may be mistaken for mitral re gur-
gitation. But the maximum intensity of the murmur of aortic
stenosis is almost invariably in the aortic area, and its association
with a thrill and a long, slow pulse should enable us easily to dif-
ferentiate the two lesions.

By the foregoing differentiae aortic stenosis may be distinguished
from the other conditions which resemble it, provided it occurs
uncomplicated, but unfortunately this is very rare. As a rule, it
occurs in connection with aortic regurgitation, and its characteristic
signs are therefore obscured or greatly modified by the signs of the
latter disease. We may suspect it in such cases (provided the mi-
tral valve is sufficient) when we have, in addition to the signs of
aortic regurgitation, a systolic murmur and palpable thrill in the
aortic area transmitted into the great vessels, a modification of the
Corrigan pulse in the direction of the "pnh-us tardus, r<n->n*. jun-
vus," and less visible arterial pulsation than is to be expected in
pure aortic regurgitation.

Occasionally one can watch the development of an aortic steno-
sis out of what was formerly a pure regurgitant lesion, the stenosis
gradually modifying the characteristics of the previous condition.
One must be careful, however, to exclude a relative mitral insuffi-

VALVULAR LESIONS. 187

ciency which, as has been already mentioned above, is very apt to
supervene in cases of aortic disease, owing to dilatation of the mi-
tral orifice, and which may modify the characteristic signs of aortic
regurgitation very much as aortic stenosis does.

TRICUSPID REGURGITATIOX.

Endocarditis affecting the tricuspid. valve is rare in post-fcetal
life ; in the foetus it is not so uncommon. In cases of ulcerative
or malignant endocarditis occuring in adult life, the tricuspid valve
is occasionally involved, but the majority of cases of tricuspid dis-
ease occur as a result of disease of the mitral valve and in the follow-
ing manner : Hypertrophy of the right ventricle occurs as a result
of the mitral disease, is followed in time by dilatation, and with
this dilatation comes a stretching of the ring of insertion of the
tricuspid valve, and hence a regurgitation through that valve. Tri-
cuspid regurgitatiou, then, occurs in the latest stages of almost
every case of mitral disease and sometimes during the severer at-
tacks of failing compensation.

Out of 405 autopsies at Guy's Hospital in which evidence of
tricuspid regurgitation was found, 271, or two-thirds, resulted from
mitral disease, 68 from myocardial degeneration, 55 from pulmonary
disease (bronchitis, emphysema, cirrhosis of the lung). Very few of
these cases had been diagnosed during life, and in all of them the
valve was itself healthy but insufficient to close the dilated orifice.

Gibson and some other writers believe that temporary tricuspid
regurgitation is the commonest of all valve lesions, and results from
weakening of the right ventricle in connection with states of anae-
mia, gastric atony, fever, and many other conditions. It is very
difficult to prove or disprove such an assertion.

Tricuspid regurgitation is often referred to as serving like the
opening of a " safety valve " to relieve a temporary pulmonary en-
gorgement. This " safety-valve " action, however, may be most
disastrous in its consequences to the organism as a whole, despite
the temporary relief which it affords to the overfilled lungs. The
engorgement is simply transferred to the liver and thence to the

188 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

abdominal organs and the lower extremities, so that as a rule the
advent of tricuspid regurgitatiou is recognized not as a relief but
as a serious and probably fatal disaster.

Physical S'ujns.

(1) A systolic murmur is heard loudest at or near the fifth left
costal cartilage.

(2) Systolic venous pulsation in the jugulars and in the liver.

(3) Engorgement of the right auricle producing an area of dul-
ness beyond the right sternal margin.

(4) Intense cyanosis.

(1) The Jfin'/nin: The maximum intensity of the systolic mur-
mur of tricuspid regurgitation is usually near the junction of the fifth
or sixth left costal cartilages with the sternum. Leube finds the
murmur a rib higher up, but it is generally agreed that the tricuspid
area is a large one, so that the murmur may be heard anywhere
over the lower part of the sternum or even to the right of it. On the
other hand, there are some tricuspid murmurs which are best heard
at a point midway between the apex impulse and the ensiform carti-
lage. The murmur is not widely transmitted and is usually inaudi-
ble in the back; at the end of expiration its intensity is increased.

In some cases we have no evidence of tricuspid regurgitation
other than the murmur just described, but

(2) Of more importance in diagnosis is the presence of a sys-
tolic pulsation in the external jugular veins and of the liver, which
unfortunately is not always present, but which when present is
pathognornonic. I have already explained (see p. 35) the distinc-
tion between true systolic jugular pulsation, which is practically
pathognonionic of tricuspid regurgitation, and simple presystolic
undulation or distention of the same veins, which has no necessary
relation to this disease. The decisive test is the effort permanently
to empty the vein by stroking it upward from below. If it in-
stantly refills from below and continues to pulsate, tricuspid regur-
gitation is almost certainly present. If, on the other hand, it does
not refill from l>elow, the cause must be sought elsewhere.

VALVULAR LESIONS.

189

Pulsation in the liver must be distinguished from the "jogging "
motion which may be transmitted to it from the abdominal aorta or
from the right ventricle. To eliminate these transmitted impulses
one must be able to grasp the liver biinanually, one hand in front
and one resting on the lower ribs behind, and to feel it distinctly ex-
pand with every systole, or else to take its edge in the hand and
to feel it enlarge in one's grasp with every beat of the heart.

Dilated right
auricle.

Systolic murmur. -

Enlarged and pul-
sating liver.

FIG. 108. Tricuspid Regurgitation. The murmur is heard best over the shaded area.

Pressure upon the liver often causes increased distention and pulsa-
tion of the external jugulars if tricuspid regurgitation is present.

(3) Enlargement of the heart, both to the right and to the left,
as well as downward, can usually be demonstrated. In rare cases
a dilatation of the right auricle may be suggested by a percussion
outline such as that shown in Fig. 108.

The pulnionic second sound is usually not accented. The im-
portance of this in differential diagnosis will be mentioned pres-
ently. If a progressive diminution in the intensity of the sound
occurs under observation, the prognosis is very grave.

(4) Cyanosis is usually very great, and dyspnoea and pulmonary
oedema often make the patient's condition a desperate one.

190 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Differential Diagnosis.

The statistics of the cases autopsied at the Massachusetts Gen-
eral Hospital show that tricuspid regurgitation is less often recog-
nized during life than any other val vular lesion. The diagnosis
was made ante mortem on only five out of twenty-nine cases.
This is due to the following facts :

(a) Tricuspid regurgitation may be present and yet give rise to
no physical signs which can be recognized during life.

(b) Tricuspid regurgitation occurs most frequently in connec-
tion with mitral regurgitation; hence its signs are frequently
masked by those of the latter lesion. It is, therefore, a matter of
great importance as well as of great difficulty to distinguish tricus-
pid regurgitation from

(1) Mitral Regvrgitation.

The difficulties are obvious. The murmur of mitral regurgita-
tion has its maximum intensity not more than an inch or two from
the point at which the tricuspid murmur is best heard. Both are
systolic in time. They are, therefore, to be distinguished only

(a) In case we can demonstrate that there are two areas in
which a systolic murmur is heard with relatively great intensity,
with an intervening space over which the murmur is less clearly to
be heard (see Fig. 109).

(&) Occasionally the two systolic murmurs are of different pitch
or of different quality, and may be thus distinguished.

(c) Tricuspid murmurs are not transmitted into the left axilla
and are rarely audible in the back, and this fact is of value in case we
have to distinguish between uncomplicated tricuspid regurgitation
and uncomplicated mitral regurgitation. Unfortunately these le-
sions are very apt to occur simultaneously, so that in practice our
efforts are generally directed toward distinguishing between a pure
mitral regurgitation and one complicated by tricuspid regurgitation.

(cT) In cases of doubt the phenomena of venous pulsation in the
jugulars and in the liver are decisive if present, but their absence
proves nothing.

VALVULAR LESIONS.

191

(e) Accentuation of the pulmonic second sound is almost inva-
riably present in uncomplicated mitral disease and is apt to disap-
pear in case the tricuspid begins to leak, since engorgement of the
lungs is thereby for the time relieved, but in many cases the pul-
monic second sound remains most unaccountably strong even when
the tricuspid is obviously leaking.

(2) From "functional" systolic murmurs tricuspid insufficiency
may generally be distinguished by the fact that its murmur is best

Fro. 109. Two Systolic Murmurs (Mitral and Tricuspid) with a "Vanishing Point " between.

heard in the neighborhood of the ensiform cartilage, and not in the
second right intercostal space where most functional murmurs have
their seat of maximum intensity. Functional murmurs are unac-
companied by venous pulsation, cardiac dilatation, or cyanosis.

(3) Occasionally a pericardial friction rub simulates the mur-
mur of tricuspid insufficiency, but, as a rule, pericardial friction is
much more irregular in the time of its occurrence and is not regu-
larly synchronous with any definite portion of the cardiac cycle.

TRICUSPID STENOSIS.

One of the rarest of valve lesions is narrowing of the tricuspid
valve. No case has come under my observation, and in 1898, Her-

192 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

rick was able to collect but 154 cases from the world's literature.
Out of these 154 cases, 138, or 90 per cent, were combined with
mitral stenosis, and only 12 times has tricuspid stenosis been known
to occur alone. 1 These observations account for the fact that tri-
cuspid stenosis has hardly ever been recognized during life, since the
murmur to which it gives rise is identical in time and quality and
nearly identical in position with that of mitral stenosis. Xarrow-
ing of the tricuspid valve is to be diagnosed, therefore, only by the
recognition of a presystolic murmur best heard in the tricuspid area
and distinguished either by its pitch, quality, or position from the
other presystolic murmur due to the mitral stenosis which is almost
certain to accompany it.

The heart is usually enlarged, especially in its transverse direc-
tion, but the enlargement is just such as mitral stenosis produces,
and does not aid our diagnosis at all.

The diagnosis is still further complicated in many cases by the
presence of an aortic stenosis in addition to a similar lesion at the
tricuspid and mitral valves, so that it seems likely that in the future
as in the past the lesion will be discovered first at autopsy.

PULMONARY REGURGITATIOX.

Organic disease of the pulmonary valve is excessively rare in
post-fostal life, but may occur as part of an acute ulcerative or
septic endocarditis. A temporary functional regurgitation through
the pulmonary valve may be brought about by any cause producing
very lil'jJi ///v.w/r in the J>/>//H//>II-// artery. I have known two
medical students with perfectly healthy hearts who were able, by
prolonged holding of the breath, to produce a short, high-pitched
diastolic murmur best heard in the second and third left intercostal
spaces and ceasing as soon as the breath was let out. Of the occur-
rence of a murmur similarly produced under pathological condi-
tions, especially in mitral stenosis, much has been written by
Graham Steell.

1 Out of 87 cases collected from the post-mortem records of Guy's Hos-
pital, 85, or 97 per cent, were associated with still more extensive mitral
stenosis.

VALVULAR LESIONS. 193

From the diastolic murmur of aortic regurgitation we may dis-
tinguish the diastolic murmur of pulmonary incompetency by the
fact that the latter is best heard over the pulmonary valve, is never
transmitted to the apex of the heart nor to the great vessels, and
is never associated with a Corrigan pulse nor with capillary pulsa-
tion. 1 The right ventricle is hypertrophied, the pulmonic second
sound is sharply accented and followed immediately by the murmur.
Evidences of septic embolism of the lungs are frequently. present
and assist us in diagnosis. The regurgitation which may take
place through the rigid cone of congenital pulmonary stenosis is
not recognizable during life.

PULMONAKY STENOSIS.

Among the rare congenital lesions of the heart valves this is
probably the commonest. The heart, and particularly the right
ventricle, is much enlarged. There is a history of cyanosis and
dyspnosa since birth. A systolic thrill is usually to be felt in the
second left intercostal space, and a loud systolic murmur is heard
in the same area. The pulmonic second sound is weak.

The region in which this murmur is best heard has been happily
termed the " region of romance " on account of the multiplicity of
mysterious murmurs which have been heard there. The systolic
murmur of pulmonary stenosis must be distinguished from

(ft) Functional murmurs due to anaemia and debility or to severe
muscular exertion, and possibly associated with a dilatation of the
conus arteriosus.

(!>} Uncovering of the couus arteriosus through lack of expan-
sion of the lung.

((I) Mitral regurgitation.

(e) Aneurism.

(/) Roughening of the intima of the aortic arch.

1 By registering the variations of pressure in the tracheal column of air
Gerhardt has shown graphically that a systolic pulsation of the pulmonary cap-
illaries may occur in pulmonary regurgitation. With the stethoscope a sys-
tolic whiff may be heard all over the lungs.

194 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(a and &) Functional murmurs, and those produced in the conus
arteriosus, are rarely if ever accompanied by a thrill, are rarely so
loud as the murmur of pulmonary stenosis, and are not associated
with dyspnoea, cyanosis, and enlargement of the right ventricle.

(c) The murmur of aortic stenosis is usually upon the right side
of the sternum and is transmitted to the neck, whereas the murmur
of pulmonary stenosis is never so transmitted and is not associated
with characteristic changes in the pulse (see above, p. 183).

(cT) The murmur of mitral reguryitation is occasionally loudest
in the region of the pulmonary valve, but differs from the murmur
of pulmonary stenosis in being, as a rule, transmitted to the back
and axilla and associated with an accentuation of the pulmonary
second sound.

(e) Aneurism may present a systolic murmur and thrill similar
to those found in pulmonary stenosis, but may usually be distin-
guished from the latter by the presence of the positive signs of aneur-
ism, viz. pulsation, and dulness in the region of the murmur, and
signs of pressure on the trachea or on other structures in the medi-
astinum.

(/) Koughening of the aortic arch occurs after middle life,
while pulmonary stenosis is usually congenital. The murmur due
to roughening may be transmitted into the carotids ; that of pul-
monary stenosis never. Enlargement of the right ventricle is char-
acteristic of pulmonary stenosis, but not of aortic roughening.

COMBINED VALVULAR LESIOXS.

It is essential that the student should understand from the first
that the number of murmurs audible in the precordia is no gauge
for the number of valve lesions. We may have four distinct mur-
murs, yet every valve sound except one. This is often the case in
aortic regurgitation systolic and diastolic murmurs at the base of
the heart, systolic and presystolic at the apex, yet no valve in-
jured except the aortic. In such a case the systolic aortic murmur
is due to roughening of the aortic valve. The systolic apex mur-
mur results from relative mitral leakage (with a sound valve). The
presystolic apex murmur is of the "Flint" type. Hence in this

VALVULAR LESIONS. 195

case the diastolic murmur alone of the four audible murmurs is due
to a valvular lesion.

It is a good rule not to multiply causes unnecessarily, and to
explain as many signs as possible under a single hypothesis. In
the above example the mitral leak might be due to an old endocar-
ditis, and there might be mitral stenosis and aortic stenosis as well,
but since we can explain all the signs as results direct and indirect
of one lesion (aortic regurgitation) it is better to do so, and post-
mortem experience shows that our diagnosis is more likely to be
right when it is made according to this principle.

The most frequent combinations are :

(1) Mitral regurgitation with mitral stenosis.

(2) Aortic regurgitation with mitral regurgitation (with or with-
out stenosis).

(3) Aortic regurgitation with aortic stenosis, with or without
mitral disease.

(1) Double Mitral Disease.

() It very frequently happens that the mitral valve is found
to be both narrowed and incompetent at autopsy when only one of
these lesions had been diagnosed during life. In fact mitral steno-

1st

III I "'"' I I

Illlllllllllh I Mil J

FIG. 110. Mitral Stenosis and Regurgitation, showing relation of murmur to first heart sound.

sis is almost never found at autopsy without an associated regurgi-
tation, so that it is fairly safe to assume, whenever one makes the
diagnosis of mitral stenosis, that mitral regurgitation is present as
well, whether it is possible to hear any regurgitant murmur or not
(see Fig. 110).

(>) On the other hand, with a double mitral lesion one may
have only the regurgitant murmur at the mitral valve and nothing
to suggest stenosis unless it be a surprising sharpness of the first
mitral sound. In chronic cases the changeableness of the murmurs
both in type and position is extraordinary. One often finds at one

196 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

visit evidences of mitral stenosis and at another evidences of mitral
re gurgitation alone. Either murmur may disappear altogether for
a time and reappear subsequently. This is peculiarly true of the pre-
systolic murmur, which is notoriously one of the most fleeting and
uncertain of all physical signs.

As a rule the same inflammatory changes which produce mitral
regurgitation in early life result as they extend in narrowing the
mitral valve, so that the signs of stenosis come to predominate in
later years. Coincidently with this narrowing of the diseased valve
a certain amount of improvement in the patient's symptoms may
take place, and Rosenbach regards the advent of stenosis in such a
case as an attempt at a regenerative or compensatory change. In
many cases, however, no such amelioration of the symptoms follows.

(2) Aortic Reyuryitation with jMitral Disease.

The signs of mitral disease occurring in combination Avith
aortic regurgitation do not differ essentially from those of pure

Systolic murmur
over dilated--'
aortic arch.

Maximum intensity
and diastolic mur-

' m u r, conducted
up and down.

Systolic murmur.

FIG. 111. Aortic and Mitral Regurgitation. The shaded areas are those in which the murmurs

are loudest.

mitral disease except that the enlargement of the heart is apt to
be more general and correspond less exclusively to the right ven-
tricle (see Figs. Ill and 112). The manifestations of the aortic le-

VALVULAR LESIONS. 197

sion, on the other hand, are considerably modified by their associa-
tion with the mitral disease. The Corrigan pulse is distinctly less
sharp at the summit and rises and falls less abruptly. Capillary

1st 1st

2nd

FIG. 112. Showing Relation of Murmurs to Heart Sound in Regurgitation at the Aortic and

Mitral Valves.

pulse is less likely to be present, and the throbbing of the peripheral
arteries is less often visible.

(3) Aortic Reyurgitation ivith Aortic Stenosis.

If the aortic valves are narrowed as well as incompetent, we
find very much the same modification of the physical signs charac-
teristic of aortic re gurgitation as is produced by the advent of a
mitral lesion ; that is to say, the throbbing in the peripheral ar-
teries is less violent, the characteristics of the radial pulse are less
marked, and the capillary pulsation is not always to be obtained
at all. Indeed, this blunting of all the typical manifestations of
aortic regurgitation may give us material aid in the diagnosis of
aortic stenosis, provided always that the mitral valve is still per-
forming its function.

(4) The association of mitral disease with tricuspid insufficiency
has been already described on p. 159.

CHAPTER VIII

PARIETAL DISEASE. CARDIAC NEUROSES. CONGENI-
TAL MALFORMATIONS OF THE HEART.

PARIETAL DISEASE OF THE HEART.

Acute Myocarditis.

THE myocardium is seriously, though not incurably, affected in
all continued fevers, owing less to the fever itself than to the tox-
semia associated with it. " Cloudy swelling, " or granular degener-
ation of the muscle fibres, is produced by relatively mild infections,
while a general septicaemia due to pyogenic organisms may produce
extensive fatty degeneration of the heart within a feAV days.

The physical signs are those of cardiac weakness. The most
significant change is in the quality of the first sound at the apex
of the heart, which becomes gradually shorter and feebler until its
quality is like that of the second sounds, while its feebleness makes
the second sounds seem accented by comparison. Soft blowing
systolic murmurs may develop at the pulmonary orifice, less often
at the apex or over the aortic valve.

The apex impulse becomes progressively feebler and more like
a tap than a push. Irregularity and increasing rapidity are omi-
nous signs which may be appreciated in the radial pulse, but still
better by auscultation of the heart itself. In most of the acute in-
fections evidence of dilatation of the weakened cardiac chambers is
rarely to be obtained during life (although at autopsy it is not in-
frequently found), 1 but in acute articular rheumatism an acute dila-
tation of the heart appears to be a frequent complication, independ-

1 Henchen's recent monograph on this subject, "Ueber die acute Herzdila-
tation bei acuten Infectionskrankheiten," Jena, 1899, does not seem to me
convincing.

PARIETAL DISEASE. 199

ent of the existence of any valvular disease. Attention has been
especially called to this point by Lees and Boynton (British Med.
Jour., July 2, 1898) and by S. West.

IXFLUEXZA is also complicated not infrequently by acute cardiac
dilatation.

Chronic Myocarditis (" Weakened Heart ").

Fatty or fibroid changes in the heart wall occurring in chronic
disease are usually the result of sclerosis of the coronary arteries
and imperfect nutrition of the myocardium, but chronic toxaemias,
like pernicious anaemia, may also produce a very high grade of fatty
degeneration of the heart and especially of the papillary muscles.

Whether fatty or fibroid changes predominate, the physical signs
are the same.

Physical Signs of Chronic Myocarditis.

For the recognition of these changes in the myocardium our
present methods of physical examination are always unsatisfactory
and often wholly inadequate. Extensive degenerations of the
heart -wall are not infrequently found at autopsy when there has
been no reason to suspect them during life. On the other hand,
the autopsy often fails to substantiate a diagnosis of degeneration
of the heart muscle, although all the physical signs traditionally
associated with this condition were present during life. 1 To a con-
siderable extent, therefore, our diagnosis of myocarditis must de-
pend upon the history and symptoms of the case ; physical exami-
nation can sometimes supplement these, sometimes not. Symptoms
of cardiac weakness developing in a man past middle life, especially
in a patient who shows evidences of arterio-sclerosis or high ar-
terial tension, or who has suffered from the effects of alcohol and
syphilis, suggest parietal disease of the heart, fatty or fibroid.
The probability is increased if there have been attacks of angina
pectoris, Cheyne-Stokes breathing, or of syncope.

Inspection and palpation may reveal nothing abnormal, or there

1 A well-known Boston pathologist recently told me that he had neyer
known a case of myocarditis correctly diagnosed during life.

200 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

may be an unusually diffuse, slapping cardiac impulse associated
perhaps with a displacement of the apex beat to the left and down-
ward. Marked irregularity of the heart beat, both in force and in
rhythm, is sometimes demonstrable by these methods, and an in-
crease in the area of cardiac dulness ma} 7 " be demonstrable in case
dilatation has followed the weakening of the heart wall. Auscvlta-
tion may reveal nothing abnormal except that the aortic second
sound is unusually sharp; in some cases feeble <unl im'yuhu' lem-t
sounds are heard, although the first sound at the apex is not infre-
quently sharp. Reduplication of one or both sounds and disturb-
ance of rhythm, especially the "gallop rhythm," are not infre-
quent. If the mitral sphincter is dilated, or the papillary muscles
are weakened, as not infrequently happens, we may have evidences of
mitral re gurgitation, a systolic murmur at the apex heard in the left
axilla and back with accentuation of the pulrnonic second sound.

SHI i) mart/.

1. The history and symptoms of the case or the condition of
other organs are often of more diagnostic value than is the physical
examination of the heart itself, which may show nothing abnormal.

2. Among the rather unreliable physical signs, those most often
mentioned are :

(a) Weakness and irregularity of the heart sounds.

(7;) Accentuation of the aortic second sound.

(ci) Reduplication of some of the cardiac sounds (gallop
rhythm).

(e) Evidences of cardiac dilatation.

(/) Murmurs especially the murmur of mitral insufficiency
which often occurs as a result of dilatation of the valve orifices and
weakening of the cardiac muscle.

Differential Diagnosis.

We have to distinguish myocarditis from
(/') Uncomplicated valvular lesions.
Cardiac neuroses.

PARIETAL DISEASE. 201

(.) It has been already pointed out that valvular lesions do not
necessarily give rise to any murmurs when compensation has failed.
Under such circumstances one hears only irregular and weak heart
sounds, as in myocarditis. The history of a long-standing valvu-
lar trouble, a knowledge of the previous existence of murmurs, the
age, method of onset, and symptoms of the case may assist us in
the diagnosis. Cases of myocarditis are less likely to be associated
with extensive dropsy than are cases of valvular disease whose com-
pensation has been ruptured.

(7>) Weakness and irregularity of the cardiac sounds, when due
to nervous affection of the heart and unassociated with parietal or
valvular changes, is usually less marked after slight exertion. The
heart " rises to the occasion " if the weakness is a functional one.
On the other hand, if fatty or fibroid changes are present, the signs
and symptoms are much aggravated by any exertion.

In some cases of myocarditis the pulse is excessively slow and
shows no signs of weakness. This point will be referred to again
in the chapter on Bradycardia.

Fatty Overgrowth.

An abnormally large accumulation of fat about the heart may
be suspected if, hi a very obese person, signs of cardiac embarrass-
ment (dyspnoea, palpitation) are present, and if on examination we
find that the heart sounds are feeble and distant but preserve the
normal difference from, each other. When the heart wall is seri-
ously weakened (as in the later weeks of typhoid), the heart sounds
become more alike owing to the shortening of the first sound.

In fatty overgrowth this is not the case.

The diagnosis, however, cannot be positively made. We sus-
pect it under the conditions above described, but no greater cer-
tainty can be attained.

Fatty Degeneration.

There are no physical signs by which fatty degeneration of the
heart can be distinguished from other pathological changes which
result in weakening the heart walls. An extensive degree of fatty

202 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

degeneration is often seen post mortem in cases of pernicious anaemia,
although the heart sounds have been clear, regular, and in all re-
spects normal during life. The little we know of the physical
signs common to fatty degeneration and to other forms of parietal
disease of the heart has been included in the section on Myocar-
ditis (see p. 198).

CARDIAC XEUROSES.
Tachycardia (Rapid Heart).

Simple quickening of the pulse rate, or tachycardia, which may
pass altogether unnoticed by the patient himself, is to be distin-
guished from palpitation, in which the heart beats, whether rapid
or not, force themselves upon the patient's attention.

The pulse rate may vary a great deal in health. A classmate
of mine at the Harvard Medical School had a pulse never slower
than 120, yet his heart and other organs were entirely sound. Such
cases are not very uncommon, especially in women. Temporarily
the pulse rate may be greatly increased, not only by exercise and
emotion, but by the influence of fever, of gastric disturbances, or of
the menopause. Such a tachycardia is not always of brief duration
The effects of a great mental shock may produce an acceleration of
the pulse which persists for days or even weeks after the shock.

Among organic diseases associated with weakening of the pulse
the commonest are those of the heart itself. Next to them, exoph-
thalmic goitre, tumors or hemorrhage in the medulla, and obscure
diseases of the female organs of generation, are the most frequent
causes of tachycardia.

The only form of tachycardia which is worthy to be considered
as a more or less independent malady is

Paroxysmal Tachycardia.

As indicated in the name, the attacks of this disease are apt to
begin and to cease suddenly. They may last a few hours or several
days. The pulse becomes frightfully rapid, often 200 per minute or
more. Bristowe records a case with a pulse of 308 per minute.

CARDIAC NEUROSES. 203

In the radial artery the pulse beat may be impalpable. The heart
sounds are regular and clear, but the diastolic pause is shortened and
the first sound becomes short and "valvular," resembling the sec-
ond ("tic-tac heart"). The paroxysm may be associated with
aphasia and abnormal sensations in the left arm. Occasionally the
heart becomes dilated, and oedema of the lungs, albuminuria, and
other manifestations of stasis appear. As a rule, however, paroxys-
mal tachycardia can be distinguished from the rapid heart-beat
associated with cardiac dilatation by the fact that the heart remains
perfectly regular. This same fact also assists us in excluding the
cardiac neuroses due to tobacco, tea, and other poisons. From the
tachycardia of Graves' disease the affection now in consideration
differs by its paroxysmal and intermittent character.

Bradycardia (Slow Heart).

In many healthy adults the heart seldom beats over 50 times a
minute.

I. Among the causes which may produce for a short time an
abnormally slow heart-beat are :

(a) Exhaustion; for example, after fevers, after parturition, or
severe muscular exertion.

(ft) Toxaemia; for example, jaundice, uraemia, auto-intoxications
in dyspepsia.

(c) In certain hysterical and melancholic states and in neurotic
children, the pulse may be exceedingly slow. Pain has also a ten-
dency to retard the pulse.

(d) An increase of intracranial pressure, as in meningitis, cere-
bral hemorrhage, depressed fracture of the skull. Possibly in this
category belong the cases of bradycardia sometimes seen in epilep-
tiforni or during syncopal attacks. Bradycardia from any one of
these causes is apt to be of comparatively short duration.

II Permanent Lradycardia is most often associated with coro-
nary sclerosis and myocarditis. In this disease the pulse may re-
main below 40 for months or years, though strong and regular, yet
the patient may be free from disagreeable symptoms of any kind.
The rate of the heart-beat cannot always be estimated by counting

204 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

the radial pulse. Not infrequently many pulsations of the heart
are not of sufficient force to transmit a wave to the radial artery,
and the mistake should never be made of diagnosing bradycardia
simply by counting the radial pulse.

Arrhythmia.

1. Physiological Arrhyth mia. Arrhythmia, or irregularity in the
force or rhythm of the heart-beat, is to a certain extent physiologi-
cal. The heart normally beats a little faster and a little more strongly
during inspiration than during expiration. Any psychical disturb-
ance or muscular exertion may produce irregularity as well as a
quickening of the heart -beat. Rarely the pulse may be irregular
throughout life in perfectly healthy persons. This irregularity is
usually of rhythm alone ; every second or third beat may be regu-
larly omitted without the individual knowing anything about it or
feeling any disagreeable symptoms connected with it. More rarely
the heart's beats may be permanently irregular in force as well as
rhythm despite the absence of any discoverable disease.

In children the pulse is especially apt to be irregular, and dur-
ing sleep some children show that modification of rhythm known
as the "jiaradozica? pulse," which consists in a quickening of the
pulse with diminution in volume during inspiration.

(2) If we leave on one side diseases of the heart itself, patho-
logical arrhythmia is most frequently seen in persons who have used
tobacco or tea to excess, or in dyspepsia. In these conditions it is
often combined with palpitation and becomes thereby very distress-
ing to the patient. In connection with cardiac disease the follow-
ing types of arrhythmia may be distinguished :

() Paradoxical Pulse. Any cause which leads to weakening
of the heart's action may occasionally be associated with paradoxical
pulse. Fibrous pericarditis has been supposed to be frequently
associated with this type of arrhythmia, but if so it is by no means
its only cause.

(6) The bigeminal pulse is seen most frequently in cases of un-
conipensated heart disease (particularly mitral stenosis) after the
administration of digitalis. Every other beat is weak or abortive

CARDIAC NEUROSES. 205

and is succeeded by an unusually long pause. Sometimes every
third beat is of the abortive type, or an unusually long interval
may divide the heart-beats into groups of three ("trireminal
pi i he ").

(c) Embryocardia, or the "tic-tac heart," represents a shorten-
ing of the diastolic pause and of the first sound of the heart so that
it resembles the second sound, as in the fretal heart. Any case of
uncompensated heart disease, whether valvular or parietal, may be
associated with this disturbance of rhythm.

(cT) The rjallop rhythm.

Owing to a reduplication of one of the heart sounds (usually
the second), AVC may have three sounds instead of two with each
beat of the heart, the sounds possessing a rhythm which reminds us
of the hoof -beats of a galloping horse (see p. 123). This rhythm is
heard especially in the failing heart of interstitial nephritis or cor-
onary sclerosis.

(e) Delirium cordis is a term used to express any great irregu-
larity and rapidity of the heart-beats which cannot be reduced to
a single type or rhythm. It is seen in the gravest stages of uncom-
pensated heart disease.

Palpitation,

Defined by Osier as " irregular or forcible heart action percep-
tible to the indiridunl." The essential point is that the individual
becomes conscious of each beat of his heart, whether or no the heart
action is in any way abnormal.

(rt) In irritable conditions of the nervous system, such as occur
at puberty, at climacteric, or in neurasthenic persons, palpitation
may be very distressing. Temporary disturbances, such as fright,
may produce a similar and more or less lasting effect.

(V) The effect of high altitudes, or of even a moderate eleva-
tion (1,500 feet) is sufficient to produce in many healthy persons a
quickening and strengthening of the heart's action, so that sleep
may be prevented. After a few nights this condition usually
passes off, provided the heart is sound.

206 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Auscultation of a palpitating heart shows nothing more than
unusually loud and ringing heart sounds, but since palpitation is
often associated with arrhythmia of one or another type we must be
careful to exclude the palpitation symptomatic of acute dilatation
of the heart, such as may occur in debilitated persons after violent
or unusual exertion. In this condition the area of cardiac dulness
is increased and dyspnoea upon slight exertion becomes marked. It
goes without saying that in almost any case of organic disease of
the heart palpitation may be a very marked and distressing symp-
tom.

CONGENITAL HEAET DISEASE.

From, the time of birth it is noticed that the child is markedly
and permanently cyanosed, hence the term "blue baby." Dyspnoea
is often, though not always, present, and may interfere with suck-
ing. The cyanosis is practically sufficient in itself for the diag-
nosis.

Among congenital diseases of the heart the commonest and the
most important (because it is less likely than any of the others to
prove immediately fatal) is :

1. Pulmonary Stenosis.

This lesion is usually the result of foetal endocarditis, and is
often associated with malformations and defects, such as patency
of the foramen ovale and persistence of the ductus arteriosus. The
physical signs of pulmonary stenosis are :

(a) A palpable systolic thrill most distinct in the pulmonary
area.

(1} A loud murmur (often rough or musical) heard best in the
same region, but usually transmitted to all parts of the chest.

(d) An increased area of cardiac dulness corresponding to the
right ventricle.

Unlike most other varieties of congenital heart disease, pulmo-
nary stenosis is compatible with life for many years, and "blue
babies " with this lesion may grow up and enjoy good health, al-

CONGENITAL HEART DISEASE. 207

though usually subject to pulmonary disorders (pneumonia or tu-
berculosis). For a discussion of the differential diagnosis of this
lesion, see above, p. 193.

2. Defects in the Ventricular Septum.

The loud systolic murmur produced by the rush of blood through
an opening between the ventricles is heard, as a rule, over the whole
precordia. Its point of maximum intensity differs in different
cases, but is hardly ever near the apex of the heart. The most im-
portant diagnostic point is the absence of a palpable thrill. With
almost every other form of congenital heart disease in which a loud
murmur is audible, there is a thrill as well. Hypertrophy of both
ventricles may be present, but is seldom marked in uncomplicated
cases.

(P"atency of the foramen ovale, if unassociated with other de-
fects, does not usually produce any murmur or other signs by which
it can be recognized during life, and causes no symptoms of any
kind.)

3. Persistence of the Ductus Arteriosus.

The most characteristic sign is a loud, vibratory systolic mur-
mur with its intensity at the base of the heart and unassociated u-ith
hypertrophy of either ventricle. If complicated with stenosis at or
close above the pubnonary valves, persistence of the ductus arte-
riosus cannot be diagnosed, as the murmur produced by it cannot
with certainty be distinguished from that of the pulmonary ste-
nosis, and the presence of hypertrophy of the right ventricle de-
prives us of the one relatively characteristic mark of a patent arte-
rial duct.

It has been claimed that a murmur persisting through systole
and into diastole is diagnostic of an open arterial duct, but this
supposition is not borne out by post-mortem evidence.

The signs produced by the other varieties of congenital heart
disease, such as aortic stenosis and tricuspid or mitral lesions, do
not differ materially from those characterizing those lesions in

208 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

adults. Excluding these, we may summarize the signs of the other
lesions as follows :

(ft) Practically all cases of congenital heart disease, which pro-
duce any physical signs beyond cyanosis and dyspnoea, manifest
themselves by a loud systolic murmur heard all over the precordia
and often throughout the chest. Its maximum intensity is usually
at or near the base of the heart.

(b) If there is no thrill and no hypertrophy, the lesion is prob-
ably a defect in the ventricular septum.

(d) If there is a thrill and hypertrophy of the right ventricle,
the lesion is probably pulmonic stenosis, especially if the pulmonic
second sound is feeble.

CHAPTER IX.

DISEASES OF THE PERICAKDIUM.

I. PERICARDITIS.

THREE forms are recognized clinically :

(1) Plastic, dry, or fibrin ous pericarditis.

(2) Pericarditis with effusion (serous or purulent).

(3) Pericardial adhesions or adherent pericardium.
Fibrinous pericarditis may be fully developed without giving

rise to any physical signs that can be appreciated during life. In
several cases of pneumonia in which I suspected that pericarditis
might be present, I have listened most carefully for evidences of
the disease and been unable to discover any; yet at autopsy it was
found fully developed the typical shaggy heart. We have every
reason to believe, therefore, that pericarditis is frequently present
but unrecognized, especially in pneumonia and in the rheumatic at-
tacks of children. On the other hand, it may give rise to very
marked signs which are the result of

(a) The rubbing of the roughened pericardial surfaces against
one another when set in motion by the cardiac contractions.

(b) The presence of fluid in the pericardial sac.

(c) The interference with cardiac contractions brought about by
obliteration of the pericardial sac together with the results of ad-
hesions between the pericardium and the surrounding structures.

(1) DRY OR FIBRINOUS PERICARDITIS.

The diagnosis rests upon a single physical sign "pericardial

friction " which is usually to be appreciated by auscultation alone,

but may occasionally be felt as well. Characteristic pericardial

friction is a rough, irregular, yrating or shuffling sound which oc-

210 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

curs irregularly and interruptedly during the larger part of each
cardiac cycle. It is almost never accurately synchronous either
with systole or diastole, but overlaps the cardiac sounds, and en-
croaches upon the pauses in the heart cycle. It is seldom exactly
the same in any two successive cardiac cycles and differs thereby
from sounds produced within the heart itself. Pericardial friction
seems very near to the ear and may often be increased by pressure

J^J I Pericardial friction.

FIG. 113. Showing Most Frequent Site of Audible Pericardial Friction.

with the stethoscope ; it is not materially influenced by .the respi-
ratory movements.

It is best heard in the majority of cases in the position shown
in Fig. 113; that is, over that portion of the heart which lies near-
est to the chest wall and is not covered by the margins of the lungs ;
bnt not infrequently it may be heard at the base of the heart or
over the whole precordial region. The sounds are fainter if the
patient lies on the right side, and sometimes intensified if, while
sitting or standing, he leans forward and toward the left, so as to
bring the heart into closer apposition with the chest wall.

Pericardial friction sounds often change rapidly from hour
to hour, and may disappear and reappear in the course of a
day.

DISEASES OF THE PERICARDIUM. 211

In rare cases the friction may occur only during systole or only
during diastole. In such cases the diagnosis between pericardial
and iutracardial sounds may be very difficult.

DIFFERENTIAL DIAGNOSIS.

(a) Plewo- Pericardial Friction.

Fibrinous inflammation affecting that part of the pleura which
overlaps the heart may give rise to sounds altogether indistinguish-
able from, those of true pericardial friction when the inflamed pleu-
ral surfaces are made to grate against one another by the move-
ments of the heart. Such sounds are sometimes increased in
intensity during forced respiration and disappear at the end of
expiration, while true pericardial friction is usually best heard if
the breath is held at the end of expiration. If a friction sound
heard in the pericardial region ceases altogether when the breath
is held, we may be sure that it is produced in the pleura and not
in the pericardium, but in many cases the diagnosis cannot be made
correctly.

(&) Intmcardiac Murmurs.

From murmurs due to valvular disease of the heart, pericardial
friction can usually be distinguished by the fact that the sounds to
which it gives rise do not accurately correspond either with systole
or diastole, and do not occupy constantly any one portion of either
of these periods. Cardiac murmurs are more regular, seem, less
superficial, and vary less with position and from hour to hour.
Pressure with the stethoscope does not increase so considerably the
intensity of intracardiac murmurs. When endocarditis and peri-
carditis occur simultaneously, it may be very difficult to distinguish
the two sets of sounds thus produced. The pericardial friction is
usually recognized with comparatively little difficulty, but it is
hard to make sure whether in addition we hear endocardial mur-
murs as well.

212 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(2) PERICARDIAL EFFUSION*.

Following the fibrin ous exudation, which roughens the pericar-
dial surface and produces the friction sounds just described, serum
may accumulate in the pericardial sac. Its quantity may exceed
but slightly the amount of fluid normally present in the pericar-
dium, or may be so great as to embarrass the cardiac movements
and finally to arrest them altogether. In chronic (usually tubercu-
lous) cases, the pericardium may become stretched so as to hold a
quart or more without seriously interfering with the heart's action,
while a much smaller quantity, if effused so rapidly that the peri-
cardium has no time to accommodate itself by stretching, will prove
rapidly fatal.

Hydropericardium denotes a dropsy of the pericardium occur-
ring by transudation as part of a general dropsy in cases of renal
disease or cardial weakness. The physical signs to which it gives
rise do not differ from those of an inflammatory effusion, and, ac-
cordingly, all that is said of the latter in the following section may
be taken as equally an account of the signs of hydropericardium.

Hsemopericardium, or blood in the pericardial sac, due to stabs
or to ruptures of the heart, is usually so rapidly fatal that no
physical signs are recognizable.

Physical Signs of Pericardial Effusion.

In most cases a pericardial friction rub has been observed prior
to the time of the fluid accumulation. The presence of fluid in the
pericardial sac is shown chiefly in three ways :

(1) By percussion, which demonstrates an area of dulness more
or less characteristic (see below).

(2) By auscultation, which may reveal an unexpected feebleness
in the heart sounds when compared with the power shown in the
radial pulse.

(3) By the signs and symptoms of pressure exerted by the peri-
cardial effusion upon surrounding structures.

Bulging of the precordia is occasionally to be seen in children ;

DISEASES OF THE PERICARDIUM.

213

in adults we sometimes observe a flattening of the interspaces just
to the right of the sternum between the third and sixth ribs.

(1) The Area of Percussion Dulness. (a) One of the most char-
acteristic points is the unusual ' extension of the percussion dulness
a considerable distance to the left and beyond the cardiac impulse.
(/;) Next to this, it is important to notice a change in the angle
made by the junction of the horizontal line corresponding to the
upper limit of hepatic dulness and the nearly perpendicular line
corresponding to the right border of the heart. In health this

Tympany,

_ J Dulness,

Cardiac impulse.

Liver dulness.

FIG. 114. Percussion Dulness in Pericardial Effusion, with Tympanitic Kcsonance Under the

Left Clavicle.

cardio-hepatic angle is approximately a right angle ; in pericardial
effusion it is much more obtuse (see Fig. 114). Rotch has called
attention to the importance of dulness in the fifth right intercostal
space as a sign of pericardial effusion, but a similar dulness may be
produced by enlargement of the liver.

Except for the two points mentioned above (the unusual extension
of the dulness to the left of the cardiac impulse and the blunting of
the cardio-hepatic angle), there seems to me to be nothing charac-
teristic about the area of dulness produced by pericardial friction.

1 In health the cardiac dulness extends about three-fourths of an inch be-
yond the cardiac impulse, but in pericardial effusion the difference is greater.

214 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

The " pear-shaped " or triangular area of percussion clulness men-
tioned by many writers has not been present in cases which have
come under my observation. In large effusions percussion reso-
nance may be diminished in the left back, and under the left clav-
icle the percussion note may be tympanitic from relaxation of the
lung. Traube's semilunar space may be obliterated, but this occurs
also in pleuritic effusions.

In some cases the area of dulness may be modified by change in
the patient's position. After marking out the area of percussion
dulness with the patient in the upright position, let him lie upon
his right side. The right border of the area of dulness will some-
times move considerably farther to the right. A dilated heart can
be made to shift in a similar way, but to a lesser extent. Compar-
atively little change takes place if the patient lies on his left side,
and no important information is elicited by placing him flat on his
back or by getting him to lean forward.

Unfortunately, it is only with moderate-sized effusions occur-
ring in a pericardial sac free from adhesions to the surrounding
parts that this shifting can be made out. Large effusions may not
shift appreciably, and less than 150 c.c. of fluid probably cannot be
recognized by this or by any other method. But with large effu-
sions the lateral extension of the area of dulness may be so great
as to be almost distinctive in itself, i.e., from the middle of the left
axilla nearly to the right nipple.

(2) The feebleness of the heart sounds, especially those at the
apex, is of diagnostic importance only in the rare cases when it oc-
curs in connection with a relatively normal condition of the radial
pulse. In most diseases feeble heart sounds are associated with a
weak pulse, but occasionally in pericardial effusion the p\ilse may
be of good quality, although the heart sounds are heard with diffi-
culty.

Broncho-vesicular breathing with increased voice sounds may
be heard over the tympanitic area below the left clavicle and occa-
sionally between the scapulae behind. This is a result of compres-
sion of the lung.

(3) Pressure exerted by the pericardial exudation upon sur-

DISEASES OF THE PERICARDIUM. 215

rounding structures may give rise to dyspnoea, especially of a
paroxysmal type, to dysphagia, to aphonia, and to an irritating
cough. The "paradoxical pulse," small and feeble during inspira-
tion, is occasionally to be seen, but is by 110 means peculiar to this
condition and has no considerable diagnostic importance.

(4) Inspection and palpation usually help us very little, but two
points are occasionally demonstrable by these methods :

() A smoothing out of the intercostal depression in the precor-
dial region, especially near the right border of the sternum between
the third and the sixth ribs.

(V) A progressive diminution of the intensity of the apex im-
pulse until it may be altogether lost. If this change occurs while
the patient is under observation, and especially if the apex impulse
ri'tippears or becomes more distinct when the patient lies on the
right side, it is of considerable diagnostic value. In conditions
other than pericardial effusion, the apex impulse becomes less visible
in the right-sided decubitus.

Differential Diagnosis.

(1) Our chief difficulty is to distinguish the disease from hyper-
trophy and dilatation of the heart. In the latter, which often com-
plicates acute articular rheumatism with or without plastic pericar-
ditis, the apex impulse is often very indistinct to sight and touch
as in pericardial effusion. But the area of dulness is less likely to
extend beyond the apex impulse to the left or to modify the cardio-
hepatic angle, or to shift when the patient lies on the right side.
Pressure symptoms are absent, and there are no areas of broncho-
vesicular breathing with tympanitic resonance under the left clavicle
or in the axilla. Yet not infrequently these differentiae do not
serve us, and the diagnosis can be made only by puncture.

(2) I have twice known cases of encapsulated empyema mistaken
for pericardial effusion. In one case a needle introduced in the
fifth intercostal space below the nipple drew pus from what turned
out later to be a localized purulent pleurisy, but the diagnosis was
not made until a rib had been removed and the region thoroughly
explored. It is not rare for pleuritic effusions to gather first

216 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

in this situation, viz., just outside the apex impulse in the left
axilla.

Such effusions may gravitate very slowly to the bottom of the
pleural cavity or may become encapsulated and remain in their
original and very deceptive position. In such cases the signs of
compression of the left lung are similar to those produced by a
pericardial effusion, and the results of punctures may be equivocal
as in the case just mentioned. If there is any dulness, even a very
narrow zone, in the left axilla between the fifth and eighth ribs,
though there be none in the back, the likelihood of pleurisy should
be suggested.

As between pleuritic and pericardial effusion the presence of a
good pulse and the absence of marked dyspnoea favors the former.
In the two cases above referred to in which encapsulated pleurisy
was mistaken for pericarditis, the general condition of the patient
struck me at the time as surprisingly good for pericarditis.

If both pleurisy and pericarditis are present, the area of peri-
cardial dulness is not characteristic until the pleuritic fluid has been
drawn off. The persistence of dulness in the cardio-hepatic angle
and beyond the apex beat after a left pleurisy has been emptied by
tapping, and after the heart has had time to return to its normal
position, should make us suspect a pericardial effusion.

Despite the utmost care and thoroughness in physical examina-
tion, many cases of pericardial effusion go unrecognized, especially
in infants, in elderly persons, or when the lung borders are adher-
ent to the pericardium or to the chest wall.

In the rheumatic attacks of children, it should be remembered
that pericarditis is even more common than endocarditis.

Adherent Pcr'n-i/ rii'nnn.

In the majority of cases the diagnosis cannot be made during
life, unless the pericardium is adherent, not only to the heart, but
to the walls of the chest as well. \Vlien this combination of peri-
carditis with chronic mediastinitis is present, the diagnosis may be
suggested by

(a) A systolic retraction of the chest wall in the region of the

DISEASES OF THE PERICARDIUM. 217

apex impulse at the base of the left axilla and in the region of the
eleventh and twelfth ribs in the left back (Broadbent's sign). Such
retraction is more marked during a deep inspiration. (It should
be remembered that systolic retraction of the interspaces in the
vicinity of the apex is very commonly seen in cases of cardiac hy-
pertrophy from any cause, owing to the negative pressure produced
within the chest by the contraction of a powerful heart.) A quick
rebound of the cardiac apex at the time of diastole (the diastolic
shock) is said to be characteristic of pericardial adhesions, but is
often absent.

(&) Collapse of the cervical veins during diastole has been no-
ticed by Friedreich, and the paradoxical pulse, above described, is
said to be more marked in adherent pericardium than in any other
known condition. Most recent writers, however, place no reliance
upon it.

(c) When the lungs are adherent to the pericardium or to the
chest wall, as is not uncommonly the case, the absence of the phrenic
phenomenon (Litten's signs) and of any respiratory excursion of
the pulmonary margins may be demonstrated. Since pericardial
adhesions are most often due to tuberculosis, the discovery of tu-
berculosis in the lung or elsewhere may be of aid in diagnosis.

(rf) Broadbent considers that the absence of any shift in the
position of the apex beat, with respiration or change of patient's
position, is an important point in favor of mediastino-pericarditis.
In health and in valvular or parietal disease of the heart, the apex
beat will sAving from one to tAvo inches to the left when the patient
lies on his left side, and the descent of the diaphragm during full
inspiration loAvers the position of the cardiac impulse considerably.

(e) The presence of hypertrophy or dilatation affecting espe-
cially the right side of the heart, and not accounted for by the
existence of any disease of the cardiac valves, of the lung, or of
the kidney, should make us suspect pericardial and mecliastinal
adhesions. Such adhesions embarrass especially the right ven-
tricle, because it is the right ventricle far more than the left which
becomes attached to the chest wall. The left ventricle is more
nearly free.

218 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(/) Since the space enclosed by the divergent costal cartilage
just below the ensiform is but loosely associated with the cen-
tral tendon of the diaphragm, Broadbent looks especially at thr*

FIG. 115. FIG. 116.

FIGS. 115, 116. Adherent Pericardium, Ascites.

point for evidence of mediastinal or pericardial adhesions, the
effect of which is to arrest completely the slight respiratory move-
ments of this part of the abdominal wall.

(y) Adherent pericardium, occurring as a part of a widespread

DISEASES OF THE PERICARDIUM. 219

chain of fibrous processes involving the pleura, the mediastinum,
and the peritoneum, may give rise in young persons to a train of
symptoms and signs suggesting cirrhosis of the liver. Ascites
collects, the liver is enlarged, yet there are no signs in the heart,
kidneys, or blood sufficient to explain the condition. In any such
case adherent pericardium should be considered. Figs. 115 and 11G
show the appearance in cases of this kind in which the diagnosis
was verified by autopsy.

Summary.

The diagnosis of adherent pericardium with chronic mediastini-
tis is suggested by

() Systolic retraction of the lower intercostal spaces in the
left axilla and in the left back, followed by a diastolic rebound.

(li) The absence of any change in the position of the apex im-
pulse with respiration or change of position.

((Z) The absence of any respiratory excursion of the lung bor-
ders near the heart and of the abdominal wall at the costal angle.

CHAPTER X.

THORACIC ANEURISM.
ANEURISM OF THE THORACIC AORTA.

FOR clinical purposes thoracic aneurisms may be divided into
the diffuse and the saccular. Saccular aneurisms of the ascending
or descending portion of the arch of the aorta are apt to penetrate
the chest wall, while aneurism of the transverse aorta or diffuse
dilatations of the whole aortic arch are more likely to extend within
the chest without eroding the thoracic bones. Practically any
aneurism which penetrates the thoracic bones may be inferred to
be saccular, but if no such penetration takes place, it may be im-
possible to make out whether the dilatation is diffuse or circum-
scribed. I shall consider:

I. The signs of the presence of aneurism.

II. The evidences of its seat.

Inspection and palpation give us most of the important informa-
tion in the diagnosis of aneurism. The patient should be placed in
the position shown in Fig. 117, so that the light will strike obliquely
across the surface of the chest, and the observer should be so placed
that his eyes are as nearly as possible at the level at that part of
the chest at which he hopes to see pulsation.

In the majority of cases of aneurism some abnormal pulsation
may be made out either to the right of the sternum in front or in
Abnormal the region of the left scapula behind. If the aneur-
Pulsation. ism is large, a considerable area of the chest wall may
be lifted with each beat of the heart; with smaller growths the
pulsating area may be small and sharply circumscribed. Not in-
frequently an abnormal pulsation at the sternal notch or in the

THORACIC ANEURISM.

221

neck may be observed. Other causes of abnormal pulsations in
the chest, such as dislocation or uncovering of the heart, must of
course be excluded. Pulsations due to aneurism can sometimes
be distinctly seen to occur later than the apex impulse of the heart.

Palpation controls the results of inspection, but at times a pul-
sation may be seen better than felt ; at others may be felt better
than seen. Bimanual palpation one hand over the suspected area
in front and one in a corresponding position behind is useful.

If the aneurism involves the ascending portion of the aortic

FIG. 117. Position When Looking for Slight Aneurismal Pulsation.

arch, it is likely sooner or later to erode the right margin of the
sternum and the adjacent parts of the second or third costal car-
tilages and appear externally as a round swelling in
Tumor. wn j cn a S y S t o lic pulsation is to be seen and felt. This
pulsation is almost always distinctly expansile in character, and
differs in this respect from the up-and-down motion which may
be communicated to a tumor of the chest wall by the beating of
a normal aorta. The tumor is usually firm, rarely soft, and may
be as hard as any variety of malignant new growth. Occasionally

222 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

the thickness of the lamellated clot within it is so great that no
pulsations are transmitted to the surface.

"Whether the aneurism penetrates the chest or not, it is often
possible to feel over it a ri/n-itfiitr/ t/t fill, usually sys-
tolic in time. If the layer of lamellated clot in the
sac is very thick, the thrill is less apt to be felt.

More important in diagnosis is a ilitistnllr shock or tap which is
appreciated by laying the palm of the hand lightly over the affected

FIG. 118. Aneurismal Tumor (A). The arrow D points to a guumiatous swelling near the en-
siform cartilage. The radiographic appearances of this case are shown below (Fig. 121).

area. This diastolic shock is due to the recoil of the blood in the di-
lated aorta, and is one of the most important and characteristic signs
Diastolic i* 1 aneurism. As the wall of the sac becomes weaker,
Shock, the intensity of this shock diminishes. This diastolic
shock may be appreciated over the trachea also, and is thought by
some to have even more significance when felt in this situation.

Of special importance in aneurism of the transverse arch is the
sign known as the tmcheul tufj. The arch of the aorta runs over

THORACIC ANEURISM. 223

the left primary bronchus in such a way that when the aorta is

dilated, the bronchus is pressed upon with each expansile pulsation

Tracheal f the artery. This systolic pressure transmitted to

Tug. the trachea produces a distinct downward tug upon it

with each systole of the heart. The tug is best felt by making the

patient throw back his head so as to put the trachea upon a stretch.

The physician then stands behind him and gently presses the tips

of the fingers of both hands up under the lower border of the cri-

FiG. IW.-Aneurism Tumor Perforating the Sternum at A. At B there is a gummatous mass.
(See below. Fig. 121, a radiograph of this case).

coid cartilage. In feeling thus for the tracheal tug as transmitted
to the cricoid cartilage certain precautions must be observed :

(a) One must distinguish the tracheal tug from a simple pulsa-
tion transmitted to the superficial tissues by the vessels under-
neath. Such pulsation makes the tissues move out and in rather
than up and down.

(1} A tracheal tug felt only during inspiration has no patho-
logical significance and is frequently present in health.

While preparing to try for the tracheal tug we may notice
whether there is any dislocation of the trachea, as shown by the

224 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

displacement of Ad?.m's apple. Other and less important signs of
aneurism, which are due to the pressure of the dilated aorta upon
the nerves or vessels of the mediastinum, are :

(1) Inequality of the pupils.

(2) Inequality of the radial pulses.

(3) (Edema and cyanosis of one arm or of one side of the neck
and head.

(4) Pain in one arm from the pressure of an aneurism involving
the subclavian artery upon the brachial plexus.

(5) Clubbing of the fingers of one hand (rare).

(6) Prominence of one eye (rare).

(7) Flushing or sweating of one side of the face (very rare).
Contraction or dilatation of the pupil is due to an irritative or

paralytic affection of the sympathetic nerves. This symptom is
much commoner than the other effect cf pressure upon the sympa-
thetic nerves ; namely, flushing or sweating of one side of the face.

In comparing the pulses in the two radials we must bear in mind
the possibility of a congenital difference between them, due to a
difference either in the size of the arteries or in their position, and
also that a tumor pressing on the subclavian may affect the pulse
exactly as an aneurism. The pulse wave upon the affected side
(most often the left) may be either less in volume or later in time
than the wave in the other radial artery, according as the pulse
wave is actually delayed in the aneurismal sac or merely diminished
by it. In marked cases the pulse upon the affected side may be
nearly or quite absent. On the other hand the inequality of the
pulses may be so slight that the sphygmograph has to be employed
to demonstrate differences in the shape of the wave not perceptible
to the fingers.

Examination of the heart itself may show some dislocation of
the organ to the left and downward, owing to the direct pressure
of the aneurismal sac.

II. Percussion.

If the aneurism is deep-seated, the results of percussion are
negative. If, on the other hand, it be situated immediately be-

225

neath the sternum or close under the thoracic wall, an area of dul-
ness, not present in the normal chest, may be mapped out. The
outlines most commonly seen in such cases are shown in Fig. 120.
\Yhen the aneurism involves the descending aorta, an area of dulness
may be found in the region of the left scapula or below it, and pul-
sation may be detected in the same area.

III. Auscultation.

The signs revealed by auscultation are not of much diagnostic
value as a rule. In about one-half of the cases of sacculated aneu-

Aneurismal
dulness.

_(\_ L - Heart dulness.

FIG. 120. Diagram of Percussion Dulness in Aortic Aneurism.

rism there are no sounds or murmurs to be heard over the tumor.
In other cases a systolic murmur, the audible counterpart of the
vibratile thrill, may be heard over the area of pulsation, tumor, or
dulness corresponding to the aneurismal sac. This systolic mur-
mur may be due to many causes other than aneurism, and has noth-
ing characteristic about it. A similar systolic sound is sometimes
heard over the trachea (Drummond's sign) or in the mouth, if the
patient closes his lips around the pectoral extremity of the steth-
oscope (Sansom's sign).

A loud, low-pitched diastolic sound, corresponding to the pal-
15

226 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

pable diastolic shock, is generally to be heard in the aortic region.
This diastolic sound, which is probably not produced by the aortic
valves, is remarkably deep-toned and loud, and is, on the Avhole, the
most important sign of aneurism revealed by auscultation.

If a portion of either lung is directly pressed upon by the an-
eurisnial sac, we may have the signs of condensation of the lung
in the area pressed upon (slight dulness, broncho-vesicular breath-
ing, and exaggerated voice sounds). If one of the primary bronchi

From the front.

From behind.

FIG. 121. Radiograph of Case whose Photograph is Reproduced as Figs. 118 and 119. In the
right-hand cut are shown the appearances seen from behind. The left-hand cut, A, A,
aneurismal sac; B, heart displaced ; C. liver (not in focus).

is pressed upon, as occasionally happens, atelectasis of the corre-
sponding lung may be manifested by the usual signs (dulness, ab-
sence of tactile fremitus and of respiratory and vocal sounds).

Since aneurism is frequently associated with regurgitation at
the aortic valve, a diastolic murmur is not infrequently to be
heard.

If the aneurismal sac is of very great size, the pulse wave in
the femorals may be obliterated, as happened in a case described
by Osier.

THORACIC ANEURISM.

227

IV. Radioscopy.

With the fluoroscope and through photography one can often
make out a shadow corresponding to the position of the aneurism.

Dilated aortic
arch.

Hypertrophied
heart.

FIG. 123. Aortic Regurgitation with Diffuse Dilatation of the Aortic Arch. Front view.

The position of the shadow is best explained by reference to Figs
121, 122, and 123.

Summary.

The most important signs of aneurism are :

1. Abnormal pulsation visible or palpable

2. Tumor over which a

3. Thrill and a

228 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

4. Diastolic shock may be felt.

5. Tracheal tuy.

6. Pressure siyns (unequal pulses, pupils, hoarseness, pain, etc.)=

7. Dulness on percussion over the suspected area.

8. Loud, low-}; itched aort!<- si.-n,/id sound.

9. Systolic murmur (least important of all).

Aneurismalsac.

Heart displaced
downward by

the aneurism.

FK;. 12}. Extensive Aortic Aneurism Displacing the Heart.

10. Radioscopy may demonstrate a shadow higher up than that
corresponding to the heart and extending beyond that produced by
the sternum, spinal column, and great vessels.

Diagnosis of the S<-at of the Lesion.

(a) Aneurism of the ascending arch generally approaches or
penetrates the chest wall in the vicinity of the secoml r!<jJit inter-
costal space near the sternum. Previous to perforating the thoracic

THORACIC ANEURISM. 229

parietes, the growth of the aneurism may give rise to pain, pulsa-
tion, and dulness and thrill in this region.

(1) Aneurism of the transverse arch or diffuse dilatation of the
aorta, such as usually occurs in long-standing cases of aortic regur-
gitation, may not give rise to any visible pulsation of the chest
wall, and, if deep-seated, need not produce any abnormal dulness
on percussion. In such cases an aneurism is to be recognized, if
at all, by evidences of pressure on the nerves or vessels of the medi-
astinum (cough, aphonia, inequality of the pupils, tracheal tug,
etc.).

(c) Aneurism of the descending aorta gives rise usually to severe
and persistent pain in the back, which radiates along the intercos-
tal nerves or downward. Other pressure symptoms are not marked,
but in advanced cases an area of abnormal dulness and pulsation
may be found in the region of the left scapula or below it.

(rf) If the innominate artery or one of the carotids is involved,
we usually find a pulsating lump in the region of one or the other
claviculo-sternal joint or at the root of the neck, and the trachea
may be displaced to one side. If the subclavian is involved or
pressed upon, there may be pain and osdema in the corresponding
arm.

Differential Diagnosis.

() Some writers draw a distinction between the diffuse dilata-
tion of the aortic arch, which sooner or later complicates almost
every case of incompetency of the aortic valves, and saccular aneu-
rism of the transverse portion of the aorta. Clinically, such dis-
tinction seems to be impossible, although if symptoms resembling
those of aneurism gradually develop in a case of aortic regurgita-
tion, one may suspect that the dilatation of the aorta is merely
part of the distention of the whole arterial tree, which aortic regur-
gitation tends to produce.

(Z) Aneurism is not infrequently mistaken for aortic stenosis, in
which a systolic murmur and thrill, similar to those occurring in
aneurism, are to be heard over the region of the aortic arch. From
aortic stenosis aneurism is distinguished by the fact that it does

230 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

not produce characteristic changes in the pulse, and by the presence
of some one of the symptoms above described, such as tracheal
tug, pressure symptoms, abnormal area of percussion dulness, etc.

(c) Simple dynamic throbbing of a normal aortic arch similar
to that which occurs in the abdominal aorta may lift the chest wall
so as to simulate aneurism. The other positive symptoms and
signs of aneurism are, however, absent.

(d) Pulmonary tuberculosis or cancer of the oesophagus, produc-
ing as they may substernal pain, cough, and aphonia by pressure
upon mediastinal structures, have been mistaken for aneurism,
from which, however, they may be distinguished by the absence of
the positive signs above described, by the more rapid emaciation
of the patient, and by the positive evidences of cancer or tubercu-
losis.

(e) Empyema necessitatis may produce a pulsating tumor like
that of aneurism and the area of dulness may be similar, but there
is no diastolic shock, no tactile thrill or murmur, and the history
of the case is usually very different from that of aneurism. It is
perfectly safe to insert a fine hollow needle in doubtful cases. Xo
serious hemorrhage results if aneurism is present, and the diagnosis
and treatment may be greatly assisted.

(/) Mediastinal tumors are sometimes almost indistinguishable
from aneurism during life. They may produce a more intense and
widespread dulness which is usually in the median line, while the
dulness of aneurism is oftener at one side. The pulsation transmit-
ted to a tumor by the heart has not the expansile character of aneu-
risrnal pulsation. Tumors are not associated with any diastolic
shock, rarely with a tracheal tug.

The course of most mediastinal tumors is progressive and at-
tended by great cachexia, while the symptoms of aneurism are often
more or less intermittent, and unless pain i ? severe there is no such
emaciation or anaemia as is commonly seen with mediastinal tu-
mors. Pressure symptoms may be the same in both diseases, but
are usually more marked with mediastinal growths. A metastatic
nodule over the clavicle sometimes betrays the presence of a pri-
mary focus within the chest.

THORACIC ANEURISM. 231

(g) Retraction of the riyht limy (fibroid phthisis), with or without
displacement of the heart toward the diseased side, may uncover
the heart so as to produce some of the signs of aneurism, i.e., pul-
sation and dulness in the upper right intercostal spaces near the
sternum, with a loud aortic second sound and sometimes a systolic
murmur in the dull area.

The history of the case and a careful examination of the lungs
usually suffice to set us right.

(h) Dilatation of the heart may be so extreme that pulsation
and percussion dulness appear in the characteristic aneurismal area
to the right of the sternum, especially if there is solidification of
the left lung. But the pulse is in such cases much weaker and
more irregular than is to be expected in uncomplicated cases of aortic
aneurism, and the history of the case is usually decisive.

PART III.

DISEASES OF THE LUNGS.

CHAPTER XI.

BKONCHITIS, PNEUMONIA, TUBERCULOSIS. V

I. TRACHEITIS.

IN connection with bronchitis or as a forerunner thereof, inflam-
mation of the trachea is not uncommon. It gives rise to no char-
acteristic physical signs, but is to be suspected when the patient
complains of cough ivitli pain over the upper portion of the sternum.

BRONCHITIS.

Inflammation of the larger bronchial tubes is not often the
cause of any definite physical signs, but with every paroxysm of
coughing the patient may feel pain in an area corresponding ex-
actly to the anatomical position of the primary bronchi. I have
seen patients indicate most accurately the situation of the large
tubes when pointing out the position of pain produced by coughing.

In the vast majority of cases of acute bronchitis the smaller
bronchi are involved, and the swelling of their Avails, Avith or with-
out exudation, is manifested by the following physical signs : '

(1) Diminution in the intensity of vesicular breathing over the
area affected (rarely in the earliest stages the breath sounds are
exaggerated and harsh, especially in the upper portions of the
chest).

1 Bronchitis may exist without rales, but cannot be diagnosed without
them. Occasionally they are present only an the early morning.

234 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(2) fidles, which are squeaking or piping over bronchi which
are narrowed without any considerable amount of exudation, as is
the case in the earliest stages of many cases, and bubbling, crack-
ling, or clicking in later stages, when watery or viscid exudation is
present in the tubes. The calibre of the bronchi affected can be
estimated from the coarseness or fineness of the rales. Low-pitched
groaning sounds point to a stenosis of a relatively large bronchus,
while squeaking and whistling sounds are usually produced in the
smaller tubes. Large, bubbling rales are much less often heard
than the finer, crackling variety. The latter are produced in the
smallest tubes, the former in the larger variety.

Simple non-tuberculous bronchitis is almost invariably bilateral
or symmetrical, and affects most often the lower two-thirds of the
lungs, leaving the apices relatively free. It is almost never con-
fined to an apex. When rales are to be heard on one side of the
chest only, and when they persist in the same spot for days and
weeks, tuberculosis is always to be suspected, especially if the
rales are localized at the summit of one or both lungs. It should
never be forgotten that the tubercle bacillus is capable of exciting
a bronchitis indistinguishable from other varieties of bronchitis,
except by its tendency to show itself at the apex of the lung and
on one side only; most cases of pulmonary tuberculosis begin in
this way

The only other variety of bronchitis which is often unilateral is
that due to influenza bacillus. In the course of a case of influenza,
a unilateral localized bronchitis not infrequently occurs. Over a
patch of lung, perhaps the size of the palm of the hand, fine, moist
rales may persist for weeks, finally clearing up only after the pa-
tient has resumed his ordinary occupation. Doubtless such local-
ized patches of bronchitis are often accompanied by foci of lobular
pneumonia too small to be detected by our present methods of
physical examination.

Percussion dulness is absent in bronchitis except near the end
of fatal cases, when the lung is stuffed with mucus and pus, or
Avhen atelectasis has occurred owing to extensive plugging of the
larger bronchi. These events are rarely seen, and in general the

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 235

negative results of percussion are of great value in excluding sol-
idification or fluid exudation.

Occasionally percussion resonance may be increased owing to
a slight temporary overdistention of the air vesicles from coughing. '

Inspection usually shows little or nothing of diagnostic impor-
tance in acute bronchitis. Long-standing cases, complicated as
they almost invariably are by emphysema, present changes in the
shape of the thorax ; but these are due to the emphysema rather
than to the bronchitis. In children acute bronchitis sometimes
involves so many of the smaller bronchi that dyspnoea and use of
accessory muscles of respiration are notable. But this usually
means atelectasis, broncho-pneumonia, or laryngeal spasm, in addi-
tion to the bronchitis.

From violent coughing the jugulars may be distended, but no
systolic pulsation occurs in them.

Voice sounds and tactile fremitus are normal.

Differential Diagnosis.

(Edema of the lung and bronchial asthma are the only pathologi-
cal processes (except hemorrhage into the lung substance) which
give rise to signs like those of bronchitis.

(1) In oedema of the lung, or pulmonary apoplexy, one may
find, as in simple bronchitis, a diminished vesicular breathing with
crackling rales, but oedema of the lung is almost always best marked
in the dependent portions ; that is, in the posterior parts of the
lung if the patient has been lying upon the back, or in the lower
lobes if he has been sitting up. The rales of oedema are always
moist, are more uniform in size when compared to those of bron-
chitis, and are never mingled with squeaking or groaning sounds.
The recognition of a cause for the oedema, for example a non-com-
pensated heart lesion, materially aids in the diagnosis.

(2) Bronchial asthma or spasm of the finer bronchi produces dry
squeaking and groaning sounds similar to those heard in the earlier

1 In children examined during a crying-spell a cracked-pot sound can
usually be elicited by percussion. This is in no way characteristic of bron-.
chilis and can often be obtained in healthy infants.

236 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

stages of many cases of bronchitis. But in bronchial asthma the
rales are chiefly expiratory, and expiration is prolonged and inten-
sified. Moreover, the inhalation of a few drops of aniyl nitrite will

temporarily dispel rales due to bronchial
spasm, while on the rales of dry bronchitis
it has no effect (Abrarns).

(3) Broncho-pneumonia. In many
cases of lobular or broncho-pneumonia the
physical signs are exclusively those of the
coexisting bronchitis. In such cases the
diagnosis of bronchitis is not wrong, but
does not cover the whole ground. I shall
discuss further under broncho-pneumonia
the evidence which leads us to suspect
that something more than bronchitis is
present.

(4) Muscle sounds. Under certain
circumstances (cold, nervousness), the
rumbling noises produced by muscular
contractions in the chest wall may simu-
late rales so closely that the diagnosis of
bronchitis may be strongly suggested.
The differentiation between rales and
muscle sounds has already been discussed
(see above, p. 87).

(5) Atelectatic crepitation. Crackling
rales heard over the thin margins of the
lungs at the base of the axilla or along
the edges of the manubrium are often due

to atelectasis (see above). From bronchitis they are distinguished
by their situation and by the lack of symptoms. They are best
heard at the point shown in Fig. 124.

Chronic Bronchitis.

So far as the bronchitis itself is concerned, there may be no
difference in the physical signs between the acute and chronic forms

FIG. 124. The Dots are Placed
over the Area where Atelecta-
tic Crepitation is Oftenest
Heard.

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 237

of the disease ; but in the latter one abnost invariably finds asso-
ciated with the bronchitis itself a considerable degree of emphy-
sema, of asthma, or of both conditions. Indeed, the foreground of
the clinical picture and the bulk of the physical sign are made up
by the emphysema and asthma, rather than by the bronchitis itself.
Accordingly, I shall not discuss chronic bronchitis any further at
this point, but will return to the subject in the chapter on Emphy-
sema.

CKOUPOUS PNEUMONIA.

In its typical form, croupous or fibrinous pneumonia produces
solidification of one or more lobes, usually the lower, the process
being accurately bounded by the interlobular fissures. Although
the physical signs of the earlier stages differ considerably from
those of the later ones, there seems to be no sufficient ground for
marking off stages of engorgement and of red and gray hepatiza-
tion, for clinically these stages cannot be distinguished.

The solidification may begin in the deeper parts of the lung
(" central pneumonia "), so that no physical signs are obtainable
until later in the course of the disease, when the process extends
to the surface of the lung.

Massive pneumonia, in which the bronchi as well as the air cells
are plugged with fibrin and leucocytes, is a relatively rare form of
the disease, but possesses great clinical importance on account of the
marked resemblance between its physical signs and those of pleura!
effusion.

The frequency of endocarditis and pericarditis in connection
with lobar pneumonia, especially with those of the left side, should
be borne in mind.

Physical Signs.

(a) Inspection. -The aspect of the patient frequently suggests

the diagnosis; the face is anxious, often flushed or slightly cya-

nosed, the flush sometimes affecting most strikingly the side of the

face corresponding to the lung affected. 1 Herpetic vesicles ("cold

1 Perhaps because the patient is apt to lie upon the affected side.

238 PHYSIC AI DIAGNOSIS OF DISEASES OF THE CHEST.

sores ") are often to be seen around the mouth or nose. The rapid,
difficult breathing is at once noticable, and expiration is often ac-
companied by a grunt. The use of the accessory muscles of respi-
ration and the dilatation of the nostrils attract attention.

The combination of marked dyspnoea with absence of dropsy is
met with more frequently in pneumonia than in any other disease.
Both sides of the chest usually move alike, but occasionally the
affected side shows deficient expansion especially in the later stages
of the disease, and the other side of the chest shows increased re-
spiratory movements (compensatory). Rarely the pulsations of the
heart may be transmitted to the chest wall through the affected lung.

"NYhen pneumonia attacks a feeble old man, or follows injuries
(surgical pneumonia), its onset may be insidious, and none of the
phenomena just described may be seen.

(b) Palpation. In the great majority of cases tactile f remit us is
markedly increased over the affected area, 1 but in case the bronchi
are occluded by secretions or fibrinous exudate, fremitus may be di-
minished or altogether absent. A few hard coughs will sometimes
clear out the tubes and thus materially assist the diagnosis. Occa-
sionally an increase in superficial temperature of the affected side
may be noticed by palpation, and rarely one feels a friction rub
due to the fibrinous pleurisy which almost invariably accompanies
the disease.

(c) Percussion. Over the area affected the percussion note is gener-
ally dull and may be almost fiat, except in the earliest and latest
stages of the disease, in which it may have a tyrnpanitic quality with
or without an element of slight dulness. More marked tympany is
usually present over the unaffected lobes of the diseased lung (that
is, over the upper lobes in the great majority of cases.)

The conditions just described represent the great majority of
cases, but the following exceptions occur :

(1) In the pneumonias of children, and occasionally in adults,
dulness may be absent.

1 By using the edge instead of the flat of the hand the boundaries of sol-
idified lobes may often be very accurately marked out by means of the tactile
fremitus.

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 239

(2) When the lower lobe of the left lung is affected, a distinctly
tympanitic quality may be transmitted to the consolidated area
from a distended stomach or colon.

(3) In rare cases, the percussion over the consolidated area may
be of a metallic quality, or produce the " cracked-pot " sound.

(4) In central pneumonia there may be no change in the percus-
sion note, or it may be unusually full and deep so that the sound
side seems dull by comparison.

A solidified lobe increases so much in size that the area of dul-
ness corresponding to it often seems incredibly large. Thus, al-
though the lower lobe reaches in health not more than half-way up
the scapula, when solidified it produces dulness throughout nearly
the whole back.

The right base is the most frequent seat of pneumonic solidifica-
tions, but the dulness corresponding to it is often first noticeable in
the posterior axillary line. A dulness appreciable only in the front
of the chest is almost sure to correspond to the upper lobe, while
signs in the lower part of the right axilla correspond to the middle
lobe. Many cases of central pneumonia first appear at the surface
in one or the other axilla.

As regards the amount of solidification needed to produce per-
cussion dulness, Wintrich says that the minimum is a patch 5 cm.
in diameter, 2 cm. deep, and superficially situated.

Percussion often makes us aware of an increased resistance or
diminished elasticity of the affected side, although the resistance is
seldom as marked as in large pleural effusions.

((/) Atiw'itlfiifioH. In the great majority of cases typical tubular
breathing is to be heard over the affected area. Since a whisper
is practically a forced expiration, this tubular quality is very well
brought out if the patient is made to whisper "one, two, three,"
or any other succession of syllables, and by this method the fatigue
and pain of deep breathing may be saved. By this use of the
whispered voice one may accurately mark out the boundaries of the
consolidated area, and demonstrate in many cases that it coincides
with the boundaries of one lobe of the lung.

In the earliest stages of the disease the breathing may be bron-

240 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

cho-vesicular ; more often it is feeble or suppressed over the con-
solidated area, and ''crepitant rales," that is, very tine crackling
sounds, may be heard at the end of inspiration, but these are much
more common in the stage of resolution 1 ('* crepitaiis redux ").

If some of the smaller bronchi are blocked, as is not infre-
quently the case, respiration is absent or very feeble, and such
cases are often mistaken for pleuritic effusion. In pneumonia of
the upper lobe it is not rare for bronchial breathing to be absent
even without plugging of the bronchi.

In cases of "central pneumonia," that is, when the area of
solidification is in the interior of the organ, there may be no
change in the breath sounds, or a bronchial element may be faintly
audible on auscultation with the unaided ear, and only by this
method.

The intensity of the spoken or whispered voice is greatly in-
creased over the area of consolidation, and sometimes the words
can be distinguished. The nasal twang known as " erjophony " is
occasionally to be heard. In the majority of cases, as has been
already stated, the right lower lobe posteriorly is affected, so that
the consolidated area is immediately in apposition with the spinal
column. Under these circumstances, it is not ob all uncommon to
hear bronchial breathing transmitted from the consolidated lobe
to a narrow zone close along the spinal column on the sound side.
Such a zone is often mistaken for consolidation (see Fig. 125).

The signs are usually less marked in the axilla and in the front
of the lung, but in a minority of cases, and especially when the
upper lobes are affected, the signs are wholly in the front. When
searching for evidences of consolidation in persons suspected to
have pneumonia, one should never omit to examine the apices and
very summit of the armpit, pressing the stethoscope up behind the
anterior fold of the axilla.

In examining the posterior lobes, when the patient is too weak
to sit up and is loath even to turn upon the side, the Bowles steth-

1 Crepitant rales are rarely heard in the pneumonias of infancy and old
age. They are not peculiar to pneumonia, but occur in pulmonary cedema or
hemorrhagic infarction conditions easily distinguished from pneumonia.

BROXCBFTIS, PXEUUOXIA, TUBERCULOSIS.

241

oscope is a great convenience, owing to the ease with which its flat-
tened extremity may be worked in between the patient and the bed-
clothes without causing any discomfort.

When resolution begins, the signs may suddenly and completely
disappear within a few hours. More frequently the bronchial
breathing is modified to broncho-vesicular, dulness and broncho-
phony become less marked, fine crackling rales (crepitans redux)
or coarser moist bubbles appear, and the lung gradually returns to
its normal condition within a period of three or four days. In the

' TjTnpanv.

Bronchial breathing

transmitted by

spinal column to

? .IL'i . -Z.

Solidification.

FIG. L5.-Diagram of Sign* in

active stages of the disease the entire absence of rales is very char-
acteristic. In about 19 per cent, of the cases the solidification of
the lung persists after the fall of the temperature ; indeed, it may
be weeks or even months before it clears up, and yet the lung may
be perfectly sound in the end. On the other hand, abscess or gan-
grene may develop in the solidified lobe, or the hitter may be trans-
formed into a mass of tough fibrous tissue, and the adjacent portion
of the chest may fall in (cirrhosis of the lung, chronic interstitial
pneumonia).

" Wondering pneumonia " is a term applied to eases in which
16

242 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

the consolidation disappears in one lobe only to reappear in another ;
or spreads gradually from lobe to lobe. The physical signs in such
cases do not differ essentially from those already described.

Summary.

In a typical case one finds (oftenest at the right base behind)

1. Dulness on percussion.

2. Increased tactile fremitus and voice sounds.

3. Tubular breathing and occasionally crepitant rales.

These signs occurring in connection with fever, cough, rusty
sputa, pain in the side, dyspnoea, and herpes, are sufficient for the
diagnosis.

But many cases some say the majority are not typical when
first seen. The following are the commonest anomalies :

() There may be tympany instead of dulness, especially in
children or when the solidification is at the left base.

(b~) The breathing may be feeble but vesicular in character, or
it may be absent, in case bronchi are plugged ; from the same cause

A hard cough may clear out the bronchi and produce a sudden
metamorphosis of the physical signs with a return to the normal
type.

In these atypical cases, we have to fall back upon the symp-
toms, the history, the blood, and sputa for help in the diagnosis.

Deep-seated pneumonic processes may appear at the surface in
out-of-the-way places, e.g., at the summit of the axilla, and the
area of demonstrable physical signs may be no larger than a silver
dollar. A thorough examination of every inch of the chest is
therefore essential in doubtful cases.

In the later stages of the disease crepitant or other fine rales
often appear, and the signs of solidification suddenly or gradually
disappear.

Dlfft'fi-nti<il I >!<!</ ll nttis.

Pneumonic solidification is to be distinguished from

(1) Pleuritic effusion.

(2) Tuberculosis of the lung.

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 243

(1) From pleuritic effusion, pneumonia is to be distinguished
in the great majority of cases by differences in the onset, course,
and general symptoms of the disease. In pneumonia the patient is
far more suddenly and violently attacked, the dyspnoea is much
greater, cough and pain are more distressing and more frequent,
the temperature is higher, and the sputum often characteristic. In
pleuritic effusion the dulness is usually more intense than in pneu-
monia. Tactile fremitus and voice sounds are increased in pneu-
monia (except when the bronchi are plugged) ; decreased or absent
in pleuritic effusion. Bronchial breathing may be heard in both
diseases, but is usually feeble and distant when occurring in pleu-
risy, and loud in pneumonia. If the affection be on the left side,
the diagnosis is much aided by the presence of dislocation of the
heart, which is produced by pleuritic effusion and never by pneu-
monia. In cases of pneumonia with occluded bronchi, one may
have every sign of pleuritic effusion flatness, absent breathing,
voice and fremitus and in such cases the absence of any disloca-
tion of the heart, provided the disease is upon the left side, is very
important. If a similar condition of things occurs upon the right
side, one may have to fall back upon the symptoms and upon such
evidence as the blood count, herpes, sputum, etc.

(2) Tuberculosis of the lung causing, as it may, a diffuse sol-
idification of the organ, may be indistinguishable from pneumonia
if we take account only of the physical signs, but the two diseases
can usually be distinguished without difficulty by the difference in
their symptoms and course, and by the presence or absence of tuber-
cle bacilli in the sputum.

ISTHALATIOX PXEUMOXIA. ASPIRATION PXEUMOXIA.

When food or other foreign substances are drawn into the air
passages, as may occur, for example, during recovery from ether
narcosis, a form of broncho-pneumonia may be set up, in which the
solidified patches are not infrequently large enough to be recognized
by the ordinary methods of physical examination.

The lesions are usually bilateral and accompanied by a general
bronchitis. Slight dulness and indistinct bronchial breathing can

244 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

usually be made out over an irregular area in the backs of both
lungs.

The signs are considerably less marked than in croupous pneu-
monia, and the boundaries of the irregular patches of disease do
not correspond to those of a lobe of the lung.

If not rapidly fatal, the disease may be complicated by pulmo-
nary gangrene or abscess and large quantities of fetid pus may be
spit up.

BKOXCHO-PXEUMOXIA.

(Catarrhal or Lobular Pneumonia.)

Multiple small areas of solidification scattered through both
lungs, interspersed with areas of collapse, and usually associated
with diffuse bronchitis, occur very frequently in children producing
severe dyspnoea, cyanosis, cough, and somnolence, and running a
very fatal course.

The solidified lobules may fuse so as to form considerable areas
of hepatized lung, or there may be no lesion larger than a pea.

This is the usual type of " lung fever " in infants, although or-
dinary lobar pneumonia is not rare in infancy and in childhood.

The widespread atelectasis of the lower lobes which is associated
with the disease in most cases owing to the plugging of the bronchi
with tenacious secretions, is probably as serious in its effects as the
pneumonic foci themselves.

The anterior and upper parts of the lungs often become dis-
tended with air (vicarious emphysema) and render the physical
signs very confusing and deceptive.

Physical Signs.

In the majority of cases there are no characteristic physical
signs, and the diagnosis has to be made largely from the symptoms
and course of the disease. The consolidated areas are usually too
small to give rise to any dulness on percussion, or to any change in
the breath sounds, voice sounds, or fremitus, so that auscultation
shows, as a rule, nothing more than patches of fine rales occurring
at the end of expiration. Localized tyinpanitic resonance is some-

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 245

times present over the diseased area, making the sounder portions
of the lungs seem dull by comparison. Occasionally, when many
lobules have fused into a single mass of larger area, the ordinary
signs of consolidation may be obtained, although they are apt to
disappear within twenty-four or forty-eight hours and appear in
another situation. As above said, the diagnosis is usually to be
made, if at all, from the combination of the physical siyns of a
localized bronchitis with the symptoms of pneumonia. "This pa-
tient," we say, "has only the signs of bronchitis, but he is too
sick. The cyanosis, dyspnoea, and fever are too marked. He is
sicker than simple bronchitis will account for."

Differential Diagnosis.

(ft) Acute pulmonary tuberculosis may be indistinguishable from
broncho-pneumonia by the physical signs alone. The diagnosis
must be made from the history and course of the disease or from
the presence of tubercle bacilli in the sputa.

(6) The extensive atelectasis of the lower lobes which may ac-
company broncho-pneumonia gives rise to dulness and absence of
respiratory and vocal sounds. Thus, the signs of pleuritic effusion
are simulated, and in children the possibility of einpyerna should
not be forgotten. As a rule, broncho-pneumonia gives rise to much
greater dyspnoea, and is associated with a more extensive bronchitis,
than usually coexist with pleural effusion. The atelectatic lobules
may be expanded by coughing or by the cutaneous stimulus of cold
water, and thus resonance and breath sounds may suddenly return.
With pleuritic effusions, of course, such a change is impossible.

TUBEKCULOSIS OF THE LUXGS.

(1) Incipient Tuberculosis.

In the earlier stages of the disease there may be absolutely no
recognizable physical signs, and the diagnosis may be established
only by the positive result of a tuberculin injection or by the com-
bination of debility ivith slight fever not otherwise to be accounted
for.

246 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

In some cases the earliest evidence of the disease is hcemoptysis. l
AVhen. a patient consults a physician on account of haemoptysis, it
is frequently impossible to find any physical signs of disease in the
lungs ; not until weeks or months later do the characteristic changes
recognizable by physical examination make their appearance.

The very early hoarseness of the voice in tuberculous patients is
of great importance and often attracts our attention to the lungs
when the patient has said nothing about them. Definite physical
signs in the lungs and tubercle bacilli in the sputa (artificially ob-

Rales.

FIG. 126. Diagram to Show Position of Earliest Signs in Tuberculosis.

tained through the use of potassic iodide, see below) may occasion-
ally be demonstrated before any cough has appeared. On the other
hand, the patient may cough for weeks before anything abnormal
can be discovered in the lungs. Occasionally tuberculosis begins
with an ordinarily bilateral bronchitis. I have found tubercle ba-
cilli in four such cases. More often the earliest physical signs
are:

(a) Fine crackling rales at the apex of one lung, heard only

1 Never percuss a patient within forty-eight hours after a hemorrhage, and
never encourage cough or forced respiration in such a one. There is danger
of starting a fresh hemorrhage.

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 247

with or after cough and at the end of inspiration. [More rarely
squeaks may be heard.] (See Fig. 126).

(If) A slight diminution in the excursion of the diaphragm on
the affected side, as shown by Litten's diaphragm shadow.

(c) Slight diminution in the intensity of the respiratory mur-
mur, with or without interrupted inspiration ("coy-wheel breath-
iny").

() In examining the apices of the lungs for evidence of early
tuberculosis one should secure if possible perfect quiet in the room,
and have the clothes entirely removed from the patient's chest.
The ordinary hard-rubber chest-piece is better than the chest-piece
of the Bowles instrument when we wish to search the apices for
fine rales. After listening during quiet breathing over the apices
above and below the clavicle in front, and above the spine of
the scapula behind, the patient should be directed to breathe out
and then, at the end of expiration, to cough. During the deep
inspiration which is likely to precede or to follow such a cough one
should listen as carefully as possible at the apex of the lung, above
and below the clavicle, concentrating attention especially upon the
last quarter of the inspiration, when rales are most apt to appear.
Sometimes only one or two crackles may be heard with each inspi-
ration, and not infrequently they will not be heard at all unless the
patient is made to cough, but even a single rale, if persistent, 1 is
important. In children who cannot cough at will, one can accom-
plish nearly the same result by making them count as long as pos-
sible with one breath and then listening, to the immediately suc-
ceeding inspiration. When listening over the apex of the lung,
one should never allow the patient to turn his head sharply in the
other direction, since such an attitude stretches the skin and mus-
cles on the side on which we are listening so as to produce annoy-
ing muscle sounds or skin rubs.

In cases in which one suspects that incipient tuberculosis is

1 Rales heard only during the first few breaths and not found to persist on
subsequent examinations, may be due to the expansion of atelectatic lobules
(see above, p. 105 .

248 PHYSICAL DIAGNOSIS OF DISEASES GF THE CHEST.

present and yet in which no positive evidence can be found, it is a
good plan to give iodide of potassium (gr. vii. three times a day) for
a few days. The effect of this drug is often to make rales more
distinct, and sometimes to increase expectoration so that tubercle
bacilli can be demonstrated when before none were to be obtained. '

(6) The diminution in the excursion of the diaphragm upon the
affected side in cases of incipient phthisis has been much insisted
upon by F. H. AVilliams and others who have interested themselves
in the radioscopy of the chest. Litteii's diaphragm shadow gives
us a method of observing the same phenomenon without the need
of a fluoroscope. Even very slight tuberculous changes in the lung
are sufficient to diminish its elasticity and so to restrict its excur-
sion and that of the diaphragm. Comparisons must always be
made with the sound side in such cases, as individuals differ very
much in the extent with which they are capable of depressing the
diaphragm. It must be remembered that pleuritic adhesions, due
to a previous inflammation of the pleura, may diminish or alto-
gether abolish the excursion of the diaphragm shadow, independ-
ently of any active disease in the lung itself.

Those who are expert in the use of the fluoroscope believe that
they can detect the presence of tuberculosis in the lung by radi-
oscopy at a period at which no other method of physical examina-
tion shows anything abnormal. I shall return to the consideration
of this point in the section on Radioscopy. 2

Interrupted or cog-wheel respiration, in which the inspiration
is made up of sharp, jerky puffs, signifies that the entrance of the
air into the alveoli is impeded, and such impediment is most likely
to be due to tuberculosis when present over a considerable period
in a localized area of pulmonary tissue.

1 Any irritating vapor for example, creosote vapor which produces vio-
lent cough and expectoration, may be used to expel bronchial secretions in
doubtful cases. Tubercle bacilli may then be found in the sputum of patients
who, without the irritating inhalation, have no cough and so no sputa.

See Appendix C.

BRONCHITIS, PNEUMONIA. TUBERCULOSIS.

249

(2) Moderately Advanced Cases

So far T have been speaking of the detection of tuberculosis at
a stage prior to the production of any considerable amount of solid-
ification. The signs considered have been those of bronchitis
localized at the apex of the lung, or of a slightly diminished pul-
monary elasticity, whether due to pleuritic adhesions or to other
causes. We have next to consider the signs in cases in which so-
lidification is present, though relatively slight in amount This
condition is comparatively easy to recognize when it occurs at the

Rales. -____

Complete

solidiliration.

Partial
-"" solidification.

, J Rales.

FIG. 127. Diagram of Sigrns in Phthisis.

left apex, but more difficult in case only the right apex is diseased
Partial solidification of a small area of lung tissue at the left apex
gives rise to

(a) Slight dulness on light percussion, 1 with increased resist-
ance.

(6) Slight increase in the intensity of the spoken and whispered
voice, and of the tactile fremitus (in many cases)

i Other causes of dulness, such as asymmetry of the chest, pleural thicken-
ing, and tumors, must be excluded. Emphysema of the lobules surrounding
the tuberculous patch may completely mask the dulness.

250 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST

(<) Some one of the numerous varieties of broncho-vesicular
breathing (true bronchial breathing is a late sign).

(d) Abnormally loud transmission of the heart sounds, espe-
cially under the clavicle.

(e) Cardio-respiratory murmurs (fide p. 139) are occasionally
(hie to the pressure of a tuberculous lobule upon the subclavian
artery. In connection with other signs they are not altogether
valueless in diagnosis

In case there is also a certain amount of secretion in the bron-
chi of the affected area or ulceration around them, one often hears
rales of a peculiar quality to which Skoda has given the name of
" consonatiny rales." Rales produced in or very near a solidified
area are apt to have a very sharp, crackling quality, their intensity
being increased by the same acoustical conditions which increase
the intensity of the voice sounds over the same area. AYhen such
rales are present at the apex of either lung, the diagnosis of tuber-
culosis is almost certain, but if, as not infrequently occurs, there
are no rales to be heard over the suspected area, our diagnosis is
clear only in case the signs occur at the left apex Precisely the
same signs, if present at the right apex, leave us in doubt regard-
ing the diagnosis, for the reason that, as has been explained above,
we find at the apex of the right lung in health signs almost exactly
identical with those of a slight degree of solidification. Hence, if
these signs, and only these, are discovered at the right apex, we
cannot feel sure about the diagnosis until it is confirmed by the
appearance of rales in the same area of the left side (whether under
the influence of iodide of potassium or spontaneously), or by the find-
ing of tubercle bacilli in the sputum. 1

A sign characteristic of early tuberculous changes in the lung and
one Avhich I have frequently observed in the lower and relatively
sounder lobes of tuberculous lungs is a raising of the pitch of inspi-
ration, without any other change in the quality of the breathing or
any other physical signs The importance of this sign in the cliag-

1 The natural disparity between the two apices is less marked in the supra-
spi nous fossa behind than over the clavicle in front, and hence pathological
dulness at the apex is more often demonstrable behind than in front.

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 251

nosis of early tuberculosis of the lungs was insisted upon by the
elder Flint in his work on "The Respiratory Organs" (I860), and
has more recently been mentioned by Norman Bridge.

It must never be forgotten that tuberculosis may take root in

FIG. 128. This Patient has Solidification at both Apices and Tubercle Bacilli in the Sputa. He

feels perfectly well.

the most finely formed chests and in persons apparently in blooming
health. The " phthisical chest " and the sallow, emaciated figure of
the classical descriptions apply only to very advanced cases. Fig.
128 represents a patient with moderately advanced signs of phthisis
and abundant tubercle bacilli in the sputa. He feels perfectly

252 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

well and is at work. On the other hand, a patient with very slight
signs may be utterly prostrated by the toxaemia of the disease.

(3) Advanced Phthisis.

Characteristic of the more advanced stages of tuberculosis in the
lungs is the existence of large areas of solidified and retracted lung,
and, to a lesser extent, the signs of cavity formation. The patients
are pale, emaciated, and feverish. The signs of solidification have
already been enumerated in speaking of pneumonia. They are :

1. Marked dulness, or even flatness, 1 with increased sense of re-
sistance.

2. Great increase of voice sounds or of tactile fremitus.

3. Tubular breathing, sometimes loud, sometimes feeble.

4. As a rule, coarse rales, due to breaking down of the caseous
tissue, are also to be heard over the solidified areas. Sometimes
these rales are produced within the pleuritic adhesions, which are
almost invariably present in such cases. If they disappear just
after profuse expectoration, one may infer that they are produced
within the lung.

Increase in the intensity of the spoken voice, of the whispered
voice, or of the tactile fremitus may be marked and yet no tubular
breathing be audible. Each of these signs may exist and be of im-
portance as signs of solidification without the others. As a rule,
it is true, they are associated and form a very characteristic group,
but there are many exceptions to this rule.

The tendency of the spinal column to transmit to the sound
lung sounds produced in an area of solidification immediately
adjacent to it on the other side, has been already alluded to in
the section on pneumonia, and what was then said holds good of tu-
berculous solidification. Owing to this it is easy to be misled into
diagnosing solidification at both apices when only one is affected.

Since solidification is usually accompanied by retraction in the
affected lung in very advanced cases, the chest falls in to a greater

1 Unless senile emphysema masks it. Fibroid phthisis (vide infra) may
show no dulness. Remember that gastric tympauy may be transmitted to the
left lung and mask duluess there.

i J J

BRONCHITIS, PNEUMONIA, TUBERCULOSIS.

253

or less extent over the affected area, and the respiratory excursion
is much diminished, as shown by ordinary inspection and by the
diminution or disappearance of the excursion of the diaphragm
shadow. The intensity of the tubular breathing depends on the
proximity of the solidified portions to the chest wall and to the
large bronchi, as well as on the presence or absence of pleuritic
thickening.

It is rare to find a whole lung solidified. The process, begin-
ning at the apex or just below, extends 1 down as far as the fourth

Bronchi:il breath-
ing. dUllH'SS.

Increased fremittis.

Increased voice
sounds.

Rales.

* Rales.

FIG. 139. To Illustrate Progress of Sipns in Pulmonary Tuberculosis.

rib in front, i.e., through the upper lobe, in a relatively short time,
but below that point its progress is comparatively slow and the
lower lobes may be but little affected up to the time of death. On
the relatively sound side the exaggerated (compensatory) resonance
may mask the dulness of a beginning solidification there, which
sooner or later is almost sure to occur. It is exceedingly rare for
the disease to extend far in one lung without involving the other.

About the time that the tuberculous process invades the previ-
ously sound lung it is apt to show itself at the apex of the lower lobe

254 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

of the lung first affected. Consonating rales appear posteriorly along
the line which the vertebral border of the scapula makes when the
arm is raised over the shoulder. These points are illustrated in
Fig. 129.

Car iff/ Formation.

Cavities of greater or lesser extent are formed in almost every
case of advanced phthisis, but very seldom do they attain such size
as to be recognizable during life. Indeed, the diagnosis of cavity
hi phthisis plays a much larger part in the text-books than it does
in the practice of medicine, since to be recognizable by physical
examination a cavity must not only be of considerable size but its
walls must be rigid and not subject to collapse, 1 it must communi-
cate directly with the bronchus and be situated near the surface of
the lung, and it must not be filled up with secretions. It can read-
ily be appreciated that it is but seldom that all these conditions are
present at once ; even then the diagnosis of cavity is a difficult one,
and I have often known skilled observers to be mistaken on this
point.

The signs upon which most reliance is usually placed are :

() Amphoric or cavernous breathing.

(7>) "Cracked-pot resonance " on percussion.

(</) Cavernous or Amphoric Il^Kpiration. AVhen present, this
type of breathing is almost pathognomonic of a cavity. It is also
to be heard in pneumothorax, but the latter disease can usually
be distinguished by the associated physical signs. Cavernous
breathing differs from bronchial or tubular breathing in that its
pitch is lower and its quality hollow. The pitch of expiration
is even lower than that of inspiration. Since a pulmonary cavity
is almost always surrounded by a layer of solidified lung tissue, we
usually hear around the area occupied by the cavity a ring of bron-
chial breathing with which we can compare the quality of the cav-
ernous sounds.

1 Yet not so rigid as to be uninfluenced by the entrance and exit cf air.

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 255

(6) Percussion sometimes enables us to demonstrate a circum-
scribed area of tympanitic resonance surrounded by marked dul-
ness. More often the " cracked-pot " resonance can be elicited by
percussing over the suspected area while the chest-piece of the
stethoscope is held close to the patient's open mouth.

Cracked-pot resonance is often absent over cavities ; rarely oc-
curs in any other condition (?.</., in percussing the chest of a
healthy, crying baby, and occasionally over solidified lung).

(e) The voice sounds sometimes have a peculiar hollow quality
(amphoric voice and whisper).

(d) Cough or the movements of respiration may bring out over
the suspected area splashing or gurgling sounds, or occasionally
a metallic tinkle. Flint has also observed a circumscribed bulging
of an interspace during cough. Bruce noted a high-pitched suck-
ing sound during the inspiration following a hard cough ("rubber-
ball sound ").

Very important in the diagnosis of cavity is the intermittence of
all above-mentioned signs, which are present only when the cavity
is comparatively empty, and disappear when it becomes wholly or
mostly filled with secretions. For this reason, the signs are very
apt to be absent in the early morning before the patient has expelled
the accumulated secretions by coughing.

Wintrich noticed that the note obtained when percussing over
a pulmonary cavity may change its pitch if the patient opens his
mouth. Gerhardt observed that the note obtained over a pulmo-
nary cavity changes if the patient shifts from an upright to a re-
cumbent position. Neither of these points, however, is of much
importance in diagnosis. The same is true of metamorphosing
breathing (see above, p. 98).

Tuberculous cavities differ from those produced by pulmonary
abscess or gangrene in that the latter are usually situated in the
lower two-thirds of the lung. Bronchiectasis, an exceedingly rare
condition, cannot be distinguished by physical signs alone from a
tuberculous cavity.

256 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Fibroid P/it/i As- As-.

This term applies to slow tuberculous processes with relatively
little ulceration and much fibrous thickening.

In a considerable number of cases the physical signs do not
differ materially from those of the ordinary ulcerating forms of
the disease, but occasionally when a slow chronic process at the
apex of the lung results in the falling-away of the parenchyma of
the lung so that we have left a cluster of bronchi matted together
by fibrous tissue, the percussion note may be noticeably tympani-
tic; similar tympany may be due to emphysema of the lobules
sin-rounding the diseased portion. In such cases rales are usu-
ally entirely absent ; otherwise, the signs do not differ from those
of ordinary phthisis, except that falling-in of the chest walls over
the retracted lung may be more marked. Occasionally the heart
may be drawn toward the affected lobes, e.g. , upward and to the
right in right-sided phthisis at the apex. In two cases of fibroid
disease at the left base, Flint found the heart beating near the
lower angle of the left scapula.

Phthisis n-tt/i Predominant Pleural Thickeninr/.

Tuberculosis in the lung is in certain cases overshadowed by the
manifestations .of the same disease in the pleura, so that the signs
are chiefly those of thickened pleura. To this subject I shall return
in the section of Diseases on the Pleura (see below, p. 271).

EinpJiysematoitx Form of PJithisis.

Tubercle bacilli are not very infrequently found in the sputa of
oases in which the history and physical signs point to chronic bron-
chitis with emphysema. I have seen two such cases within a year
Dulness is wholly masked by emphysema, tubular breathing is
absent, and piping and babbling rales are scattered throughout both
lungs. The emphysema may be of the senile or small-lunged type,
as in one of my recent cases (with autopsy), or it may be associ-
ated with huge downy lungs and the "barrel chest." Such cases

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 257

cannot be identified as phthisis during life unless we make it an
invariable rule to examine for tubercle bacilli the sputa of every
case in which sputa can be obtained, no matter what are the physi-
cal signs.

Phthisis with Anomalous Distribution of the Lesions.

Very rarely a tuberculous process may begin at the base of the
lung When the process seems to begin in this way, a healed focus
is often to be found at one apex surrounded by a shell of healthy
lung.

The summit of the axilla should always be carefully examined,
as tuberculous foci may be so situated as to produce signs only at
that point.

Another point often overlooked in physical examination is the
linf/ula pulmomdis or tongue-like projection from the anterior mar-
gin of the left lung overlapping the heart. Tuberculosis is some-
times found further advanced at this point than anywhere else.

As a rule cases in which signs like those of phthisis are found
at the base of the lung turn out to be either empyema, or abscess,
or unresolved pneumonia (cirrhosis of the lung).

Acute Pulmonary Tuberculosis.

No one of the three forms in which acute phthisis occurs, viz.,

(a) Acute tuberculous pneumonia,

(6) Acute tuberculous bronchitis and peribronchitis,

(c) Acute miliary tuberculosis, involving the lungs, can be rec-
ognized by physical examination of the chest. The first form is
almost invariably mistaken for ordinary croupous pneumonia, until
the examination of the sputa establishes the correct diagnosis. In
the other two forms of the disease, the physical signs are simpiy
those of general bronchitis.
17

CHAPTER XII.

EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC.

I. EMPHYSEMA.

FOR clinical purposes, the great majority of cases of emphy-
sema may be divided into two groups.

(1) La rye-lunged emphysema, usually associated with chronic
bronchitis and asthma.

(2) Small-lunged, or senile, emphysema.

Although the second of these forms is exceedingly common, it
is so much less likely than the first form to give rise to distressing
symptoms that it is chiefly the large-lunged emphysema which is
seen by the physician. In both conditions we have a dilatation
and finally a breaking down, of the alveolar walls until the air spaces
are become relatively large and inelastic. In both forms, the elas-
ticity of the lung is diminished ; but in the large-lunged form we
have an increase in the volume of the whole organ in addition to
the changes just mentioned.

Large-Lunged Emphysema.

The diagnosis can usually be made by inspection alone. In
typical cases the antero-posterior diameter of the chest is greatly
increased, the in-spaces are widened, and the costal angle is blunted,
while the angle of Liuhvig' becomes prominent. The shoulders are
high and stooping and the neck is short (see Fig. 130). The patient
is often considerably cyanosed, and his breathing rapid and difficult.
Inspiration is short and harsh ; expiration prolonged and difficult.
The ribs move but little, and, owing to the ossification of their car-

1 Formed by the junction of the mauubrium with the second piece of the
sternum.

EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 259

tilages, are apt to rise and fall as if made in one piece (en cul-
rasse). The working of the auxiliary muscles of respiration is not
infrequently seen. The diaphragm shadow (Litten's sign) begins
its excursion one or two ribs farther down than usual and moves a
much shorter distance than in normal cases.

I'lil/iatlon shows a diminution in the tactile fremitus, through-
out the affected portions; that is, usually throughout the whole of
both lungs. Sometimes it is
scarcely to be perceived at all.

Percussion yields very in-
teresting information. The
disease manifests itself

(a) By hyper-resonance on
percussion, with a shade of
tympanitic quality in the note.

(&) By the extension of the
margins of the lung so that
they encroach upon portions of
the chest not ordinarily reso-
nant.

The degree of hyper-reso-
nance depends not only upon
the degree of emphysema but
upon the thickness of the chest

walls. The note is most resonant and has most of the tympanitic
quality when the disease occurs in old persons with relatively thin
chest walls. The encroachment of the over-voluminous lungs upon
the liver and heart is demonstrated by the lowering of the line of
liver flatness from its ordinary position at the sixth rib to a point
one or two interspaces farther down or even to the costal margin,
while the area of cardiac dulness may be altogether obliterated,
the lungs completely closing over the surface of the heart. At the
apices of the lungs resonance may be obtained one or two centi-
metres higher than normally and the quality may be markedly tym-
panitic. In the axillae and in the back the pulmonary resonance
extends down one inch or more below its normal position.

FIG. 130. Barrel Chest due to Chronic Bron-
chitis and Emphysema.

260 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Auscultation shows in uncomplicated cases no very marked mod-
ification of the inspiratory murmur, which, however, may be short-
ened and enfeebled. The most striking change is a great prolonga-
tion and enfeeblement of expiration, with a lowering of its pitch
(see Fig. 131).

This type of breathing is like bronchial breathing in one re-
spect; namely, that in both of them expiration is made prolonged,
but emphysematous breathing is feeble and low-
pitched, while bronchial breathing is intense
and high-pitched. At the bases of the lungs
the respiration is especially feeble and may be
altogether replaced by crackling rales.

In " small-lunged emphysema " we have

precisely the same physical signs, except that
FIG. 131. Diagram to f, , , . , f ,

illustrate Empbyse- ^ ne boundaries of the lung are not extended,

ma to us Breathing expiration is less prolonged and less difficult.

with Musical Expira- , . . J . .

tory Rales. and inspiration is normal. It does not tend

to be complicated by bronchitis and asthma;
indeed the small-lunged emphysema rarely gives rise to any symp-
toms, and is discovered as a matter of routine physical examination.

Summary.

1. Hyper-resonance on percussion.

2. Feeble breathing with prolonged expiration.

3. Diminished fremitus and voice sounds.

4. Encroachment of the resonant lungs on the heart and liver
dulness (in the large-lunged form).

Differential Diagnosis.

(a) Emphysema may be confounded with pnenmotkora-r, since in
both conditions hyper-resonance and feeble breathing are present.
But emphysema is usually bilateral, encroaches upon but does not
displace neighboring organs, and is not often associated with hydro-
thorax. Emphysema, if extensive, is usually associated with
chronic bronchitis and so with squeaking or bubbling rales, while in

EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 261

pneuinothorax breathing is absent or distant amphoric without
rales.

(b) The signs of aneurism of the aorta pressing on the trachea
or on a primary bronchus are sometimes overlooked because the fore-
ground of the clinical picture is occupied by the signs of a coexist-
ing bronchitis with emphysema. The cough and wheezing which
the presence of the aneurism produces may then be accounted for
as part of the long-standing bronchitis, and the dulness and thrill
over the upper sternum to which the aneurism naturally gives rise
may be masked by extension of lung borders. But the evidence of
pressure on mediastinal nerves and vessels (aphonic, unequal pulses
or pupils, etc.), and the presence of a diastolic shock and tracheal
tug are usually demonstrable ; the danger is that we shall forget to
look for them.

(c) Uncompensated mitral stenosis may produce dyspnoea and
cyanosis and weak rapid heart action somewhat similar to that seen
in emphysema, and may not be associated with any cardiac mur-
mur, but the dyspnoea is not of the expiratory type, and the irregu-
larity of the heart, with evidence of dropsy and general venous
stasis, should make it evident that something more than simple em
physema is present.

(rf) The occurrence of an emphysematous form of phthisis I
have already mentioned in discussing the latter disease (see p. 256).

Emphysema with Bronchitis or Asthma.

In the great majority of cases, emphysema of the lungs is asso-
ciated with chronic bronchitis and very often with asthmatic parox-
ysms. Such, association is especially frequent in elderly men who
have had a winter cough for many years and in whom arterio-scle-
rosis is more or less well marked. In such cases the prolonged and
feeble expiration is usually accompanied by squeaking and groaning
sounds, or by moist rales of various sizes and in various parts of
the chest. When the asthmatic element predominates, dry rales
are more noticeable, and occur chiefly or wholly during expiration,
while inspiration is reduced to a short, quick gasp.

262 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Interstitial Emphysema .

In rare cases violent paroxysms of coughing may rupture the
walls of the alveoli so as to allow the passage of air into the inter-
stitial tissue of the lung, from whence it may work through and
manifest itself under the skin, giving rise to a peculiar crackling
sensation on palpation, and to a similar sound on auscultation.
More frequently the trouble arises in connection with a tracheot-
omy wound, the air penetrating under the skin and producing a
downy, crepitating swelling.

" Complementary Emphysema."

When extra work is thrown upon one lung by loss of the func-
tion of the other, as in pleuritic effusion a true hypertrophy of the
overworked sound lung may take place. The elasticity of the lung
is not diminished as in emphysema, but is greatly increased.
Hence the term complementary emphysema should be dropped and
the term complementary (or compensatory) hypertrophy substituted.

Like emphysema, this condition leads to hyper-resonance on per-
cussion and to encroachment of the pulmonary margins upon the
neighboring organs (as shown by a reduction hi the area of dulness
corresponding to them), but the respiratory murmur is exaggerated
and has none of the characteristics of einphysernatous breathing.

A word may here be added regarding the condition described
by West under the name of

Acute Pulmonary Tympanites.

In fevers and other acute debilitating conditions West has ob-
served that the lungs may become hyper-resonant and somewhat
tyrnpanitic on percussion, owing, he believes, to a loss of pulmo-
nary elasticity. The tympanitic note, often observable around the
solidified tissue in pneumonia, is to be accounted for, he believes,
in the same way. Like the shortening of the first heart sound,
acute pulmonary tympanites points to the weakening of muscle fibre
which toxaemia is so apt to produce. Apparently the muscle fibres
of the lung suffer like those of the heart.

EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 263

BKOXCHIAL ASTHMA.

(PRIMARY SPASM OF THE BRONCHI).

During a paroxysm of bronchial asthma our attention is at-
tracted even at a distance by the loud, wheezing, prolonged expira-
tion preceded by an abortive gasping inspiration. The breathing
is labored, much quickened in rate, and cyanosis is very marked.
The chest is distended and hyper-resonant, the position of the dia-
phragm low and its excursion much limited, and the cardiac and
hepatic dulness obliterated by the resonance of the distended lungs.
On auscultation, practically no respiratory murmur is to be heard
despite the violent plunging of the chest walls. We hear squeaks,
groans, muscular rumbles, and a variety of strange sounds, but
amid them, all practically nothing is to be heard of the breath
sounds. " The asthmatic storm flits about the chest, now here now
there," the rales appearing and disappearing.

At the extreme base of the lungs there may be dulness due to
atelectasis of the thin pulmonary margins.

Differential Diagnosis.

(a) Mechanical irritation of the bronchi, as by the pressure of
an aneurism or enlarged gland, may set up a spasm of the neigh-
boring bronchioles much resembling that of primary bronchial
asthma, but thorough examination should reveal other evidence
of mediastinal pressure, and the history of the case is very different
from that of asthma.

(b) Spasm of the glottis produces a noisy dyspnoea, but the diffi-
culty is with inspiration, instead of with expiration, and the crow-
ing or barking sound is not like the long wheeze of asthma. No
r^les are to be heard, and the signs in the lungs are those of col-
lapse instead of the distention characteristic of asthma.

(c) The paroxysmal attacks of dyspnrea, which often occur in
chronic nephritis, myocarditis, and other diseases of the heart and
kidney, may be entirely indistinguishable from primary bronchial
asthma but for the evidence of the underlying cardiac or renal dis-

264 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

ease. As a rule, however, the element of spasm is much less
marked ; the breathing is quick and labored but not wheezing, expi-
ration is less prolonged, and the squeaking and groaning rales of
asthma are not present.

SYPHILIS OF THE LUNG.

The diagnosis cannot be made with certainty from the physical
signs, and rests entirely (in the rare cases in which it is made at all)
on the history, the evidence of syphilis elsewhere in the body, and
the result of treatment. Most cases are mistaken for phthisis.

Any case supposed to be phthisis, but in which the examination
of the sputa for tubercle bacilli is repeatedly negative, should be
given a course of syphilitic treatment.

The physical signs, as in phthisis, are those of localized bron-
chitis or of solidification, but the lesions are not at the apex but
usually about the root of the lung or lower down. Cavities are not
formed. Stenosis of a bronchus may occur with resulting atelecta-
sis of the corresponding lobules.

BRONCHIECTASIS (BRONCHIAL DILATATION).

This rare disease is still more rarely to be recognized during
life. It is sxiggested by the history of raising within a few seconds
or minutes a very large amount of sputa, a pint or more in marked
cases. The physical signs may not be in any way distinctive, or
may be those of pulmonary cavity due to tuberculosis. From the
latter bronchiectasis is to be distinguished in some cases by a
knowledge of the previous history. Signs of cavity in phthisis are
preceded and surrounded by signs of solidification in the same area,
while in bronchiectasis this is not the case. Again, a bronchiecta-
tic cavity is apt to occur, not at the apex, as in phthisis, but in the
middle and lower thirds of the lung posteriorly. Aside from the
history and situation of the cavity and the presence or absence of
solidification around it, we cannot tell from physical signs whether
it be due to tuberculosis or to dilatation of a bronchus. In either
case we have the signs discussed on page 254 (cracked-pot reso-

EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 265

nance, amphoric breathing and voice sounds, coarse gurgling or
splashing sounds on cough) all these signs disappearing when the
cavity becomes filled with secretions.

The disease may cause marked retraction of the chest on the
affected side, and neighboring organs may be drawn out of place.

CIRRHOSIS OF THE LUXG.

(Chronic Interstitial Pneumonia.)

As an end stage of unresolved croupous pneumonia, or as a
result of chronic irritation from mineral or vegetable dust, a shrink-
age of a part or the whole of the lung may occur, which progresses
until the pulmonary tissue is transformed into a fibrous mass en-
closing bronchi.

The side of the chest corresponding to the affected lung becomes
shrunken and concave ; fremitus is increased, percussion resonance
diminished or lost, respiration tubular with coarse rales.

From tuberculosis the condition is to be distinguished solely by
the history, the absence of bacilli in the sputa, and the comparative
mildness of the constitutional symptoms.

The right ventricle of the heart may become hypertrophied and
later dilated with resulting tricuspid insufficiency.

CHAPTER XIII.

DISEASES AFFECTING THE PLEURAL CAVITY.

I. HYDROTHORAX.

IN cases of nephritis or of cardiac weakness due to valvular
heart disease a considerable accumulation of seruni may take place
in both pleural cavities. The physical signs are identical with
those of pleuritic effusion (see below, page 273) except that the
latter is almost always unilateral, while hydrothorax is usually bi-
lateral. Exceptions to this rule occur, however, especially on the
right side or in cases in which one pleural cavity has been obliter- 1
ated by fibrous adhesions, the results of an earlier pleurisy. The
fluid obtained by tapping in cases of hydrothorax is usually con-
siderably lower in specific gravity and poorer in albumin than that
exuded in pleuritic inflammation.

The fluid shifts more readily with change of position than is the
case with many pleuritic effusions, owing to the absence of adhe-
sions in hydrothorax.

Friction sounds, of course, do not occur, as the pleural surfaces
are not inflamed. A few grains of potassium iodide by mouth soon
produce a reaction for iodine in the fluid of hydrothorax and not in
pleuritic effusion.

II PXEUMOTHORAX.

Pneumothorax, or the presence of air in the pleural cavity, may
result from stabs or wounds of the chest wall, but is usually a com-
plication of pulmonary tuberculosis which weakens the lung until
by a slight cough or even by the movements of ordinary respiration
the pulmonary pleura is ruptured and air from within the lung leaks
into the pleural cavity.

If the opening is of considerable size, and the air is not hindered

DISEASES AFFECTING THE PLEURAL CAVITY. 267

or encapsulated by adhesions, great and sudden dyspnoea with pain
and profound "shock " may result. More commonly the air enters
the pleural cavity gradually, the other lung has time to hyper-
trophy, and the heart and other organs become gradually accus-
tomed to their new situations.

Physical Signs.

1 . Inspection. The affected side may lag behind considerably in
the movements of respiration. In very marked cases it is almost
motionless and the interspaces are more or less obliterated. The
diaphragm is much depressed and Litten's sign absent. In right-
sided pneumothorax, which is relatively rare, the liver is depressed
and the edge can be felt below the ribs.

The heart is displaced as by pleuritic effusion, but usually to a
less extent. With left-sided pneumothorax the cardiac impulse
may be lowered as well as displaced, owing to the descent of the
diaphragm.

2. Palpation. Fremitus is absent over the lower portions of the
chest corresponding to the effused air. At the summit of the chest
over the retracted lung, fremitus may be normal or increased. In
rare cases when the lung is adherent to the chest wall and cannot
retract, freniitus is preserved.

The positions of the heart and liver are among the most impor-
tant points determined by palpation. Xot infrequently no cardiac
impulse is to be obtained. Sometimes it may be felt to the right
of the sternum (see Fig. 132) or in the left axilla, but not infre-
quently it is so fixed by pleuropericardial adhesions that it is drawn
upward toward the retracted lung or remains near its normal situa-
tion. The liver is greatly depressed in cases of right-sided pneumo-
thorax, and may be felt as low as the navel.

3. Percussion. Loud tynipanitic resonance is the rule through-
out the affected side. Even a small amount of air is sufficient to ren-
der the whole side tympanitic and often to obscure the dulness which
the frequently associated pleural effusion would naturally produce.
Indeed, it is the rule that small effusions are wholly masked by the
adjacent tympany.

268 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

In no other disease do we get such clear, intense tympanitic
resonance over the chest.

The only exception to this rule occurs in cases in which the air
within the chest is under great tension, making the chest walls so
taut that, like an over-stretched drum, they cannot vibrate properly.
Under these conditions the percussion note becomes muffled, at
times almost dull.

Areas of dulness corresponding to the displaced organs (heart
or liver) may sometimes be percussed out.

4. Auscultation. Respiration and voice sounds are usually in-
audible in the lower portions of the chest. At the top of the chest,
and rarely in the lower parts, a faint amphoric or metallic breathing
may be heard, but as a rule the amphoric quality is brought out
much better by cough which is followed by a ringing after-echo.
Or the air in the pleura may be set to vibrating and made to give
forth its characteristic, hollow, ringing sound if a piece of metal
(e.g., a coin) be placed on the back of the chest and struck with
another coin, while we listen with the stethoscope over the front of
the chest opposite the point where the coin is.

The clear ringing sound heard in this way is quite different
from the dull chink obtainable over sound lung tissue.

The "falling-drop sound" or "metallic tinkle," and the lung
fistula sound are occasionally audible (see above, p. 112).

On the sound side the breath sounds are exaggerated. At the
top of the affected side over the collapsed lung the breathing is
bronchial and rales are occasionally heard.

In the great majority of cases pneumothorax is complicated by
an effusion of fluid in the affected pleural cavity and we have then
the signs of

III. PNEUMOHYDROTHORAX OR PNEUMOPYOTHORAX.

When both fluid and air are contained in the pleural cavity, the
patient may himself be able to hear the splashing sounds which
the movements of his own body produce. These are more readily
appreciated if the observer puts his ear against the patient's chest
and then shakes him briskly. Splashing sounds heard within the

DISEASES AFFECTING THE PLEURAL CAVITY. 269

chest are absolutely pathognomonic and point only to the combina-
tion of fluid and air within the pleural cavity. One must distin-
guish them, however, from similar sounds produced in the stomach.
By observing the position of maximum intensity of the sounds, this
distinction may be easily made. Unfortunately the critical condi-
tion of the patient may make it impossible to try succussion, as in
the acute cases with great shock it is dangerous to move him at all.
The movements of breathing or coughing may bring out a " metal-
lic tinkle " (see above, p. 112). At the base of the chest, over an

Tuberculous so-
lidiflcation.

Exaggerated
resonance and
breathing.

f Tympany ;
i absent voice ;
- Air= < breathing ab-

Displacedcardiac "A ^~^X /\^X^i) A sent or distant

impulse. \^y^y\f^S^/Jr lamphonc,

Dulness, shifting
with change of po-
sition = (fluid).

FIG. 132. Pneumohydrothorax with Displaced Heart.

area corresponding to the position of the fluid, an area of dulness
may be easily marked out by percussion, and this area shifts very
markedly with change of position. The shifting dulness of pneu-
mohydrothorax is strongly in contrast with the difficulty of obtain-
ing any such shift in ordinary pleuritic effusion (see Fig 132)

(The distinction between "open pneumothorax," in which the
rent in the lung through which the air escaped in the pleura re-
mains open, and "dosed pneumothorax," in which the rent has
become obliterated is one which cannot be established by physi-
cal signs alone. It is often said that amphoric breathing, and espe-
cially an amphoric ring to the voice and cough sounds, denote an

270 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

open pneumothorax, but post-mortem evidence does not bear this
out. Practically an open pneumothorax is one in which the
amount of effused air increases, and closed pneumothorax is one in
which the physical signs remain stationary )

Differential Diagnosis.

The distinction between pneumothorax and emphysema has al-
ready been discussed (see p. 260).

(a) When the air in the pleural sac is under such tension that
the percussion note is dull, the physical signs may simulate pleu-
ritic effusion, but real flatness, such as characterizes effusion, has
not, so far as I know, been recorded in pneumothorax, and the
sense of resistance on percussing is much greater over fluid than
over air. In case of doubt puncture is decisive.

(b) Acute pneumothorax, coming on as it does with symptoms
of collapse and great shock, may be mistaken for angina pectoris,
cardiac failure, embolism of the pulmonary artery, or acute pulmo-
nary tympanites (see above, p. 202).

From all these it can be distinguished by the presence of am-
phoric or metallic sounds, which are never to be obtained in the
other affections named.

(e) Hernia of the intestine through the diaphragm, or great
weakening of the diaphragmatic muscular fibres, may allow the
intestines to encroach upon the thoracic cavity and simulate pneumo-
thorax very closely. The history and course of the case, the ab-
dominal pain, vomiting, and indicanuria, generally suffice to distin-
guish the condition. The peristalsis of the intestine may go on even
in the thorax, and gurgling metallic sounds corresponding to it and
unlike anything produced in the thorax itself may be audible

The distinction between open and closed pneumothorax, to which
I have already alluded, is far less important than the presence or
absence of

(a) Pulmonary tuberculosis

(b) Encapsulating adhesions in which the air is confined to a
circumscribed area

(a) The examination of the sputa and of the compressed lung

DISEASES AFFECTING THE PLEURAL CAVITY. 271

may yield evidence regarding tuberculosis. On the sound side the
compensatory hypertrophy covers up foci of dulness or rales so that
it is difficult to make out much.

(6) Encapsulated pneumothorax gives us practically all the signs
of a phthisical cavity, from which it is distinguished by the fact
that with a cavity the nutrition of the patient is almost always
much worse.

Encapsulated pneumothorax needs no treatment. Hence .the
importance of distinguishing it from the non-encapsulated form of
the disease, in which treatment is essential.

PLEUE1SY.

Clinically, we deal with three types :

(a) Dry or plastic pleurisy.

(b) Pleuritic effusion, serous or purulent.

(a) DRY OR PLASTIC PLEURISY.

Doubtless many cases run their course without being recognized.
The frequency with which pleuritic adhesions are found post mor-
tem would seem to indicate this.

It is usually the characteristic stitch in the side which suggests
physical examination. The pain and the physical signs resulting
from the nbrinous exudation are usually situated at the bottom of
the axilla where the diaphragmatic and costal layers of the pleura
are in close apposition. Doubtless the pleuritic inflammation is
not by any means limited to this spot, but it is here that the two
layers of the pleura make the largest excursion while in apposition
with each other. In the vast majority of cases, then, the physical
signs are situated at the spot indicated in Fig. 133.

Occasionally pleuritic friction is to be heard in the precordial
region, and after the absorption of a pleuritic effusion evidences
of nbrinous exudation in the upper parts of the chest are sometimes
demonstrable. Most rarely of all, evidence of plastic pleurisy may
be found at the apex of the lung in connection with early phthisis.
In diaphragmatic pleurisy, when the nbrinous exudation is espe-

272 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

cially marked upon the diaphragmatic pleura, friction sounds may
be heard over the region of the attachment of the diaphragm in
front and behind as well as in the axillae. Hiccup often occurs and
gives exquisite pain.

Our diagnosis is based upon a single physical sign, pleuritic
friction. The nature of this sound and the
manoeuvres for eliciting it have already
been described (see above, p. 108), and I
will here only recapitulate what was there
said. During the first few deep breaths
one hears, while listening over the painful
area, a grating or rubbing sound usually
somewhat jerky and interrupted, most
marked at the latter part of inspiration,
but often audible throughout the whole
respiratory act. After a few breaths it
often disappears, but will usually reap-
pear if the patient lies for a short time
upon the affected side, and then sits iip
and breathes deeply. In marked cases
the rubbing of the inflamed pleural sur-
faces may be felt as well as heard, and it
is not very rare for the patient to be able
to feel and hear it himself. Pleuritic fric-
tion may be present and loud Avithout
giving rise to any pain. On the other
hand, the pain may be intense, and yet
the friction-rub barely audible. When
heard at the summit of the chest, as in
cases of incipient phthisis, pleural fric-
tion produces only a faint grazing sound, much more delicate and
elusive than the sounds produced at the base of the chest.

Occasionally the distinctive rubbing or grating sounds are more
or less commingled with or replaced by crackling sounds indistin-
guishable from the drier varieties of rales. It is now, I think,
generally believed that such sounds may originate in the pleura as

FIG. 133. Showing the Point at
which Pleural Friction is most
Often Heard.

DISEASES AFFECTING THE PLEURAL CAVITY. 273

well as within the lung. The greatest care should be taken to
prevent any shifting or slipping of the stethoscope upon the surface
of the chest, as by such means sounds exactly like those of pleura!
friction may be transmitted to the ear. In case of doubt one
should always wet or grease the skin so that the stethoscope can-
not slip.

Mi i. tele sounds are sometimes taken for pleura! friction, but they
are bilateral, usually low-pitched, sound less superficial than pleu-
ral friction, and are not increased by pressure. When listening
for friction at the base of the left axilla, I have once or twice been
puzzled by some low-pitched rumbling sounds occurring at the end
of inspiration, and due (as afterward appeared) to gas in the stom-
ach which shifted its position with each descent of the diaphragm.

In children friction sounds and pleuritic pain are much less
common than in adults, and the signs first recognizable are those
of effusion. In adults the presence of a very thick layer of fat
may make it difficult or impossible to feel or hear pleura! friction.

The breath sounds over the affected area are usually absent or
greatly diminished, owing to the restraint in the respiratory move-
ments due to pain. Not infrequently pleuritic friction may be
heard altogether below the level of the lung.

(b) PLEURITIC EFFUSION.

Many cases are latent, and the patients consult the physician on
account of slight cough, weakness, or gastric trouble, so that the
effusion is first discovered in the course of routine physical ex-
amination. Since it is usually the results of percussion which first
put us on the right track, I shall take up first

Percussion.

1. A small effusion first shows as an area of dulness

(a) Just below the angle of the scapula.

(&) In the left axilla between the fifth and the eighth rib.

(d) In the right front near the angle made by the cardiac and
hepatic lines of dulness (see Fig. 134).

274 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

In the routine percussion of the chest, therefore, one should
never leave out these areas. A small effusion is most easily de-
tected in children or in adults with thin chest walls, provided our
percussion is not too heavy. An effusion amounting to a pint
should always be recognizable, and smaller amounts have frequently
been diagnosed and proved by puncture.

The amount of a pleuritic effusion is roughly proportional to
the area of dulness on percussion, but not accurately. It is very
common to find on puncture an amount of fluid much greater than

Area of dulness
due to small
pleural effusion.

Area of cardiac
dulness.

FIG. 134. Small Pleural Effusion Accumulating (in part) near the Right Border of the Heart.

could have been suspected from the percussion outlines ; on the other
hand, the dulness may be extensive and intense on account of great
inflammatory thickening of the costal pleura, by the accumulation
of layer after layer of fibrinous exudate and its organization into
fibrous plates, while very little fluid remains within.

The amount of dulness depends also upon the thickness and elasti-
city of the chest wall and the degree of collapse of the lung within.

2. Large Effusions. When the amount of fluid is large, the dul-
ness may extend throughout the whole of one side of the chest with
the exception of a small area above the clavicle or over the primary
bronchus in front. This area gives a high-pitched tynytanitie note,

DISEASES AFFECTING THE PLEURAL CAVITY. 275

provided the bronchi remain open, as they almost always do. This
tympany is high-pitched and sometimes astonishingly clear. I re-
cently saw a case in which the note above the clavicle was almost
indistinguishable with the eyes shut from that obtained in the epi-
gastrium. Occasionally " cracked-pot " resonance may be obtained
in the tynipanitic area.

The pitch changes if the patient opens and closes his mouth
while we percuss ("Williams' tracheal tone").

The dulness over the lower portions of a large effusion is usual-
ly very marked, and the percussing finger feels a greatly increased

Normal resonance '
and vesicular
breathing.

Tympany, voice and
f r em 1 1 us i n -

creased.

Flatness, no breath-
ing, voice sounds,
or fremitus.

Zone of condensed
lung above the
fluid.

. Exaggerated (com-
pensatory) breath-
ing and reso-
nance.

FIG. 135. Diagram to Illustrate Physical Signs in Moderate-Sized Effusion in the Left Pleura.

resistance to its blows when compared with the elastic rebound of
the sound side.

3. Moderate Effusions. Three zones of resonance can often be
mapped out in the back: at the base dulness or flatness, above
that a zone of mingled dulness and tympany, and at the top normal
resonance. The lowest zone corresponds to the fluid, the middle
zone to the condensed lung immediately above it, and the top zone
to the relatively unaffected part of the lung (see Fig. 135). Not
infrequently there is no middle zone but simply dulness below and
resonance above, as is usually the case in the axilla and front

276 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

The position of the effusion depends only in part upon the in-
fluence of gravity, and is greatly influenced by capillarity and the
degree of retraction of the lungs, Consequently the surface of
the fluid is hardly ever horizontal except in very large accumula-
tions. With the patient in an upright position it usually reaches
a higher level in the axilla than in the back. Xear the spine and
near the sternum (in right-sided effusions) the line corrresponding
to the level of the fluid may rise sharply.

The S-curve of Ellis, as worked out so elaborately by Garland,
varies still further the uneven line which corresponds to the sur-

Trianfrular space
dull until patient
has coughed and
breathed deeply.

Area of dul ness
hounded above by
the S-curve of
Ellis.

FIG. 136.-The S-Curve of Ellis.

face of the fluid (see Fig. 136). This curve can be obtained only
after the patient has, by cough and forced breathing, expanded the
lung as fully as possible.

All these curves are to be found with the patient in the upright
position. None of them has any considerable diagnostic impor-
tance, and the chief point to be remembered is that the upper sur-
face of the fluid, not being settled by gravity alone, is hardly ever
horizontal.

With change in the position of the patient the level of the fluid
sometimes changes very slowly and irregularly, and sometimes does

DISEASES AFFECTING THE PLEURAL CAVITY. 277

not change at all. If, for purposes of thorough examination, we
raise to a sitting posture a patient who has been for some days or
weeks in bed, we should never begin the examination at once, since
it may take some minutes for the lungs and the fluid to accommo-
date themselves to the new position. It is well also to get the
patient to cough and to take a number of full breaths before the
examination is begun.

To test the mobility of the fluid with change of the patient's
position, mark out the upper limit of the dulness in the back with
the patient in the upright position. Then let the patient lie face
downward upon a couch, and, after waiting a few minutes, percuss
the previously dull area. It may be found to. have become resonant. '

When the fluid is absorbed or removed by tapping, one would
expect an immediate return of the percussion resonance. But in
fact the resonance returns very slowly and is wholly unreliable as
a test of the amount of absorption which has occurred. Thickened
pleura and atelectatic lung may abolish resonance long after the
fluid is all gone. AYe depend here far more upon the evidence ob-
tained by auscultation and palpation and on the general condition
of the patient.

To determine the returning elasticity of the lung and the degree
of movability of its lower border, percussion is very useful during
the stage of absorption. After percussing out the lower border of
pulmonary resonance in the back, the patient is directed to take a
long breath and hold it. If the lung expands, the area of percus-
sion resonance will increase downward.

Percussion aids us in determining whether neighboring organs
are displaced by the pressure of the accumulated fluid. The liver
is often pushed down, the spleen very rarely. Dislocation of the
heart is one of the most important of all the signs of pleural effu-
sion, and is often the crucial point in differential diagnosis. It is

1 This test, however, is somewhat fallacious and of very little diagnostic
value, since the lungs tend to swing up toward the back when the patient lies
prone, even when no fluid is present, and increase of resonance in the back with
this change of position might, therefore, occur when the dulness was due to
thickened pleura and not to fluid.

278 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

a very striking and at first surprising fact that a left-sided effusion
displaces the heart far more than a right-sided effusion of the same
size. Small or moderate right-sided effusions often do not displace
the heart at all.

With left-sided effusions, unless very small, we find the area of
cardiac dulness shifted toward the right and often projecting be-
yond the right edge of the sternum (see Fig. 134). (Inspection and
palpation often give us even more valuable information on this
point. See below, p. 281.). We must be careful to distinguish such
an area of dulness at the right sternal margin from that which may
be produced in right-sided effusions by the fluid itself (see above).

As mentioned above, a right pleural effusion may very early
show itself as an area of dulness along the right sternal margin.
Light percussion will usually demonstrate that this dulness is con-
tinuous with a narrow strip of flatness at the base of the axilla
(ninth and tenth ribs). Such an effusion is late in creeping up the
axilla. It appears first and disappears first along the right margin
of the sternum.

On the sound side the percussion resonance is often increased,
owing to compensatory hypertrophy of the sound lung ; the dia-
phragm, is pushed down and the borders of the heart or of the liver
may be encroached upon. When the hyper-resonance of the sound
side is present, it should warn us to percuss lightly over the effu-
sion, else we may bring out the resonance of the distended lung.

Summary of Percussion Signs. (1) Flatness corresponding
roughly to the position of the fluid.

(2) Tympany above the level of the fluid over the condensed
lung.

(3) The level of the fluid is seldom quite horizontal.

(4) Shifting of the fluid with change of position is rare, slow,
and has little or no importance in diagnosis.

Exceptions and Possible Errors. (a) Great muscular pain and
spasm may produce an area of dulness which simulates that of
pleural effusions, especially as the auscultatory signs may be equally
misleading. A hypodermic of morphine will dispel the dulness
along with the pain if it is due to muscular cramp.

DISEASES AFFECTING THE PLEURAL CAVITY. 279

(b) If the lung on the affected side fails to retract (owing to
emphysema or adhesions to the chest wall), the area of dulness and
its intensity will be much diminished.

(c) It must be remembered that dulness in Traube's space may
be due to solidification of the lung, to tumors, or to overfilling
of the stomach and intestine with food, as well as to pleura! effu-
sion ; also that the size of the tympanitic space varies greatly in
health.

(rf) Rarely percussion may be tyinpanitic over an effusion at
the left base owing to distention of the stomach or colon.

(e) The diagnosis between fluid and thickened pleura will be
considered later.

Auscultation.

The auscultatory phenomena vary greatly in different cases, and
in the same case at different times, because the essential condi-
tions are subject to similar variations. Whatever sounds are pro-
duced in the lungs or in the bronchi may be heard over the fluid un-
less interfered with by inflammatory thickening of the costal pleura.
Fluid transmits sounds well, but there may be no breath sounds pro-
duced and hence none audible over the fluid. Or tubular sounds
only may be produced because only the bronchi remain open, the
rest of the lung being collapsed.

Or again, if rales or friction sounds are produced in the lung,
they, too, may be transmitted to the fluid and may (alas!) deter
the timid " observer " from tapping.

In about two-thirds of all large effusions no breathing at all is
audible over the area of flatness on percussion. In the remaining
third, and especially in children, tubular breathing, sometimes
feeble, sometimes very intense, is to be heard.

In moderate effusions there are often three zones in the back
At the bottom we hear nothing, in the middle zone distant bron-
chial or broncho-vesicular breathing, while at the summit of the
chest the breathing is normal.

The roice sounds correspond When breath sounds are absent,
the voice sounds are likewise absent When the breathing is tubu-

280 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

lar, the voice, and especially the whisper, is also tubular and inten-
sified. That is, whenever the bronchi are open, the hi'ig retracti'd.
and the chest walls thin, the breatliiiii/. roice, and whlsjwr will eorre~
spond to the tracheal and bronchial sounds. Since children have es-
pecially thin chest walls, these bronchial sounds are especially fre-
quent and intense in children. 1

Xear the angle of the scapula and in a corresponding position
in front, the sound of the spoken voice may have a peculiar high-
pitched, nasal twang, to which the term egophony is applied.
This sign has no importance in diagnosis, since it is not constant,
and not peculiar to fluid accumulations

Rales are rarely produced in the retracted lung, and so are
rarely to be heard over the fluid.

All these sounds may be diminished or abolished if the costal
pleura is greatly thickened

The influence of cough upon the lung, and so upon the sounds
produced in it and transmitted through the fluid, may be very great
and very puzzling Rales may appear or disappear, breathing
change in quality or intensity, and in the differential diagnosis of
difficult cases the patient should always be made to cough and then
breathe deeply before the examination is completed.

In very large effusions, when only the primary bronchi are
open, there may be signs like those of pulmonary cavity at the site
of the bronchi in front or behind (amphoric breathing, large metallic
rales, etc.). Over the sound lung the breathing is exaggerated and
extends unusually far down in the back and axilla, owing to hyper-
trophy of the lung.

The heart sounds may be absent at the apex owing to disloca-
tion of the heart. In left-sided effusions the apex sounds are often
loudest near the ensiform cartilage or beyond the right margin of
the sternum. Right-sided effusions have much less effect upon the
heart, but occasionally we find the heart sounds loudest at the left
of the nipple or in the axilla.

Since many cases of pleural effusion are due to tuberculosis, we

'Bacelh's theory that the whispered voice is conducted through serum
but not through pus is not borne out by facts.

DISEASES AFFECTING THE PLEURAL CAVITY. 281

should never omit to search for evidences of this disease at the
apex of the lung on the sound side, since experience has shown that
phthisis is more apt to begin here than on the side of the effusion.

Summary of Auscultatonj Sljns.

(1) In most cases voice and breath sounds are absent or very
feeble over the area occupied by the fluid.

(2) In a minority of the cases the breathing and voice sounds
may be tubular and intensified, especially in children.

(3) Over the condensed lung at the summit of the chest the
breathing is bronchial or broncho-vesicular, according to the degree
of condensation. If the amount of fluid is small, the layer of con-
densed lung occupies the middle zone of the chest and the breath-
ing is normal at the top of the chest.

(4) Rales and friction sounds are rarely heard over fluid.

(5) On the sound side the breathing is exaggerated.

((5) The heart sounds may be absent at the apex and present in
the left axilla or to the right of the sternum owing to dislocation
of the heart.

Inspection and Palpation.

The most important information given us by inspection and
palpation relates to the displacement of various organs by the pres-
sure of the accumulated fluid. In left-sided pleuritic effusions the
heart is usually displaced considerably toward the right, even when
the level of the fluid reaches no higher than the sixth rib in the
nipple line. The apex impulse is to be seen and felt to the right
of the sternum, somewhere between the third and the seventh rib,
when a large amount of fluid is present. With smaller effusions
one may find the apex beat lifting the sternum or close to its left
border. The position of the heart may be confirmed by percussion.

The spleen is scarcely ever displaced.

Eight-sided effusions are far less likely to displace the heart, and
it is only when a large amount of fluid is present that the apex of
the heart is pushed outward beyond the nipple. Moderate right-
sided effusions often produce no dislocation of the heart whatever.
The liver is often considerably pushed down by a right-sided pleu-

282 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

ritic effusion, and its edge may be palpable several inches below the
costal margin. Its upper margin cannot be determined by percus-
sion, as it merges into the flatness produced by the fluid accumula-
tion above it.

Tactile fi-emitus is almost invariably absent or greatly dimin-
ished over the areas corresponding to the fluid; just above the level
of the fluid it is often increased.

Occasionally a slight fulness of the affected side may be recog-
nized by inspection, and the interspaces may be less readily visible
than upon the sound side. Bulging of the interspaces I have never
observed. When the accumulation of fluid is large the respiratory
movements upon the affected side are somewhat diminished,' the
shoulder is raised, and the spine curved toward the affected side.
The diaphragm is depressed, and Litten's sign therefore absent.

There are no reliable means for distinguishing purulent -from
serous effusions. The whispered voice may be transmitted through
either pus or serum. But we know that in children two-thirds of
all effusions are purulent, while in adults three-fourths of them are
serous.

Physical Signs During Absorption of Pleural Effusions.

When the fluid begins to disappear, either spontaneously or as
a result of treatment, the dulness very gradually disappears and
the breath sounds, voice sounds, and fremitus reappear. In case
the heart has been dislocated, its return to its normal position is
often much slower than one would anticipate, and indeed all the
physical signs are disappointingly slow to clear up even after tap-
ping. Pleural friction appears when the roughened pleural surfaces,
which have been held apart by the fluid, are allowed by the disap-
pearance of the latter to come into apposition again. Owing to pul-
monary atelectasis and permanent thickening of the pleura, con-
siderable dulness often remains for weeks after the fluid has been
absorbed.

1 1 have purposely made but little of the changes in the shape of the chest
produced by pleuritic effusions, as it has seemed to me that by far too much
stress has usually been laid upon such signs.

DISEASES AFFECTING THE PLEURAL CAVITY. 283

In persons who have previously suffered from pleurisy with
effusion, and in many who have never to their knowledge had any
such trouble, a considerable thickening of the pleura! membrane
with adhesion of the costal and visceral layers may be manifested
by the following signs :

(1) Duluess on percussion, sometimes slight, sometimes marked.

(2) Diminished vesicular respiration.

(3) Diminished voice sounds and tactile freinitus.

(4) Absence of Litten's phenomenon and diminution in the
normal respiratory excursion of the chest.

These signs are most apt to be found at the base of the lung
behind and in the axilla. Occasionally a similar thickening may
be demonstrated throughout the whole extent of the pleura, and the
lung failing to expand, the chest may fall in as a result of atmos-
pheric pressure (see Fig. 20).

The ribs approximate and may overlap, the spine becomes
curved, the shoulder lowered, the scapula prominent, and the whole
side shrunken . The heart may be drawn over toward the affected
side.

In the diagnosis of pleural thickening Rosenbach's "palpatory
puncture " is sometimes our only resource. Under antiseptic pre-
cautions a hollow needle is pushed between the ribs and into the
pleural cavity. As the needle forces its way through the tough
fibrous, or perhaps calcified, pleura, the degree and kind of resist-
ance are very enlightening. Again, the amount of mobility of the
point after the chest wall has been pierced tells us whether the
needle is free in a cavity, entangled in a nest of adhesions, or fixed
in a solid " carnified " lung. There is no danger if the needle is
sterile.

EXCAPSTLATED PLEURAL EFFrSIOX.

Small accumulations of serum or pus may be walled off by ad-
hesions so that the fluid does not gravitate to the lowest part of
the pleural cavity or spread itself laterally as it would if free.

284 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Such localized effusions are most apt to be found in the lower axil-
lary regions or behind sometimes between the base of the lung and
the diaphragm, and more rarely between the lobes of one of the
lungs or higher up. I have twice seen an encapsulated purulent
effusion so close to the left margin of the heart that the diagnosis
of pericardial effusion was made.

The diagnosis of encapsulated pleural effusion is a difficult one
and oftentimes cannot be made except by puncture. The signs are
those of fluid in the pleura, but anomalously placed. Even punc-
ture may fail to clear up the difficulty, since the needle may pass
entirely through the pouch of fluid and into some structure behind
so that no fluid is obtained.

PULSATING PLEURISY (EMPYEMA XECESSITATIS).

Under conditions not altogether understood the movements
transmitted by the heart to a pleural effusion (usually purulent)
may be visible externally as a circumscribed pulsating swelling near
the precordial region, or as a diffuse undulation of a considerable
portion of the chest wall. Sometimes this pulsation is visible be-
cause the fluid has worked its way out through the thoracic wall
and is covered only by the skin and subcutaneous tissues, but occa-
sionally pulsation in a pleural effusion becomes visible, although no
such perforation of the chest Avail has occurred.

The condition is a rare one, and is of importance only because it
may be mistaken for an aneurism, from which, however, it should
be readily distinguished by the absence of a palpable thrill or dias-
tolic shock and by the evidence of fluid in the pleura.

DIFFERENTIAL DIAGNOSIS OF PLEURITIC EFFUSION.

The following conditions are not infrequently mistaken for
pleuritic effusion :

(1) Croupous pneumonia with occlusion of the bronchi.

(2) Pleural thickening, with pulmonary atelectasis.

(3) Subdiaphragmatic abscess or abscess of the liver.

In croupous pneumonia with plugging of the bronchi one may

DISEASES AFFECTING THE PLEURAL CAVITY. 285

have present all the physical signs of pleuritic effusion except dis-
placement of the neighbor ing organs. The presence or absence of
such displacement, together with the history, symptoms, and course
of the case, is therefore our mainstay in distinguishing the two
diseases.

From ordinary croupous pneumonia (without occlusion of the
bronchi) pleuritic effusion differs in that it produces a greater de-
gree of dulness and a diminution of the spoken voice sounds and
tactile fremitus. Bronchial breathing and bronchial whisper may
be heard either over solid lung or over fluid accumulation, although
the bronchial sounds are usually feeble and distant in the latter
condition. The displacement of the neighboring organs is of im-
portance here as in all diagnoses in which pleuritic effusion is a
possibility. In pleuritic effusion we can sometimes determine that
the line marking the upper limit of dulness shifts with change of
the patient's position. This is, of course, impossible in pneumo-
nia. A few hard coughs may open up an occluded bronchus and
so clear up the diagnosis at once. In doubtful cases the patient
should always be made to cough and breathe deeply before the
examination is finished.

It should always be remembered that one may have both pneu-
monia and pleuritic effusion at the same time, and that pneumonia
is often followed by a purulent effusion. In children the bronchi
are especially prone to become occluded even as a result of a simple
bronchitis, and we must then differentiate between atelectasis and
effusion in the main by the use of the criteria just described.

(2) It is sometimes almost impossible to distinguish small fluid
accumulations in the pleura! cavity from pleural thickening with
pulmonary atelectasis. In both conditions one finds dulness, dimi-
nution of the voice sounds, respiration, and tactile fremitus, and
absence of Litten's phenomenon, but the tactile fremitus is usually
more diminished when fluid is present than in simple pleural thick-
ening and atelectasis. An area of dulness which shifts with change
of position points to pleuritic effusion. The presence of friction
sounds over the suspected area speaks strongly in favor of pleural
thickening, but it is possible to hear friction sounds over fluid,

286 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

probably because they are conducted from a point higher up in the
chest at which no fluid is present. In doubtful cases the diagnosis
can and should be cleared up by puncture.

(3) In two cases I have known enlargement of the liver due to
multiple abscesses to be mistaken for enipyeina. In both condi-
tions, one finds in the right back dulness on percussion as high as
mid-scapula, with absence of voice sounds, breath sounds, and
fremitus. These conditions are due in one case to the presence of
fluid between the lung and the chest wall, and in the other case to

FIG. 137. Area of Dulness in Solitary (tropical) Abscess of the Liver.

the liver which pushes up the lung together with the diaphragm.
By physical signs alone I do not see how this diagnosis is possible,
though Litten's sign may be of use, since the shadow is absent
in empyema and sometimes present in moderate-sized subdia-
phragmatic accumulations. Some of the symptoms, such as chills,
sweating, and irregular fever, are common to both conditions. A
careful consideration of the history and the associated signs and
symptoms may help us to decide.

Large solitary abscess of the liver, occurring as it almost in-
variably does in the posterior portion of the right lobe, produces an
area of flatness on percussion, which rises to a much higher level in

DISEASES AFFECTING THE PLEURAL CAVITY. 287

the axilla and back than in front or near the sternum (see Fig. 137),
and may be in this way distinguished from empyema; but when the
liver contains many small abscesses, as in suppurative cholangitis,
this peculiar line of dulness is not present.

(cT) Kare diseases, such as cancer or hydatid of the lung, may
be mistaken for pleuritic effusion. The history of the case and the
results of exploratory puncture usually clear up the difficulty.

CHAPTER XIV.

ABSCESS, GANGRENE, AND CANCER OF THE LUNG,
PULMONARY ATELECTASIS, (EDEMA, AND HYPO-
STATIC CONGESTION.

ABSCESS AXD GAXGREXE OF THE LUXG.

I COXSIDEK these two affections together because the physical
signs, exclusive of the sputa, do not differ materially in the two
affections. In some cases there may be no physical signs at all,
and the diagnosis is made from the character of sputa and from a
knowledge of the etiology and symptomatology of the case. In
other cases we find nothing more than a patch of coarse rales or a
small area of solidification, over which distant bronchial breathing,
with increased voice sound and fremitus, may be appreciated.
Rarely there may be slight dulness on percussion, but as a rule the
area is not sufficiently large or sufficiently superficial to produce
this. One may find the signs of cavity (amphoric breathing,
cracked-pot resonance, and gurgling rales), but this is unusual.

Gangrene of the lung is not a common disease. The diagnosis
usually rests altogether upon the smell and appearance of the sputa.
In fetid bronchitis one may have sputa of equal foulness, but the
odor is different. The finding of elastic tissue in the sputa proves
the existence of something more than bronchitis.

Pulmonary abscess, which, like gangrene, is a rare affection, is
often simulated by the breaking of an empyema into the lung and
the emptying of the pus through a bronchus. Large quantities of
pus are expectorated in such a condition, and abscess of the lung is
suggested, but the other physical signs are those of empyema and
should be easily recognized as such. The finding of elastic fibres
is the crucial point in the diagnosis of intrapulmonary abscess,

ABSCESS, GANGRENE, AND CANCER OF THE LUNG. 289

whether due to the tubercle bacillus or to other organisms. Tuber-
culous abscess (cavity) is usually near the summit of the lung, and
other varieties of abscess are near the base, but often there are
110 physical signs by which we can distinctly localize the process.

MALIGNANT DISEASE OF THE LUNG.

In its earlier stages this affection is often mistaken for empy-
ema or serous effusion in the pleura! cavity, and indeed the physi-
cal signs may be in part due to an accumulation of fluid secondary
to the malignant growth within the lung. The rapid emaciation
of the patient and the presence of a dark-brown bloody fluid in the
pleura! cavity, as determined by puncture, make us suspect ma-
lignant disease. The sputa rarely contain fragments of tissue
whose structure can be recognized as characteristic of malignant
disease. Secondary deposits in the supraclavicular glands may
suggest- the diagnosis.

The thorax is usually somewhat asymmetrical. The affected
side may be either contracted or distended according to the nature
of the malignant growth within ; occasionally it is not deformed at
all. When the growth attacks only the lung tissue itself, leaving
the bronchi and mediastinum free, we get signs like those of pleu-
ral effusion (flatness, absent breathing, voice sounds, and tactile
fremitus), but the line of dulness is apt to be higher in front than
behind, which is rarely the case in pleural effusion.

If the disease begins in the bronchi, we may have a noisy dysp-
noea from stenosis of a bronchus, and a weakening of the respiratory
sounds normally to be heard over the trachea in front has several
times been noted. Percussion dulness, if present, is usually over
the upper portions of the chest, and may disappear and reappear
or skip from place to place in a very irregular and confusing way.

Signs and symptoms of pressure in the mediastinum due to sec-
ondary involvement of the peribronchial glands may be present and
may simulate aneurism, but with aneurism the cachexia is usually
less marked.
19

290 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST

ATELECTASIS.

(a) Areas of atelectasis or collapse of pulmonary tissue are
often present in connection with various pathological processes in
the lung (such as tuberculosis or lobular pneumonia), but are usu-
ally too small to give rise to any characteristic physical signs;
nevertheless

(&) In most normal individuals a certain degree of atelectasis
of the margins of the lungs may be demonstrated in the following
Avay : The position of the margins of the lungs in the axillae, in the
back, or in the precordial region are marked out by percussion at the
end of expiration. The patient is then directed to take ten full
breaths, and the pulmonary outlines at the end of expiration are
then percussed out a second time. The pulmonary resonance will
now be found to extend nearly an inch beyond its former limits,
owing to the distention of previously collapsed air vesicles.

If one auscults the suspected areas during the deep breaths
which are used to dispel the atelectasis, very fine rales are often
to be heard at the end of expiration, disappearing after a few
breaths in most cases, but sometimes audible as long as we choose
to listen to them. These sounds, to which Abrams has given the
name of " atelectatic crepitation, " are in my experience especially
frequent at the base of either axilla. The same writer has noticed
an opacity to the ce-rays over such atelectatic areas.

Forcible percussion may be sufficient to distend small areas of
collapsed lung, or at any rate to dispel the dulness previously pres-
ent (see above, p. 76, the lung reflex).

(c) When one of the large bronchi is compressed (as by an
aneurism) or occluded by a foreign body, collapse of the corre-
sponding area of lung may be shown by diminished motion of the
affected side, dulness on percussion, and absence of breathing, voice
sounds, and tactile fremitus.

In new-born babies whose lungs do not fully expand at the time
of birth, similar physical signs are present over the non-expanded
lobes. The right lung is especially apt to be affected

In the differential diagnosis of extensive pulmonary collapse,

ATELECTASIS, (EDEMA, AND HYPOSTATIC CONGESTION 291

the etiology, the suddenness of their onset, the absence of fever and
of displacement of neighboring organs enable us to exclude pneu-
monia and pleuritic effusion.

OEDEMA OF THE LUNGS.

In cardiac or renal disease one can often demonstrate that the
lungs have been invaded by transuded serum as a part of the gen-
eral dropsy. More rarely pulmonary oedema exists without much
evidence of oedema in other organs or tissues.

The only physical sign characteristic of this condition is the
presence of fine moist rales in the dependent portions of the lungs ;
that is, throughout their posterior surfaces when the patient has
been for some time in a recumbent position ; or over the lower por-
tions of the axillae and the back if the patient has not taken to
his bed.

The rales are always bilateral (unless the patient has been lying
for a long time on one side), and the individual bubbles appear to
be all of the same size, or nearly so, differing in this respect from
those to be heard in bronchitis. N~o squeaking or groaning sounds
are to be heard. The respiratory murmur is usually somewhat
diminished in intensity.

Dulness on percussion and modification of voice sounds are not
present, unless hydrothorax or hypostatic pneumonia complicate
the oedema.

HYPOSTATIC PXEUMONIA.

In long, debilitating illness, such as typhoid fever, the alveoli
of the dependent portions of the lungs may become so engorged
with blood and alveolar cells as to be practically solidified. Under
these conditions examination of the posterior portions of the lungs
shows usually :

(a) Slight dulness on percussion reaching usually from the
base to a point about one-third way up the scapula. At the very
base the dulness is less marked and becomes mixed with a shade of
tympany.

(1} Feeble or absent tactile fremitus.

292 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(e) Diminished or suppressed breathing and voice sounds.

The right lung is apt to be more extensively affected than
the left.

Occasionally the breathing is tubular and the voice sounds are in-
creased, making the physical signs identical with those of croupous
pneumonia, but as a rule the bronchi are as much engorged as the
alveoli to which they lead, and hence no breath sounds are pro-
duced.

Rales of oedema or of bronchitis may be present in the adjacent
parts of the lungs. The fact that the dulness is less marked at the
base of the lung than higher up helps to distinguish the condition
from hydrothorax.

The diagnosis is usually easy, owing to the presence of the un-
derlying disease. Fever, pain, and cough such as characterize
croupous pneumonia are usually absent.

APPENDICES.

APPENDIX A.

DISEASES OF THE MEDIASTINUM
I. MEDIASTIXAL TUMORS.

NEW growths of the mediastinal glands 1 usually manifest their
presence by the following symptoms and signs :

(1) Cachexia and substernal pain.

(2) Evidence of pressure against :

(a) The gullet.

(b) The windpipe or primary bronchi.

(d) Nerves which pass through the mediastinum.
(<?) The subclavian arteries.

(/) The heart.

(ff) The ribs, clavicle, or sternum.

(3) Secondary deposits in the cervical or axillary glands.

(a) By pressure on the gullet swallowing may be rendered diffi-
cult or impossible (dysphagia).

(b ) By pressure on the windpipe may be produced displacement
of the latter to one side, or fixation so that it cannot be moved in
any direction. The larynx may be drawn down into a noticeably
low position, and the laryngoscope may demonstrate that the tra-
cheal wall is bulged inward by the pressure of the new growth
upon it.

Dyspnoea, either inspiratory or expiratory, or both, and often

1 Tuberculous glands not being here included.

294 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

of noisy strident type, may result from stenosis of the trachea or
primary bronchi. Owing to pressure on one of the large bronchi,
the resonance and breath sounds and fremitus may be diminished
over the corresponding lung, in which finally abscess or gangrene
may develop, owing to the retention and decomposition of the
bronchial secretions.

(c) If the pulmonary veins are pressed upon, a systolic murmur
may be audible in the left back, and congestion of the lungs may
ensue.

Pressure on the innominate and subclavian veins produces cya-
nosis or oedema of the head, neck, shoulder, and arm, while the
superficial veins of the chest may become enlarged and prominent
owing to an attempt at collateral circulation, especially if the vena
cava superior is pressed upon. Fluid may accumulate in one or
both pleural cavities if the vena azygos or thoracic duct is in-
volved.

(d) Aphonia or hoarseness points to pressure on the recurrent
laryngeal nerve, and on laryngoscopic examination one vocal cord
may be found in the cadaveric position. Inequality of the pupils,
due to pressure on the sympathetic nerves, is not uncommon, and
severe pain along the distribution of the intercostals or running
4own the arm indicates that the spinal ganglia or brachial plexus
are pressed upon. Much rarer are symptoms of pressure on the
vagus (slowing or quickening of the heart) and on the phrenic
nerve (hiccup, unilateral spasm, or paralysis of the diaphragm).

(e) Weakening or delay in one radial pulse may be due to press-
are on the subclavian artery.

(/) Occasionally the heart itself may be pushed out of place.

(</) Pressure of the new growth against the bones of the chest
may give rise to an area of percussion dulness over or near the
manubrium, which, however, is not likely to show itself until late
in the course of the disease when the new growth has reached a
considerable size. In many cases there is tympanitic resonance in-
stead of dulness over the affected area. The ribs or sternum may
be pushed forward, but this is not usually the case. Occasionally
the new growth, if very vascular, may pulsate like an aneurism or

DISEASES OF THE MEDIASTINUM. 295

transmit the pulsations of the heart to the chest wall, and a systo-
lic murmur may be heard over the pulsating area, so that the resem-
blance to aneurism is increased.

Differential Diagnosis.

Mediastinal tumors may be mistaken for

(1) Aneurism of the aortic arch.

(2) Syphilitic stenosis of a bronchus.

(3) Phthisis.

Aneurism may be confounded with mediastinal new growths
even by the most competent observers. Tactile thrill, diastolic
shock, and tracheal tugging, if present, should suggest aneurism.
If these signs are absent, aneurism may still be present but cannot
be surely diagnosed. The degree of anaemia and emaciation is usu-
ally greater in malignant disease than in aneurism, but this is not
always the case. The presence of secondary nodules in the neck or
armpit speaks strongly in favor of new growth.

Stenosis of a bronchus, due to syphilis and giving rise to dysp-
noea, cough, stridor, pulmonary, atelectasis, may be very difficult to
distinguish from mediastinal growth, but the degree of anaemia and
emaciation is usually less in syphilis, and the beneficial results of
antisyphilitic treatment may render the diagnosis possible, espe-
cially if there is evidence of syphilis elsewhere in the body or in
the history of the case.

Phthisis may be suggested by the weakness, emaciation, and
persistent cough produced by mediastinal growths, but should be
easily excluded by the examination of the lungs and sputa.

II. MEDIASTIXITIS.

The acute suppurative forms of this rare disease do not give rise
to any characteristic physical signs in the chest.

The evidences of chronic fibrous mediastinitis have been already
sufficiently considered in connection with adhesive pericarditis.

296 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST

III. TUBERCULOSIS OF THE MEDIASTIXAL GLANDS.

Probably every case of pulmonary tuberculosis is preceded or
accompanied by tuberculosis of the bronchial lymph glands, and in
numberless cases the tuberculous process never gets beyond these
glands but is choked off there. In post-mortem examinations of
children, no matter what the cause of death, it is exceptional not
to find the bronchial glands tuberculous.

Nevertheless the disease can but rarely be recognized during
life. We may suspect it if, in a child showing tuberculous cervical
glands or phthisis, we find evidence of pressure upon the right
bronchus, increased tactile fremitus above the manubrium, lateral
displacement of the trachea, or weakening of the pulse during in-
spiration. If a bronchus is compressed, the resonance, tactile
fremitus, and breath sounds are diminished over the correspond-
ing lung. Wiederhofer lays stress upon an increase in the inten-
sity of the expiratory murmur over the situation of the left primary
bronchus.

APPENDIX B.
ACUTE ENDOCARDITIS.

Whether the disease be of the benign or of the malignant (sep-
tic) type, the results of physical examination of the heart are usu-
ally very equivocal. We may guess that endocarditis is present
owing to the presence of a cause (rheumatism), of a fever not oth-
erwise explained, of a rapid irregular pulse of low tension, but the
physical signs over the heart will not usually assist our guess ma-
terially.

Murmurs are often present but have usually the characteristics
of " functional " murmurs (systolic, limited, soft, without accentu-
ation of the pulrnonic second sound or cardiac enlargement). If
we can observe the advent of a diastolic murmur in such a case, we
may fairly attribute it to a fresh endocarditis of the aortic (very
rarely of the pulmonic) valve, but if we have not had the oppor-

PHYSICAL EXAMINATION OF THE CHEST IN INFANTS. 297

tunity to examine the heart previous to the onset of the present
attack it is impossible to exclude a long-standing valvular lesion as
the cause of the murmur.

If murmurs come and go from day to day, or suddenly increase
in intensity, we may suspect an acute endocarditis, especially if a
musical murmur is present or if there be evidence of embolism.

Inspection, palpation, and percussion usually yield no signs of
importance. There is no enlargement of the heart, no accentuation
of the second sounds, and no evidence of stasis.

APPENDIX C.
PHYSICAL EXAMINATION OF THE CHEST IN INFANTS.

(1) Tactile fremitus and voice sounds can be investigated only
in case the child cries or crows. The cry-sound is intensified over
solidified areas and may or may not be lost over fluid accumula-
tions.

(2) Percussion must be very delicately performed if we are to
avoid setting the whole chest in vibration with every stroke. It is
best to strike wholly with the finger, keeping the hand (as well as
the wrist and arm) unmoved.

(3) In listening to an infant's lungs patience and concentration
are essential. The child is apt to stop breathing when the exami-
nation begins, and we have to wait patiently to catch the long-de-
layed inspiration " on the wing, " as it were, before the long expi-
ratory wail begins. Luckily the inspiration, when it does come, is
unusually intense owin^ to the thinness of the chest in infancy.

(4) Long flexible rubber tubes connecting the chest-piece of the
stethoscope with the ear-pieces are very convenient when examin-
ing a wriggling child (see Fig. 48, p. 79), as they make it possible
to hold the chest-piece in position despite the constant movements
of the struggling sufferer.

(5) It is advisable to examine first the back while the child is
held in the mother's arms with its back to the physician.

298 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

(6) Children almost always cry if made to lie down flat. If
we wish to bring out the cry sound in order to test the vocal and
tactile fremitus, this is a simple and humane method of producing
it. If, on the other hand, peace is what we most desire, it is best
to avoid putting the child in a recumbent position.

(7) There is no type of breathing peculiar to children or in-
fants. Puerile breathing is simply vesicular breathing heard very
distinctly on account of the thinness of the chest. If, in a healthy
child, the expiratory murmur is prolonged and high-pitched, this is
probably because the child blows out the breath forcibly in the
effort to breathe deeply as it is told to do. A young infant never
does this, and its breathing is like that of adults except that it is
more rapid, more irregular, and better heard.

APPENDIX D.

RADIOSCOPY OF THE CHEST.

Radioscopy gives assistance in the diagnosis of diseases of the
chest in tAvo ways :

1. Through the use of the fluoroscopic screen.

2. Through the use of radiographs.

Those who are accustomed to the use of the fluoroscope gain
far more information from it than from radiographs, but the record
of the photographic plate is objective, permanent, and demon-
strable, Avhile the impressions gained from the fluoroscope are more
apt to be modified by the personal equation.

For the present, therefore, Ave need both methods.

I shall not attempt to discuss the advantages of the various
forms of apparatus used for producing Roentgen rays in a Crookes
tube ; the subject would carry me beyond my depth as Avell as be-
yond the limits of this book ; but Avhatever form of instrument is
used, the vacuum in the tube should be less perfect when Ave desire
to use it for the chest than when searching for foreign bodies or
studying fractures. We need a " IOAV " or " soft " tube Avhich giA r es

RADIOSCOPY OF THE CHEST. 299

rays of a relatively slight degree of penetration. With high pene-
tration rays the outlines of the solid organs are less distinct because
the rays traverse the heart and liver almost as easily as they do the
lungs. If the penetrating power is less, the rays are arrested by
the solid organs, but not by the lungs, and hence the outlines of the
former become visible.

/. The Use of the F I Horoscope.

1. It is advisable to remain in a dark room or to wear smoked
glasses for a short time before attempting to use the fluoroscope.
This applies especially to beginners. Skilled observers do not need
such preparation of the retina, but many novices who complain at first
that they can " see absolutely nothing " when they apply the fluoro-
scope to the chest, find their vision suddenly and permanently im-
proved after fifteen minutes in a dark room. Practice increases our
powers with the fluoroscope as much as it does with the micro-
scope, and it is unreasonable to expect to see from the first all that
an expert sees.

2. The patient should be placed at least three feet from the
tube, else there is likely to be distortion and magnification of the
shadows corresponding to the organs examined. The tube should
be placed at such a height as to be opposite the most important
object to be examined, and always in the median line.

3. Patients may be examined either in the upright position
the tube about three feet from the patient's back the fluoroscope
resting against the chest or in the recumbent position, supported
on a canvas cot with the tube underneath. I prefer the upright
position. The patient's arms should always be extended forward
so as to get the scapulae out of the way.

4. To concentrate the light upon a spot of special interest, we
may use a metal plate with a rectangular opening about two by
three inches near one end. When this plate is held between the
tube and the patient, so that the opening is opposite the spot to
be examined, the rays pass through the opening, but are intercepted
by the metal around it. The hand which holds this plate should
be protected from the action of the rays.

300 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

5. To mark on the chest the outlines of the shadows seen with
the fluoroscope, a pencil enclosed in a tube of brass is useful ; the
brass jacket makes the pencil visible and enables us to adjust its
point to the outlines on the chest. An ordinary pencil is pene-
trated by the rays completel}-, and it is hard to draw with a pencil
which we cannot see.

II. The Normal Fluoroscopic Picture (see Fig. 138).

The lungs appear as the lightest part of the field owing to the
large amount of air they contain ; at the end of full inspiration,
they become still lighter. Against the light lung areas, the out-
lines of the ribs and of the vertebral column (with the sternum super-
imposed) are clearly visible. Less clear, but usually quite distin-
guishable, are the outlines of the heart and the upper border of the
liver. A slight shadow (see Fig. 139) is often noticed just to the
right and to the left of the heart in a position corresponding to the
larger bronchi. The spleen is not usually to be made out clearly,
but the upper surface of the diaphragm above it is generally visible.
The contractions of the heart and the movements of the diaphragm
are usually clear, and any restriction of the respiratory excursion
on one side can be noted, though the fluoroscope has no advantages
over the inspection of Litteii's diaphragm shadow (see p. 23) for
this purpose.

Abrams has noted that if the skin of the precordia is irritated
by cold or pain, a reduction in the size of the heart occurs ("heart
reflex ") for a few seconds.

In children all these phenomena are especially clear, owing to
the thinness of their chest walls and we note at once how much
more horizontal the child's heart is than the adult's (see Fig. 138).

III. The Fluoroscope in Disease.

I shall mention first those diseases in which the fluoroscope fur-
nishes us the most valuable information.

1. Aneurism. Small aneurisms of the transverse or descending
aorta may sometimes be recognized by the ar-rays when 110 other

RADIOSCOPY OF THE CHEST.

301

Chest < if Healthy Coy aged Incipient Phthisis at Right Chest of Healthy Adult,

nine years. A pox.

Advanced Phthisis (cavity?). Advanced Phthisis. Eilateral Phthisis at Apices.

Advanced Phthisis.

Advanced Phthisis. Pulmonary Emphysema.

Aortic Aneurism. Aneurism of Left Auricle. Fibroid Phthisis of Right Lung.

Heart drawn to the right.

FIG. 138. Twelve Radiographs of the Chest, as Seen from Behind (after Walsham).

302 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

method of physical examination yields satisfactory evidence. An
abnormal shadow appears at one side of the sternum (see Fig. 140)
and may sometimes be seen to pulsate. In other cases the fluoro-
scopic evidence is not the only evidence, but tends to confirm or

FIG. 139. Radiograph of a Case of Transposition of the Viscera. (After Gibson.)

dispel suspicions aroiised by the ordinary methods of examination.

Aneurism of the heart itself is recognizable, according to F. H.
Williams, by the fluoroscopic examination. No other method of
examination gives us any evidence of such a lesion.

2. Determination of the Cardiac Outlines in Patients with Em-
pJnjsnna and Fat Chest Watts. Emphysema spoils cardiac percus-

RADIOSCOPY OF THE CHEST. 303

sion and interferes with inspection and palpation. But in fluoro-
scopic work emphysema is a boon and a blessing, for it renders the
cardiac outlines more distinct than usual. Hence, for determining
the size and position of the heart in such cases, the a-rays give
genuine assistance, as they also do when mapping out the heart in
women with large breasts and fat chest walls.
/ 3. Central Pneumonia. Williams and others have succeeded

Aneurismal sac.

Heart.

FIG. 140. Front View of Thoracic Aneurism. The heart displaced downward.

in identifying foci of solidification beneath the surface of the lungs
when no other physical signs could be obtained. It must be re-
membered, however, that congestion of the lung, oedema, atelec-
tasis, and pleural thickening produce shadows similar to those of
solidified lung.

4. Tuberculosis. It is still a matter of doubt whether tubercu-
lous foci can be recognized by the fluoroscope before the disease has

304 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

progressed sufficiently to produce localized rales, diminished breath
sounds, or restriction of Litteirs phrenic phenomenon.

Slight opacities have been noted in cases which later turned out
to be tuberculosis, and which had not previously been diagnosed,
but the shadows perceived by the fluoroscope are capable of many
interpretations and correspond (as above said) to various pathologi-
cal conditions. Old quiescent foci may appear like advancing le-

Aneurismal sac.

Heart.

FIG. 141. Aneurismal Sac Radiographed from Behind.

sions and thus lead to serious errors. We do not want to hurry a
patient off to Colorado or Davos on account of the shadow thrown
by a long-healed lesion. Further, in some cases of rheumatism,
anaemia, debility, and convalescent typhoid, appearances very simi-
lar to those of tuberculosis may be found (Williams). Hence the
intrepretation of slight lung shadoAvs in cases of suspected incipient
phthisis is by no means easy.

RADIOSCOPY OF THE CHEST. 305

Advanced phthisis renders the lungs relatively opaque to the
Eoentgen rays except where extensive excavation has occurred;
here we see a light area in a dark background (see Fig. 138).

No satisfactory radiographs of cases of incipient phthisis have
so far been published, so far as I am aware.

5. Pleuritic Effusions. The displacement of the heart is some-
times better shown by the cc-rays than by ordinary methods of ex-
amination, since the compensatory hypertrophy of the sound lung,
which interferes with percussion and palpation of the heart, renders
radioscopy easier.

The fluid exudate intercepts the rays perceptibly, and Avhen the
movements of the diaphragm are not abolished on the affected side,
the line corresponding to the surface of the fluid can be seen to
move up and down with respiration.

Small fluid accumulations flatten the normal curve of the upper
surface of the diaphragm by filling up the chink between the inner
surface of the chest in the axilla and the line of the diaphragm at
that point.

6. Emphysema. The lungs become unusually transparent and
owing to the low poeition of the diaphragm the heart descends and
assumes a very vertical position ("ptosis of the heart"); these
points are very clearly seen with the fluoroscope.

Radiographs.

But little use has thus far been made of radiographs in study-
ing diseases of the chest. The movements of the heart, of the
chest walls, and of the diaphragm render all the outlines .indistinct.
For aneurisms, especially those containing a thick layer of clot, and
for intrathoracic tumors, radiographs may be very useful, and
bronchial lymph glands are sometimes rendered visible.
20

306 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

APPENDIX E.
THE SPHYGMOGRAPH.

This instrument consists of a system of levers by means of which
the pulsations of the radial artery are transferred to a needle whose
oscillations can be graphically recorded upon a piece of smoked pa-
per. It is a very fascinating little toy, but in its present form is
almost devoid of practical usefulness owing to the impossibility of
eliminating the personal equation when using it. The size and, to
a certain extent, the shape of the wave traced upon the smoked
paper can be influenced at will by the amount of pressure with
which the instrument is applied to the wrist. If an instrument is
applied with a pressure of three ounces to the wrist of A, and then
Avith the same pressure to the wrist of B, the force exerted upon
the artery may be quite different in the two cases owing to the dif-
ferent shape of the wrist in the two individuals.

Almost any type of tracing can be obtained from a normal pulse
by varying the pressure.

This objection is fatal to the use of the sphygniograph as an in-
strument of precision, and although it is capable of recording tiny
secondary waves unpalpable by the fingers, it has yet to be shown
that it reveals anything of practical diagnostic value which is not
appreciated by skilled fingers. For these reasons I have given no
account of the instrument in the body of this work.

INDEX.

ABRAMS, 76, 105, 292

Abscess, pulmonary, 290

Adenitis. 41

Amphoric breathing, 103

Anatomy, 2

Aneurism, 220-229, 293

Aortic aneurism, 33. 220-229

disease, 170-187

regurgitation, 170

roughening, 184

second sound, 121

stenosis, 181
Apex, cardiac, displacement of, 29

position of, 20

retraction, 31
Arrhythmia, 161, 204
Arterial movements, 36

murmurs, 140

sounds, 124

wall, condition of, 55
Asthma, 261, 263
Atelectasis, 104, 292
Auscultation, 77-141

mediate and immediate, 78

of the heart, 113-141

of the lungs, 91-112

BARREL CHEST. 9

Bradycardia. 51. 203

Breathing (set Respiration), 16, 21,

23, 92
Broadbent. 161. 217

Bronchial (see Tubular)

breathing, 95, 102, 239, 280
Bronchiectasis, 264
Bronchitis, 233, 245

CANCER OF LUXG, 291
Capillary pulse, 38, 172
Cardiac (see Heart)
impulse, 23, 42

displacement of, 29, 281

character of, 148
Cirrhosis of the lung, 205
Compensation, establishment and

failure of, 144

Congenital heart disease, 206
Cough, effect of, 107, 245
Curvature, spinal, 14
Cyanosis, 39

DEFORMITIES, 14
Diaphragm, movements of, 23
Diastolic murmur, 137, 181, 192

shock, 222

sound, 104, 225
Dilatation, cardiac, 146, 199
Ductus arteriosus, persistence of, 207
Dyspnoea, 18

EGOPHONY, 111

Emphysema, 258

complementary. 202
interstitial, 202
large-lunged, 258

308

INDEX.

Emphysema, senile, 258

with bronchitis, 261
Empyema, 283, 284
Endocarditis, acute, 296

chronic, 151

Epigastric pulsation, 32
Expansion, 16

diminished, 17

increased, 18

FATTY DEGENERATION, 201

overgrowth. 201
Flattening of the chest, 14
Foramen ovale, patency of, 207
Freniitus. tactile, 44

vocal, 109
Friction, pleural, 107, 271

peri card ial, 209

GANGRENE OF LUNGS, 290
Glands, 41

H.EMIC MURMURS, 13(3

Heart (see also Cardiac), 141
aneurism of, 301
dilatation of, 146
diseases of, 141-205
hypertrophy of, 146
murmurs, 126

sounds, accentuation of, 120
doubling of, 118
metallic, 124
muffled, 124
rhythm of. 123
shortening of, 117
Hydropcricardium, 219
Hydrothorax, 266

Hypertrophy, cardiac, signs of, 146
Hypostatic congestion of lung, 293

INFANTS, examination of, 297
JAUNDICE, 40

LlTTEN, 20

Lung reflex, 76
Lungs, abscess of, 290

cancer of, 291

diseases of. 23:5-293

emphysema of, 258

fistula-sound, 112

gangrene of. 290

cederna of, 293

MEDIASTINAL TUBERCULOSIS, 296

tumors, 2 '.3
Mediastinitis, 216, 29.")
Mediastinum, diseases of, 293
Metallic heart sounds. 124

tinkle, 112
Mitral valve, diseases of, 151-170

insufficiency of, 151

stenosis of, 161
Murmurs, arterial, 140

cardiac, 126-140

cardio-respiratory, 138

functional or hseniic, 136

venous, 139
Muscle-sounds, 84
Myocarditis, acute, 199

chronic, 201

NEUROSES, cardiac, 202
CEuEMA, 235, 293

PALLOR, 40

Palpation, 42

Palpitation, 205

Paralytic chest, 8

Parietal disease (see Myocarditis), 198

Percussion, 58

auscultatory, 65

immediate, 58

mediate. 58

pal pat or y, 67

resonance, 67

INDEX.

309

Percussion resonance, amphoric, 75
cracked-pot, 74
diminished, 69
tympanitic, 70
vesicular, 68

technique of, 58

Pericardium, diseases of, 209, 219
Pericarditis, 209

adhesive, 32, 216

plastic, 209

with effusion, 212
Phthisis, 252
Pleural thickening, 283
Pleurisy, 271-284

encapsulated, 283

plastic, 271

pulsating, 284

with effusion, 273
Pneumonia, croupous, 237

inhalation, 244
Pneumohydrothorax, 208
Pneumothorax, 111, 266
Pulmonary abscess, 290

atelectasis, 104, 292

emphysema, 258

gangrene, 290

oedema, 293

regurgitation, 192

stenosis, 193

tuberculosis. 245

tympanites, 202
Pulmonic second sound, 120
Pulsation, abnormal, 48
Pulse, 49

capillary, 173

compressibility of, 52

Corrigan's, 172

dicrotic, 52

rate, 51

rhythm, 51

tension, 53

wave, size and shape of, 52

RACHITIS, effects on the thorax, 7
Radioscopy, 227, 298
Rales, 103

bilateral, 234

crepitant, 105

dry, 104

moist, 104

musical, 106

palpable, 47

subcrepitant, 105

unilateral, 245
Resistance, sense of, 76
Resonance (see Percussion), 67
Respiration, amphoric, 98

asthmatic, 21, 97, 263

bronchial or tubular, 96

broucho-vesicular, 96

Cheyne-Stokes, 22

cogwheel, 98

diminished, 100, 279

emphyseinatous, 97

exaggerated, 99, 266, 279

metamorphosing, 98

normal, 68

restrained, 22

shallow, 23

stridulous, 23

types of, 92

vesicular, 93
Rhythm, cardiac, 123, 165

modifications of, 123, 165

respiratory, 21

SPHYGMOGRAPH, 235
Stethoscope, choice of, 78

use of, 83
Succussion, 111
Syphilis of the lung, 264

TACHYCARDIA, 202

Tactile frernitus (see Fremitus) s
44

310

INDEX.

Tension of the pulse, 53
Thrills, 43

in aueurism, 222

in aortic stenosis, 184

in congenital heart disease, 206,
208

in mitral stenosis, 164
Tracheal tug, 223
Tracheitis, 233
Tricuspid regurgitation, 187

stenosis, 191
Tuberculosis, advanced, 249

incipient, 245

pulmonary, 244

Tumors, 15, 48, 221, 291, 293

VALVE AREAS, 113

lesions, 151-197
Valvular disease, 141, 151-197

heart sounds, 117, 199, 202
Venous murmur, 139

pulsations, 35, 188

sound, 125
Ventricle, left, hypertrophy of, 147

right, hypertrophy of, 148
Ventricular septum, defects in, 207
Voice sounds, spoken, 110

whispered, 109, 238

Date Due

PRINTED IN U.S... CAT. NO. 24 161

WF9T5
cn6p

1901
Cabot, Richard C

Physical diagnosis of diseases of the
chest .

MEDICAL SCIENCES LIBRARY

UNIVERSITY OF CALIFORNIA, IRVINE

IRVINE, CALIFORNIA 92664