\i LiEilAKY UF CUMiiiiiSS. # ^/. T .^/.e 'T At ^Vc If UNITED STATES OF AMERICA.! | i COM PENDIUM THE PHYSICAL DIAGNOSIS OF Diseases affecting the Lungs and Hearti ; j By Austin Flint, M.D, Fourth Edition, New York : WILLIAM WOOD & COMPANY. 1869. Entered according to Act of Congress, in the year 1868, by AUSTIN FLINT, M.D,, In the Clerk's Office of the District Court of the United States for the Southern District of New York. The New York Printing Company, 8 1, 83, and S5 Centre Street ^ New York. PEEFACE h This little compendium was prepared several years ago, by request of a medical friend who intended it for insertion in an annual Physician's Visiting Book. The latter publication was aban- doned, and the compendium was published by itself. It has been found convenient in aiding to memorize physical signs, by the private pupils of the writer, and by others, and it has been reprinted in compliance with a demand for this purpose. It is designed, not as a substi- tute for works treating of auscultation and per- cussion, but, on the contrary, to promote the study of treatises which consider fully these and the other methods of physical exploration, together with the diagnosis of diseases affecting the respiratory organs and the heart. COMPENDIUM OF PERCUSSION AND AUSCULTATION, AND OF THE PHYSICAL DIAG:N^0SIS OF DISEASES AFFECTING THE LUiS^GS AND HEART. By AUSTIN FLINT, M.D. SUMMARY OF PULMONARY SIGNS OBTAINED BY PERCUSSION AND AUSCULTATION, THEIR DIS- TINCTIVE CHARACTERS AND SIGNIFICANCE.* PERCUSSION. Normal Vesicular Resonance. — The reso- nance obtained by percussing the healthy chest, varying in intensity in different persons, the pitch low, the quality peculiar and distinguished as vesicular. The resonance greater, the vesic- * For a fuller exposition of the distinctive characters and significance of the signs obtained by percussion and auscul- tation, vide the work of the writer entitled "^ Practical Treatise on the Physical Exploration of the Chest and the Diag- nosis of Diseases affecting the Respiratory Organs^ — 2d Edition, Vide, also, article in Am. Jour, of Med. Sciences, No. for April, 1862. ular quality more marked, and the pitch lower at the left than at the right summit of the chest in front. ABNORMAL MODIFICATIONS OF THE NORMAL VESICULAR RESONANCE. Diminished Resonance, or Dulness. — The resonance less and the pitch higher than the normal vesicular resonance. Denotes that the proportion of solids, or of liquid, over air within the chest, is greater than in health. Incident to partial solidification of lung in pneumonia, tuberculosis, &c., to pulmonary congestion, to moderate or small pleuritic effusion, to moderate oedema of lung, and to collapsed lobules. Absence of Resonance, or Flatness. — Eeso- nance wanting, i.e. complete abolition of sono- rousness. Denotes absence of air within the part of the chest percussed. Incident to com- plete solidification of lung, to liquid effusion, to great oedema of lung, and to tumor within the chest. Tympanitic Resonance. — A resonance de- void of the vesicular quality which distinguishes the normal vesicular resonance. The intensity of the resonance either greater or less than in health. It is invariably higher in pitch than the normal vesicular resonance. It proceeds from air in the pleural sac, or in pulmonary cavities, or in the large bronchial tubes sometimes on percus- sion over the upper lobes ; and it may be con- ducted from the stomach or colon by solidified lung. Incident to pneumo-thorax, to some cases of solidified lung, and to tuberculous exca- vations. Amphoric Resonance. — A variety of tym- panitic resonance, characterized by a musical intonation like that produced by blowing over the open mouth of a phial. Incident to some cases of pneumo-thorax, and to tuberculous cavities ; occasionally produced over solidified lung. Cracked Metal Resonance. — Another vari- ety of tympanitic resonance. Incident to tuber- 8 culous cavities, but occasioriallj produced over solidified lung, and sometimes in the infra-cla- vicular region of young subjects in health. Vesiculo-Tympanitie or Exaggerated Resonance. — The resonance of greater intensity than in health ; the character not vesicular as in health, nor purely tympanitic, but presenting the tympanitic and the vesicular quality mixed in variable proportions; the pitch raised in proportion as the tympanitic quality predom- inates. Incident especially to dilatation of the air-cells in emphysema, to lung containing air and floating on liquid within the chest, and to a healthy lobe when its fellow is solidified. AUSCULTATION. 1. Auscultation of the Sespiration. Normal Vesicular Murmur. — The respira- tory sound obtained by auscultation in health. The murmur produced by the act of inspiration is more or less intense, low in pitch, and has a peculiar quality distinguished as vesicular. The murmur with expiration is not always present ; 9 when present it is much shorter than the in- spiratory murmur, less intense, stiUJower in pitch, and it has a simple blowing quality. These characters vary considerably, within the limits of health, in different persons. The mur- mur with inspiration is more intense, more vesicular, and lower in pitch at the left than at the right summit of the chest in front. The ex- piratory sound is not infrequently prolonged at the right summit, especially in females, and it may be more or less high in pitch. ABNORMAL MODIFICATIONS OF THE NORMAL VESICULAR MURMUR. Exaggerated Vesicular . Murmur. — In- creased intensity of the murmur on the healthy side when the respiratory function on^ the op- posite side is compromised by disease, as in cases of pleurisy with large effusion, pneumonia, etc. The characters of the murmur, irrespective of intensity, not essentially changed; called, also, supplementary ^nd2nceril6 respiration. Diminished Vesicular Murmur. — The mur- 10 mur weakened, but its distinctive characters otherwise not materially affected. Incident to dilatation of the air cells or emphysema, and to cases of bronchitis. Suppressed Respiratory Murmur. — Absence of any sound with the respiratory acts. Incident to large pleuritic effusion, to some cases of solidification of lung, and to tumor within the chest. Bronchial or Tubular Respiration — An inspiratory sound devoid of the vesicular quali- ty, and, in place thereof, a quality distinguished as tubular, the pitch higher than the inspiratory sound in the normal vesicular murmur, and the intensity variable ; an expiratory sound as long as, or longer than, the sound of inspiration, the pitch higher than that of the inspiratory sound, the intensity usually greater, and the quality, like that of the inspiratory sound, tubular. These characters of the bronchial, as compared with the normal vesicular respiration, are iden- tical with the characters of the normal laryngeal 11 and traclieal respiration. The bronchial respira- tion denotes complete or considerable solidifica- tion of lung, from morbid deposit, as in pneumo- nia, tuberculosis, etc., or from condensation, as when compressed by liquid effusion, and in cases of collapse. Broneho-Vesieular Respiration. — The ve- sicular quality of the inspiratory sound more or less diminished, but not entirely wanting as it is in bronchial respiration ; the quality approach- ing the tubular in proportion as the vesicular quality is diminished, and the pitch raised in proportion as the tubular predominates over the vesicular quality. The expiratory sound more or less prolonged, its intensity increased, its quality tubular, and its pitch raised in propor- tion as the inspiratory sound has less of the vesi- cular and more of the tubular quality. This abnormal modification is distinguished, as the name implies, by the mixture, in various pro- portions, of the characters of the bronchial and the normal vesicular respiration. The presence 12 of any of the vesicular quality in inspiration shows that the respiration is not bronchial, but broncho-vesicular. The characters may approx- imate, on the one hand, to the bronchial, or, on the other hand, to the normal vesicular respira- tion ; and between these extremes there is every degree of gradation. The sign denotes partial solidification of lung. In proportion as the solid- ification approximates to an amount sufficient to give rise to the bronchial respiration, the characters of the broncho- vesicular will approx- imate to the bronchial. On the other hand, the characters will approximate to the normal vesi- cular when the solidification is slight. By means of this sign, therefore, not only the existence of solidification, but its amount, may be determined. This has been called mcde^ roitgh^ and harsh respiration. Its intensity may be greater or less than that of health}^ respirations. Cavernous Respiration. — An inspiratory sound, devoid of vesicular quality, not tubular but blowing, and low in pitch ; an expiratory 13 sound, lower in pitch than the inspiratory. (Contrast these characters with those of bron- chial respiration.) Heard within a circum- scribed space, and not infrequently surrounded by bronchial respiration. Denotes passage of air into and from a cavity with flaccid walls. Amphoric Respiration. — A variety of cav- ernous respiration characterized by a musical in- tonation resembling the sound produced by blow- ing over the mouth of an empty phial. Denotes generally pneumo-thorax and perforation of lung, but sometimes due to a tuberculous cavity with rigid walls. ADVENTITIOUS SOUNDS, OR RALES, PRODUCED WITHIN THE AIR-CELLS, BRONCHIAL TUBES, PULMONARY CAVITIES, AND THE PLEURAL SAC. Crepitant Rale. — A dry^ very fine, crack- ling sound, heard only with the act of inspira- tion, and, if heard in only a part of this act, always confined to the latter part. Almost pathognomonic of pneumonia. Heard especial- ly in the first stage of that disease. Occasion- 14 ally incident to CBdema of the lungs and to haemoptysis. Produced within the air vesicles and bronchioles. Sub-Crepitant Rale. — A moist^ fine, bub- bling sound, conveying the idea of small bub- bles, heard with either inspiration or expiration, or with both acts, not infrequently intermingled with the crepitant rale. Produced within the bronchial tubes of small size. Incident to capil- lary bronchitis, oedema of lungs, hasmoptysis, and heard in the resolving stage of pneumonia. Moist Bronchial or Mucous Rales. — Bubbling sounds due to the presence of mucus or other liquid in the bronchial tubes of larger size than those in which the sub-crepitant rale is produced. They are called coarse or Jine^ ac- cording to the size of the tubes in which they are produced. Incident to bronchitis and other affections giving rise to the presence of liquid in the tubes. Sibilant and Sonorous Rales. — Dry sounds, frequently musical, produced by narrowing of 15 the calibre of the bronchial tubes. If high in pitch, they are sibilant or whistling, and gen- erally produced within small-sized tubes. If low, they are sonorous or snoring, and produced within large-sized tubes. Incident to asthma especially ; also to bronchitis. Cavernous Rale or Gurgling. — A moist sound produced hy the bubbling and agitation of liquid within a cavity. The name gurgling is descriptive of the character of the sound. Its situation is circumscribed. Pleural Friction Sound. — A sound of gra- zing, rubbing, or grating, due to the movements, in opposite directions, of the costal and pulmo- nary pleural surfaces with inspiration and expi- ration. The sound is more or less intense, dry, appears to be near the ear, heard usually with both acts of respiration, and conveys to the mind the idea of friction of roughened surfaces. The sound is generally not continuous, but in- terrupted ; that is, there is a series of friction sounds with either inspiration or expiration, or in 16 both acts. Denotes that the pleural surfaces are roughened by lymph or other deposit. Incident to pleurisy, especially after the absorption of liquid effusion. Metallic Tinkling. — A series of tinkling sounds, with expiration, or inspiration, or both acts ; also produced by speaking and coughing. Denotes air and liquid within a space of con- siderable size. Incident chiefly to pneumo-hy- drothorax; sometimes produced within a large tuberculous excavation. 2. AusGidtation of the Voice. Normal Vocal Resonance. — A diffused, distant resounding of the voice in health, accom- panied with more or less vibration of the walls of the chest, or fremitus. Yaries much in degree in different healthy persons. Always louder on the ris'ht than on the left side of the chest. 'iD^ Normal Bronchial Whisper. — A blowing sound heard with whispered words, at the upper part of the- chest, in front and behind, and more 17 marked in proportion as the ear approaclies the site of the primary bronchi. The sound varies considerably in intensity in different healthy persons. It is louder at the right than at the left summit of the chest ; but the pitch is some- what higher on the left side. It is comparative- ly feeble, and often wanting, over the middle and the lower third of the chest. Its characters correspond to those of the expiratory sound in forced breathing. ABNORMAL MODIFICATIONS OF VOCAL RESO- NANCE AND BRONCHIAL WHISPER, Bronchophony. — The voice concentrated, near the ear, raised in pitch, and more or less intense. Denotes solidification of lung, either complete or considerable. Whispering Bronchophony. — A high- pitched, tubular sound, with whispered words, near the ear, and more or less intense. The signification the same. This and the preceding sign are correlative with bronchial respiration. 2 18 Exaggerated Vocal Resonance. — The re- sonance of the voice diffused and distant as in health, but its intensity abnormally more or less increased. Denotes a degree of solidification in- sufficient for the production of bronchophon3^ Exaggerated Bronchial Whisper. — A sound, with whispered words, abnormally intense, but not so intense, and not so acute nor so near the ear, as in whispering bronchophony. Has the same significance as exaggerated vocal reso- nance. This and the preceding sign are correla- tive with broncho- vesicular respiration. Pectoriloquy. — Transmission of the speech, i.e. articulate words, to the ear. It may be either bronchophonic or cavernous. Cavernous Whisper. — A sound, with whis- pered words, notably low in pitch, and blowing or hollow in quality, as compared with whisper- ing bronchophony. Denotes a cavity. Amphoric Voice or Echo. — A musical 19 sound like that produced by blowing into an empty bottle. It may accompany or follow the loud voice or whispered words. Incident espe- cially to pneumo-thorax, but also occasionally to tuberculous cavities. ^gophony. — A modification of bronchopho- ny, consisting in tremulousness of the sound, causing it to resemble the bleating of a goat. Occasionally heard in pleurisy and pneumonia. Diminished and Suppressed Vocal Reso- nance.^-The resonance either more or less ab- normally lessened or wanting. Incident espe- cially to pleuritic effusion, and to pneumo- thorax. PHYSICAL SIGNS INVOLVED IN THE DIAGNOSIS OF PULMONARY AFFECTIONS. Bronchitis Affecting the Large Tubes. — Normal vesicular resonance on percussion. Sibilant or sonorous rales, or both, in early stage, on both sides of the chest ; feebleness of respiratory murmur. Temporary suppression 20 of murmur over portions of chest. Subse- quently mucous rales on both sides of the chest. The rales very variable, not always present, coming and going, and changing their situation. The vocal resonance normal. Bronchitis Affecting the Small Tubes. — ITormal vesicular resonance on percussion. Sub- crepitant rales on both sides of the chest. Weak- ened or suppressed respiratory murmur. Normal vocal resonance. Asthma. — Eesonance on percussion either normal or increased. Sibilant and sonorous rales diffused over the chest, often loud enough to be heard at a distance. Normal vocal resonance. Pulmonary Emphysema. — Yesiculo-tym- panitic resonance on percussion over both upper lobes, generally most marked at the left summit in front. Eespiratory murmur feeble or sup- pressed. The inspiratory sound shortened (de- ferred). The expiratory sound frequently pro- longed, but not tubular nor raised in pitch. 21 . Sibilant and sonorous rales frequently present. The superior and middle thirds of chest, in front, bulging, and the lower part contracted. Marked and characteristic deformity of chest in some cases. Vocal resonance not affected. Pleurisy Tvith Effusion and Empyema. — If the pleural sac be filled either with lympho- serous liquid or pus, universal flatness on per- cussion over the affected side. Generally ab- sence of respiratory sound except over the com- pressed lung at the summit, and, here, bronchial respiration. Enlarged dimensions of the affected side, if the liquid be sufficient to dilate the chest, as shown by mensuration or the eye. Deficient respiratory movements or immobility. The in- tercostal spaces on a level with the ribs, and sometimes bulging. Dislocation of the heart, its site being shown by the impulse or sounds. Normal vocal resonance diminished or suppress- ed. Vocal fremitus wanting. Exceptionally, the bronchial respiration emanating from the compressed lung is more or less diffused, and 22 it may extend over the whole of the affected side. If the chest be partially filled, flatness or dul- ness on percussion from the base of chest, extending upward to a horizontal line, denoting the level of the liquid, when the patient is sitting or standing. Eesonance extending below this line, in front, in some cases, when the patient lies on the back, owing to a change of level of the liquid. Vesiculo- tympanitic resonance fre- quently over the lung above the level of the liquid. Diminution or absence of respiratory sound below the level of the liquid. Above the liquid the respiration broncho- vesicular, and sometimes bronchial near the liquid. Vocal resonance and fremitus diminished or wanting below the level of the liquid, and both may be exaggerated above the liquid. Bronchophony or segophony sometimes near the level of the liquid. Diminution of intercostal depressions may be apparent when the chest is partially filled. Ex- aggerated respiration on the healthy side when the chest is partially, and still more when it is 23 completely, filled. Pleural friction sound some- times prior to and with liquid effusion ; fre- quently during and after absorption of liquid. A characteristic contraction of the chest on the affected side follows chronic pleurisy with con- siderable effusion. Pneumo-Hydrothorax. — Tympanitic reso- nance extending either over the whole of the affected side, or a certain distance from the summit, when the patient is sitting or standing, with dulness or flatness extending below to the base. The relation of dulness or flatness and tympanitic resonance changing when the patient lies on the back, owing to change of level of the liquid. The tympanitic resonance sometimes amphoric. Amphoric respiration and voice frequently present, also metallic tinkling. Splashing sound on succussion, and this sound frequently amphoric. Suppression of respiratory murmur and of vocal resonance. Dilatation of the affected side in certain cases, with deficient motion, and abolition of intercostal depres- 24 ^- . . sions. The heart removed from its normal situation. Hydrothorax or Dropsical Pleural Effu- sion. — The signs denoting presence of liquid in both pleural sacs ; the amount of liquid often greater in one side. The evidence of liquid afford- ed by its change of level with the change of position of the patient is almost alwaj^s available. Pneumonia. — In first stage, slight or mode- rate dulness over the affected lobe, and frequent- ly, but not invariably, the crepitant rale, the latter being almost pathognomonic. In second stage, marked dulness, or flatness, over a space corresponding to that occupied by the affected lobe or lobes. Vesiculo-tympanitic resonance over the upper lobe if the lower lobe be alone affected, and over the lower lobe if the upper be alone affected. The relation of resonance and dulness or flatness not changing with change of the position of the patient. Bronchial respiration generally present in this stage, and usually bronchophony with the loud voice, together 25 with whispering bronchophony. Persistence of crepitant rale in some cases. In stage of puru- lent infiltration, dulness or flatness continuing, with mucous rales. During resolution, progres- sive diminution of dulness, the bronchial respira- tion giving place to the broncho-vesicular, the latter approximating to, and at length eventuating in, the normal vesicular murmur. During this period, sometimes a return of the crepitant rale, and frequently a sub-crepitant rale. Bronchophony, during resolution, giving place to exaggerated resonance, and the latter diminishing and ending in the normal vocal resonance. Collapse of Pulmonary Lobules in Con- nection -w^ith Bronchitis in Children, or Lobular Pneumonia. — Dulness on percussion, greater or less, and more or less diffused, often- est on the posterior surface of chest on both sides, with either diminution of respiratory mur- mur or feeble bronchial respiration. Mucous or subcrepitant rales on both sides. 26 Pulmonary (Edema. — Dulness or flatness on percussion more or less diffused over the posterior surface of the chest, on both sides. Subcrepitant, sometimes intermingled with crepitant, rale. Absence of respiratory murmur, or feeble broncho-vesicular respiration. No change as regards the situation of, or space over which the dulness extends, with change of position of the patient. Pulmonary Gangrene. — Dulness or flatness on percussion over a space more or less circum- scribed, oftenest over the scapula. Absence of respiration within this area, or bronchial respira- tion, together with, in some cases, either bron- chophony or increased vocal resonance. Mucous or subcrepitant rales within the area of dulness or flatness and its neighborhood. Cavernous signs may be present after the sloughing away of a circumscribed portion of lung. The signs of pneumo-hydrothorax become developed if perforation of the lung take place. Pulmonary Apoplexy.— Dulness or flatness 27 on percussion within a circumscribed space or in circumscribed spaces. Absence of respiratory- murmur within the limits of the extravasations, or bronchial respiration. Mucous or subcrepi- tant rales. Carcinoma of Lung. — The signs of solidifi- cation, greater or less in degree, and more or less diffused. Sometimes contraction of one side and lessened respiratory movement. Pulmonary Tuberculosis. — If the deposit of tubercle be abundant, dulness on percussion at the summit of the chest on one side, greater or less, with bronchial or broncho-vesicular respiration, bronchophony or exaggerated vocal resonance, whispering bronchophony or exag- gerated bronchial whisper, and increased vocal fremitus. Frequently, depression below the clavicle, and diminished respiratory movement in that situation. The signs of solidification may show a less amount of deposit at the other summit. Exceptionally, the signs may denote a tuberculous deposit at the base. A cavity, or 28 cavities, may be shown by cavernous respiration, amphoric respiration and voice, cracked metal or amphoric resonance on percussion, and gurgling. If the deposit be small or moderate, slight dulnesson percussion at the summit on one side, or sometimes a vesiculo-tympanitic resonance due to emphysematous lobuies in the neighbor- hood of the deposit, with diminished respiratory murmur, or a broncho-vesicular respiration, increase of vocal resonance, and exaggerated bronchial whisper. Accessory signs important in determining the existence of a deposit of tubercle, when the amount is small or moderate, are, mucous or subcrepitant rales, limited to the summit on one side ; a friction-murmur, crumpling or crackling sounds, interrupted or jerking respiration, limit- ed in like manner ; also, abnormal transmission of the heart-sounds, and a subclavian bellows murmur. Diaphrag-matic Hernia.— Tympanitic reso- 29 nance on percussion not otherwise explicable, with suppression of respiratory murmur, and the presence of the characteristic intestinal sounds. PHYSICAL SIGNS INVOLVED IN THE DIAGNOSIS OF AFFECTION OF THE HEART. Aortic Obstructive Lesions. — An organic endocardial murmur accompanying and follow- ing the first sound of the heart (systolic) ; loud- est at, or limited to, the base of the organ ; generally propagated into the carotid arteries ; its maximum of intensity in the second inter- costal space on the right side near the sternum, provided the normal relation of the aorta to the chest walls be preserved; the aortic second sound of the heart, as heard in the situation just designated, weakened or lost, if the aortic valves be damaged. ^ * An aortic direct murmur may be inorganic or anaemic. This is to be inferred when the murmur is variable in its in- tensity, or intermittent, unaccompanied by weakening of the aortic second sound, the heart not enlarged, and murmurs heard in the large arteries and in the veins of the neck. 30 Aortic Regurgitant Lesions. — An endocar- dial murmur accompanying and following the second sound of the heart (diastolic) ; loudest just below the base of the heart on the left side of, or over, the sternum, propagated thence downward toward the ensiform cartilage. The aortic second sound weakened in proportion as the aortic valves are defective. This murmur is frequent- ly conjoined with the aortic direct murmur. Mitral Regurgitant Lesions. — An endocar- dial murmur accompanying and following the first sound of the heart (systolic) ; loudest at, or limited to, the apex of the organ ; extending more or less to the left of the apex laterally around the chest, and heard at the lower angle of the scapula ; not propagated into the carotids. The aortic second sound of the heart weakened in proportion to the amount of regurgitation, and the pulmonic second sound (heard in the left second intercostal space near the sternum) intensified in proportion to the amount of hy- pertrophy of the right ventricle induced by the 81 mitral lesions. A mitral murmur, beginning with the first sound of the heart, does not always denote mitral regurgitation. Such a murmur may be distinguished as a mitral systolic mur- mur, or an intra- ventricular murmur. Mitral Obstructive Lesions. — An endocar- dial murmur not connected with the second sound of the heart, but preceding the first sound (proe-systolic), and abruptly arrested at the oc- currence of the first sound ; the murmur limited to a circumscribed space around the apex of the organ; the character frequently peculiar, re- sembling the sound caused by throwing the lips or tongue into vibration with the breath ot expiration. The pulmonic second sound of the heart intensified, if the mitral lesions have led to hypertrophy of the right ventricle. This murmur is frequently associated with the mitral regurgitant. It does not denote mitral lesions, in all cases, when it is associated with aortic regurgitant lesions. Tricuspid Regurgitation.— An endocardial 32 murmur with the first sound of the heart (systolic), heard within a circumscribed area at the lower part of the sternum. Frequently, if not generally, associated with pulsation or un- dulation in the jugular veins. Lesions at Pulmonic Orifice. — An endo- cardial organic murmur with the first sound of the heart (systolic), at the base of the organ, in the left second intercostal space ; not propagated into the carotids."^ Endocarditis in cases of Articular Rheu- matism. — An endocardial murmur, loudest at the apex of the heart, i. e., a mitral systolic murmur, developed (i. e. not having existed previously) in connection with articular rheuma- tism. Pericarditis. — A pericardial friction murmur * A pulmonic direct murmur is frequently inorganic or anaemic. This is to be inferred when the circumstances are present which have been mentioned in connection with an inorganic aortic direct murmur. 33 (exocardial), distinguished from an endocardial murmur by the following points: Conveying the idea of rubbing or friction ; apparently su- perficial ; usually two sounds for each beat of the heart; varying in intensity and character during auscultation; its relation to the heart sounds not definite, or the rhythm irregular; not propagated much, if at all, beyond the limits of the heart, and frequently limited to the super- ficial cardiac space ; intensified notably by firm pressure with the stethoscope ; disappearing, in some cases, during the stage of pericardial eff\i- sion, and finally ceasing after pericardial adhe- sions have taken place. Generally associated with endocardial murmur or murmurs. The existence and amount of pericardial effu- sion are shown by increased dulness or by flatness in the pericardial region, within a triangular or pyriform space, corresponding to the size and figure of the distended pericardial sac; the base situated a little below the level of the apex of the heart, and the summit extending toward or quite to the sternal notch ; the praecordia some- 3 34 times projecting, and the intercostal depressions pushed out ; the impulse of the heart lost, or, if appreciable, raised to the fourth or third inter- costal space; the heart-sounds weakened and distant ; the first sound short and val^irular like the second sound. In chronic pericarditis, with large effusion, the dilatation of the pericardial sac is shown by dul- ness or flatness extending laterally, more or less, from the prsecordia, on both sides of the chest, together with the other signs just mentioned. Hypertrophy of Heart or Enlargement with Predominant Hypertrophy. — The apex- beat lowered from the fifth intercostal space to the sixth, seventh, or eighth, according to the amount of enlargement, and often removed to the left of its normal situation one, two, or three inches. The apex-beat in some cases notably strong, but in other cases weak, in consequence of the change in form of the heart. Impulses in the intercostal spaces above the apex-beat, and these notably strong. Heaving movement of the whole of the 35 praBCordia, with more or less power. Enlarge- ment of the superficial cardiac space, as shown by percussion, and the degree of dulness notably greater than in health. The left margin of the heart extending without the left nipple, as deter- minable by deep percussion. The intensity, length, and booming quality of the first sound of the heart, over the apex or body of the organ, increased. If the hypertrophic enlargement exist without valvular lesions (which is rare), absence of or- ganic murmur. Enlargement of the Heart with Predo- minant Dilatation. — The fact of enlargement and its degree determined by the same signs as when the enlargement is due to predominant hypertrophy. The predominance of dilatation shown by feebleness of the apex-beat and of other impulses ; by absence of heaving of the prse- cordia, and by the diminished intensity of the first sound, and its being short and valvular like the second sound. Absence of organic murmur if valvular lesions do not coexist, which is rare. 86 Patty Degeneration of the Heart. — Per- sisting feebleness of the apex-beat or other im- pulses; weakness of the first sound, with short- ening, and valvular quality like the second sound, these signs not being referable to dilatation. 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