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Radiograph of a Healthy Child's Chest.
PHYSICAL DIAGNOSIS
OF
DISEASES OF THE CHEST
' y
BY
RICHARD C. CABOT, M.D.
PHYSICIAN TO OUT-PATIENTS, MASSACHUSETTS GENERAL HOSPITAL; ASSISTANT IN
CLINICAL MEDICINE, HARVARD MEDICAL SCHOOL
WITH ONE HUNDRED AND
FORTY-TWO ILLUSTRATIONS
NEW YORK
WILLIAM WOOD AND COMPANY
MDCCCC
B8774
ji.ibrfe.iy of OonciiHSM
OCT 31 1900
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SECOND COPY.
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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.
65
(b) 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. The
line along which we percuss, when approaching an organ whose bor-
ders ice desire to mark out, must neither approach the chest piece 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 he
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.
67
(c) Palpatory P
ercussion.
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.
Liver flatness.
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 Resonance of the Normal Chest.
The note obtained by percussing the normal chest varies a great
deal in different areas. In Pig. 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.
„^- Lower 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 air-
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
"flat" sound, flatness designating
the extreme of the qualities that
characterize dulness. Over the
parts shaded dark in Pig. 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.
Fig. 47.— Position of the Left
Lung in the Axilla.
Normal 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
PERCUSSION. 69
lightly shaded corresponds to that portion of the heart which is
overlapped by the margin of the right and left kings.
Over the portion of the heart not overlapped by the lnng (see
Fig. 46, p. 67) the percussion note is nearly flat to light percus-
sion, and very dull even Avhen 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, while 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 comes 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 we attempt to map out the deep cardiac dulness.
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 on 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 ensiform 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 dul-
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 scapulse 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 Ter cussing 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 dis-
tention brought about by the unusual 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
kings 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 on 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 Movah'dit y 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 below 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 palm
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 usually 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 auscultatory hands free for
percussing.
PERCUSSION. 75
(e) Amphoric Resonance.
A low-pitched hollow sound approximating in quality to tym-
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
Sum mary
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 scapulce, 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 Lung 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. Sexse 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 scapulae, 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).
(b) On grounds of cleanliness (although the chest may be cov-
ered with a towel so as to protect the auscultator to a certain
extent).
(c) Because we cannot conveniently reach the supraclavicular
or the upper axillary regions in this way.
(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 neve? yet learned to hear anything with my
unaided ear which 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. Nevertheless 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 case 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.
79
(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
Avhich 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.
Fig. 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 Stethoscojw.—fiee 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.
With 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.— Bowles 1 Stetho
scope. Front view.
Fig. 51. — Bowies'
Stethoscope.
Back View.
AUSCULTATION.
81
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 simnlate 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. 1 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.
6
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. Bowles' 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. 83
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 and What to Disregard.
Accordingly, the art of using a stethoscope successfully depends
upon the acquisition of two powers —
(a) A knowledge of what to disregard, (b) A selective atten-
Fig. 55.— Bowies' 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 qniet 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 recumbent 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 my 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. When 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 FHYSICAL 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.
AUSCULTATION. 87
Or close both ears with the fingers and strongly contract the rnas-
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. Bales 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-shapecl 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 over
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. (Stethoscope 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 ice should, in
fig.
Stethoscope Held Right 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 hi 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 hi 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
(b) 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 can despite his mistakes. When he cannot be made
to take a fnll 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 tabular 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 breathing is to be heard over the remaining portions of
the lung — that is, in the front of the thorax except where the heart
AUSCULTATION. 93
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 compared with
expiration.
94 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.
(3) The thickness of the up -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- Fig. 63.— Distant Vesicular Fig. 64. -Exaggerated Ve-
ing. Breathing. sicular Breathing.
stroke makes with the perpendicular as compared with that which
the down-stroke makes with the perpendicular. The pitch of a
roof may 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 —
(a) More intense.
(b) Longer.
(c) Higher pitched.
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 loudness 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-
ing of Moderate Intensity.
Fig.
—Distant Bronchial
Breathing.
Fig. 67.— Very Loud Bron-
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
quality 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 certam 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 pitGh 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. 61 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 " (" unbestimmt ") . 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.
97
moving. Expiration is a little longer, intenser, or higher pitched
than in vesicular breathing, and inspiration a little shorter, feebler,
A
Fig. 68.— Two Common Types of Broncho-
Vesicular Breathing.
Fig.
-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.
71. — Asthmatic Breathing. 8, s,
squeaking (musical) rales.
are usually obscured to a great extent by the presence of piping and
squeaking rales (see below) .
7
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
LtTC
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 Breathing.
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.
AUSCULTATION. 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 rales to the breath sounds themselves, we usually
notice that they are very feeble, especially over the lower two-
thirds of the chest. (Edema of the lung may diminish the breath
sounds in a similar way.
(77) Pain in the thorax, 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, 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 or 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).
(b) 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.
(d) 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-Yesicular 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. Amphoric Breathing (Amphora = A Jar).
Eespirations 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.g., in phthisis) or in pneumothorax,
i.e. } under conditions in which the air passes in and out of a large
empty cavity within 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. Bales.
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. 1 Rales are best classified as
follows :
(1) Moist or bubbling rales, including (a) coarse, (b) medium,
and (c) fine rales.
(2) Dry or crackling rales (large, medium, or fine) .
The smallest varieties of this type are known as " crepitant " or
" subcrepitant n 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 Riles 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 the
fingers of the observer. (See above, page 80.)
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 numer-
fig 74 — Expio- ous during inspiration and especially during the latter
sion of Fine part of this act. Their relation to respiration may be
(/inspiration, represented graphically as in Fig. 74, using large dots
for coarse rales and small dots for fine rales. Musical
rales can be symbolized by the letter S (squeaks).
(2) Crackling Rales.
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 which bubbling rales occur, but are more fre-
quent in tuberculosis than in simple bronchitis.
Crepitant rales, 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
! 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 rue 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 groaning sound, while narrowing of the finer tubes re-
sults in piping, squeaking, whistling noises of various qualities.
Such sounds are often known as " dry rales " in contradistinction
to the " bubbling rales " above described, but as many non -musical
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.
AUSCULTATION. 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. Pleural Friction.
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 fibrinous 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 may be compared to grazing,
rubbing, rasping, and creaking 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 wall. 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 simulate
pleural friction. In well-marked cases pleuritic friction can be
felt 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 manoeuvres suggested by Abrams 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."
(b) 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 or 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 fatigne 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 my opinion, a
more delicate test for solidification than tubular breathing. The
latter sign is present only when a considerable area of lung tissue
is solidified, while the increase of the whispered voice may be ob-
tained over much smaller areai. Eetraction 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.
Where 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. "Bronchophony," or the distinct transmission
AUSCULTATION. HI
of audible words, and not merely of diffuse, unrecognizable voice
sounds, is considerably commoner in the solidifications due to pneu-
monia than in those due to phthisis; it occurs in some cases of
pneumothorax and pulmonary cavity.
(c) Egophony.
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 Pneumohydrothorax and Pneu-
MOPYOTHORAX.
(1) Succussion.
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 "succussion." Such sounds are absolutely
diagnostic of the presence of both air and fluid 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 succussion 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 well as liquid, in the pleural cavity is absolutely essential to
the production of succussion sounds. 1
(2) Metallic Tinkle or Falling-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 pneumohy-
drothorax and pneumopyothorax.
(3) The Lung-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, hy 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 HEART.
I. "Valve Akeas."
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 near
the nipple, the "mitral area."
Aortic area.
Tricuspid area.
_J — 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 ; 1
while those which are most distinct near the origin of the ensiform
cartilage are produced at the tricuspid orifice.
II. The Normal Heart Sounds.
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 stiller.
In obese, indolent adults it is sometimes difficult to hear any heart
sounds at all, Avhile 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 describedo 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
118 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.
(c) Doubling of the first sound at the apex.
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 louder
than the aortic. In the next decade (from the tenth to the twen-
tieth year) the pulmonic second sound is louder in two-thirds of
the cases. About half of 207 cases, between the ages of twenty and
twenty-nine, showed an accentuation of the pulmonic second, while
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 cases examined. These facts are exhibited in tabular form in
1 Vierordt: "Die Messung der Intensitat der Herztone" (Tubingen,
1885). See also Hochsinger, "Die Auscultation des Mndlichen Herzens" ;
Gibson, "Diseases of the Heart" (1898) ; Rosenbach, "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.
Fig. T<
100
DECADES.
10-19 | 20-29 1 30-39 | 40-49 j 50-59 j 60-69 j 70-79;
-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 pulmonic second sounds are sometimes
DECADES.
-90%
-80%
~
m
30%-
20%—
10%-
Path ological Variations.
A. Accentuation of the Pulmonic Second Sound.
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 —
(a) 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.
(b) 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.
carditis, fatty degeneration, and 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 welLas 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 when 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 Soimds.
(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, ^ w — ', w w — ', ww — ', or of
this type : w — ' w, w — ' w ? s^ — ' w.
Doubling 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 n 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 pneumothorax 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 n 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. Souxds 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.
CHAPTEE VI.
AUSCULTATION OF THE HEAET : 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. Pericardial 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.
(d) 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
o ■
Fig. 80.— Diagram to Illustrate the Production of a Cardiac Murmur Through Stenosis of a
Valve-Orifice.
valves fail to close and so allow the blood to pass back through
them, we speak of the lesion as regurgitation, 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 136.)
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 hi 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
"presystolic " 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 n eared the
tricuspid orifice, and may be confirmed by the discovery of other
evidences of a double lesion. No diagnosis is satisfactory which
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 upon 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 Murmurs. — 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-
FlG. 83.— Mitral Regurgitation and Aortic Stenosis. The systolic murmur is loudest at the ex-
tremities of the shaded area and faintest at its
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-
mur, 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 down 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 valvular
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
ifc 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 pulmonic
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. 1
(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. Res-
piration, position, and exercise produce greater variations in them
than in " organic " murmurs.
(8) They are especially apt to be associated with ancemia,
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.g.,
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 Murmurs.
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.
VALVULAR LESIONS.
Clixicallt 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
tenclineae 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").
Valvula aemilun
sinistra a. prtlmonal
"Valvula semilunaris
riestra a. pnlmcmalis.
A"
Valvula semilunaris
" .posterior aortao
_}y. Cuspis
Valvula©
tricus-
pidalia
\
t —
<.__--
\
/
/
\
/
...J s.^--*
f >
'
\
y
\ ,
,-~
— K"
\ v
Fig. 84.— The Base of the Contracted Heart Showing Sphincteric 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.
(b) Those which produce leakage through a valve orifice or
prevent its closing effectively ("regurgitation," "insufficiency,"
11 incompetency ") .
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
(«) Deformity of a valve, or
(b) 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
Mitral curtains.
in all
Chordea
tendinese.
Papillary
muscle.
Circular or
— sphincteric
fibres.
— Endocardium.
Myocardium.
— Pericardium.
papillary muscles are
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; but 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.
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 both 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 without) dilatation.
I shall consider, then,
(a) The establishment and the failure of compensation.
(b) Cardiac hypertrophy.
(c) Cardiac dilatation.
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. 1
(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-
noea and precordial pain (angina pectoris) are more prominent.
HYPERTROPHY AND 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 (and 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.
(a) 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.
2 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 regurgitation, 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 Right 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 pulmonic second sound, which is often
palpable as well as audible.
The apex beat is displaced both to the left and downward, but
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 op 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 :
(a) Feebleness anal irregularity of the apex impulse and of the
radial impulse, (h) 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 "flapping" 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 right 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 ensiform 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 Regurgitation.
The commonest and on the whole the least serious of valvular
lesions is incompetency 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
Aveakening of the cardiac muscles may allow of a leakage through
the mitral, which ceases with 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
oedema of the lungs, and —
Fig. 86.
'-D/jtasa/Jftfta/
Fig. 87.
Fig. 86.— Normal Heart during Systole. Mitral valve closed ; blood flowing through the open
aortic valves into the aorta.
Fig. 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.
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.
Eeturning now to the signs of mitral regurgitation, 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 " hsemic " 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.
(b) Second Stage — Compensation Established.
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) A systolic murmur whose maximum intensity 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).
(b) 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:
(c) Enlargement of the heart as shown by inspection, palpation,
and percussion.
(d) Evidence of congestion of the lungs (dyspnoea, orthopncea,
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 common and 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 LESLONS.
155
Eeturning now to the details of the sketch just given, we will
take up first—
(a) The Murmur. — In children the murmur of mitral regurgita-
tion may be among the loudest of all murmurs to be heard in val-
lst
I
1st
2nd
±±
2nd.
J_L
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 k * tapers " off characteristically at the end. .
vular disease, but this doe's not necessarily imply that the lesion is
a very severe one. A murmur which grows louder under observar
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
IIM t
2nd
In 1 1 i 1
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 regurgitation, are said to point to a rela-
tively slight amount of disease in- the valve (see Fig. 90). Eosen-
lst
I
2nd
1st
1
2nd
Fm. 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).
(6) 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 valves.
(c) Enlargement of the heart, and more especially of the right
ventricle, is generally to be made out, and in the majority of cases
this 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. While 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.
(e) Third Stage — Failing Compensation.
When 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 pulmo-
VALVULAR LESIONS. 159
nary cederaa manifested by crackling rales at the base of the lungs
posteriorly, and possibly also by hsenioptysis 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-
gitation 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 pulmonic 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 pulmonic 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 " (Broaclbent). 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 regurgitation. 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
yte/i.
? _
.^ Complete
. solidification.
Partial
solidification.
_ —\~~ Rales.
Fig. 127.— Diagram of Signs 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.
(b) Slight increase in the intensity of the spoken and whispered
voice, and of the tactile fremitus (hi many cases)
1 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
(c) 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) Cardiorespiratory murmurs (vide p. 139) are occasionally
due 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
" consonating rales." Kales 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. When 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 which 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 diag-
1 The natural disparity between the two apices is less marked in the supra-
spinous 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 " (1866), 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.
feels perfectly well.
He
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 tympany may be transmitted to the
left lung and mask dulness there.
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 down as far as the fourth
Bronchial breath-
ing, dulness.
Increased fremitus.
Increased voice
sounds.
Fig. 129.— To Illustrate Progress of Signs 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.
Cavity 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
in 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 :
(a) Amphoric or cavernous breathing.
(b) " Cracked-pot resonance " on percussion.
(c) Coarse, gurgling rales.
(a) Cavernous or Amphoric Respiration. — When 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 of air.
BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 255
(b) 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 {e.g., in percussing the chest of a
healthy, crying baby, and occasionally over solidified lung).
(c) 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 intermitte7ice 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.
Fibro id Fh th is is .
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
surrounding 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
maybe 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 with Predominant Pleural Thickening.
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).
Emphysematous Form of Phthisis.
Tubercle bacilli are not very infrequently found in the sputa of
cases 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 icith 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
lingula pulmonalis 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,
(b) 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 simply
those of general bronchitis.
17
CHAPTER XII.
EMPHYSEMA, ASTHMA, 'PULMONARY SYPHILIS, ETC.
I. Emphysema.
For clinical purposes, the great majority of cases of eniphy-
senia may be divided into two groups.
(1) Large-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 Ave 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 Ludwig 1 becomes prominent. The shoulders are
high and stooping and the neck is short (see Eig. 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 manubrium 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 cui-
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.
Palpation 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.
(b) 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 emfeeblement 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
illustrate ^mphyse- the boundaries of the lung are not extended,
matous Breathing expiration is less prolonged and less difficult,
with Musical Expira- \ . . . _ Tl , , . '
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 pneumothorax, 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
pneumothorax 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.
(d) The occurrence of an emphysematous form of phthisis I
have already mentioned in discussing the latter disease (see p. 256).
Emphysema ivith 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 coniplenientary 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 in the area of dulness
corresponding to them), but the respiratory murmur is exaggerated
and has none of the characteristics of emphysematous 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
tympanitic 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, i
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
BKONCHIAL 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
rales 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 dyspnoea, 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 suggested 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 arid 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 Lung.
(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 PLEUKAL CAVITY.
I. Hvdrothorax.
In cases of nephritis or of cardiac weakness due to valvular
heart disease a considerable accumulation of serum 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-
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 Pneumothorax.
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, fremitus is preserved.
The positions of the heart and liver are among the most impor-
tant points determined by palpation. Not 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 tympanitic 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 snch 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 ;
{ absent voice ;
-Air= < breathing ab-
Displacedcardiac """ j\ [t^ZJ^(^/\ f^^T^ll] A ' ( sent or distant
impulse. \ K\~V y/\ /\V vy7 / ' I amphoric.
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 "closed 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. 262).
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.
(c) 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.
(b) 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.
PLEURISY.
Clinically, we deal with three types :
(a) Dry or plastic pleurisy.
(b) Pleuritic effusion, serous or purulent.
(c) Pleural thickening.
(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 fibrinous 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 fibrinous 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 fibrinous 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 up
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 without
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 pleural
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.
Muscle sounds are sometimes taken for pleural 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 pleural 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.
(b) In the left axilla between the fifth and the eighth rib.
(c) Obliterating Traube's semilunar area of tympany; or
(d) In the right front near the angle made by the cardiac and
hepatic lines of dulness (see Fig. 134).
18
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. "^-^
-1 Area of cardial
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 tympanitic 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 tympanitic 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
fremitus in-
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 npon 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. Near the spine and
near the sternum (in right-sided effusions) the line corresponding
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-
Triangular space
dull until patient
has coughed and
breathed deeply.
Area of dulness
bounded 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. x
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. TTe 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 abo\'e, 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 pleural effu-
sion ; also that the size of the tympanitic space varies greatly in
health.
(d) Rarely percussion may be tympanitic 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 kings 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 voice 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 lung retracted,
and the chest walls thin, the breathing, voice, and whisper will corre-
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
Near 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.
Kales 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. Eight-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
'Bacelli'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 Auscultatory Signs.
(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.
(6) 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.
Right-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 fremitus 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, 1 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 JEffusions.
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
(c) Pleural Thickening.
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 pleural membrane
with adhesion of the costal and visceral layers may be manifested
by the following signs :
(1) Dulness on percussion, sometimes slight, sometimes marked.
(2) Diminished vesicular respiration.
(3) Diminished voice sounds and tactile fremitus.
(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.
Encapsulated Pleural Effusion.
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 Necessitatis).
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 wall 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 neighboring 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 pleural 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 tc
multiple abscesses to be mistaken for empyema. 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 stermim (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.
(d) 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 OE THE LUNG,
PULMONARY ATELECTASIS, (EDEMA, AND HYPO-
STATIC CONGESTION.
Abscess axd Gangrene of the Lung.
I consider these two affections together because the physical
signs, exclusive of the sputa, clo 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
no physical signs by which we can distinctly localize the process.
Maligxaxt Disease of the Luxg.
In its earlier stages this affection is often mistaken for empy-
ema or serous effusion in the pleural 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
pleural 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
(5) In most normal individuals a certain degree of atelectasis
of the margins of the lungs may be demonstrated in the following
way : 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 arrays 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) ~S\ "hen 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, GEDEMA, 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.
(Edema 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. No 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 Pneumonia.
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.
(b) Feeble or absent tactile fremitus.
292 PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.
(c) 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. Mediastinal 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 luindjjipe or primary bronchi.
(c) The large venous trunks.
{d) Nerves which pass through the mediastinum.
(e) The subclavian arteries.
(/) The heart.
(g) 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
down 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 maybe due to press-
ure on the subclavian artery.
(/) Occasionally the heart itself may be pushed out of place.
{g) 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.
D iffe i •ential 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 ansemia 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. Mediastinitis.
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 Mediastinal 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 pulmonic 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
trinity 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-souncl 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 owing 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 two 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, while the impressions gained from the fluoroscope are more
apt to be modified by the personal equation.
For the present, therefore, we 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 well as be-
yond the limits of this book ; but whatever form of instrument is
used, the vacuum in the tube should be less perfect when we desire
to use it for the chest than when searching for foreign bodies or
studying fractures. We need a "low " or " soft " tube which gives
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 tlte
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.
I. The Use of the Fluoroscope.
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 completely, 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 Litten'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 se-rays when no other
RADIOSCOPY OF THE CHEST.
301
Chest of Healthy Boy aged
nine years.
Incipient Phthisis at Right Chest of Healthy Adult.
Apex.
Advanced Phthisis (cavity?). Advanced Phthisis. Bilateral Phthisis at Apices.
Advanced Phthisis.
Advanced Phthisis.
Pulmonary Emphysema.
n
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 aroused 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-
physema and Fat Chest Walls. — Emphysema spoils cardiac percus-
RADIOSCOPY OF THE CHEST.
303
sion and interferes with inspection and palpation. Bnt 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 arrays 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 Littems 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. TVe 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,
ansemia, debility, and convalescent typhoid, appearances very simi-
lar to those of tuberculosis may be found (Williams). Hence the
intrepretation of slight lung shadows 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
Roentgen rays except where extensive excavation has occurred;
here we see a light area in a dark background (see Fig. 138).
Xo 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 arrays 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 when 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 pocition 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
with 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 sphygmograph as an in-
strument of precision, and although it is capable of recording tiny
secondary waves impalpable 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, 26
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 (see Respiration), 16, 21,
23, 92
Broadbent, 161, 217
Bronchial (see Tubular)
breathing, 95, 102, 239, 280
Bronchiectasis, 264
Bronchitis, 233, 245'
Cancer of lung, 291
Capillary pulse, 38, 172
Cardiac (see Heart)
impulse, 23, 42
displacement of, 29, 281
character of, 148
Cirrhosis of the lung, 265
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, 164, 225
Dilatation, cardiac, 146, 199
Ductus arteriosus, persistence of, 207
Dyspnoea, 18
Egophony, 111
Emphysema, 258
complementary, 262
interstitial, 262
large-lunged, 258
308
INDEX.
Emphysema, senile, 258
with bronchitis, 261
Empyema, 283, 28-4
Endocarditis, acute, 296
chronic, 151
Epigastric pulsation, 82
Expansion, 16
diminished, 17
increased, 18
Eattt degeneration, 201
overgrowth, 201
Flattening of the chest, 14
Eoramen ovale, patency of, 207
Fremitus, tactile, 44
vocal, 109
Friction, pleural, 107, 271
pericardial, 209
Gangrene of lungs, 290
Glands, 41
ILemic murmurs, 136
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
Hydropericardium, 219
Hydrothorax, 266
Hypertrophy, cardiac, signs of, 146
Hypostatic congestion of lung, 293
Infants, examination of, 297
Jaundice, 40
Litten, 23
Lung reflex, 76
Lungs, abscess of, 290
cancer of, 291
diseases of, 233-293
emphysema of, 258
fistula-sound, 112
gangrene of. 290
oedema of, 293
Mediastinal tuberculosis, 296
tumors, 293
Mediastinitis, 216, 295
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 haemic, 136
venous, 139
Muscle-sounds, 84
Myocarditis, acute, 199
chronic, 201
Neuroses, cardiac, 202
(Edema, 235, 293
Pallor, 40
Palpation, 42
Palpitation, 205
Paralytic chest, 8
Parietal disease (see Myocarditis), 198
Percussion, 58
auscultatory, 65
immediate, 58
mediate. 58
palpatory, 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, 268
Pneumothorax, 111, 266
Pulmonary abscess, 290
atelectasis, 104, 292
emphysema, 258
gangrene, 290
oedema, 293
regurgitation, 192
stenosis, 193
tuberculosis, 245
tympanites, 262
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, 95
broncho-vesicular, 96
Cheyne-Stokes, 22
cogwheel, 98
diminished, 100, 279
emphysematous, 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 fremitus
44
(see Fremitus) ,
310
INDEX.
Tension of the pulse, 53
Thrills, 43
in aneurism, 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
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