Presented by 
 Dr Piggott 
 
 COLLEGE OF OSTEOPATHIC PHYSICIANS 
 AND SURGEONS LOS ANGELES, CALIFORNIA 
 
 ^
 
 If*
 
 /TABULAR HANDBOOK 
 
 AUSCULTATION AND PERCUSSION^ 
 
 ano 
 
 BV 
 
 HERBMT C. dl\PP, A.M., M.D. 
 
 PROFESSOR Of DISEASES i^JHE\CHEST IN THE BOSTON UNIVERSITY SCHOOL OF MEDICINE, AND 
 ND LUNGS DEPARTMENT OF THE COLLEGE DISPENSARY. 
 
 ITH FOUR PLATES. 
 
 m esse meditia sine atisculttitione et percitssione." 
 
 CORVISART. 
 
 FIFTH EDITIOK. 
 
 BOSTON AND NEW YORK : 
 HOUGHTON, MIFFLIN AND COMPANY. 
 tbtr)StlrE ^rcs'i, Camirttrge. 
 1886. 
 
 t>.
 
 u C 58 
 
 
 Copyright, 1878, 
 BT HERBERT C. CLAPP, 
 
 RIVERSIDE, CAMBRIDGE: 
 
 ILECTROTYPED AND PRINTED BY 
 
 H. 0. HOCGHTON ANJ> COMPANY.
 
 PREFACE. 
 
 IN the preparation of this little book, I have con- 
 sulted the works and compared the views of many 
 who have been eminent in the physical exploration 
 of the chest, such as Laennec, Avenbrugger, Corvi- 
 sart, Piorry, Skoda, Barth and Roger, Walshe, Hope, 
 Stokes, Fuller, Grisolle, Bennett, Latham, Flint, Bal- 
 four, Hayclen, Ziemssen, Fothergill, and Loomis, and 
 here desire in a general way to acknowledge my in- 
 debtedness to them, as it has seemed impossible to do 
 so in the text in each instance. 
 
 Since the illustrious Laennec discovered the art of 
 auscultation in 1816, very many investigations have 
 been made and much has been written on the sub- 
 ject. While on the one hand it is perfectly surpris- 
 ing how little the master mind of Laennec left to be 
 done, and how many of his descriptions, classifications, 
 and meanings of sounds still remain unimproved upon 
 in spite of sharp criticism, yet on the other hand, as 
 would naturally be expected, other experimenters 
 since have discovered new facts, and by a wider ex- 
 perience have been able to point out more or less 
 error here and there in the works of the father of 
 auscultation. I have endeavored to give, arranged in 
 tabular form, a condensed summary of the most au- 
 thentic observations down to the present time. 
 
 S'65
 
 iv PREFACE. 
 
 As to the theories of the mechanism of the produc- 
 tion of some of the sounds, there has been a great 
 deal of controversy, in which Skoda with his " con- 
 sonance " and " tension " and ojther theories has taken 
 quite a prominent part. Those theories have been 
 given in the following tables which seem most rational 
 and which are at present most generally accepted. 
 
 In the nomenclature of the physical signs, care has 
 been taken not to use those terms which merely ex- 
 press somebody's theory of their mode of production, 
 Skoda's " consonating rale," for instance, is a very 
 ill-advised term, as the theory of consonance is far 
 from being universally accepted, and no one who re- 
 jects the theory would like to use such a term. 
 Even the common term " mucous rale " has been 
 made to give place to the much more expressive 
 " bubbling rale^" which does not imply that it is 
 always caused by mucus, but leaves room for its pro- 
 duction sometimes also by pus, serum, softened tuber- 
 cle, etc. 
 
 To avoid confusion, and for the convenience of 
 those who may have become familiar with some par- 
 ticular authority, many of the synonyms have been 
 added in small type in parentheses. 
 
 In determining what classification to follow, it has 
 been thought desirable to avoid the excessive and 
 complicated refinements of some authors, without, on 
 the other hand, losing sight of the necessity for suffi- 
 cient thoroughness. 
 
 There has been an effort to make the arrangement 
 of material in the following tables so systematic, that 
 any special point needing investigation can be imme- 
 diately referred to, without a tedious and laborious
 
 PREFACE. v 
 
 search through many pages and perhaps many vol- 
 umes. The condensed tabular arrangement will be 
 found especially advantageous also in differential di- 
 agnosis, as it brings into such close juxtaposition in- 
 formation which is usually widely scattered, rendering 
 comparison easy, point by point. 
 
 Studied in connection with Chapter IV. of Da 
 Oosta's excellent work on Diagnosis, with its graphic 
 descriptions and convenient, helpful diagrams, these 
 tables will probably furnish the student with all that 
 is really necessary in the majority of cases coming 
 under observation. If, however, he desires to make 
 a special study of the subject, he is referred to the 
 two large and valuable treatises on the " Diseases 
 of the Respiratory Organs " and " Diseases of the 
 Heart," written by Dr. Austin Flint of New York, 
 who is probably the greatest authority on the phys- 
 ical diagnosis of such diseases in this country, and to 
 whom I desire to acknowledge myself especially in- 
 debted. It should be remembered, however, that the 
 pathology of these works is not quite up to date. 
 
 It is also hoped that this handbook may be found 
 useful by physicians in active practice. It is hardly 
 to be expected that practitioners who do not make a 
 specialty of lung and heart diseases, even if they 
 have at some time carefully studied into the subject, 
 and have been well posted, can retain in their memories 
 for 'immediate use at all times every point necessary 
 for a delicate physical diagnosis. If the case be at 
 all obscure, they feel the necessity of consulting some 
 authority. In such emergencies, the busy doctor may 
 appreciate such a time and labor saving contrivince 
 as the present. It often needs only a word here and 
 there to revive memories of extensive reading.
 
 vi PREFACE. 
 
 It is very doubtful if at this late day any well edu- 
 cated physician could be found to despise the value 
 of auscultation and percussion as aids to diagnosis. 
 Such a contempt would at once stamp the man who 
 showed it as an ignorant pretender. But there are 
 many who do not feel thoroughly at home in this 
 branch, and on account of too slight practical ac- 
 quaintance with it, and lack of time or inclination 
 for a laborious research into its theory, prefer to trust 
 for the most part to the symptoms alone rather than 
 to the uncertainties (to them) of physical signs. 
 Here most truly " a little knowledge is a dangerous 
 thing." For if the practitioner, finding jerking res- 
 piration, for example, in a given case, knows that 
 jerking respiration is a sign of phthisis, and does not 
 remember that it may be a sign of several other dis- 
 eases too, and on the strength of this sign alone diag- 
 nosticates the case as phthisis, it would, indeed, be far 
 better for him to have known nothing whatever of 
 auscultation and percussion, and to have been guided 
 entirely by the symptoms. It is such partial knowl- 
 edge, to say nothing of the utter ignorance of others, 
 that has to some extent brought auscultation and per- 
 cussion into disrepute in certain places. 
 
 It is very desirable to have a proper appreciation 
 of the comparative value of physical signs and symp- 
 toms, without enthusiastically overestimating either. 
 He who trusts to symptoms alone for his diagnosis of 
 heart and lung diseases will very, very often be led 
 astray. On the other hand, the mistake may be made 
 in the opposite direction of placing too exclusive reli- 
 ance on physical signs alone. In fact, they must be 
 taken together and complement each other. If they
 
 PREFACE. vii 
 
 are, and proper attention is paid to the history of 
 each case, and also to its well-known pathological 
 laws, an accurate diagnosis can be made in the great 
 majority of instances. 
 
 When speaking of heart diseases, Da Costa says : 
 " A knowledge of the physical signs is the solid 
 foundation, without which any structure that may be 
 reared will soon tumble to pieces." 
 
 In fact, the symptoms of heart disease are compara- 
 tively insignificant. Quite so much cannot be said of 
 the comparative value of signs and symptoms in lung 
 diseases ; but even here the great importance of the 
 former is attested by the immense strides which have 
 been made in the diagnosis of such affections since 
 the discovery of the present methods of physical ex- 
 ploration, which would have been utterly impossible 
 before. 
 
 The plates have been reproduced (with slight alter- 
 ations), by the " direct transfer " process, from the 
 " Hand bud i und Atlas der topographischen Percus- 
 sion," by Professor Weil of Heidelberg, published 
 at Leip/ig in 1877. 
 
 H. C. CLAPP. 
 
 BOSTON, ('totx'r 3, 1878.
 
 CONTENTS. 
 
 VAtt 
 
 INTRODUCTION. xi 
 
 PAET I. 
 
 TABLE NO. 1. 
 
 RESPIRATION IN HEALTH. 
 
 Vesicular, puerile, senile, and tracheal or laryngeal .... 20 
 
 TABLE NO. 2. 
 
 RESPIRATION IN DISEASE. (1.) ABNORMAL INTENSITY. 
 Exaggerated, feeble, and suppressed .22 
 
 TABLE NO. 3. 
 
 RESPIRATION IN DISEASE. (2.) ABNORMAL RHYTHM. 
 Jerkiug respiration and prolonged expiration 24 
 
 TABLE NO. 4. 
 
 RESPIRATION IN DISEASE. (3.) ABNORMAL QUALITY AND PITCH. 
 Bronchial, broncho-vesicular, cavernous, and amphoric .... 26 
 
 TABLE NO. 5. 
 RALKS. 
 
 I. Tracheal and laryngeal ; dry and moist 30 
 
 II. Bronchial ; dry (sonorous and sibilant), and moist (coarse and fine 
 
 bubbling and subcrepitant) ....... 30 
 
 III. Vesicular ; crepitant ...... 34 
 
 IV. Cavernous ; gurgling ......... 34 
 
 TABLE NO. 6. 
 
 MORBID PLEURAL SOUNDS. 
 
 Friction sounds, metallic tinkling, and splashing 36
 
 X CONTENTS. 
 
 TABLE NO. 7. 
 THE VOICE IN HEALTH. 
 
 Tracheal or laryngeal voice and whisper, normal thoracic vocal reso- 
 nance and fremitus, and normal bronchial whisper .... 40 
 
 TABLE NO. 8. 
 THE VOICE IN DISEASE. 
 
 Suppressed, diminished, and increased vocal resonance and fremitus, in- 
 creased bronchial whisper, broncho phony and whispering bron- 
 chophony, cavernous whisper, amphoric voice and whisper, pec- 
 toriloquy and whispering pectoriloquy, aegophony, and metallic tink- 
 ling 42 
 
 TABLE NO. 9. 
 PERCUSSION SIGNS. 
 
 Normal vesicular resonance, flatness, dullness, and tympanitic, exag- 
 gerated, amphoric, and cracked-metal resonance 46 
 
 PART II. 
 
 TABLE NO. 10. 
 THE PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNGS. 
 
 Acute and chronic pleurisy, empyema, hydrothorax, pulmonary oedema, 
 pneumo-hydrothorax, pnoumothorax, emphysema, asthma, bron- 
 chitis, capillary bronchitis, plastic bronchitis, croupons pneumonia, 
 catarrhal pneumonia, chronic pneumonia, acute miliary tuberculo- 
 sis, phthisis, dilatation of bronchi, carcinoma of lung, and intra-tho- 
 racic tumors, especially aneurism 54 
 
 TABLE NO. 11. 
 THE PHYSIC \L DIAGNOSIS OF DISKASES OF THE HEART. 
 
 The healthv heart, pericarditis, emlocarditi-. hypertrophy of the left and 
 rierht h"art, dilatation, valvular lesions of the left heart (aortic ob- 
 struction and rejruriritation. and mitral obstruction and regurpita- 
 tion). and of the risrht heart (pulmoni- o!, ^motion and repurgita- 
 tion, and tricn<pid obstruction and re.u'U rjritation), fatty degenera- 
 tion, and cardiac neuroses ........ 78
 
 INTRODUCTION. 
 
 PATHOGNOMO^TIC physical signs are exceedingly 
 rare. It is not true that each disease has belonging 
 to it one or more individual signs like labels, which 
 are always associated with it and no other. The no- 
 menclature of diseases is not so rigidly prescribed by 
 nature as it would be in such a case. Physical signs, 
 instead of representing individual diseases, represent 
 merely physical conditions which may be common to 
 several diseases. For instance, dullness on percus- 
 sion, bronchial or broncho-vesicular respiration, bron- 
 chophony, and increased vocal fremitus in combina- 
 tion would indicate solidification of the lung, but 
 they do not tell us on what the solidification depends. 
 It may be pneumonia, it may be phthisis, it may be 
 collapse of pulmonary lobules, it may be lung tissue 
 compressed by a pleuritic exudation. The disease, 
 the particular cause of the solidification, we have to 
 reason out from the presence or absence of other 
 physical signs, from our knowledge of pathology, and 
 from the history and symptoms of the case. 
 
 Before beginning the study of auscultation and per- 
 cussion, the student should be thoroughly posted in 
 the anatomy and physiology of the organs of respira- 
 tion and circulation. Then naturally follows the to- 
 pography of these organs. As an aid in constantly
 
 Xll INTRODUCTION. 
 
 keeping before the mind this topography, which is of 
 very great importance, especially in the diagnosis of 
 heart diseases, the plates have been added to this vol- 
 ume, and should be carefully studied and often re- 
 ferred to. The details of pictorial illustrations are 
 easier for most persons to remember than long verbal 
 descriptions, no matter how accurate they may be. 
 
 For convenience in localizing, recording, and com- 
 paring signs, the surface of the chest has been mapped 
 out into anterior, lateral, and posterior regions, right 
 and left, as follows : 
 
 ANTERIORLY The supra-clavicular region, extend- 
 ing from the clavicle upwards a distance varying from 
 half an inch to an inch and a half; clavicular, the 
 space occupied by the clavicle ; infra-clavicular, be- 
 tween the clavicle and the third rib ; mammary, be- 
 tween the third and sixth ribs; infra-mammary, be- 
 low the sixth rib ; supra-sternal, the hollow space 
 above the sternum ; superior-sternal, under the ster- 
 num above the third rib ; inferior-sternal, under the 
 sternum below the third rib. 
 
 LATERALLY The axillary region, having for its 
 lower boundary a horizontal extension of the lower 
 boundary of the mammary region ; infra-axillary, be- 
 low this line. 
 
 POSTERIORLY The scapular region, the space oc- 
 cupied by the scapula, extending also to a homont'l 
 line drawn through its lower angle ; infra-sen fiitl'ir, 
 below this line to the twelfth rib ; inter-scapular, be- 
 tween the inner margin of the scapula and the spinal 
 column. 
 
 It is very essential that the healtJnj sounds of aus- 
 cultation and percussion should become thoroughly
 
 INTRODUCTION. xiii 
 
 familiar to the student before he spends much time 
 on the morbid sounds. And yet, there is a constant 
 tendency to hurry over and neglect the former for 
 the sake of getting at the practical work of the lat- 
 ter. No one would undertake to tune a piano without 
 being so familiar with the true tones that he could 
 recognize the least departure from them. Very often 
 in the most important cases brought to the physician, 
 where there is the greatest desire for information, as, 
 for example, in the detection of the very beginnings 
 of phthisis, the deviations from the normal sounds are 
 so slight as to be entirely disregarded by those who 
 do not know by practice exactly what the normal 
 sounds in the different regions of the chest ought to 
 be. And even where one thinks he knows this, con- 
 stant reference to the healthy standard is necessary. 
 
 Auscultation is said to be immediate when the un- 
 assisted ear is applied to the chest of the patient, and 
 mediate when a stethoscope is used. Both methods 
 are in use, and it is very desirable to become practi- 
 cally familiar with each. Some physicians think that 
 they can hear as well with the unassisted ear as with 
 the stethoscope ; but the great majority of those who 
 have much to do with auscultation give a very de- 
 cided preference to that instrument. Those who have 
 used a stethoscope for any considerable length of 
 time very seldom like to give it up. It is often pref- 
 ernble on grounds of delicacy when examining 'lady 
 patients, and the avoidance of too close contact which 
 it insures is certainly pleasanter to the examiner, 
 when the patient happens to be at all uncleanly. 
 Besides, it can be applied to certain places (such as 
 the hollow over the clavicle, for instance) to which it
 
 xiv INTRODUCTION. 
 
 is difficult or impossible to adjust the ear. With it, 
 also, particular sounds, which we may wish to locate 
 definitely and to hear as far as possible unmixed with 
 others (as, for instance, valvular murmurs), can be 
 circumscribed. With Cammanns double or binaural 
 stethoscope, which is the best, the sounds are intensi- 
 fied and made more distinct, and some are rendered 
 audible which would be inappreciable to the unassisted 
 ear. At first, until one gets accustomed to it and 
 learns how to use it, there is a disagreeable humming 
 or buzzing which is very confusing, but this soon 
 passes off. The pectoral extremity should be closely 
 applied with moderate pressure, and the edges should 
 fit the skin exactly all around, not being tilted up at 
 one side to allow the air to enter. The room should 
 be quiet and there should be no friction between the 
 stethoscope and the clothing. Stiff hair on the chest 
 tinder the instrument often occasions a sound which 
 might be confused with the crepitant rale. Beginners 
 almost always get the ear-pieces in the wrong way. 
 They should follow the direction of the auditory canal. 
 The stethoscope should be applied to the bare skin. 
 When the unassisted ear is used, it is pleasante/ to 
 have over the chest one thickness of soft cloth, like 
 the undergarment, or a towel. When an accurate ex- 
 amination in a doubtful case is desired, it is utterly 
 impossible to make it without removing the most, if 
 not all, of the clothing from the chest ; and the man 
 who, in such a case, gives two or three raps, puts his 
 head down over a stiffly starched shirt or creaking 
 corsets or rustling silk, and then solemnly and oracu- 
 larly pronounces an opinion, is generally acting igno- 
 rantly or dishonestly by his patient. It might almost
 
 INTRODUCTION. xv 
 
 be said that if the intra-thoracic noises are all so loud 
 that they can be heard above the noise which the 
 outside clothing makes, it is not of very much im- 
 portance to the diagnosis that they be heard at all, 
 for in such conditions the symptoms are generally 
 enough. The great danger in listening through all 
 the clothing is that of not hearing (or mixing up) deli- 
 cate and important signs. In many cases, where the 
 problem is to decide whether or not phthisis is pres- 
 ent, it is sufficient to unbutton the upper part of the 
 clothing and turn it aside so as to expose the infra- 
 clavicular regions for examination, as phthisis gener- 
 ally attacks these regions first. But even here, if no 
 deposit be found, particular thoroughness demands a 
 further search. 
 
 In immediate auscultation it is advisable to close 
 one ear with the finger to exclude outside noises, 
 and particularly when studying vocal phenomena. In 
 the latter case, besides, the patient should turn his 
 head to one side and put his hand up to his mouth to 
 prevent the auscultator's confusing his voice com- 
 ing directly from the mouth with the vocal resonance 
 coming through the chest. The auscultator should 
 also avoid stooping over too much when listening, as 
 the congestion of blood caused by such a position 
 dulls somewha t the acuteness of hearing. Unless too 
 weak, the patient is best examined in the sitting post- 
 ure, with his arms hanging down for the anterior 
 portion of the chest, raised and crossed over his head 
 for the lateral regions, and crossed with the body bent 
 forwards for the posterior regions. Generally he has 
 to be instructed to breathe harder than usual, and often 
 has to be shown how to breathe properly. In children
 
 xvi INTRODUCTION. 
 
 it is easy to judge of the vocal resonance when they 
 cry. Finally, one side of the chest should be con- 
 stantly compared with the other, portion by portion. 
 
 Percussion, as a method of diagnosticating disease, 
 was discovered by Avenbrugger, whose researches 
 were published at Vienna in 1761. They attracted 
 but little attention, however, until Corvisart fifty 
 years afterwards translated them into French and in- 
 troduced the practice into the French hospitals. Per- 
 cussion, like auscultation, is both immediate and medi- 
 ate. The immediate (which was the only method 
 known to Avenbrugger and Laennec), where the chest 
 was struck directly by the fingers, is now never re- 
 sorted to, having been entirely superseded by the 
 invention by Piorry of mediate percussion, which 
 interposes some solid substance, called a pleximeter, 
 between the chest and the percussing agent. For 
 this purpose, little plates of ivory or wood with han- 
 dles have been used, or a flat piece of common elastic 
 India rubber. The best pleximeter, however, is a 
 tapering cylinder of hard rubber or gutta-percha 
 about two inches long, flanging at each end, one cir- 
 cular end-piece being smaller than the other for ap- 
 plication to the intercostal spaces and supra-clavicular 
 regions, the body of the cylinder (which is applied 
 to the chest at right angles) making an excellent 
 handle. The best percussor is a little hammer with 
 a hard rubber rod or handle which can be detached 
 from the head, which is madje of brass and tipped 
 with soft rubber. Most physicians use for a plexime- 
 ter the left middle or forefinger, with its palmar sur- 
 face applied to the chest, and for a percussor the right 
 middle or forefinger (or both together), bent so as to
 
 INTRODUCTION. xvii 
 
 strike at a right angle. Although it takes considera- 
 ble time and practice to become really expert in per- 
 cussing with the fingers, much more than with the 
 instruments just described, yet everybody should 
 learn this method, as it is a very valuable one, and 
 the instruments cannot always be at hand to be de- 
 pended upon. Where one has a great deal of per- 
 cussing to do, however, he generally prefers the in- 
 struments, as so much pounding on the back of the 
 finger used as a pleximeter is apt to make it sore. 
 Besides, the instruments bring out the sounds more 
 distinctly, especially for purposes of demonstration to 
 others. 
 
 Unless the patient is really obliged to lie down, he 
 should be percussed in the sitting or standing posture, 
 with his arms placed as already described for aus- 
 cultation, the examiner being directly in front. The 
 two sides should be percussed at the same stage of 
 respiration, as the expanded^ lung occupies more room, 
 pushing down the liver and spleen and pressing more 
 in front of the heart ; the difference between a full 
 inspiration and a deep expiration being very consid- 
 erable. 
 
 Since we draw our inferences as to the condition 
 of the lungs from the comparative sound in differ- 
 ent parts of the chest rather than from the absolute 
 sound, this varying somewhat in different individu- 
 als, it is important to strike, immediately after each 
 other and with the same force, portions on one side 
 which correspond as nearly as possible to portions 
 on the other side. Four or five raps in succession 
 are best, and should be quick and sharp rather than 
 slow and heavy. More forcible blows are required to
 
 xvni INTRODUCTION. 
 
 elicit the sounds of deeply seated than of superficial 
 portions. The finger or pleximeter should be applied 
 firmly on the spot to be examined, and with precisely 
 the same amount of firmness on the corresponding 
 spot on the other side. 
 
 The pressure should be sufficient to condense the 
 soft parts on the outside of the chest. Percussion 
 should be performed by a movement of the wrist 
 alone, the arm and forearm remaining motionless. It 
 would be well for the beginner to commence by per- 
 cussing the right infra-clavicular region in a healthy 
 subject, and to contrast the vesicular resonance found 
 here with the flatness of the liver. Next he might 
 try to bring out the proper sound of that part of the 
 liver which lies underneath the lung. After becoming 
 practically familiar with all the sounds in the different 
 regions in health, he can try, as a final test of his 
 powers, the deep cardiac space. If he can bring out 
 the sounds of that satisfactorily, he may consider him- 
 self proficient. 
 
 Heart-sounds. In health there is no difficulty in 
 telling by auscultation which is the first and which 
 the second sound of the heart by the rhythm and 
 the distinctive characters of the two sounds at the 
 apex and base ; and generally it is easy to decide the 
 question in the same way if the heart is diseased, 
 when it is desired to know whether a murmur is sys- 
 tolic, presystolic, or diastolic. But sometimes it is 
 impossible or difficult to do so. In such cases, if the 
 apex-beat can be felt, this being synchronous with the 
 first sound, the problem is at once solved. If it can- 
 not be felt, the radial pulse will settle the point, or 
 still better the carotid, which is more nearly synchro- 
 nous with the first sound of the heart.
 
 1. 
 
 ~ ct+v*** 
 
 6CO'^6t^>c
 
 ff
 
 PART I. 
 PHYSICAL SIGNS.
 
 20 
 
 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 1. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 VESICULAR RESPIRATION. 
 (Pulmonary.) 
 
 Inspiration. 
 A soft, diffused sound of a breezy character, grad- 
 ually developed and continuous. Increased in in- 
 tensity with the rapidity and force of respiration, 
 and prolonged by a full inspiration. Low pitch. 
 
 Expiration. 
 Not vesicular, but feebly blowing in quality. 
 Pitch lower and intmsity much lessthauin inspi- 
 ration. Usually not more than one fourth the 
 length of inspiration, and absent in about one 
 third of the cases. No interval between inspira- 
 tion and expiration. 
 
 PUERILE RESPIRATION. 
 
 The same quality, pitch, and rhythm as the (pul- 
 monary) vesicular murmur, but exaggerated or 
 intensified in degree. 
 
 SENILE RESPIRATION. 
 
 The same as the vesicular respiration, except 
 that the intensity is diminished and the expiration 
 relatively more developed and longer. 
 
 TRACHEAL OR LARTNGEAL 
 RESPIRATION. 
 
 Inspiration. 
 Tubular in quality, loud, dry, and hollow. 
 High pitch. An interval between inspiration 
 and expiration. 
 
 Expiration. 
 Tubular in quality. Uniformly present. As 
 long as the inspiratory sound, and generally 
 longer. More intense and higher in pitch.
 
 AUSCULTATION AND PERCUSSION. 
 
 21 
 
 RESPIRATION IN HEALTH. 
 
 HOW PRODUCED. 
 
 USUAL SEAT. 
 
 Inspiratory Sound. 
 1. "By vibrations excited in the in- 
 ward current of air by its friction 
 against the walls of the air passages. 
 2. By the obstacles presented by the 
 subdivision of the bronchi ; " and 
 3. By the forcible separation of the 
 walls of the pulmonary vesicles, which 
 after the previous expiration have be- 
 come more or less adherent on account 
 of their natural moisture. 
 
 Expiratory Sound. 
 Simply " by the vibrations excited in 
 the expired air by its friction against 
 the walls of the air-passages." 
 
 All parts of the chest. There are 
 variations in the intensity of the mur- 
 mur in the different regions of the chest, 
 there being more in the infra-clavicular 
 and inter-scapular and in the axillary 
 and infra-axillary regions than in the 
 mammary and infra-mammary regions, 
 and least of all in the scapular region. 
 
 Sometimes there is r.lso a plight disparity be- 
 tween the two sides, in which case the vesicu- 
 lar quality is more marked and the pitch lower 
 on the left than on the right side, in the latter 
 there being a slight approach to the character 
 of broncho- vesicular respiration (Table No. 
 4), i. e., expiration a little longer with higher 
 pitch, and inspiration a little shortened. 
 
 The greater intensity of the murmur 
 is owing to the greater freedom of the 
 action of the lungs in early childhood. 
 
 In children, in all parts of the chest 
 where the ordinary vesicular respira- 
 tion is audible. 
 
 The change is owing to the attenua- 
 tion of the walls of the air-cells in aged 
 persons. 
 
 In old age, in all parts of the chest 
 where the ordinary vesicular respira- 
 tion is audible. 
 
 By the rush of air through a tube of 
 considerable diameter, rough and irreg- 
 ular on its internal surface, and possess- 
 ing sound-reflecting properties. " The 
 hiirher pitch of the expiratory sound is 
 due to the greater contraction of the 
 glottis by the approximation of the vo- 
 cal chords in expiration." 
 
 In the supra-sternal region, over the 
 trachea and larynx.
 
 22 
 
 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 2. - RESPIRATION IN DISEASE. 
 
 VARIETIES. 
 
 CHARACTER OP THE SOUND. 
 
 HOW PRODUCED. 
 
 
 Like the healthy vesic- 
 
 By the excessive action 
 
 
 ular murmur in pitch, 
 
 of certain healthy portions 
 
 EXAGGERATED RES- 
 PIRATION. 
 
 rhythm, and quality, but 
 intensified in degree. Iden- 
 
 of the lungs, set up to sup- 
 ply the deficiency of res- 
 
 
 tical in character with the 
 
 piration in other portions, 
 
 (Puerile, supplementary, 
 increased, hypervesicu- 
 lar.) 
 
 puerile respiration of 
 healthy children. 
 
 which are destroyed or 
 affected by disease. 
 
 
 " The ordinary vesicular 
 murmur, not altered in 
 character, hut simply di- 
 minished in intensity and du- 
 ration." 
 
 By any cause which in- 
 terferes with and prevents 
 the full inflation of the 
 lungs. Such as 
 1 . An obstruction to the 
 
 
 
 passage of air in some por- 
 
 FEEBLE RESPIRA- 
 
 
 tion of the air tubes. 
 
 TION. 
 
 
 2. An obstruction or 
 
 
 
 over-distention of the air 
 
 (Diminished, weak.) 
 
 
 vesicles. 
 
 
 
 3. Some restraint on 
 
 
 
 the movements of the 
 
 
 
 chest- 
 
 g 
 
 
 4. The respiratory mur- 
 
 
 
 mur may be imperfectly 
 
 
 
 transmitted to the ear, 
 
 
 
 owing to intervening fluids, 
 
 
 
 solids, or air. 
 
 
 No sound is heard. 
 
 By very great obstruc- 
 
 SUPPRESSED RESPI- 
 
 
 tion to the entrance of air, 
 
 RATION. 
 
 
 or by the interposition of 
 
 
 
 fluid or air in the cavity 
 
 (Absent.) 
 
 
 of the pleura, preventing^ 
 
 
 
 the transmission of the 
 
 
 
 sound.
 
 AUSCULTATION AND PERCUSSION. 
 
 23 
 
 ABNORMAL INTENSITY. 
 
 USUAL, SEAT. 
 
 DISEASES INDICATED. 
 
 Not peculiar to any portion of the 
 chest, and not diffused generally 
 throughout both sides of the chest, like 
 the healthy puerile breathing, but 
 limited to certain spots in the vicinity 
 of diseased portions of the lungs, or 
 heard all over the healthy lung, when the 
 other is diseased. If heard all over 
 both lungs, it is to be regarded merely 
 as an individual peculiarity and not 
 as a sign of disease. 
 
 Pleurisy. 
 
 Pneumonia. 
 
 Phthisis. 
 
 Vesicular emphysema. 
 
 Apoplectic effusion. 
 Carcinoma. 
 Spasmodic asthma. 
 Pneumothorax. 
 Foreign body in bronchus. 
 Aneurismal or other intra-thoracic tumors 
 pressing on certain bronchi. 
 
 Variable. The whole or a part of a 
 lung. 
 
 Feeble respiration, occurring in so 
 many conditions, becomes of diagnos- 
 tic importance only when associated 
 with other phenomena. 
 
 1. Croup ; oedema or spasm of the glottis ; 
 inflammatory exudations in the larynx ; for- 
 eign body in a bronchus; mucus, serum, blood, 
 or pus in bronchus ; swelling of mucous mem- 
 brane in bronchitis ; asthma ; permanent con- 
 traction of bronchi ; tumors pressing on bron- 
 chi, i. e., aneurism or enlarged lymphatic 
 gland. 
 
 2. Phthisis, pneumonia, pulmonary oede- 
 ma, vesicular emphysema, extravasation of 
 blood. 
 
 3. Paralysis of costal muscles or of dia- 
 phragm; general debility; permanent contrac- 
 tion after chronic pleurisy ; old pleuritic ad- 
 hesions ; deformity of chest ; the pain of acute 
 pleurisy, pneumonia, intercostal neuralgia, 
 pleurodynia, or peritonitis : the mechanical 
 interference of ascites, pregnancy, and abdom- 
 inal tumors. 
 
 4. Pleuritic effusion, thick layer of lymph 
 on pleura, hydrothorax, pneumo-hydrotho- 
 rax, tumors, thick layer of fat on outside of 
 chest. 
 
 " May occur in any portion of the 
 chest, but always limited to one or more 
 parts, and usually to the whole or some 
 portion of one lung only." 
 
 Same diseases as feeble respiration, 
 with this difference, thnt it indicates 
 more decided anatomical lesions. Most 
 commonly observed in connection with 
 excessive effusions of fluid or air in the 
 pleura.
 
 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 3. RESPIRATION IN DISEASE. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 HOW PRODUCED. 
 
 JERKING 
 RESPIRATION. 
 
 (Interrupted, wavy, 
 cogged-wheel.) 
 
 Both sounds, especially 
 the inspiratory, instead of 
 being even and continuous 
 from their commencement 
 to their close, are broken 
 into one, two, or more parts. 
 
 1. By some local obstacle 
 to the ingress or egress of air. 
 Usually the pressure of tu- 
 bercular or other deposit, or 
 the presence of thick mucus 
 in the air passages, or spasm 
 of a tube. 
 
 2. By nervousness or shrink- 
 ing on account of pam. 
 
 PROLONGED 
 EXPIRATION. 
 
 The rhythm changed so 
 that the expiration is'length- 
 ened absolutely and rela- 
 tively to the inspiration, 
 which is generally short- 
 ened. 
 
 1. When the air-cells are 
 over-distended and have lost 
 their natural elasticity from 
 this distention or (2) on ac- 
 count of deposits in their 
 walls, the air has difficulty in 
 making its escape. This dif- 
 ficulty may be increased in 
 the latter case by the promi- 
 nences produced by the de- 
 posit on the interior of the 
 final bronchial ramifications, 
 these prominences opposing 
 obstacles to the rapid egress 
 of air.
 
 AUSCULTATION AND PERCUSSION. 
 
 25 
 
 ABNORMAL RHYTHM. 
 
 USUAL SEAT. 
 
 DISEASES INDICATED. 
 
 1. Limited to a part of the chest, 
 usually one of the apices, where it is 
 of more clinical significance than when 
 
 2. Generally diffused over the chest. 
 
 1. Incipient phthisis. 
 Circumscribed bronchitis. 
 Asthma. 
 
 2. Nervousness. 
 Pleurisy. 
 Plenrodynia. 
 Intercostal neuralgia. 
 
 This sound is occasionally observed even 
 in healthy persons. 
 
 1. All over one or both sides of "the 
 chest, especially the upper parts. 
 
 2. In the infra-clavicular region, es- 
 pecially on the left side. 
 
 1. Emphysema 
 
 (if non-tubular and of low pitch). 
 
 2. Phthisis 
 
 (if tubular and of high pitch). 
 
 Occasionally heard to a slight extent on 
 the right side of the healthy chest.
 
 26 
 
 AUSCULTATION AND PERCUSSION. 
 
 . TABLE NO. 4. RESPIRATION IN DISEASE. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 HOW PRODUCED. 
 
 BRONCHIAL 
 RESPIRATION. 
 
 (Tubular.) 
 
 Inspiration. 
 
 Quality tubular, non- 
 vesicular. Intensity vari- 
 able, pitch high. Inspi- 
 ratory sound shortened ; 
 ends before end of inspi- 
 ratory act. Rarely ab- 
 sent. Can be imitated by 
 blowing through a tube 
 formed by the fingers and 
 palm of one hand. 
 
 Expiration. 
 
 Quality tubular. Pro- 
 longed; as long as or 
 longer than the sound of 
 inspiration and more in- 
 tense. Pitch still higher. 
 Rarely absent. 
 
 It always denotes consid- 
 erable or complete solidifica- 
 tion of pulmonary substance, 
 either by the addition of 
 some morbid material or by 
 compression. This involves 
 suppression of the vesicular 
 murmur. The sound pro- 
 duced by the passage of air 
 through the bronchi, which 
 in health is stifled by the 
 vesicular murmur and ren- 
 dered inaudible, is now trans- 
 mitted- to the ear intensified 
 by the. solidified lung, which 
 is a better sound-conductor 
 than the healthy lung. 
 
 BRONCHO-VESICU- 
 I.AR RESPIRATION 
 
 (Rude, rough, harsh, 
 
 Yesiculo-bronchial, tu- 
 
 bulo- vesicular.) 
 
 Inspiration. 
 
 The tubular and vesic- 
 ular quality combined in 
 varied proportions, and 
 the pitch raised in pro- 
 portion to the amount of 
 tubular quality. Dura- 
 tion frequently shortened 
 at the end. Intensity va- 
 riable. Sometimes ab- 
 sent. 
 
 Expiration. 
 
 Prolonged. Generally 
 more intense than inspi- 
 ration. Pitch higher than 
 in inspiration. Quality 
 according to quality in in- 
 spiration. Sometimes ab- 
 sent. 
 
 Being a combination, in 
 varied proportions, of the 
 bronchial and vesicular res- 
 piration, it is produced by 
 the same cause as the pre- 
 ceding, although not to the 
 same extent ; the amount of 
 solidification not being suf- 
 ficient to extinguish all vesic- 
 ular murmur.
 
 AUSCULTATION AND PERCUSSION. 
 
 ABNOKMAL QUALITY AND PITCH. 
 
 USUAL SEAT. 
 
 DISEASES INDICATED. 
 
 In phthisis and pleurisy generally 
 in the upper part of the chest. In 
 pneumonia generally the lower part 
 behind, especially on the right side. 
 In other cases variable. 
 
 Being identical with the healthy " Tracheal 
 Respiration," it may be studied in the supra- 
 eternal region of a sound person. 
 
 Pneumonia. 
 Phthisis. 
 Pleuritic effusion. 
 
 Collapse of pulmonary lobules. 
 
 Pulmonary oedema. 
 
 Pulmonary apoplexy. 
 
 Carcinoma. 
 
 Hydrothorax. 
 
 Hy dro -pericardium . 
 
 Aneurism and other tumors. 
 
 Same as the preceding. A very 
 important sign in the diagnosis of in- 
 cipient phthisis. 
 
 Same diseases as the preceding, 
 only indicating a lesser amount of solid- 
 ification. In the resolution of acute 
 lohar pneumonia (croupous), all vari- 
 eties of the sound may be heard by 
 daily auscultation, from that which 
 verges on the bronchial in complete 
 solidification, to th;it which verges on 
 the vesicular, which conies with re- 
 covery.
 
 28 
 
 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 4, Continued. RESPIKATION IN DISEASE. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 HOW PRODUCED. 
 
 CAVERNOUS 
 RESPIRATION. 
 
 Inspiration. 
 
 Quality blowing simply ; 
 non-vesicular, non-tubu- 
 lar. Often mixed with 
 gurgling. (Table No. 5.) 
 
 Expiration. 
 
 Quality blowing. Low- 
 er pitch than inspiration. 
 May be absent. Often 
 mixed with gurgling. 
 
 Some recognize also a bron- 
 cho - cavernous respiration, 
 which, as its name signifies, 
 is a combination in varied 
 proportions of this and the 
 bronchial respiration. 
 
 Produced by the passage 
 of air into and from a cav- 
 ity with^ZomW walls. 
 
 Absent when the cavity is 
 filled with liquid, or when 
 the tubes leading to it are 
 obstructed. If deep-seated, 
 and beneath solidified lung, 
 it may be drowned out by the 
 loud bronchial respiration. 
 R&les also may obscure it. 
 
 It can be imitated by blow- 
 ing into a cavity formed by 
 the two hands. 
 
 AMPHORIC 
 RESPIRATION. 
 
 A kind of musical in- 
 tonation like the sound 
 produced by blowing 
 upon the open mouth of 
 a decanter or phial. It 
 may accompany either 
 inspiration or expiration 
 or both. It may be hum- 
 ming and of low pitch or 
 decidedly ringing and 
 metallic. 
 
 Not caused, like cavernous 
 respiration, " by the free circu- 
 lation of air within a cavity, 
 but by the current of air in 
 the bronchial tubes acting 
 upon the air contained within 
 a cavity." The cavity must 
 have more or less rigid walls, 
 which do not collapse with 
 expiration; it must be of 
 considerable size, partially or 
 entirely free from liquid con- 
 tents ; there must be an un- 
 obstructed communication 
 (or merely a very thin sep- 
 tum) between a bronchial 
 tube and the cavity, and the 
 perforation must be above 
 the level of the liquid, if 
 there be any liquid.
 
 AUSCULTATION AND PERCUSSION. 
 
 29 
 
 ABNORMAL QUALITY AND PITCH, Continued. 
 
 USUAL SEAT. 
 
 Heard over a circumscribed area, 
 corresponding to the size of the cavity. 
 
 Being vastly more common m 
 phthisis than in other diseases, its 
 seat is generally at the summit of the 
 chest. 
 
 DISEASES INDICATED. 
 
 Phthisis. 
 
 Rarely in 
 
 Pulmonary abscess. 
 Gangrene. 
 Cancer. 
 Bronchial dilatation. 
 
 Generally confined to a circum- 
 scribed space, but is sometimes dif- 
 fused more or less over the chest. 
 
 Almost pathognomonic of pnen- 
 mo-hydrothorax with pulmonary fis- 
 tula. Sometimes in phthisis. 
 
 Still more rarely in abscess, etc.
 
 30 
 
 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 5. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 RELATION TO INSPIRATION 
 AND EXPIRATION. 
 
 I. TRACHEAL 
 
 AND 
 
 LARYNGEAL 
 RALES. 
 
 Whistling, wheezing, crow- 
 ing, whooping, etc. Most 
 of them are heard without 
 special auscultation and at a 
 distance. 
 
 Mostly with inspiration. 
 Sometimes with both. 
 
 a. Dry or vibrat- 
 ing. 
 
 
 
 b. Moist or bub- 
 bling. 
 
 Bubbling sounds, often 
 called " death-rattles." 
 
 With both. 
 
 II. Bronchial 
 Kales. 
 
 Low-pitched, musical sounds, 
 compared to snoring, cooing, 
 buz/ing, grunting, humming, 
 a note of a bass-viol, etc. 
 
 With both or either, es- 
 pecially with expiration. 
 
 a. Dry or vibrat- 
 ing. 
 
 
 
 <1.) SONOROUS 
 RALES. 
 
 
 
 nVa>frJ 
 
 (2.) SIBILANT 
 RALES. 
 
 
 
 High-pitched, whistling, 
 hissing, or clicking sounds of 
 variable intensity and dura- 
 tion and irregular recur- 
 rence. Often compared to 
 shrill musical tones, the cries 
 of young animals, the chirp- 
 ing of birds, whistling of 
 wind through a keyhole, etc. 
 Heard with the respiratory 
 murmur, or the latter may 
 be masked. Loudest in asth- 
 
 With both or either, es- 
 pecially with inspiration. 
 
 ft 
 
 ma. 
 
 
 Kl
 
 AUSCULTATION AND PERCUSSION. 
 
 31 
 
 EALES (Rhonchi). 
 
 HOW PRODUCED. 
 
 USUAL SEAT. 
 
 DISEASES INDICATED. 
 
 1. By contraction at 
 
 Larynx and trachea. 
 
 1. Laryngismus stridu- 
 
 the glottis from spasm, 
 
 These sounds are often 
 
 lus. 
 
 eedema, exudation of 
 
 propagated through the 
 
 Pertussis. 
 
 lymph, etc. 
 
 bronchial tubes and 
 
 Croup. 
 
 2. By diminution of 
 
 heard in the chest, where 
 
 
 calibre of tube below the 
 
 they may, in a few cases, 
 
 2. Pressure of a tumor. 
 
 glottis. 
 
 be thought to originate. 
 
 Morbid growths or depos- 
 
 
 Auscultation of the 
 larynx and trachea will 
 at once settle the point. 
 
 its. 
 Cicatrization of ulcers. 
 Paralysis of laryngeal 
 muscles. 
 
 By the passage of air 
 
 Larynx and trachea. 
 
 The moribund state. 
 
 through mucus or other 
 
 
 Coma. , 
 
 liquid in the tube. 
 
 
 Inability to expectorate. 
 
 " By the vibrations ex- 
 
 Constantly liable to 
 
 1. Asthma. 
 
 cited by the passage of 
 
 change position. May 
 
 Bronchitis. 
 
 air through the larger 
 
 sometimes disappear af- 
 
 2. Circumscribed bron- 
 
 bronchi, irregularly nar- 
 
 ter coughing. They are 
 
 chitis occurring with 
 
 rowed, either by spas- 
 
 either 
 
 pneumonia or phthisis. 
 
 modic contraction of their 
 
 1. More or less diffused 
 
 
 circular fibres," or by 
 
 over the whole chest ; or, 
 
 
 swelling of their mucous 
 
 2. Confined to one side 
 
 
 membrane, or by the ad- 
 
 of the chest, or limited 
 
 
 hesion of viscid mucus to 
 
 to a circumscribed space. 
 
 
 their walls, or by the 
 
 (In phthisis the circum- 
 
 
 pressure of a tumor. 
 
 scribed space is gener- 
 
 
 
 ally at the summit of the 
 
 - 
 
 
 chest.) 
 
 
 Produced in the same 
 
 Same as sonorous 
 
 Same diseases as the 
 
 manner, but in the smaller 
 
 rales, with which they 
 
 sonorous rales, and indi- 
 
 bronchial tubes. 
 
 are frequently mingled. 
 
 cating that the smaller 
 
 
 
 tubes are affected.
 
 32 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 5, Continued. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 RELATION TO INSPIRATION 
 AND EXPIRATION. 
 
 
 A coarse bubbling sound, 
 
 With either or both. 
 
 
 conveying the impression of 
 
 
 
 the bursting of bubbles of 
 
 
 b. Moist or bub- 
 
 somewhat large size. The 
 
 
 bling. 
 
 " death-rattles " are an ex- 
 
 
 
 aggerated type of them. If 
 any solidification of the lung 
 
 
 (1.) COARSE BUB- 
 
 exists around the tubes in 
 
 
 BLING RALES. 
 
 which the sound is produced, 
 
 
 
 the pitch is raised in propor- 
 
 
 (Coarse mucous 
 
 tion to the amount. 
 
 
 rales.) 
 
 
 
 (2.) FINE BUB- 
 BLING RALES. 
 
 (Pine mucous rales.) 
 
 The same quality of sound, 
 but the bubbles are smaller. 
 The coarse and .fine bub- 
 bling rales may be imitated 
 by blowing into a tumbler 
 of water through different 
 
 With either or both. 
 
 
 sized tubes. 
 
 
 (3.) SUBCREPI- 
 
 The same quality, but the 
 bubbles are very small in- 
 
 With either or both. 
 When with inspiration, 
 
 TANT RALES. 
 
 deed. Still, they are some- 
 
 near the beginning. 
 
 
 what unequal in size, as in 
 
 
 
 the other moist rales. 
 
 
 
 Slowly evolved. 

 
 AUSCULTATION AND PERCUSSION. 33 
 
 RALES, Continued. 
 
 HOW PRODUCED. 
 
 USUAL SEAT. 
 
 DISEASES INDICATED. 
 
 By the bubbling of air 
 through liquid (mucus, 
 ]iiis. softened tubercle, 
 blood, or serum), in the 
 larger bronchial tubes. 
 Bubbling rales, both 
 coarse and line, are very 
 often called mucous rales. 
 This term is not so ap- 
 propriate, as the liquid 
 by means of which they 
 are produced is not al- 
 ways mucus. Unless 
 specified, when " bubbling 
 rales " are mentioned, 
 bronchial and not tra- 
 cheal are understood. 
 
 Constantly liable to 
 change position, espe- 
 cially after expectora- 
 tion or coughing, and 
 not occurring with every 
 respiration. 
 They are either 
 1. More or less dif- 
 fused over the whole 
 chest, especially the in- 
 fra-scapular regions, or 
 2. Confined to one side 
 of the chest, or limited 
 to a circumscribed space. 
 (In phthisis the circum- 
 scribed space is generally 
 the summit of the chest. ) 
 
 1. Bronchitis. 
 2. Circumscribed bron- 
 chiiis, occurring with 
 phthisis or pneumonia. 
 Softened tubercle, etc., 
 in tubes in phthisis, blood 
 in haemoptysis or pulmo- 
 nary apoplexy, serum in 
 oedema, pus in pulmo- 
 nary or hepatic abscess. 
 
 Produced in the same 
 manner in the smaller 
 bronchial tubes. 
 
 Same as coarse bub- 
 bling rales, with which 
 they are frequently min- 
 gled. 
 
 Same as coarse bub- 
 bling rales, but smaller 
 tubes affected. 
 
 Produced in the same 
 manner in the very mi- 
 nute bronchial ramifica- 
 tions. 
 
 Same as coarse bub- 
 bling rales, excepting 
 that they are very much 
 less liable to change po- 
 sition. 
 
 1 . Capillary bronchitis. 
 Pulmonary oedema. 
 2. Lobar pneumonia 
 during resolution. 
 Incipient phthisis.
 
 34 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 5, Continued. 
 
 III. Vesicular 
 Rales. 
 
 CBEPITAST 
 KALES. 
 
 IV. Cavernous 
 Rales. 
 
 GURGLING 
 RALES. 
 
 CHARACTER OF THE SOUND. 
 
 Fine, dry, crepitating or 
 crackling sounds, compared to 
 those produced by fine salt 
 on a fire, or by rubbing a 
 lock of hair between the 
 thumb and finger close to 
 the ear. They resemble the 
 subcrepitant, from which 
 they must be distinguished. 
 The crepitations ;uv < 
 size, dry, not bubbling, con- 
 stant, not variable, ra/iidly 
 evolved, not suspended by 
 coughing and expectoration, 
 and occur only with inspira- 
 tion. 
 
 A hollow, gurgling sound, 
 bften very intense, some- 
 times metallic or amphoric, 
 usually of low pitch, convey- 
 ing the impression of very 
 large bubbles bursting in a 
 large space, the loudness.of 
 the gurgling being propor- 
 tionate to the size of the cav- 
 ity. When this is small, 
 hardly distinguishable from 
 coarse bubbling bronchial 
 rales. 
 
 RELATION TO INSPIRATION 
 AND EXPIRATION. 
 
 With inspiration exclusively, 
 and near the end of it, es- 
 pecially in forced inspira- 
 tion. 
 
 With either or both. 
 Oftener with inspiration 
 than expiration.
 
 AUSCULTATION AND PERCUSSION. 
 BALES, Continued. 
 
 35 
 
 HOW PRODUCED. 
 
 . Produced, according to 
 the most rational theory 
 (Dr. Carr's), by the abrupt 
 separation, during inspi- 
 ration, of the walls of the 
 'cles, which had, 
 after the preceding ex- 
 piration, become adherent 
 by means of the viscid 
 exudation incident to the 
 early stage of inflamma- 
 tion. 
 
 This mode of its production 
 can be illustrated by moisten- 
 ing the thumb and finger with 
 a little puste or solution of 
 gum arabic, and alternately 
 prus.-in<; them together and 
 separating them near the ear. 
 
 Produced by the burst- 
 ing of larirc bubbles arid 
 the agitation of a mass of 
 liquid in a cavity of con- 
 siderable size. When the 
 cavity is empty, cavern- 
 Otis respiration takes the 
 place of the cavernous 
 rules. The two signs 
 may thus confirm each 
 other. Not produced if 
 the cavity, is full. The 
 communication with the 
 bronchial tubes must be 
 unobstructed and below 
 the level of the liquid. 
 Therefore gurgling is not 
 heard iu every case of a 
 cavity. 
 
 USUAL SEAT. 
 
 Most commonly over 
 the lower part of the 
 chest behind, on one side, 
 oftener the right. 
 
 Often associated with 
 the subcrepitant rales in 
 the resolution of pneu- 
 monia. 
 
 A circumscribed space, 
 in forty-nine out of fifty 
 cases at the summit of 
 the chest. 
 
 DISEASES INDICATED. 
 
 Almost 
 of pneumonia. 
 
 If heard only over a 
 circumscribed space at 
 the summit of the chest, 
 phthisis is generally indi- 
 cated. Even in such 
 cases the crepitant rale is 
 indicative of a circum- 
 scribed pneumonic proc- 
 ess. 
 
 Phthisis. 
 
 Cavity from abscess, cir- 
 cumscribed gangrene, can- 
 cer, etc.
 
 36 
 
 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 6. 
 
 CHARACTER OF THE SOUND. 
 
 RELATION TO INSPI- 
 RATION AND EX- 
 PIRATION. 
 
 FRICTION 
 SOUNDS. 
 
 Grazing, rubbing, creaking like new 
 leather, grating, crumpling, rasping, 
 the harshness varying according to 
 the roughness of the surface of the 
 pleura. 
 
 The grazing and rubbing sounds, 
 which are the most common, may be 
 imitated by placing over the ear the 
 palm of one hand and moving over 
 its dorsal surface slowly the pulpy por- 
 tion of a finger of the other hand. 
 
 Intensity very variable, sometimes 
 heard even by the patient. The 
 sound is dry and appears to be near 
 the ear, not continuous generally, but 
 jerking, rhythmical with respiration. 
 Transient or lasting. Occasionally 
 attended with fremitus. 
 
 With both or with 
 inspiration alone. 
 
 Very rarely with 
 expiration alone. 
 
 METALLIC TINK- 
 LING. 
 
 A high-pitched, abrupt, short, sil- 
 very tone, like the tinkling of a small 
 bell, dropping small shot into a brass 
 basin, etc., consisting of a single 
 sound, or more commonly of two, 
 three, or more in quick succession. 
 Accompanies respiration, speaking, 
 and coughing, especially the two lat- 
 ter. Irregular in its appearance. 
 Only liable to be confounded with a 
 somewhat similar sound in the stom- 
 ach. 
 
 With both or 
 either ; especially- 
 at the end of inspi- 
 ration.
 
 AUSCULTATION AND PERCUSSION. 
 
 37 
 
 MORBID PLEURAL SOUNDS. 
 
 HOW PRODUCED. 
 
 USUAL SEAT. 
 
 DISEASES INDI- 
 CATED. 
 
 By the rubbing together of two 
 pleural .surfaces (pulmonary with cos- 
 tal, aiid ofteu diaphragmatic with cos- 
 tal) which have been roughened by 
 lymph or other deposit. 
 
 In common 
 pleurisy usually 
 confined to a 
 small space at the 
 middle or lower 
 part of the chest 
 laterally or pos- 
 teriorly ; but may 
 be more or less 
 diffused, and occa- 
 sionally is heard 
 over the entire 
 chest. 
 
 In phthisis at 
 the summit of the 
 chest. 
 
 Pleurisy. 
 
 Also in phthisis 
 and pneumonia 
 where there is ac- 
 companying s e c- 
 ondary .pleurisy. 
 
 There must be a large cavity, contain- 
 ing liquid and air or gas, and almost 
 invariably there is communication with 
 a bronchial tube. 
 
 There are several different theories 
 as to the production of this sound, and 
 probably each one of the following 
 (which have all been experimentally 
 verified) may account for it either alone 
 or in connection with the others. 
 
 1. Drops of fluid fall from the upper 
 part of the space upon the surface of 
 the liquid below, when the patient, 
 previously 1\ ing down, sits or stands 
 up. ( Laennec. ) 
 
 2. Air, working through a fistnlous 
 orifice opening below the level of the 
 liquid, ri.-es to the surface, forming bub- 
 bles which break and produce the 
 sound. (Spittel.) 
 
 3. Simple agitation of the liquid may 
 give rise to the sound, as in succussion, 
 coughing, etc. 
 
 4. Bubbles of mucus bursting at the 
 opening of a fistulou.s orifice situated 
 above the level of the liquid. 
 
 Generally at the 
 middle third of 
 the chest, in front, 
 behind, or at the 
 side. 
 
 Sometimes dif- 
 fused over the 
 entire chest on 
 one side. 
 
 Sometimes a 
 circum scribed 
 space at the sum- 
 mit. 
 
 Almost pathog- 
 nomonic of pneu- 
 mo-hydrothorax. 
 
 Very rarely in. 
 phthisical cavities.
 
 38 
 
 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 6, Continued. 
 
 VARIETIES. 
 
 I 
 
 CHARACTER OF THE SOUND. 
 
 RELATION TO INSPI- 
 RATION AND EX- 
 PIKAT1ON. 
 
 SPLASHING. 
 
 (Hippocratic succus- 
 SIOQ sound.) 
 
 Such a noise as is produced by 
 shaking a bottle partly filled with 
 liquid. 
 
 Only liable to be confounded with a 
 somewhat similar sound in the stom- 
 ach. 
 
 Often it has a high-pitched am- 
 phoric tone, and may be mingled with 
 metallic tinkling. Sometimes loud 
 enough to be heard at a distance.
 
 AUSCULTATION AND PERCUSSION. 
 
 39 
 
 MORBID PLEURAL SOUNDS, Continued. 
 
 HOW PRODUCED. 
 
 USUAL SEAT. 
 
 DISEASES IN- 
 
 
 
 DICATED. 
 
 Produced by jerking the body of the 
 patient with an abrupt forcible move- 
 
 Generally over 
 the whole of the 
 
 Pathognomonic 
 of pneumo-hydro- 
 
 ment, the ear being in contact with or 
 
 affected side, un- 
 
 thorax. 
 
 in close proximity to the chest. 
 
 less there are ad- 
 
 
 Sometimes produced unintentionally 
 by the patient himself, by quick mo- 
 tions, such as horseback exercise, 
 
 hesions. 
 Very rarely at the 
 
 Very rarely in tu- 
 bercular and other 
 cavities in the lung. 
 
 . , 
 
 summit of the chest. 
 
 
 jumping, etc. 
 
 
 
 The liquid must not be too abun- 
 
 
 
 dant nor too thick, and there must 
 
 
 
 also be air in the cavity. 
 

 
 40 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 7. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 TBACHEAL VOICE. 
 
 (Tracheophony, laryn- 
 
 geal voice, laryngoph- 
 
 ony.) 
 
 A strong resonance, with a powerful sensation of con- 
 cussion or shock, and also with a strong sense of vibration 
 or thrill called fremitus, which can be appreciated bv the 
 ear as well as by palpation. The voice is concentrated and 
 near the ear, seeming to pass right through the stethoscope. 
 Sometimes the articulated words are transmitted so as to 
 be heard as distinctly as when coming direct from the 
 lips. When this occurs over the chest as a result of dis- 
 ease, it is called perfect pectoriloquy. Oftener, however, 
 the transmission of speech from the trachea furnishes a 
 type of imperfect pectoriloquy. All these phenomena 
 may differ in intensity. The variations in the first three, 
 however, resonance, shock, and fremitus, do not al- 
 ways correspond with the variations in the distinctness 
 with which speech is transmitted. 
 
 TRACHEAL 
 WHISPER. 
 
 (Whispering 
 tracheophony.) 
 
 There is little or no shock or fremitus-. Whispered 
 words are transmitted more or less perfectly, more so 
 generally than loud words ; this feature corresponding to 
 the morbid sign called whispering pectoriloquy. 
 
 NORMAL THORACIC 
 VOCAL 
 
 RESONANCE. 
 
 The resonance is much weaker than in tracheophony, 
 and is quite variable in intensity. Often over portions of 
 the chest none is appreciable, and in some persons it is 
 absent over the entire chest. The sound is diflust-d and 
 seems farther removed from the ear, rarely accompanied 
 with shock, and not always with fremitus. The sound 
 often amounts to little more than a humming or buzzing. 
 No pectoriloquy. 
 
 NORMAL 
 
 BRONCHIAL 
 
 WHISPER. 
 
 The characters of the sounds produced by the whis- 
 pered voice are identical with those produced by the act of 
 expiration, in all respects except that the souncn are more 
 
 intense, generally, than those even of a forced 'expira- 
 'ion. Tlif h,i"ii~irv is varhhle, as in the preceding. 
 There i> t u e same difference between thi< and the tracheal 
 whisi-er \virh regard to diffusion, concentration, and near- 
 ness to the ear that there i< between the normal thoracic 
 vocal resoii-mc' 1 and the tracheal voice.
 
 AUSCULTATION AND PERCUSSION. 
 THE VOICE IN HEALTH. 
 
 41 
 
 HOW PRODUCED. 
 
 USUAL SEAT. 
 
 The resonance by the reverberation 
 of the voice in the sound-reflecting 
 tube, the shock by the sudden arrest 
 of the column of expired air by the 
 act of speaking, the fremitns by the 
 vibrations of the tracheal tube in con- 
 nection with those of the vocal chords, 
 and the distinct transmission of speech 
 by the concentrating and sound-reflect- 
 ing properties of the hollow tube. 
 
 Trachea and larynx. 
 
 Apply the stethoscope over the broad sur- 
 face of the thyroid cartilage or just above 
 the sternal notch. To bring out the vocal 
 phenomena to the best advantage, both here 
 and over the chest in health and in disease, 
 the' patient should be instructed to count 
 slowly one, two, three, one, two, three, etc., 
 at first with the loud voice and afterwards in 
 a whisper. 
 
 The sound corresponds to the sound 
 of expiration in tracheal or laryngeal 
 respiration, and is in fact identical 
 with it. 
 
 Trachea and larynx. 
 
 The vibrations are weakened and 
 diffused by passing through the sub- 
 divisions of the bronchi and the 
 spongy tissue of the lung before reach- 
 ing the surface of the chest. 
 
 There are considerable variations 
 in this sound in the different regions 
 of the chest, it being more intense in 
 the infra-clavicular and inter- scapular 
 regions than in the axillary and infra- 
 axillary ; and in the latter more than 
 in the mammary and infra-mammary. 
 There is the least resonance in the 
 scapular region. 
 
 There is also often a slight difference in 
 the two sides comparatively When there is 
 any difference, the right side is the more 
 resonant. This 1'ist rcmnrk applies also to 
 fremitus. The amount of the fremitus, how- 
 ever, is not necessarily proportionate to that 
 of the resonance. 
 
 The conduction of sound by the 
 whispered voice is chiefly by the air 
 contained in the bronchial tubes. 
 
 About the same variations are ob- 
 served as in the preceding.
 
 42 
 
 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 8. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 DIMINISHED AND SUP- 
 PRESSED VOCAL 
 RESONANCE AND FBE- 
 
 M1TDS. 
 
 Simply less in intensity than normal, or absent 
 altogether. There being no standard of inten>ity, 
 comparison must be made between the two sides, 
 allowing, of course, for the slight possible differ- 
 ence in health. (Table No. 7.) 
 
 The fremitus generally, but not always, lessened 
 in the same proportion as the resonance. 
 
 INCREASED VOCAL 
 
 RESONANCE AND 
 
 FREMITUS. 
 
 Merely an increase in intensity, without change 
 in other respects. Generally associated with the 
 broncho-vesicular respiration. 
 
 INCREASED BRONCHIAL 
 WHISPER. 
 
 Same as the expiratory sound in broncho-vesic- 
 ular respiration, namely, increase of intensity and 
 length, more or less tubular in quality, and higher 
 iu pitch than the whisper in health, these altera- 
 tions being proportionate to the degree of solid- 
 ification. 
 
 Vocal sound concentrated and near the ear. 
 Pitch higher than normal. Intensity and fremi- 
 tns variable ; may be greater or less than in 
 health. 
 
 BRONCHOPHONY. 
 
 WHISPERING BRON- 
 CHOPHONY. 
 
 Sanv ;IN the expinitorv sound in the bronchial 
 respiration, namely, intensified, long, high pitched, 
 and tnliiiiar.
 
 AUSCULTATION AND PERCUSSION. 
 THE VOICE IN DISEASE. 
 
 HOW PRODUCED. 
 
 USUAL SEAT. 
 
 DISEASES INDICATED. 
 
 By th% removal of the 
 lungs from the thoracic 
 walls, or by anything that 
 prevents the circulation of 
 the column of air in the 
 tubes which propagate the 
 sound. 
 
 When the pleural 
 cavity is partially filled 
 with fluid, the vocal 
 resonance and f remitus 
 are diminished or sup- 
 pressed below the level 
 of the liquid, but in- 
 .creased generally just 
 above the level, owing 
 to the condensation. 
 
 Pleuritic effusion, em- 
 pyema, hydrothorax, 
 pneumo - hydrothorax, 
 obstruction of bron- 
 chial tubes by mucus or 
 by the pressure ofaneu- 
 rismal or other tumors. 
 
 Exceptional in solidifica- 
 tion, but sometimes observed 
 in complete solidification of 
 pneumonia, abscess full of 
 pus, cavity filled with liquid, 
 pulmonary cedcina. 
 
 By slight consolidation of 
 the lung tissue around the 
 air tubes, whereby the 
 sound-reflecting power of 
 the tubes is increased, and 
 the pulmonary parenchyma 
 is rendered more homoge- 
 neous and a better sound- 
 conductor. 
 
 Not confined to any 
 part of the chest, but 
 usually most marked 
 and of the greatest sig- 
 nificance towards the 
 apices of the lungs in 
 phthisis. 
 
 Phthisis. 
 Pneumonia. 
 Compressed lung in 
 moderate pleuritic ef- 
 fusion and collapse of 
 pulmonary lobules. 
 
 Carcinoma, haemorrhagie 
 infarctus. Sometimes over 
 cavities. 
 
 Same as the preceding. 
 
 Same as the preceding. 
 
 Same as the preceding. 
 
 Same as the preceding, 
 except that the solidifica- 
 tion is greater, and some- 
 times complete. Less solid- 
 ification is required than 
 for the production of bron- 
 chial respiration. There- 
 fore bronchophony may be 
 associated with a broncho- 
 vesicular respiration as 
 well as with bronchial. 
 
 In pneumonia gen- 
 erally the middle and 
 lower thirds behind. 
 Of great importance 
 aa&nggesthre of phthisis 
 when existing at the 
 apex of the lung. 
 In pleuritic effusion, 
 over condensed lung at 
 summit of chest. 
 
 Pneumonia. 
 
 Phthisis. 
 
 Lung condensed by effu- 
 sion in pleurisy or pneumo- 
 hydrothorax, or by pressure 
 of a tumor, collapse of 
 pulmonary lobules, cancer, 
 or bronchial dilatation, the 
 tubes being surrounded by 
 condensed and indurated 
 lung. 
 
 Same as the preceding. 
 
 Same as the preced- 
 ing. 
 
 Same as the preced- 
 ing.
 
 44 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 8, Continued. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 CAVERNOUS WHISPER. 
 
 Same as the expiratory sound in the cavernous 
 respiration, namely : low pitch and blowing (non- 
 tubular) quality, with variable intensity. 
 
 AMPHORIC VOICE AND 
 WHISPER. 
 
 A ringing sound of a metallic quality, not dis- 
 tinctly articulated, not transmitted forcibly 
 through the stethoscope, but resembling the 
 sound produced by speaking into an empty jar. 
 The amphoric quality may accompany the loud 
 voice or whisper, more especially the latter, the 
 resonance and fremitus of the loud voice obscuring 
 somewhat the musical intonation. 
 
 PECTORILOQUY AND 
 
 WHISPERING PECTO- 
 
 KILOQUY. 
 
 Articulated words are transmitted directly through 
 the stethoscope into the ear. This is more fre- 
 quent with the whispered than with the loud 
 voice. Care must be taken not to confuse the 
 words coming directly from the patient's mouth 
 with the transmission of them through the chest. 
 Unless a double stethoscope is used, one ear must 
 be closed. This is a rare sign, but the type of it 
 can be studied in health in connection with 
 tracheal voice. 
 
 A tremulous, bleating or quavering sound, like 
 the cry of a goaf, from which the term is derived, 
 and often compared to the "Punch and Judy" 
 voice. Synchronous with, but of a higher pitch 
 than, the voice of the patient, or else follow- 
 ing it like a feebly whispered echo, and rarely 
 traversing the stethoscope. 
 
 METALLIC TINKLIXG. 
 
 Has the same characters when heard in connec- 
 tion with the loud or whispered voice as with res- 
 piration (which see), but is more intense.
 
 AUSCULTATION Ai\'D PERCUSSION. 
 THE VOICE IN DISEASE, Continued. 
 
 HOW PRODUCED. 
 
 USUAL SEAT. 
 
 DISEASES INDICATED. 
 
 Produced by the air 
 
 A circumscribed space, 
 
 Phthisis. 
 
 passing out of an empty, 
 
 generally at summit of 
 
 
 superficial cavity vfithjiac- 
 cid walls. 
 
 chest, 
 
 Purulent, gangrenous, or 
 cancerous excavation. 
 
 
 Or in other parts. 
 
 
 By the reverberation of 
 
 Same as amphoric 
 
 Same as amphoric 
 
 the voice, causing an echo, 
 
 respiration. 
 
 respiration. 
 
 in a lare cavity with rigid 
 
 
 
 walls, and subject to the 
 
 
 
 same conditions as in the 
 
 
 
 production of amphoric 
 
 
 
 respiration (which see). 
 
 
 
 " Sometimes by the con- 
 
 " Not confined to any 
 
 Chiefly Phthisis. 
 
 densation of lung tissue 
 
 portion of the lungs, 
 
 
 around a large bronchus, 
 whereby the transmission 
 of the sound to the ear is 
 
 but occurring most 
 commonly at the apices 
 and in the upper lobes." 
 
 Sometimes pneu m o n i a, 
 pouchlike dilatation of bron- 
 chi, circumscribed gangrene, 
 and abscess. 
 
 facilitated. More gener- 
 
 
 
 ally by the formation of 
 
 
 
 cavities possessing smooth, 
 
 
 
 sound-reflecting walls." 
 
 
 
 
 By the vibrations conse- 
 
 Not confined to any 
 
 Pleuritic effusion. 
 
 quent on the existence of a 
 
 portion of the chest, 
 
 
 thin stratum of liquid in 
 
 but most common at or 
 
 Pleuro-pneumonia. 
 
 the pleural cavity. 
 Not apt to occur when 
 
 near the inferior angle 
 of the scapula ; from 
 
 Hydrothorax. 
 Empyema. 
 
 the chest is more than half 
 
 here often extending 
 
 
 full of liquid. The lung 
 
 to the inter-scapular 
 
 
 must be more or less con- 
 
 space, and, in a zone 
 
 
 densed at the level of the 
 
 from one to three fin- 
 
 
 liquid. This accounts for 
 
 gers broiid, following 
 
 
 the elevation of pitch. 
 
 the line of the ribs to- 
 
 
 When there becomes too 
 
 wards the nipple (the 
 
 
 much liquid, the aegophony 
 
 patient sitting). This 
 
 
 stops. Therefore in acute 
 
 line indicates not the 
 
 
 pleurisy it rarely continues 
 
 level of the liquid, but 
 
 
 longer than two or three 
 
 the points where it has 
 
 
 days, sometimes only for a 
 
 the requisite degree of 
 
 
 few hours. 
 
 thinness to produce 
 
 
 
 aegophony. 
 
 
 As in Table No. 6. 
 
 As in Table No. 6. 
 
 Mostly Pneumo-hy- 
 
 
 
 drothorax.
 
 46 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 9. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 HOW PRODUCED. 
 
 NOBMAL VESIC- 
 ULAR 
 RESONANCE. 
 
 (Pulmonary.) 
 
 A full, clear, prolonged 
 sound, of low pitch, its qual- 
 ity xw r/eiieris, only to be ap- 
 preciated by actually hearing 
 it, and its intensity varying 
 with the force of the blow, 
 the elasticity of the chest 
 walls, the thickness of the 
 layer of muscles and fat cov- 
 ering them, and the degree 
 of inflation of the lungs. 
 
 By the vibration of the 
 air in the uniform, elastic, 
 spongy tissue of the lung 
 when percussed. 
 
 FLATNESS. 
 
 (Absence of reso- 
 nance.) 
 
 The sound is completely 
 deadened, and resembles that 
 produced by percussing the 
 thigh or shoulder. The 
 finger used as a" pleximeter 
 experiences a greater sense 
 of resistance than normal, 
 especially in early life, before 
 the costal cartilages have 
 ceased to be elastic. 
 
 The absence of resonance 
 is occasioned by scrum or 
 pus in the pleural sac, serum 
 in the air-vesicles, complete 
 solidification of lung tissue, 
 tumors, etc. 
 
 DULLNESS. 
 
 (Diminished reso- 
 nance.) 
 
 Intermediate between the 
 two preceding, the vesicular 
 resonance being not lost but 
 only partially deadened. The 
 degree of dullness varies in- 
 definitely. The pitch is 
 higher than normal. The 
 sense of resistance is in- 
 creased in proportion to the 
 degree of dullness. 
 
 By the same causes as the 
 preceding, though existing 
 to a lesser extent. The rela- 
 tive proportion of solids or 
 liquids to air in the lungs is 
 morbidly increased.
 
 AUSCULTATION AND PERCUSSION. 
 PERCUSSION SIGNS. 
 
 47 
 
 WHERE OBSERVED IN HEALTH. 
 
 DISEASES INDICATED. 
 
 Most strongly marked in the infra- 
 clavicular regions. In the scapular 
 and interscapular regions, on account 
 of the Livers of bone and muscles, the 
 resonance is diminished, as it is also 
 where the lung overlaps the heart and 
 liver. In different regions the reso- 
 nance varies so much that what would 
 be normal for one would be decidedly 
 abnormal for another. Each must be 
 carefully studied by itself. The area of 
 healthy resonance is of course greater 
 with a full inflation of the lungs than 
 in tranquil breathing, and less with a 
 forced expiration. 
 
 In some persons the resonance is slightly 
 diminished on the right side in the inlra- 
 clavicuiar region in health, but never on the 
 left side. 
 
 Over the liver below the line of he- 
 patic flatness. 
 
 The lower border of the right lung marks 
 the line of hepatic flatness, and the upper 
 border of the underlying liver the line of 
 hepatic dullness. 
 
 Pneumonia. 
 Pleuritic effusion. 
 Empyema. 
 Hydrothorax. 
 
 Phthisis, pulmonary oedema, condensation 
 of lung from compression or from pulmonary 
 collapse, cancer, aneurism, etc. 
 
 Over the heart and spleen ; in the 
 places where the lungs overlap the 
 liver or heart ; over the mammarv 
 gland in females ; over thick layers of 
 iiiu>cl(;s on the ribs, especially behind; 
 and all over the chest in very fat per- 
 sons. 
 
 In some persons there is in health a slight 
 degree of dullness at the summit of the chest 
 on the right side. 
 
 The same diseases as the above, 
 where the same physical conditions 
 exist to a less extent. In many of 
 them dullness is more common than 
 flatness. The deposit of phthisis is 
 very rarely sufficient to give rise to 
 more than dullness, and miliary tuber- 
 cles, unless in great quantities, may 
 not even give rise to dullness. Con- 
 gestion of the lung may give rise to 
 dullness, but never to flatness. 
 
 Rarely we find dullness in emphysema, 
 owing probably to increased tension of lungs 
 and walls of chest. There may be slight dull- 
 ness from exudation of lymph on pleura.
 
 48 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 9, Continued. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 HOW PRODUCED. 
 
 A drum-like sound, as its 
 name signifies ; the term 
 often used to denote any res- 
 onance which is not vesic- 
 ular. It is of variable in- 
 tensity, either greater or less 
 than the vesicular, of higher 
 pitch, and accompanied with 
 a sense of less resistance to 
 the finger. 
 
 TTMPANITIC 
 
 RESONANCE. 
 
 It requires for its produc- 
 tion a large space filled with 
 air, and bounded by moder- 
 ately tense, elastic walls, capa- 
 ble of reflecting.sonorous vi- 
 brations. If, however, the 
 tension is extreme, the con- 
 tained air does not vibrate, 
 the tympanitic quality is 
 lessened or destroyed, and 
 the sound may become quite 
 dull. When a common drum 
 is made extremely tight and 
 there is no escape for the air, 
 the same dull effect is pro- 
 duced on being struck. 
 
 Tympanitic resonance oc- 
 curs under the following con- 
 'ditions : 
 
 1. From air or gas in the 
 pleural cavity. (Here the 
 resonance is more intense 
 than the normal vesicular.) 
 
 2. From air in pulmonary 
 cavities. 
 
 3. Singularly enough, and 
 contrary to what might be 
 expected, tympanitic reso- 
 nance is often heard over 
 partially solidified lung (giv- 
 ing place to dullness when 
 the solidification becomes 
 complete). 
 
 Where the upper lobe is thus 
 resonant, as in phthisis before 
 cavities have formed, and in pneu- 
 monia, it is generally explained 
 by saying that the resonance must 
 come from the air in the lower 
 part of the trachea and the pri- 
 mary bronchi, being better con- 
 ducted by solidified than by 
 healthy lung ; and where the 
 lower lobe is solidified, that the 
 tympanitic resonance, if present, 
 is conducted in a similar way from 
 the stomach or colon. Fuller, 
 however, thinks it comes from the 
 presence of air pent up in lung 
 tissue in the immediate vicinity of 
 consolidated tissue. Skoda and 
 others explain it by diminution of 
 tension.
 
 AUSCULTATION AND PERCUSSION. 
 PERCUSSION SIGNS, Continued. 
 
 WHERE OBSERVED IN HEALTH. 
 
 DISEASES INDICATED. 
 
 Heard over the stomach and bowels. 
 
 Pneumothorax. 
 
 Pn eu mo-hy drothorax. 
 
 Phthisis. 
 
 Cavities after abscess, etc. 
 Dilatation of bronchi. 
 Pneumonia.
 
 50 AUSCULTATION AND PERCUSSION. 
 
 TABLE NO. 9, Continued. 
 
 VARIETIES. 
 
 CHARACTER OF THE SOUND. 
 
 HOW PRODUCED. 
 
 EXAGGERATED 
 RESONANCE. 
 
 (Vesiculo-tym- 
 panitic.) 
 
 Intermediate between the 
 normal vesicular and the 
 tympanitic resonance, and 
 partaking of the characters 
 of each. The pitch high in 
 proportion as the tympanitic 
 quality predominates. In- 
 tensity greater than normal. 
 
 1. By abnormal dilatation 
 of the air cells. 
 
 2. If the effusion in pleu- 
 risy rises much above the 
 middle of the chest, the pres- 
 sure condenses the luug above 
 the liquid, and dullness en- 
 sues. Wit a less amount 
 of liquid, however, the reso- 
 nance is generally exaggera- 
 ted. Also, where pneumonia 
 solidifies one lobe, the reso- 
 nance over the other is gen- 
 erally exaggerated. Prob- 
 ably both cases are explained 
 by assuming a condition ap- 
 proximating to emphysema 
 in the lobe above the liquid 
 in pleurisy, and in the 
 healthy lobe in pneumonia, 
 they expanding prop.ortion- 
 ally to the expansion caused 
 by the diseased condition in 
 the affected part. 
 
 AMPHORIC 
 
 RESONANCE. 
 
 A kind of musical intona- 
 tion, like the sound obtained 
 by percussing an empty jar 
 (amphora). It may be imi- 
 Jated by closing the mouth, 
 inflating the cheeks, but not 
 too tensely, and then filliping 
 them with the finger. 
 
 The cavity must contain 
 air, must have somewhat 
 rigid walls, must be super- 
 ficial or else covered by so- 
 lidified lung, and there must 
 be free communication with 
 the bronchial tubes. The 
 sound can be heard better 
 if the ear or stethoscope is 
 brought close to the patient's 
 open mouth. Use slow and 
 heavy percussion. 
 
 CRACKED-METAL 
 RESONANCE. 
 
 (Bruit du pot fete.) 
 
 Like the sound produced 
 by striking a cracked earth- 
 enware or metal jar or other 
 vessel Can be imitated by 
 the school-boy trick of fold- 
 ing the hands so as to form 
 a hollow, and striking the 
 back of one of them on the 
 knee. A loud, short, hollow, 
 metallic sound, accompanied 
 with hissing. 
 
 Produced exactly as in the 
 school-boy trick referred to, 
 by the sudden expulsion of 
 air, and its forcible contact 
 with the sides of the passage 
 through which it is driven. 
 The same conditions are nec- 
 essary to its production as in 
 amphoric resonance.
 
 AUSCULTATION AND PERCUSSION. 
 PERCUSSION SIGNS, Continued. 
 
 51 
 
 WHERE OBSERVED IN HEALTH. 
 
 DISEASES INDICATED. 
 
 Emphysema (vesicular or interlob- 
 ular or secondary to phthisical de- 
 posit, etc.). 
 
 Pleurisy with effusion. 
 
 Pneumonia. 
 
 Occasionally produced in children 
 over a primary bronchus, owing to the 
 yielding of the costal cartilages. 
 
 Mostly phthisical cavities, some- 
 times pneumo-hydrothorax. 
 
 Occasionally at the summit of the chest in 
 pleurisy with effusion. 
 
 As in the preceding 1 . 
 
 It may be produced unintentionally 
 by the imperfect application of the 
 finger or pleximeter to the chest walls, 
 and the expulsion of air from beneath 
 it. 
 
 Mostly phthisical cavities. 
 
 Occasionally in solidification of the tipper 
 lobe from inflammation or condensation, 
 where the air is suddenly and forcibly ex- 
 pelled through the bronchus, especially if 
 percussed near the sternum.
 
 PART II. 
 
 THE PHYSICAL DIAGNOSIS OF DISEASES 
 OF THE LUNGS AND HEART.
 
 54 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10. 
 
 
 INSPECTION AND 
 
 
 
 DISEASE. 
 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 
 MENSURATION. 
 
 
 
 ACUTB 
 
 Diminution in 
 
 Sometimes slight 
 
 Feeble. 
 
 PLECKISY. 
 
 respiratory move- 
 
 dullness. 
 
 Jerking. 
 
 
 ments on account 
 
 
 
 First Stage. 
 
 of pain. Body bent 
 
 
 
 
 towards affected 
 
 
 
 (Exudation of 
 
 side for the same 
 
 
 
 lymph.) 
 
 reason. 
 
 
 
 
 Little or no mo- 
 tion of the chest 
 
 A sense of re- 
 sistance, and fiat- 
 
 Feeble, broncho- 
 vesicular or bron- 
 
 
 walls on the affect- 
 
 ness or dullness at 
 
 chial respiration 
 
 
 ed side, but in- 
 
 the base of the 
 
 over the compressed 
 
 
 creased motion on 
 
 chest, terminating 
 
 lung, with occa- 
 
 
 the healthy side. 
 
 abruptly above in 
 
 sionally a feeble, 
 
 
 Enlargement of 
 
 a curved line which 
 
 distant, bronchial 
 
 
 side in all direc- 
 
 is not altered by 
 
 respiration all over 
 
 
 tions by measure- 
 
 respiration, but 
 
 the chest. 
 
 
 ment, and oblitera- 
 
 which may be made 
 
 Respiration gen- 
 
 Second Stage. 
 
 tion of intercostal 
 
 to shift by chang- 
 
 erally suppressed 
 
 (Effusion of 
 
 serum.) 
 
 spaces, especially 
 at lower part of 
 chest. 
 
 ing the patient's 
 posture, unless 
 there are adhesions 
 
 below the level of 
 the liquid, but in- 
 creased on unaf- 
 
 
 
 of the pleural sur- 
 
 fected side during 
 
 
 
 faces, or the chest 
 
 all three stages, 
 
 
 
 is full of liquid. 
 
 especially in thia 
 
 
 
 Generally exag- 
 
 stage. 
 
 
 
 gerated resonance 
 
 
 
 
 above the level of 
 
 
 
 
 the liquid, and 
 
 
 
 
 rarely the amphoric 
 
 
 
 
 or the cracked- 
 
 
 
 
 metal resonance at 
 
 
 
 
 the summit. 
 
 
 
 Mobility of chest 
 
 The line of flat- 
 
 Respiration grad- 
 
 
 walls partially re- 
 
 ness is gradually 
 
 ually returns to its 
 
 
 turning, intercostal 
 
 lowered, but dull- 
 
 normal condition 
 
 
 spaces becoming 
 
 ness often remains 
 
 from the summit 
 
 
 normal, and en- 
 
 for an indefinite 
 
 downwards, though 
 
 
 largement disap- 
 
 time at the base of 
 
 fee Me often for 
 
 Third Stage. 
 
 pearing. 
 
 the chest, where 
 
 weeks and months. 
 
 (Absorption and 
 
 After recovery 
 there occurs, in 
 
 the compression of 
 the lung and the 
 
 A bstuce of respi- 
 ration at the base 
 
 resolution.) 
 
 some cases 
 
 accumulation of 
 
 frequently remains 
 
 
 (though seldom in 
 
 solid plastic mate- 
 
 for a long time. 
 
 
 comparison with 
 
 rial is often very 
 
 
 
 chronic pleurisy), 
 
 great. 
 
 
 
 contraction of the 
 
 
 
 
 whole side. 
 

 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10. 
 
 55 
 
 RALES. 
 
 VOCAL 
 
 PALPATION. 
 
 REMARKS. 
 
 
 RESONANCE. 
 
 
 
 Rubbing friction 
 
 
 Deep-seated ten- 
 
 When not spe- 
 
 sounds often 
 
 
 derness. 
 
 cified, the signs 
 
 heard, which are 
 
 
 
 mentioned in this 
 
 almost pathogno- 
 
 
 
 table are ob- 
 
 monic when at 
 
 
 
 served over the 
 
 the middle or infe- 
 
 
 
 affected portion 
 
 rior part of chest, 
 
 
 
 of the lung only. 
 
 or all over the side. 
 
 
 
 
 A friction 
 
 Lessened or 
 
 Fluctuation some- 
 
 Generally the 
 
 sound is rarely 
 heard even in this 
 
 suppressed below 
 the level of the 
 
 times apparent. Vo- 
 cal fremitns lessened 
 
 pleural cavity is 
 not more than 
 
 stage, where the 
 
 liquid, but in- 
 
 or suppressed below 
 
 half or two thirds 
 
 lung is attached 
 
 creased above. 
 
 the level of the liquid, 
 
 full in acute 
 
 by bands of false 
 
 Sometimes bron- 
 
 but increased above. 
 
 pleurisy. 
 
 membrane to the 
 
 chophony above 
 
 If the heart is dis- 
 
 
 thoracic walls, 
 
 the level, or pec- 
 
 placed, it may be 
 
 
 and also over the 
 
 toriloquy (espe- 
 
 heard and often felt 
 
 
 compressed lung 
 
 cially in pleuro- 
 
 pulsating even to the 
 
 
 higher up. 
 
 pneumonia, or 
 
 right of the sternum, 
 
 
 
 pleurisy with 
 
 or farther to the left 
 
 
 
 phthisis), heard 
 
 than normal in the 
 
 
 
 best over the 
 
 direction of the ax- 
 
 
 
 scapular and in- 
 
 illa ; the displace- 
 
 
 
 terscapular re- 
 
 ment being to the 
 
 
 
 gions on account 
 
 right if the effusion 
 
 
 
 of the usual sit- 
 
 is on the left side, and 
 
 
 
 uation of the 
 
 to the left if the effu- 
 
 
 
 compressed lung. 
 
 sion is on the right 
 
 
 
 Sometimes 
 
 side. 
 
 
 * 
 
 aegophony near 
 
 
 
 
 the level of the 
 
 
 
 
 liquid. 
 
 
 
 A rasping, grat- 
 
 Gradually ap- 
 
 Sometimes a fric- 
 
 
 ing, creaking, 
 
 proaches to the 
 
 tion fremitus. The 
 
 
 rough, fr ictio n 
 
 normal. Some- 
 
 he-art, if previously 
 
 
 murmur is now 
 
 times aegophony. 
 
 displaced, gradually 
 
 
 very often ob- 
 
 
 returns to the prae- 
 
 
 served, especially 
 
 
 cordia, unless held 
 
 
 with a deep in- 
 
 
 by morbid adhesions ; 
 
 
 spiration, some- 
 
 
 and curiously enough, 
 
 
 times loud enough 
 
 
 the suction force 
 
 
 to be heard at a 
 
 
 caused by absorption 
 
 
 distance, and va- 
 
 
 may now even draw 
 
 
 rying in duration 
 
 
 it too far in the oth- 
 
 
 from a very short 
 
 
 er direction, if the 
 
 
 time to several 
 
 
 effusion has been 
 
 
 months, ceasing 
 
 
 right-sided, towards 
 
 
 with adhesion. 
 
 
 the right ; if left- 
 
 
 
 
 sided, further to the 
 
 
 
 
 left than normal. 

 
 56 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 INSPECTION AND 
 MENSUKATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 CHRONIC 
 PLEURISY. 
 
 (If the chest is 
 full of fluid.) 
 
 Perfect or almost 
 perfect immobility 
 of side of chest 
 (with increase of 
 motion on healthy 
 side). Generally di- 
 latation of side, 
 and as a rule, even 
 if this be not so, 
 the intercostal de- 
 pressions are ef- 
 faced or lessened. 
 This is particularly 
 noticeable at the 
 end of inspiration. 
 The maximum en- 
 largement of the 
 side is about two 
 inches. 
 
 Permanent con- 
 traction after re- 
 covery. 
 
 Flatness ev ery- 
 where on affected 
 side, even extend- 
 ing over the ster- 
 num some distance 
 on the other side. 
 
 Wanting ; except 
 at the summit over 
 or near the com- 
 pressed lung, where 
 it is bronchial. Ex- 
 ceptionally, how- 
 ever, the bronchial 
 respiration extends 
 over the whole side 
 or the greater part 
 of it. 
 
 Respiratory mur- 
 mur exaggerated on 
 healthy side. 
 
 EMPYEMA. 
 
 The amount of 
 pus is generally 
 even greater than 
 that of the serum 
 in chronic pleurisy, 
 causing still greater 
 dilatation of the 
 chest. The obliter- 
 ation of intercostal 
 depressions is oft- 
 ener noticed than 
 in pleurisy. 
 
 Same as chronic 
 pleurisy. 
 
 Same as chronic 
 pleurisy.
 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 57 
 
 RALES. 
 
 VOCAL 
 
 RESONANCE. 
 
 PALPATION. 
 
 As in acute 
 pleurisy. 
 
 Lessened o r 
 suppressed ex- 
 cept at the sum- 
 mit behind, 
 where there may 
 be loud and whis- 
 pering bron- 
 chophony and in- 
 creased vocal res- 
 onance. jEgoph- 
 ony is rare. 
 
 Fluctuation some- 
 times apparent. Vo- 
 cal fremitus lessened 
 or suppressed. 
 
 Heart displaced 
 even more than is 
 usual in acute pleu- 
 risy. Mediastinum 
 displaced laterally. 
 Liver and stomach 
 often displaced down- 
 wards, sometimes as- 
 cending even higher 
 than before with the 
 contraction accom- 
 panying recovery. 
 
 If the chest is 
 only partially 
 filled, the signs 
 are the same as 
 in acute pleurisy. 
 It is far more 
 common to have 
 the chest full in 
 chronic than in 
 acute pleurisy. 
 
 Same as chron- 
 ic pleurisy. 
 
 Same as chron- 
 ic pleurisy. 
 
 Even more dis- 
 placement of the 
 heart generally than 
 in chronic pleurisy, 
 it pulsating some- 
 times even beyond 
 the right nipple. If 
 the left side is affect- 
 ed, the effusion often 
 receives a tangible 
 and visible impulse 
 from the heart's beat; 
 hence the term " pul- 
 sating empyema." 
 
 If a spontaneous 
 perforation takes 
 place through the 
 chest walls, and the 
 skin remains un- 
 broken, the tumor 
 thus formed, besides 
 fluctuating, often has 
 a strong pulsation, 
 synchronous with the 
 systole, simulating 
 aneurism. The tu- 
 mor may also in- 
 crease and decrease 
 with respiration.
 
 58 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 INSPECTION AND 
 MENSURATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 HYDRO- 
 THORAX. 
 
 Although there 
 may .he more liquid 
 on one side than on 
 the other, yet there 
 is almost never one- 
 sided dilatation of 
 the chest and dis- 
 placement of the 
 heart and medias- 
 tinum. 
 
 Flatness or dull- 
 ness over the lower 
 part of both sides 
 of the chest. The 
 line of flatness al- 
 most always 
 changes with 
 change of posture. 
 Of course it is im- 
 possible for both 
 pleural cavities to 
 be completely 
 filled. 
 
 As in pleurisy 
 with moderate ef- 
 fusion. There is 
 rarely, however, 
 well-marked bron- 
 chial respiration, 
 as, the disease "being 
 bilateral, sufficient 
 compression to pro- 
 duce bronchial res- 
 piration could not 
 often be compatible 
 with life. 
 
 PULMONAET 
 
 (EDEMA. 
 
 More or less dull- 
 ness, generally dif- 
 fused equally over 
 the back of the 
 chest on both sides, 
 and most marked 
 at the lowest parts. 
 
 Weakened or 
 suppressed. 
 
 Rarely well- 
 marked bronchial 
 respiration.
 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 VOCAL 
 KESONANCE. 
 
 PALPATION. 
 
 REMARKS. 
 
 No exudation 
 of lymph and 
 therefore no fric- 
 tion sounds. 
 
 As in pleurisy 
 with moderate 
 effusion. 
 
 Vocal f remitus 
 lessened or sup- 
 pressed below the 
 level of the liquid, 
 but increased above. 
 
 Hydrothorax is 
 bilateral ; while 
 the different 
 kinds of pleurisy 
 are almost with- 
 out exception 
 unilateral. 
 
 Subcrepitant 
 and fine bubbling 
 
 rales. 
 
 Variable. 
 
 Vocal fremitus va- 
 riable. 
 
 Like hydro- 
 thorax, pulmo- 
 nary oedema is a 
 result of structu- 
 ral disease of the 
 heart or kidney. 
 Although gen- 
 erally bilateral, 
 and then oftener 
 found in the pos- 
 terior portions, it 
 may be unilateral 
 and extend over 
 one lobe or a 
 whole lung.
 
 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 DISEASE. 
 
 INSPECTION AND 
 MENSURATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 
 Expansion of 
 
 Flatness at the base 
 
 Suppressed be- 
 
 
 affected side and 
 
 of the chest on the 
 
 low the level of the 
 
 
 relative mobility 
 
 affected side, if there 
 
 liquid. Feeble, dis- 
 
 
 impaired. Ob- 
 
 be enough liquid (se- 
 
 tant or suppressed 
 
 
 literation and 
 
 rum or pus). Over 
 
 above, unless there 
 
 
 sometimes bulg- 
 
 the upper part of the 
 
 is a free communi- 
 
 
 ing of intercostal 
 
 same side and some- 
 
 cation between the 
 
 
 depressions. 
 
 times extending be- 
 
 bronchial tubes and 
 
 
 
 yond the sternum, 
 
 the pleural cavity 
 
 
 
 tympanitic resonance 
 
 above the level of 
 
 
 
 almost as intense as 
 
 the liquid, when 
 
 
 
 that of a tympanitic 
 
 there may be heard 
 
 
 
 abdomen. This is 
 
 amphoric respira- 
 
 
 
 heard by conduction 
 
 tion, limited to a 
 
 
 
 even below the level 
 
 circumscribed area 
 
 
 
 of the liquid, the lat- 
 
 near the perfora- 
 
 
 
 ter often extending 
 
 tion, which is gen- 
 
 
 
 twice as high as the 
 
 erally between the 
 
 
 
 line of flatness. 
 
 third and sixth ribs 
 
 PNETJMO- 
 
 
 The tympanitic res- 
 
 on the postero-lat- 
 
 HYDROTHO- 
 
 
 onance extends over 
 
 eral surface of the 
 
 RAX. . 
 
 
 the whole side, if 
 
 chest. 
 
 
 
 there be only a small 
 
 Bronchial respi- 
 
 
 
 amount of liquid. 
 
 ration over the con- 
 
 
 
 Change of posture 
 
 densed lung (which 
 
 
 
 always, in this dis- 
 
 is generally also 
 
 
 
 
 ease, changes relative 
 
 tuberculous), at the 
 
 
 
 position of flatness 
 
 top of the chest 
 
 
 
 and tympanitic reso- 
 
 behind. 
 
 
 
 nance. Sometimes 
 
 Respiration on 
 
 
 
 there is amphoric res- 
 
 healthy side exag- 
 
 
 
 o nance. Dullness 
 
 gerated. 
 
 
 
 from the condensed 
 
 
 
 
 lung may sometimes 
 
 
 
 
 be detected at the 
 
 
 
 
 summit of the chest 
 
 
 
 
 behind. If the quan- 
 
 
 
 
 tity of air or gas be 
 
 
 
 
 vert/ large, on account 
 
 
 
 
 of the extreme tension 
 
 
 
 
 there may be tympa- 
 
 
 
 
 nitic dullness. 

 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 61 
 
 RA"LES. 
 
 VOCAL 
 RESONANCE. 
 
 PALPATION. 
 
 REMARKS. 
 
 Metallic tink- 
 ling, and splash- 
 ing or Hippo- 
 cratic succussion 
 sound. 
 
 Above the liquid 
 amphoric whisper, 
 voice, and cough, if 
 there is amphoric 
 respiration. Or the 
 vocal resonance may 
 be feeble or wanting. 
 Always wanting be- 
 low the liquid. Me- 
 tallic tinkling. 
 
 Increased vocal res- 
 onance or bronchoph- 
 ony over the com- 
 pressed lung at the 
 top of the chest be- 
 hind. 
 
 Vocal fremitus 
 diminished or 
 suppressed. 
 
 Displacement 
 of heart. Fluc- 
 tuation. Sense 
 of elasticity 
 above and of re- 
 sistance below 
 the level of the 
 liquid. 
 
 When this dis- 
 ease occurs, it is 
 generally a com- 
 plication of 
 phthisis. 
 
 The relative 
 proportion of air 
 or gas and water 
 varies in different 
 cases and in the 
 same case at dif- 
 ferent times, es- 
 pecially if com- 
 munication with 
 the external air 
 continues.
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 
 INSPECTION AND 
 
 
 
 DISEASE. 
 
 
 PERCUSSION. 
 
 P.ESPI RATION. 
 
 
 MENSURATION. 
 
 
 
 
 
 As in the preceding. 
 
 Tympa n i t i c 
 
 Respiration sup- 
 
 
 
 resonance over a 
 
 pressed where the 
 
 
 
 part or the whole 
 
 air is, or it may be 
 
 
 
 of the affected 
 
 amphoric if there is 
 
 
 
 side, sometimes 
 
 free communication 
 
 PNEUMO- 
 
 
 even extending 
 
 between the bron- 
 
 TIIORAX. 
 
 
 to the right or 
 
 chial tubes and the 
 
 
 
 left beyond the 
 
 pleural cavity. Bron- 
 
 
 
 sternum. 
 
 c h i a 1 respiration 
 
 
 
 
 over the condensed 
 
 
 
 
 lung. Exaggerated 
 
 
 
 
 on the healthy side. 
 
 
 There is a character- 
 
 Exaggera ted 
 
 Weakened or 
 
 
 istic deformity of the 
 
 resonance (some- 
 
 suppressed over the 
 
 
 chest, a great bulging 
 
 times called ves- 
 
 upper lobes, more 
 
 
 of the whole upper part 
 generally, sternum and 
 
 i c u 1 o-t y m p a- 
 nitic), on both 
 
 so usually on the 
 left than on the 
 
 
 all. 
 
 sides, but gen- 
 
 right side. Inspi- 
 
 
 The antero-posterior 
 
 erally greater 
 
 ratory sound short- 
 
 
 diameter of the chest 
 
 on the left. It is 
 
 ened and expiration 
 
 
 is greatly increased. 
 
 heard over a 
 
 remarkably p r o- 
 
 
 The clavicles are ele- 
 
 greater area than 
 
 longed, though of 
 
 
 vated, and yet almost 
 
 the vesicular res- 
 
 the same quality 
 
 
 buried up. The lower 
 
 onance in health, 
 
 as in health. 
 
 
 parts of the scapulae 
 
 as the diaphragm 
 
 
 
 sometimes project. The 
 
 is pushed down 
 
 
 
 entire thorax is dragged 
 upwards as one piece in 
 
 and the heart is 
 more or less com- 
 
 
 
 inspiration, but there is 
 
 pletely covered 
 
 
 
 little or no expansion 
 
 by lung. Owing 
 
 
 
 of the chest, because the 
 
 to the slight 
 
 
 
 elasticity of the lung 
 
 movement of the 
 
 
 EMPHY- 
 
 tissue being lost, expi- 
 
 lungs, this area 
 
 
 SEMA. 
 
 ration fails to empty the 
 chest, and there is little 
 
 is not much af- 
 fected by forced 
 
 
 
 room for the introduc- 
 
 inspiration or ex- 
 
 
 
 tion of fresh air. 
 
 piration. 
 
 
 
 Respiratory efforts 
 
 If the lower 
 
 
 
 labored and powerful, 
 
 lobes are em- 
 
 
 
 yet the breathing is 
 
 physematous, the 
 
 
 
 chiefly abdominal, and 
 
 line of hepatic 
 
 
 
 the lower part of the 
 
 flatness may be 
 
 
 
 chest may even sink in 
 
 lowered to the 
 
 
 
 during inspiration. De- 
 
 ninth or tenth 
 
 
 
 pression above clavicles 
 in inspiration. 
 
 rib on the per- 
 pendicular mam- 
 
 
 
 The patient often 
 
 mary line. 
 
 
 
 stoops from antero-pos- 
 
 
 
 
 terior curvature of the 
 
 In exceptional 
 
 
 
 
 c:i-fs, there may be 
 
 
 
 spine. 
 
 Rome dullness on 
 
 
 
 In a few cases of the 
 
 percussion. 
 
 
 
 variety called "senile 
 
 
 
 
 atrophy " of the lung 
 
 
 
 
 there is no bulging. 
 

 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 63 
 
 VOCAL 
 RESONANCE. 
 
 PALPATION. 
 
 REMARKS. 
 
 Diminished or sup- 
 pressed where the air 
 is, or amphoric voice, 
 whisper, and cough, 
 if there is amphoric 
 respiration. Vocal 
 resonance increased 
 over the condensed 
 lung, or even bron- 
 chophony. 
 
 Vocal fremitus 
 diminished or 
 suppressed where 
 the air is, but 
 increased over 
 the condensed 
 lung. Displace- 
 ment of heart. 
 
 A very rare dis- 
 ease, air or gas 
 without liquid almost 
 never being found 
 in the chest. 
 
 Pneumo-hydrotho- 
 rax is often loosely 
 called pneumo-tho- 
 rax, however. 
 
 If bronchitis 
 and asthma co- 
 exist, bubbling 
 rales, and oft- 
 ener sibilant 
 and sonorous 
 rales. 
 
 Vocal resonance 
 variable. 
 
 Vocal fremitus 
 variable. 
 
 Heart's im- 
 pulse lowered, 
 sometimes being 
 felt in the epi- 
 gastrium instead 
 of in the prae- 
 cordial space. 
 
 Chest walls un- 
 usually elastic 
 to the finger. 
 
 In the great ma- 
 jority of cases, 
 vesicular emphy- 
 sema has associ- 
 ated with it chronic 
 bronchitis. It is 
 often accompanied 
 by paroxysms of 
 asthma. 
 
 Generally a bilat- 
 eral disease, al- 
 though there is 
 usually more affec- 
 tion of the left 
 lung than of the 
 right.
 
 64 
 
 THE PHYSICAL DIAGNOSIS 
 
 TABLE NO. 10, Continued. 
 
 INSPECTION AND 
 MENSURATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 ASTHMA. 
 
 Often a bulg- 
 ing of the upper 
 part of the chest, 
 and a sinking in, 
 during inspira- 
 tion, of the lower 
 part, on account 
 of the emphy- 
 sema which gen- 
 erally coexists. 
 
 Labored res- 
 piration. 
 
 Owing to the 
 commonly coexist- 
 ing emphysema, 
 there is generally 
 exaggerated per- 
 cussion resonance, 
 as iu that disease. 
 
 Diminished or sup- 
 pressed. 
 
 Sometimes exag- 
 gerated. 
 
 Jerking. 
 
 BRONCHITIS. 
 
 (Affecting the 
 larger tubes.) 
 
 Healthy r e s o- 
 nance on both 
 sides of the chest. 
 A negative sign, 
 but a good one 
 here. 
 
 Rarely a slight dull- 
 ness at the lower part 
 of the back of the 
 chest, from excessive 
 secretion which can- 
 not be raised, or from 
 collapse of pulmonary 
 lobules from obstruc- 
 tion of bronchial 
 tubes. 
 
 In many cases nor- 
 mal. 
 
 Sometimes ob- 
 scured by the rales, 
 sometimes weakened 
 or suppressed over a 
 part of the chest by 
 plugs of mucus in 
 tubes, suddenly reap- 
 pearing after cough- 
 ing, sometimes by 
 thickening of the 
 mucous membrane ; 
 but from this latter 
 cause both sides are 
 affected alike.
 
 OF DISEASES OF THE LUNGS. 
 
 65 
 
 TABLE NO. 10, Continued. 
 
 VOCAL 
 RESONANCE. 
 
 PALPATION. 
 
 REMARKS. 
 
 Loud sibilant and 
 sonorous rales with in- 
 spiration and expira- 
 tion (the sibilant, 
 however, being more 
 abundant in inspira- 
 tion, and the sonorous 
 in expiration), all over 
 the chest on both 
 sides and often heard 
 at a distance. 
 
 Sometimes bubbling 
 rales towards the close 
 of the paroxysms and 
 for several days after, 
 when they cease, un- 
 less chronic bronchitis 
 coexists. 
 
 The physical 
 signs given are 
 those of a parox- 
 ysm. This is 
 generally accom- 
 panied by a tem- 
 porary emphyse- 
 matous condition 
 at least, and by 
 bronchitis. 
 
 Regular asth- 
 matics often have 
 these for perma- 
 nent complica- 
 tions. 
 
 On both sides of the 
 chest, especially over 
 the lower lobes be- 
 hind, sonorous and sib- 
 ilant rales, according 
 to the size of the tubes 
 in which they are pro- 
 duced, are sometimes 
 heard alone, before 
 secretion takes place, 
 and after this mingled 
 with coarse and fine 
 bubbling rales. In 
 many cases no rales 
 are heard at all, and 
 when present they of- 
 ten shift their posi- 
 tion. The moist rales 
 are not heard unless 
 the mucus is unusual- 
 ly thin and abundant, 
 which is not the case 
 in many instances. 
 They occur oftener 
 in chronic than in 
 acute bronchitis, be- 
 cause in the former 
 the liquid is more apt 
 to be muco-purulent, 
 and therefore pro- 
 duces better bubbles. 
 They occur oftener 
 also in young chil- 
 dren than in adults, 
 because the former 
 expectorate less. 
 
 Sometimes a 
 rhonchial fremi- 
 tus. 
 
 A bilateral dis- 
 ease.
 
 66 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 INSPECTION AND 
 MENSURATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 CAPILLARY 
 BRONCHITIS. 
 
 (Including catar- 
 rhal pneumonia.) 
 
 If there is con- 
 siderable collapse 
 of pulmonary lob- 
 ules, with emphy- 
 sema, and with or 
 without catarrhal 
 pneumonia, the up- 
 per part of the 
 chest is more or 
 less expanded, and 
 the lower part may 
 even sink in during 
 inspiration. 
 
 Undiminished res- 
 onance on both 
 sides of the chest, 
 except sometimes 
 when there is col- 
 lapse of pulmonary 
 lobules with or 
 without catarrhal 
 pneumonia, when 
 there may be some 
 circumscribed dull- 
 ness over dissemi- 
 nated portions of 
 the lung, especially 
 over the lower 
 lobes behind, and 
 exaggerated reso- 
 nance in other 
 parts, especially 
 the upper part of 
 the chest in front, 
 if emphysema co- 
 exists. 
 
 Respiration weak- 
 ened or obscured by 
 rales. If solidifica- 
 tion from collapse 
 coexists (with or 
 without catarrhal 
 pneumonia), bron- 
 cho-vesicular or 
 bronchial or weak- 
 e n e d respiration 
 over such parts. If 
 emphysema coex- 
 ists, weak or sup- 
 pressed inspiration 
 in front above, and 
 expiration length- 
 ened. 
 
 PLASTIC 
 
 BRONCHITIS. 
 
 (Pseudo-mem- 
 branous.) 
 
 No dullness un- 
 less from collapse, 
 or from great 
 quantity of liquid 
 in bronchi. 
 
 There may be 
 suppression of res- 
 piration over parts 
 of the chest from 
 the exudation or 
 from collapse ; or 
 broncho - vesicular 
 or bronchial respi- 
 ration from col-
 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 67 
 
 RALES. 
 
 VOCAL, 
 
 PALPATION. 
 
 REMARKS. 
 
 
 RESONANCE. 
 
 
 
 Subcrepitant rales 
 
 If solidifica- 
 
 If solidifica- 
 
 A bilateral dis- 
 
 uniformly present on 
 
 tion from col- 
 
 tion from col- 
 
 ease. Inflamma- 
 
 lx>th sides of the chest, 
 with either or both 
 
 lapse exists, with 
 or without catar- 
 
 lapse exists, with 
 or without catar- 
 
 tion of the larger 
 tubes generally 
 
 respiratory acts, es- 
 pecially over the 
 
 rhal pneumonia, 
 increased vocal 
 
 rhal pneumonia, 
 increased vocal 
 
 coexists. Capil- 
 lary bronchitis is 
 
 lower third of the 
 
 resonance or 
 
 fremitus over 
 
 sometimes attend- 
 
 chest behind. 
 
 broncho phony 
 
 such parts. 
 
 ed with collapse 
 
 Sibilant and sono- 
 
 over such parts. 
 
 
 o f pulmonary 
 
 rous, especially s ibi- 
 
 
 
 lobules and ca- 
 
 lant rales, and also 
 
 
 
 tarrhal pneumo- 
 
 fine and coarse bubbling 
 
 
 
 nia, especially in 
 
 rales may be heard all 
 
 
 
 infants or in aged 
 
 over the chest on both 
 
 
 
 or feeble persons. 
 
 sides when the smaller 
 
 
 
 Collapse, by the 
 
 and larger tubes are 
 
 
 
 law of compen- 
 
 also affected. 
 
 
 
 sation, generally 
 
 
 
 
 gives rise to 
 
 
 
 
 emphysema in 
 
 
 
 
 other portions of 
 
 
 
 
 the lung. 
 
 Sonorous and sibi- 
 lant rales on both 
 
 As in the pre- 
 ceding. 
 
 As in the pre- 
 ceding. 
 
 A rare disease. 
 The .fibrinons 
 
 sides. 
 
 
 
 exudation com- 
 
 Subcrepitant rales 
 
 
 
 mences in the 
 
 limited to certain por- 
 
 
 
 minute branches 
 
 tions of chest. Also 
 
 
 
 and extends up- 
 
 bubbling rales. 
 
 
 
 wards. A few or 
 
 There may be tem- 
 
 
 
 many tubes may 
 
 porary suppression of 
 
 
 
 be affected. Col- 
 
 rales over parts of the 
 chest from the exuda- 
 
 
 
 lapse of pulmo- 
 nary lobules may 
 
 tion, or more lasting 
 
 
 
 occur from ob- 
 
 suppression from col- 
 
 
 
 struction. 
 
 lapse. 
 
 
 
 Bilateral dis- 
 
 
 
 
 ease. Either 
 
 
 
 
 acute or chronic.
 
 68 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 INSPECTION AND 
 MENSURATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 ACUTE LOBAR 
 
 OK CROUPOUS 
 
 PNEUMONIA. 
 
 First Stage. 
 (Congestion.) 
 
 Sometimes cos- 
 tal movements 
 on affected side 
 dimiuis bed on 
 account of pain. 
 
 There may be a slight 
 dullness. 
 
 We akene d 
 somewhat over 
 the congested 
 lobe. 
 
 Second Stage. 
 
 (Hepatization.) 
 
 Costal move- 
 ments dimin- 
 ished on affected 
 side (especially 
 if the whole lung 
 be inflamed), and 
 increased on the 
 other side. 
 
 There may be 
 in some cases a 
 slight increase by 
 measurement. 
 
 Over the affected lobe 
 or lobes increased sense 
 of resistance and 
 marked dullness, some- 
 times even amounting 
 to flatness. The inter- 
 lobar fissure can be dis- 
 tinctly mapped out by 
 percussion, if one or 
 two lobes of the affected 
 lung remain unaffected, 
 the latter giving forth 
 an exaggerated reso- 
 nance. In such cases 
 the resonance over the 
 healthy lung is i n- 
 creased,but not so much 
 as over these unaffected 
 lobes. 
 
 In some cases, instead of 
 the usual dullness there may 
 be tympanitic or cracked- 
 metal or amphoric reso- 
 nance over part of an upper 
 solidified lobe, this quality 
 coming from the air in thie 
 trachea or bronchi, con- 
 ducted by the solidification ; 
 also sometimes at the base 
 of the chest, if affected, be- 
 ing conducted upwards from 
 the stomach or colon. 
 
 Broncho-vesicu- 
 lar followed by 
 bronchial respira- 
 tion, as solidifi- 
 cation increases. 
 
 Exagg crated 
 on healthy side.
 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 69 
 
 VOCAL RESONANCE. 
 
 PALPATION. 
 
 REMARKS. 
 
 Generally, but 
 not invariably, the 
 ere pit ant rale. 
 When it does occur, 
 it is pathognomonic. 
 
 Rarely dry and moist 
 bronchial rales from 
 accompanying circum- 
 scribed bronchitis, or a 
 friction sound from 
 secondary pleurisy. 
 
 Generally a uni- 
 later al disease. 
 More common in a 
 lower lobe, espe- 
 cially on the right 
 side. When so situ- 
 ated, the physical 
 signs are best heard 
 in the infra-scapu- 
 lar and infra-axil- 
 lary regions. 
 
 Crepitant rale dis- 
 appears, but occa- 
 sionally it persists 
 even in this stage, a 
 few air-cells here 
 and there not being 
 filled with exuda- 
 tion. 
 
 Rarely moist bron- 
 chial rales. 
 
 Increased vocal 
 resonance and in- 
 creased bronchial 
 whisper, followed 
 by bronchophony and 
 whispering br on- 
 chophony, as solidi- 
 fication increases. 
 
 Occasionally pec- 
 toriloquy and 
 whispering pecto- 
 riloquy. 
 
 Vocal fremi- 
 tus generally 
 increased over 
 affected por- 
 tion, but some- 
 times dimin- 
 ished, and oc- 
 casionally ab- 
 sent, owing to 
 plugging of 
 bronchi or 
 pleuritic effu- 
 sion. 
 
 Sometimes the 
 heart's sounds are 
 transmitted with 
 peculiar dist i n c t- 
 ness through the 
 solidification, some- 
 times not.
 
 70 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 DISEASE. 
 
 INSPECTION AND 
 MENSURATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 CROUPOUS 
 PNEUMONIA. 
 
 Third Stage. 
 (1.) Resolution. 
 
 G r a d u a 1 re- 
 turn to the nor- 
 mal cond i t i o n, 
 and after recov- 
 ery even contrac- 
 tion may occur 
 in some cases. 
 
 Dullness grad- 
 ually disappears. 
 A little, however, 
 often remains for 
 a long time. 
 
 The bronchial 
 merges into the bron- 
 cho-vesicular respira- 
 tion, which is followed 
 for some time after 
 recovery by weakened 
 respiration. 
 
 or 
 
 (2.) Purulent 
 infiltration. 
 
 
 
 
 
 
 Dullness con- 
 tinues, and be- 
 comes more 
 marked. 
 
 Bronchial respira- 
 tion, or feeble or sup- 
 pressed respiration. 
 
 CATARRHAL 
 PNEUMONIA. 
 
 Already 
 
 explained in 
 
 connection with 
 
 (Lobular or broncho- 
 pneumonia.) 
 
 
 
 
 INTERSTITIAL 
 
 OR 
 
 CHRONIC PNEU- 
 MONIA, 
 
 OR 
 
 FIBROID PHTHI- 
 
 Difference in 
 the relative cos- 
 tal moveme n t s 
 on the two sides, 
 and after a while 
 contract ion of 
 the affected lobe. 
 
 Marked dull- 
 ness. 
 
 Occas i o n a 1 1 y a 
 tympanit i c r e s o- 
 nance. 
 
 Bronchial or bron- 
 cho-vesicular. 
 
 SIS. 
 
 

 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 71 
 
 RALES. 
 
 VOCAL 
 
 PALPATION. 
 
 REMARKS. 
 
 
 RESONANCE. 
 
 
 
 Subcrepitant 
 
 Bronchophony 
 
 Increa s e d v o- 
 
 
 rale appears, with 
 
 and whispering 
 
 cal fremitus, fol- 
 
 
 sometimes a few 
 
 bronchop h o n y, 
 
 lowed by the nor- 
 
 
 fine and coarse 
 
 followed by in- 
 
 mal. 
 
 
 bubbling rales. 
 
 creased vocal 
 
 
 
 Crepitant rale re- 
 
 resonanc e and 
 
 
 - 
 
 turns. 
 
 increased bron- 
 
 
 
 
 chial wh i s pe r, 
 
 
 
 
 and this by nor- 
 
 
 
 
 mal vocal reson- 
 
 
 
 
 ance and whisper. 
 
 
 
 Fine and coarse 
 
 Weak b r o n- 
 
 Vocal fremitus 
 
 If, as very rarely 
 
 bubbling rales 
 
 chophony or di- 
 
 variable. 
 
 happens, an abscess 
 
 generally in 
 abundance. 
 
 minished vocal 
 resonance. 
 
 
 forms and discharges; 
 it may give rise to the 
 
 
 
 
 same physical signs 
 as a phthisical cavity 
 
 
 
 
 (which see). 
 
 Capillary 
 
 Bronchitis. 
 
 
 Limited to lobules 
 
 
 
 
 scattered through 
 
 
 
 
 lung substance i n 
 
 
 
 
 patches varying i n 
 
 
 
 
 size from a hemp seed 
 
 
 
 
 to an egg, or larger. 
 
 Fine and coarse 
 
 Increased vo- 
 
 Increased vo- 
 
 Called also Cirrho- 
 
 bubbling rales, 
 
 cal reso nance 
 
 cal fremitus. 
 
 sis of Lung. It 
 
 also sibilant and 
 
 and incre a s e d 
 
 
 leads to contraction 
 
 sonorous rales. 
 
 bronchial whis- 
 
 
 of the lung and dila- 
 
 
 per. 
 
 
 tation of the bronchi, 
 
 
 Bronchophony 
 
 
 and is always accom- 
 
 
 and whispering 
 
 
 panied by bronchitis. 
 
 
 bronchophony. 
 
 
 A unilateral disease. 
 
 
 
 
 Occurs among stone 
 
 
 
 
 masons, grinders, etc. 
 
 
 
 
 This disease is " the 
 
 
 
 
 anatomical basis of 
 
 
 
 
 almost all pulmonary 
 
 
 
 
 phthisis."
 
 72 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 INSPECTION AND 
 MENSURATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 ACUTE 
 
 MlLJARY 
 
 TUBERCULO- 
 SIS. 
 
 When one lung 
 is affected a little 
 more than the 
 other, there may 
 be a slight excess 
 of dullness in the 
 former. But oft- 
 ener there is no 
 notable dullness on 
 either side, the 
 granulations, even 
 when very numer- 
 ous, remaining iso- 
 lated. 
 
 PHTHISIS. 
 
 First Stage. 
 (Incipient.) 
 
 Some dullness, es- 
 pecially if the de- 
 posit "be at all 
 superficial, at the 
 summit of the chest 
 on one side (more 
 often the left), in 
 front or behind. 
 
 There may be 
 vesiculo-tympanitic 
 resonance at the 
 apex from second- 
 ary lobular emphy- 
 sema. 
 
 Remember the 
 possible very slight 
 dullness in health 
 on the right side. 
 It is in connection 
 with the diagnosis 
 of incipient 
 phthisis that this 
 fact becomes of the 
 most importance. 
 Any dullness, 
 however slight, at 
 the left apex is al- 
 ways abnormal. 
 
 Respiration 
 weakened or bron- 
 cho-vesicular, occa- 
 sionally jerking. 
 
 [There may be 
 abnormal trans- 
 mission of the 
 heart sounds 
 (available in the 
 infra-clavicular re- 
 gion), denoting a 
 deposit on the right 
 side, if the first 
 sound be heard 
 better here than on 
 the left ; and on 
 the left side, if the 
 second sound be 
 heard better here 
 than on the right.]
 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 73 
 
 VOCAL 
 RESONANCE. 
 
 PALPATION. 
 
 REMARKS. 
 
 Subcrepitant, fine and 
 coarse bubbling, and 
 sibilant and sonorous 
 rales in different places 
 all over both sides. 
 
 The trouble 
 is apt to be 
 found about 
 equally d i f - 
 fused in both 
 lungs. This 
 disease is lia- 
 ble to be con- 
 founded with 
 typhoid fever. 
 
 There may be one or 
 more of the following 
 kinds of rales : 
 
 1. Subcrcpitant, indi- 
 cating a circumscribed 
 capillary bronchitis 
 about the deposit. 
 
 2. Crepitant, here oft- 
 en called crackling, in- 
 dicating a circumscribed 
 pneumonia. 
 
 3. Rubbing friction 
 sounds, here often called 
 crumpling, indicating a 
 circumscribed dry pleu- 
 risy. 
 
 4. Sibilant rales, indi- 
 cating a spasm of the 
 tubes, or circumscribed 
 bronchitis. 
 
 All these rales derive 
 their significance from 
 being heard at the apex 
 (oftener the left). 
 
 Increased bron- 
 chial whisper. 
 
 Increased vo- 
 cal resonance. 
 
 Remember the 
 possible normal dis- 
 parity. 
 
 Increased vo- 
 cal fremitus.
 
 74 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 
 INSPECTION AND 
 
 
 
 DISEASE. 
 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 
 M ENSURATION. 
 
 
 
 
 Some flattening 
 
 Dullness, more or 
 
 Bronchial or bron- 
 
 * 
 
 and deficient ex- 
 
 less, at upper part 
 
 c h o-v esicular or 
 
 
 pansion of the up- 
 
 of chest on affect- 
 
 weakened respira- 
 
 
 per part of chest 
 
 ed side. 
 
 tion. Occasionally 
 
 
 on one side. 
 
 Or tympanitic 
 
 jerking. (Abnor- 
 
 PHTHISIS. 
 
 Marked diminu- 
 tion in size of chest 
 
 resonance (c o n- 
 ducted from bron- 
 
 mal transmission of 
 heart sounds.) 
 
 Second Stage. 
 
 by mensuration. 
 
 chi, as there are no 
 cavities yet). 
 
 
 
 
 There may be 
 
 
 
 
 exaggerated reso- 
 
 
 
 
 nance from coex- 
 
 
 
 
 isting lobular em- 
 
 
 
 
 physema. 
 
 
 
 Extra ordinary 
 prominence of the 
 
 Ti/mpanitic reso- 
 nance within cir- 
 
 Caiwnous respi- 
 ration, especially af- 
 
 
 clavicles from the 
 
 cumscribed spaces. 
 
 ter an abundant ex- 
 
 
 falling in of tipper 
 
 Occasionally 
 
 pectoration. If the 
 
 
 parts of lung, and 
 
 cracked-metal or 
 
 cavities are quite 
 
 
 deficient e x p a n- 
 
 amphoric reso- 
 
 small, the cavern- 
 
 Third Stage. 
 
 sion. 
 Still greater dim- 
 
 nance. 
 Dullness over 
 
 ous respiration may 
 be drowned out by 
 
 (Cavernous.) 
 
 inution in size of 
 chest by mensura- 
 
 the same space, if 
 the cavity is full of 
 
 the neighboring 
 bronchial respira- 
 
 
 tion. 
 
 morbid products, 
 
 tion, or combined 
 
 
 
 as, e. g., in the 
 
 with it, forming a 
 
 
 
 morning before 
 
 kind of broncho- 
 
 
 
 copious expectora- 
 
 cavernous respira- 
 
 
 
 tion. 
 
 tion. Rarely am- 
 
 
 
 
 phoric respiration. 
 
 
 There may be 
 
 Generally dull- 
 
 Bronchial, if the 
 
 
 some depression of 
 
 ness from the con- 
 
 tubes are cylindric- 
 
 
 the chest over the 
 
 densed and con- 
 
 al and unobstruct- 
 
 
 places affected. 
 
 tracted parenchy- 
 
 ed. 
 
 
 
 ma, and also from 
 
 Cavernous o r 
 
 
 
 accumulation of 
 
 amphoric, if saccn- 
 
 DILATATION 
 
 
 mucus. 
 Sometimes tym- 
 
 lar and large 
 enough. 
 
 OF THE 
 
 BRONCHI. 
 
 
 panitic or amphor- 
 
 
 
 
 ic resonance, if the 
 
 
 (Bronchiectasis.) 
 
 
 tubes are free from 
 morbid products. 

 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 RALES. 
 
 VOCAL 
 
 PALPATION. 
 
 REMARKS. 
 
 
 RESONANCE. 
 
 
 
 Fine and coarse bub- 
 
 Increased 
 
 Increased vocal 
 
 The accompany- 
 
 bling rales, from soft- 
 
 vocal reso- 
 
 fremitus. 
 
 ing signs are ob- 
 
 ened deposit or from 
 
 nance and 
 
 
 served on the side 
 
 accompanying c i r - 
 
 whisper, or 
 
 
 first affected, gen- 
 
 cumscribed bronchitis, 
 
 bronchophony 
 
 
 erally at the apex. 
 
 generally heard bet- 
 
 and whisper- 
 
 
 By this time, 
 
 ter in the morning 
 
 ing bron- 
 
 
 however, signs de- 
 
 before much expecto- 
 
 chophony. 
 
 
 noting a less ad- 
 
 ration. Also sibilant 
 
 O c c a s ion- 
 
 
 vanced condition of 
 
 and sonorous rales, 
 
 ally bron- 
 
 
 the disease may be 
 
 friction sounds, and 
 
 choph o n i c 
 
 
 heard at the apex 
 
 crepitant and subcrepi- 
 tant rales may be heard. 
 
 pectoriloquy. 
 
 
 of the other side. 
 
 Gurgling. 
 
 Sometimes 
 
 Increased vocal 
 
 These cavernous 
 
 Very rarely metal- 
 lic tinkling. 
 
 caver nous 
 pectoriloquy 
 
 fremitus when the 
 cavity is large, 
 
 signs (to be sought 
 for especially in the 
 
 
 and whis- 
 
 superficial, and has 
 
 upper part of the 
 
 
 pering pec- 
 
 free communication 
 
 lung) often have 
 
 
 toriloquy. 
 
 with the bronchi. 
 
 in their vicinity 
 
 
 Amphoric 
 
 Sometimes gur- 
 
 many of the signs 
 
 
 voice when 
 
 gling fremitus. 
 
 of solidification al- 
 
 
 there is arrt- 
 
 When the disease 
 
 ready mentioned. 
 
 
 phoric res- 
 
 exists principally 
 
 
 
 piration. 
 
 in one lung, the 
 
 
 
 
 shrinking of this 
 
 
 
 
 lung sometimes 
 
 
 
 
 drags the heart out 
 
 
 
 
 of place. Pulsa- 
 
 
 
 
 tion detected by 
 
 
 
 
 palpation. 
 
 
 Bubbling rales from 
 
 Increased 
 
 Increased vocal 
 
 Usually affects 
 
 mucus in dilated 
 
 vocal reso- 
 
 fremitus. 
 
 many bronchi, and 
 
 tubes; sometimes even 
 
 nance and 
 
 
 occurs in both 
 
 gurgling, if there is 
 
 bronchoph - 
 
 
 lungs. Most com- 
 
 considerable dilata- 
 
 ony. 
 
 
 mon in the lower 
 
 tion. 
 
 Sometimes 
 
 
 lobos and the mid- 
 
 
 pectoril- 
 
 
 dle lobe of the right 
 
 
 oquy. 
 
 
 lung. Follows 
 
 
 
 
 bronchitis, collapse 
 
 
 
 
 of pulmonary lob- 
 
 
 
 
 ules, pleurisy, and 
 
 
 
 
 pneumonia, espe- 
 
 
 
 
 cially interstitial 
 
 
 
 
 pneumonia. T h e 
 
 
 
 
 dilatation may be 
 
 
 
 
 of three varieties, 
 
 
 
 
 cylindrical, f u s i- 
 
 
 
 
 form, or saccular.
 
 76 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 10, Continued. 
 
 INSPECTION AND 
 MENSURATION. 
 
 PERCUSSION. 
 
 RESPIRATION. 
 
 CABCINOMA 
 
 OF 
 LUNG. 
 
 Diminished costal 
 motion Flattening 
 and contraction of 
 the affected side (if 
 infiltrated). 
 
 Or the growth may 
 be so great (perhaps 
 four or five pounds) 
 as to enlarge the side. 
 
 Effacement of in- 
 tercostal depressions, 
 if pleuritic effusion 
 ensue. 
 
 Dullness, often 
 extending beyond 
 the median line, 
 with increased re- 
 sistance, uniformly 
 extending over a 
 part or the whole 
 of a lung, if infil- 
 trated, but scat- 
 tered, if there are 
 nodules large 
 enough to produce 
 dullness. 
 
 Bronchial or 
 feeble or sup- 
 pressed. (Sup- 
 pressed by press- 
 ure of cancerous 
 deposit on a large 
 bronchus.) 
 
 If only one 
 lung is affected, 
 exaggerated res- 
 piration over 
 the healthy lung. 
 
 There may be a 
 bulging or even per- 
 foration of the ribs 
 and sternum, with 
 diminished respira- 
 tory movements. 
 
 Enlargement of 
 chest not as uniform 
 as when enlarged by 
 liquid. Distention of 
 superficial thoracic 
 veins ; or of those of 
 one or both upper 
 extremities with 
 (Especially alien- , oedema; or of those of 
 one or both sides of 
 the neck (significant 
 if there is no tricus- 
 pid regnrgitrttion or 
 dilatation of the right 
 heart). 
 
 Local pulsation, 
 synchronous with 
 heart's systole, some- 
 times visible in aneu- 
 rism. 
 
 INTRA- 
 THORACIC 
 TUMORS. 
 
 There may be 
 dullness or flat- 
 ness over the tu- 
 rn o r (and over 
 pleuritic effusion 
 or compressed lnn<r 
 if they coexist). 
 The dullness over 
 an aneurism or 
 mediasn'nal tumor 
 always extends />- 
 icn rr/s and to the 
 right or left ; in 
 aneurisms espe- 
 cially to the right. 
 There must not l>e 
 too forcible percus- 
 sion over aneurism. 
 
 Over the tumor 
 weakened or sup- 
 pivssed from 
 pressure, and 
 bronchi nl over 
 compre-sed lung, 
 if there be any.
 
 OF DISEASES OF THE LUNGS. 
 TABLE NO. 10, Continued. 
 
 77 
 
 RALES. 
 
 VOCAL 
 
 PALPATION. 
 
 REMARKS. 
 
 
 RESONANCE. 
 
 
 
 Bubbling rales, 
 
 Increased 
 
 Vocal fremitus at 
 
 A rare disease. 
 
 if softening takes 
 
 vocal reso- 
 
 first increased, then 
 
 Usually encepha- 
 
 place, or if there 
 
 nance and 
 
 diminished. 
 
 loid and associated 
 
 is secondary 
 
 bronchoph - 
 
 
 with mediastinal can- 
 
 bronchitis. 
 
 ony. 
 
 
 cer. There are two 
 
 
 
 
 varieties : 
 
 
 
 
 1. Secondary nodu- 
 
 
 
 
 lar deposit, oftener af- 
 
 
 
 
 fecting both lungs, the 
 
 
 
 
 nodules varying in 
 
 
 
 
 size from a pea to an 
 
 
 
 
 orange. If few, small, 
 
 
 
 
 and scattered, they 
 
 
 
 
 may not give rise to 
 
 
 
 
 any physical signs. 
 
 
 
 
 2. Primary infiltra- 
 
 
 
 
 tion into the air-cells, 
 
 
 
 
 usually affecting one 
 
 
 
 
 lung. Pleuritic effu- 
 
 
 
 
 sion often coexists. 
 
 
 
 
 Softening and exca- 
 
 
 
 
 vation may take 
 
 
 
 
 place. 
 
 There may be 
 
 Vocal res- 
 
 Vocal fremitus di- 
 
 These tumors are, 
 
 bubbling rales 
 
 onance va- 
 
 minished or sup- 
 
 in the great majority 
 
 from secondary 
 
 riable. 
 
 pressed over tumor. 
 
 of cases, aneurisms ; 
 
 bronchitis, or 
 
 Bronchoph- 
 
 Increased over com- 
 
 but sometimes are 
 
 from softening 
 
 ony over 
 
 pressed lung and pri- 
 
 cancerous, fibrous, or 
 
 if the tumor is 
 
 c o m pressed 
 
 mary bronchi. 
 
 fatty tumors, which 
 
 cancerous. 
 
 lung tissue, 
 
 Heart pulsations 
 
 generally start from 
 
 There is often, 
 
 if there be 
 
 may often be felt out 
 
 the mediastinum. 
 
 but not always, 
 
 any. 
 
 of place in conse- 
 
 They often exert 
 
 heard over an an- 
 
 
 quence of the press- 
 
 great pressure (to 
 
 eurism a systolic 
 
 , 
 
 ure. The arteries on 
 
 their injury, of 
 
 murmur, soft or 
 
 
 one side may be com- 
 
 course) on the heart, 
 
 harsh or roaring, 
 
 
 pressed more than on 
 
 lungs, nerves, or ves- 
 
 and of variable 
 
 
 the other. Over an- 
 
 sels, with character- 
 
 intensity. Rare- 
 
 
 eurism an impulse is 
 
 istic symptoms. Tu- 
 
 ly there may be 
 
 
 felt synchronous with 
 
 mors may be on one 
 
 heard also a dias- 
 
 
 the heart's systole, 
 
 or both sides of chest. 
 
 t o 1 i c murmur, 
 
 
 sometimes stronger 
 
 Pleuritic effusion may 
 
 caused by the 
 
 
 even than over the 
 
 result, also collapse 
 
 passage of blood 
 
 
 heart, sometimes 
 
 of pulmonary lobules 
 
 out of the sac. 
 
 
 double, either throb- 
 
 or oedema. A n e n- 
 
 
 
 bing or undulating. 
 
 risms arise most com- 
 
 
 
 Often a, purring thrill 
 
 monly from the as- 
 
 
 
 is felt, generally cir- 
 
 cending portion of 
 
 
 
 cumscribed, but 
 
 the arch of the aorta. 
 
 
 
 sometimes diffused 
 
 
 
 
 over a large portion 
 
 
 
 
 of the chest. 

 
 78 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11. 
 
 AUSCULTATION. 
 
 PERCUSSION. 
 
 THE 
 
 HEALTHY 
 HEART. 
 
 When heard over the apex, the 
 two healthy heart sounds may be 
 roughly represented by a trochee 
 with dots marking the pauses, 
 thus : ^ . . . The first or sys- 
 tolic is accented, long, booming 
 and of low pitch, and the second or 
 diastolic sound is short and valvu- 
 lar. At the base of the heart the 
 two sounds may more nearly be rep- 
 resented by an iambus ^ . . . ., 
 the second sound being here ac- 
 cented and as long as, if not longer 
 than, the first sound, and more in- 
 tense. This is because the booming 
 quality, caused by the " element of 
 impulsion " or " muscular ele- 
 ment," is not transmitted so far 
 as the valvular element of the first 
 sound. 
 
 The space on the surface 
 of the chest beneath which 
 the heart lies is called the 
 prcecordia, or prajcordial 
 region. That part of the 
 praecordia which is uncov- 
 ered of lung is called the su- 
 perficial cardiac space, and 
 the rest, where lung tissue 
 intervenes between the 
 heart and chest walls, is 
 called the deep cardiac 
 space. The boundaries of 
 each of these spaces must 
 be carefully memorized. 
 They are well shown on 
 Plate I. 
 
 The dullness over the 
 deep cardiac space, though, 
 distinct, is of course much 
 less than that over the su- 
 perficial cardiac space. 
 
 PERICARDI- 
 TIS. 
 
 First Stage. 
 
 (Exudation of 
 fibrin.) 
 
 A characteristic friction sound, 
 often lasting a few hours only, but 
 sometimes for a few days, pro- 
 duced by the rubbing together of 
 the inflamed and roughened peri- 
 cardial surfaces in the systolic and 
 diastolic movements of the heart. 
 It is either single or double, strictly 
 accompanying or independent of 
 the heart sounds, always super- 
 ficial, and usually restricted to the 
 praecordial space, sometimes* 
 even to a part of it only. Heard 
 with the greatest intensity on the 
 left edge of the sternum on a level 
 with the fourth rib. Quality graz- 
 ing, crumpling, creaking, or rasp- 
 ing, and either feeble or loud. In- 
 tensity increased by bending the 
 body forward so that the heart is 
 brought nearer the chest walls. 
 Also increased by firm pressure 
 with the stethoscope ; also by a full 
 inspiration, the pericardial surfaces 
 being forced nearer together by the 
 expanded lung. A single sound 
 may be made double in this way.
 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11. 
 
 79 
 
 INSPECTION. 
 
 PALPATION. 
 
 The apex i m- 
 pulse of the healthy 
 heart can f r e- 
 quently, hut not al- 
 ways, be seen in the 
 same place in which 
 it is felt. 
 
 The healthy apex beat in the sit- 
 ting or standing posture is felt in 
 the fifth intercostal space, but often 
 in the fourth when lying on the 
 back. It is felt over an area an 
 inch in diameter, from half an inch 
 to two inches to the right of the 
 linea mammalis (a vertical line 
 drawn through the left nipple), and 
 about three inches, on an average, 
 to the left of the median line. When 
 lying on the right side, the centre 
 of the area is about half an inch 
 nearer the sternum, and when lying 
 on the left side it is felt on the linea 
 mammalis. In some persons the 
 apex beat cannot be felt at all, espe- 
 cially when lying on the right side. 
 It is felt better when on the back, 
 still better when sitting, and best 
 of all when on the left side. 
 
 For purposes of 
 compari son, the 
 signs of the 
 healthy heart are 
 placed here. 
 
 A thorough 
 knowledge of the 
 healthy heart is an 
 absolutely indispen- 
 sable prerequisite to 
 an understanding of 
 the diseased organ. 
 
 Irrit able and 
 forcible action of 
 heart. 
 
 Forcible action of heart and fric- 
 tion fremitus. 
 
 Endocarditis with 
 its physical signs 
 often coexists. 
 Rheumatic pericar- 
 ditis, which occurs 
 perhaps once in 
 every six cases of 
 rheumatic fever, 
 is almost always ao- 
 companied by endo- 
 carditis.
 
 80 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 DISEASE. 
 
 AUSCULTATION. 
 
 PERCUSSION. 
 
 PERICAR- 
 
 Second 
 Stage. 
 
 (Serous ef- 
 fusion.) 
 
 ENDO- 
 CARDI- 
 TIS. 
 
 Friction sounds generally (but 
 not invariably) disappear when 
 the effusion becomes considera- 
 ble ; often remaining, however, 
 at the base of the heart near the 
 large vessels, and sometimes be- 
 ing distinctly heard all over the 
 praecordia, in spite of the effu- 
 sion, by bending the body for- 
 wards. Heart sounds, especially 
 the first, now feeble and distant, 
 or absent altogether. Absence 
 of respiratory murmur and vocal 
 resonance over the enlarged area 
 caused by the distention of the 
 pericardial sac, the distention 
 pushing the lungs to the right 
 and left. 
 
 During absorption the friction 
 sounds reappear and may last a 
 week or more ; and the heart 
 sounds become more distinct. 
 
 With large effusion, the area of 
 prsecordial dullness is greatly in- 
 creased vertically and laterally, 
 and in the upright posture it be- 
 comes pyramidal in shape, corre- 
 sponding to the form of the dis- 
 tended sac, whose base is near the 
 sixth intercostal space, and apex 
 near the sternal notch, and which 
 may extend laterally almost from 
 one nipple to the other. 
 
 In chronic pericarditis with very 
 large effusion and dilatation of the 
 sac, the dullness or flatness may 
 extend nearly to the axillary and 
 infra-axillary regions on each side. 
 The dullness from the liquid ex- 
 tends below the point of the apex 
 beat. The anterior portion of the 
 sac is mostly uncovered of lung 
 and in contact with the chest walls. 
 When the patient lies down, the 
 lateral diameter of dullness is in- 
 creased at the expense of the ver- 
 tical. 
 
 If the effusion is small, there is 
 merely an increase in the lateral 
 diameter of dullness at the lower 
 portion of the praecordial region 
 in the upright posture. 
 
 Gradual diminution of the area 
 of dullness as convalescence ap- 
 proaches. 
 
 A systolic murmur, generally 
 soft and feeble, due to thickening 
 or roughening of the inflamed en- 
 docardium, heard sometimes at 
 the aortic orifice, but usually at 
 the apex. The swollen mitral 
 valves with shortened chords may 
 be slightly insufficient, but usu- 
 ally the murmur is mitral non-re- 
 gurgitant, caused by intra-ventric- 
 ular roughness. 
 
 Auscultation of the heart should be 
 practiced at the beginning of every case 
 of rheumatic fever, to make sure that 
 there is no old valvular lesion which 
 might be mistaken for a recent endo- 
 carditis. If there be an old valvular 
 murmur, there will be more or less 
 cardiac hypertrophy, and the murmur 
 may be loud and rough.
 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11, Continued. 
 
 81 
 
 INSPECTION. 
 
 PALPATION. 
 
 Arching forward of 
 the prascordial region 
 (mostly in young peo- 
 ple,, whose costal carti- 
 lages are pliable), often 
 extending from the sec- 
 ond to the sixth intercos- 
 tal space. The effusion, 
 if large, restrains the 
 respiratory movem e n t 
 on the left side. 
 
 The point of the apex 
 beat raised and carried 
 to the left of its normal 
 position. Friction 
 fremitus disappears. 
 
 Apex beat feeble, or 
 imperceptible, if effu- 
 sion is large. 
 
 Usually the effusion lasts 
 about a week or ten days 
 in acute cases. 
 
 Hydropericardium has 
 physical signs which do 
 not materially differ from 
 those of pericarditis, ex- 
 cept that there is no fric- 
 tion sound. 
 
 At first the area of 
 the visible impulse of 
 the heart is increased, 
 but later it is apt to be 
 indistinct. 
 
 Irregular beating. 
 
 At first violent and 
 excited action, after- 
 ward weakened. 
 
 Occurs in the great ma- 
 jority of instances as a sec- 
 ondary affection in the 
 course of acute articular 
 rheumatism. It is more 
 common than pericarditis, 
 with which it is often asso- 
 ciated, being far oftener 
 observed without pericar- 
 ditis than the latter is with- 
 out it. 
 
 It may occur in the es- 
 sential and exanthematous 
 fevers, in pyemia, Bright's 
 disease, diphtheria, etc.
 
 82 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 AUSCULTATION. 
 
 PERCUSSION. 
 
 HYPERTROPHY 
 
 OF THE 
 
 LEFT HEART. 
 
 First sound loud, dull, and 
 prolonged. Aortic second 
 sound exaggerated, if there 
 are no valvular lesions. Ab- 
 sence or great diminution of 
 vocal resonance over a larger 
 area than normal, showing 
 an enlarged superficial car- 
 diac space. This sign is es- 
 pecially available in females 
 with large breasts, where 
 percussion is difficult. 
 
 Extension of percussion 
 dullness to the left, and 
 wards in the direction of the 
 apex, especially the latter. 
 Superficial cardiac spat/u in- 
 cn-used (the lung being pushed 
 to the left), aud greater degree 
 of dullness over it than in 
 health. This increase must 
 not be confounded with that 
 produced by retraction of the 
 lung from its own diseases. 
 
 HYPERTROPHY 
 
 OF THE 
 BIGHT HEART. 
 
 First sound loud, dull, and 
 prolonged (except in some 
 cases of extensive emphy- 
 sema, where the edges of the 
 lungs by overlapping the 
 heart partially muffle the 
 sound), heard with greatest 
 intensity near the ensiform 
 cartilage. 
 
 Exaggeration of the pul- 
 monary second sound, espe- 
 cially if there is obstruction 
 to the pulmonary circula- 
 tion. Auscultation of the 
 voice available as in the 
 preceding. 
 
 Some extension of dullness 
 to the right of the normal 
 dullness, but not in propor- 
 tion to the amount of the en- 
 largement of the heart, the 
 increased area of dullness 
 being mostly to the left. 
 
 There is often dullness over 
 the second and third right 
 cartilages near the sternum, 
 owing to the enlarged right 
 auricle.
 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11, Continued. 
 
 83 
 
 INSPECTION. 
 
 PALPATION. 
 
 REMARKS. 
 
 Increased area of visi- 
 
 Apex beat is felt in 
 
 When the whole heart is 
 
 ble impulse, extending 
 
 the sixth, seventh, 
 
 hypertrophied, the physical 
 
 over several intercostal 
 
 eighth, or even ninth in- 
 
 signs of left and right side 
 
 spaces and sometimes 
 
 tercostal space, and to 
 
 hypertrophy are combined 
 
 over the whole of the 
 
 the left of the linea 
 
 in varied proportions. 
 
 praeconlia. In children 
 
 mam mail's, the down- 
 
 In the great majority of 
 
 there is often an abnor- 
 
 irard displacement being 
 
 cases of cardiac hypertro- 
 
 mal projection of the 
 
 especially marked. It 
 
 phy, valvular lesions coex- 
 
 prsecordial region. Apex 
 
 is powerful and distinct, 
 
 ist, and are accompanied by 
 
 beat sri'ii to be lower and 
 
 though sluggish. 
 
 their respective murmurs. 
 
 farther to the left than 
 
 A powerful heaving 
 
 When there are no valvular 
 
 normal. If it cannot be 
 
 movement is felt all over 
 
 lesions, chronic Bright's dis- 
 
 seen, it can almost al- 
 
 the prascordia. 
 
 ease is the most common 
 
 ways be felt. If not, it 
 
 
 cause of left heart hyper- 
 
 can be located by auscul- 
 
 
 trophy. 
 
 tation. 
 
 
 
 Increased area of im- 
 
 Apex beat is felt far- 
 
 Pulmonary emphysema 
 
 pulse and abnormal pro- 
 
 ther to the left trenerally 
 
 is the most common cause 
 
 jection as above. 
 
 than in left side hyper- 
 
 of right heart hypertrophy, 
 
 Strong epigastric im- 
 
 trophy (perhaps one, 
 
 when there are no valv ular 
 
 pulse, seen as well as felt. 
 
 two, or even three inches : lesions. 
 
 often shaking the lower 
 
 to the left of the nip- If the apex cannot be 
 
 part of the sternum and 
 
 pie), but not so far down, felt, its location can be as- 
 
 extending more or less 
 
 the lower border of the certained by finding by aus- 
 
 over the liver. 
 
 heart being almost hori- cultation the spot where the 
 
 
 zontal. 
 
 first sound has the greatest 
 
 
 Apex beat sometimes 
 
 intensity. 
 
 
 feeble on account of the 
 
 
 
 apex becoming rounded 
 
 
 
 or blunted. Even then 
 
 
 
 there will be strong im- 
 
 
 
 pulse in the intercostal 
 
 
 
 spaces above the apex. 
 
 
 
 Powerful heaving 
 
 
 
 movement all over the 
 
 
 
 praecordia. 

 
 84' 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 AUSCULTATION. 
 
 PERCUSSION. 
 
 DILATATION OF 
 THE HEART. 
 
 First sound short, feeble, 
 and valvular, lacking par- 
 tially or entirely the element 
 of impulsion or muscular 
 element, thus resembling 
 the second sound. Second 
 sound often inaudible at the 
 apex. Irregular pauses, or 
 intermissions of the beat, 
 especially on exertion. If 
 a murmur has previously 
 existed, its rhythm may 
 become lost, and it may 
 become impossible to say 
 whether it is synchronous 
 with the first or second 
 sound. This is called asys- 
 tolism. 
 
 Respiratory murmur di- 
 minished in intensity over 
 the upper part of the left 
 lung. 
 
 Area of dullness is in- 
 creased in every direction, 
 especially laterally, the trans- 
 verse diameter greatly ex- 
 ceeding the vertical. The 
 shape of the dullness is oval 
 or square instead of the nor- 
 mal triangular dullness. 
 
 An upward and lateral in- 
 crease of dullness at the base 
 of the enlarged heart indi- 
 cates dilated auricles.
 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11, Continued. 
 
 85 
 
 INSPECTION. 
 
 PALPATION. 
 
 The area of visible 
 impulse is increased, but 
 it is indistinct. 
 
 In persons with thin 
 chest walls an undulat- 
 ing motion over the 
 praecordia may be visi- 
 ble. 
 
 Feeble cardiac im- 
 pulse. No heaving move- 
 ment, but weak undu- 
 lating motion over the 
 whole praecordia. 
 
 A queer sensation of 
 rolling over, a kind of 
 diffused tumble against 
 the chest walls followed 
 by a pause. 
 
 Apex beat not so low 
 as in hypertrophy. 
 
 In a great many cases 
 hypertrophy and dilatation 
 are combined in varied pro- 
 portions, so that we have 
 enlargement with predom- 
 inating hypertrophy or en- 
 largement with predomi- 
 nating dilatation. Hyper- 
 trophy precedes dilatation 
 with rare exceptions ; if the 
 enlargement be very great, 
 dilatation predominates. 
 
 From the accompanying 
 physical signs under hyper- 
 trophy and dilatation, it can 
 generally be determined 
 which predo minates, to 
 what extent, and which side 
 (if either) is more particu- 
 larly affected. 
 
 Hypertrophy is more es- 
 pecially the characteristic 
 of the left ventricle, and 
 dilatation of the right ven- 
 tricle, although either may 
 affect both.
 
 86 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 DISEASE. 
 
 AUSCULTATION. 
 
 Rhythm of 
 Murmur. 
 
 Maximum Inten- 
 sity of Murmur. 
 
 Murmur 
 also heard. 
 
 Other things to 
 be noticed. 
 
 
 Systolic. 
 
 Second right 
 intercostal 
 
 Over the ca- 
 rotids, more or 
 
 Murmur gen- 
 erally soft, but 
 
 
 
 space, near the 
 
 less over the 
 
 may be rough 
 
 
 
 sternum. 
 
 body of the 
 
 or musical, and 
 
 VALVULAR 
 
 
 
 heart, some- 
 
 it always more 
 
 LESIONS. 
 I. Left Heart. 
 
 
 Exceptionally 
 second left inter- 
 costal space near 
 the sternum. 
 
 times in the 
 interscapul a r 
 space near the 
 spinous ridge 
 
 or less ob- 
 scures the first 
 sound of the 
 heart. 
 
 
 
 
 of the scapula, 
 
 Aortic second 
 
 
 
 
 feebly or not 
 
 sound weak- 
 
 
 
 
 at all at the 
 
 ened and in- 
 
 
 
 
 apex. 
 
 distinct in pro- 
 
 
 
 
 Transmitted 
 
 portion to the 
 
 
 
 
 better upwards 
 
 amount of ob- 
 
 
 
 
 than down- 
 
 struction. 
 
 
 
 
 wards. 
 
 Aortic re- 
 
 
 
 
 
 gurgitation is 
 
 AORTIC OB- 
 
 
 
 
 often asso- 
 
 STRUCTION. 
 
 
 
 
 ciuted, when 
 
 
 
 
 
 there is a dis- 
 
 (Stenosis.) 
 
 
 
 
 tinct double 
 
 
 
 
 
 murmur heard 
 
 12.] 
 
 
 
 
 over a large 
 
 
 
 
 
 space. 
 
 Numbers in 
 
 
 
 
 
 brackets repre- 
 
 
 
 
 
 sent order of 
 
 
 
 
 
 frequency ac- 
 
 
 
 
 
 cording to 
 
 
 
 
 
 Walshe. 
 
 
 

 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11, Continued. 
 
 87 
 
 PERCUSSION. 
 
 INSPECTION. 
 
 PALPATION. 
 
 REMARKS. 
 
 Hypertrophy of 
 
 See Left 
 
 See Left 
 
 Aortic obstruction is a 
 
 the left ventricle 
 
 Heart Hyper- 
 
 Heart Hyper- 
 
 very common form of 
 
 is induced after 
 
 trophy and 
 
 trophy and 
 
 heart disease. Besides 
 
 the obstruction 
 
 Dilatation. 
 
 Dilatation. 
 
 the very frequent associa- 
 
 has existed for a 
 
 
 
 tion of aortic regurgita- 
 
 while, and there- 
 
 
 
 tion, it may induce after 
 
 fore is found in 
 
 
 
 awhile mitral insufficiency. 
 
 the majority of 
 
 
 
 It is most frequently met 
 
 cases which come 
 
 
 
 with in middle or ad- 
 
 under observa- 
 
 
 
 vanced life. 
 
 tion. 
 
 
 
 It has to be diagnostica- 
 
 Finally dilata- 
 
 
 
 ted from an inorganic aortic 
 
 tion may ensue. 
 
 
 
 murmur which is not un- 
 
 See percussion 
 
 
 
 common in anaemia. This 
 
 signs under Left 
 
 
 
 and the other inorganic 
 
 Heart Hyper- 
 trophy and Dila- 
 tation. 
 
 
 
 murmur the pulmonic 
 are always systolic. 
 The distinguishing feat- 
 
 
 
 
 ures of the inorganic aortic 
 
 
 
 
 murmur are : 
 
 
 
 
 Uniformly soft and fee- 
 
 
 
 
 ble, not constant, not pro- 
 
 
 
 
 ductive of cardiac enlarge- 
 
 
 
 
 ment, accompanied by a 
 
 
 ' 
 
 
 continuous hum in jugular 
 
 
 
 
 veins (with sometimes a 
 
 
 
 
 musical intonation), called 
 
 
 
 
 " bruit de dialle," which is 
 
 
 
 
 suspended by pressure 
 
 
 
 
 over the veins with the fin- 
 
 
 
 
 ger, and by symptoms of 
 
 
 
 
 anaemia (which is more 
 
 
 
 
 common among females 
 
 
 
 
 than males) ; the aortic 
 
 
 
 
 second sound as intense as 
 
 
 
 
 normal, and never accom- 
 
 
 
 
 panied by aortic regurgi- 
 
 
 
 
 tation. 
 
 
 
 
 Sometimes there may be 
 
 
 
 
 an innocuous murmur, not 
 
 
 
 
 inorganic but produced by 
 
 
 
 
 mere ronr/hness not suffi- 
 
 
 
 
 cient to cause obstruction, 
 
 
 
 
 and consequently not fol- 
 
 
 
 
 lowed by cardiac enlarge- 
 
 
 
 
 ment.
 
 88 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 
 AUSCULTATION. 
 
 DISEASE. 
 
 Rhythm of 
 
 Maximum Inten- 
 
 Murmur 
 
 Other things 
 
 
 Murmur. 
 
 sity of Murmur. 
 
 also heard. 
 
 to be noticed. 
 
 
 Diastolic. 
 
 Second right 
 
 Diffused 
 
 Murmur gen- 
 
 
 
 intercostal 
 
 over a large 
 
 erally soft, but 
 
 
 
 space (or 
 
 area, extend- 
 
 may he rough 
 
 
 
 fourth left cos- 
 
 ing in the di- 
 
 or musical. It 
 
 
 
 tal cartilage), 
 
 rection of the 
 
 replaces or im- 
 
 AORTIC 
 REGURGITA- 
 
 
 near the ster- 
 num. 
 
 apex or ensi- 
 form cartilage, 
 and heard at 
 
 mediately fol- 
 lows the aortic 
 second sound, 
 
 TION. 
 
 
 
 the sides of 
 
 which is weak- 
 
 (Insufficiency.) 
 
 
 
 the chest and 
 along the spine. 
 
 ened or sup- 
 pressed. 
 
 f3l 
 
 
 
 Transmitted 
 
 Aortic ob- 
 
 L"'J 
 
 
 
 hetter down- 
 
 struction often 
 
 
 
 
 wards than up- 
 
 coexists, when 
 
 
 
 
 wards. 
 
 there is a dis- 
 
 
 
 
 
 tinct double 
 
 
 
 
 
 murmur heard 
 
 
 
 
 
 over a large 
 
 
 
 
 
 space. 
 
 
 Presystolic. 
 
 At or near 
 
 Over the su : 
 
 Murmur gen- 
 
 
 
 the apex. 
 
 perficial car- 
 
 erally rough, 
 
 
 
 
 diac space 
 
 long, and loud, 
 
 
 
 
 only. 
 
 sometimes 
 
 
 
 
 
 called "blub- 
 
 
 
 
 
 bering ; " be- 
 
 
 
 
 
 ginning after 
 
 
 
 
 
 the second 
 
 
 
 
 
 sound and end- 
 
 MITRAL 
 OBSTRUC- 
 
 
 
 
 ing abruptly 
 with the first 
 
 TION. 
 
 
 
 
 sound. 
 
 i 
 
 
 
 
 Weakened 
 
 (Stenosis.) 
 
 
 
 
 aortic second 
 
 
 
 
 
 sound, and in- 
 
 [*] 
 
 
 
 
 tensified p 11 1- 
 
 
 
 
 
 monic second 
 
 
 
 
 
 sound, the lat- 
 
 
 
 
 . 
 
 ter owing to 
 
 
 
 
 
 obstruction of 
 
 
 
 
 
 the pulmonary 
 
 
 
 
 
 circulation.
 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11, Continued. 
 
 89 
 
 PERCUSSION. 
 
 INSPECTION. 
 
 PALPATION. 
 
 REMARKS. 
 
 Great hypertrophy 
 
 See Left 
 
 See Left 
 
 Aortic regurgitation is 
 
 and afterwards dilata- 
 
 Heart Hy- 
 
 Heart Hy- 
 
 more apt to induce mitral 
 
 tion of the left ven- 
 
 pertr o p h y 
 
 pert r o p h y 
 
 insufficiency than aortic 
 
 tricle are induced. 
 
 and Dilata- 
 
 and Dilata- 
 
 obstruction is. 
 
 Therefore in the early 
 
 tion, espe- 
 
 tion, espe- 
 
 In such cases there may 
 
 part of the disease, 
 
 cially the 
 
 cially the 
 
 coexist two, three, or even 
 
 the percussion signs 
 
 latter. 
 
 latter. 
 
 all four of the murmurs 
 
 of the , former, and 
 
 
 Strong, 
 
 of the left side of the 
 
 later those of both 
 
 
 jerking, ar- 
 
 heart. 
 
 combined, will be 
 
 
 terial pulsa- 
 
 There is generally nei- 
 
 found ; finally', if the 
 
 
 tion felt in 
 
 ther dropsy nor dyspnoea 
 
 patient lives long 
 
 
 s u p e rficial 
 
 in aortic diseases, unless 
 
 enough, only those of 
 
 
 arteries all 
 
 mitral regurgitation coex- 
 
 dilatation. 
 
 
 over the 
 
 ists. 
 
 
 
 body. 
 
 
 Dilatation, and oft- 
 en hypertrophy, of 
 
 the left auricle is first 
 produced, followed by 
 
 See Eight 
 Heart Hy- 
 pertr o p h y 
 and Dilata- 
 
 See Right 
 Heart Hy- 
 pert r o p h y 
 and Dilata- 
 
 Mitral obstruction is 
 comparatively a rare dis- 
 ease, and, when met with, 
 is oftener found in con- 
 
 hypertrophy of the 
 
 right ventricle to over- 
 
 tion, espe- 
 cially the 
 
 tion, espe- 
 cially the 
 
 nection witTi mitral regur- 
 gitation than alone. Still 
 
 come the pulmonary 
 
 latter. 
 
 latter. 
 
 it may exist without re- 
 
 obstruction ; next, dil- 
 
 
 Dis t i n c t 
 
 gnrgifation. It is possible 
 
 atation of the right 
 
 
 piirriiir/ thrill 
 
 to have mitral obstruction 
 
 ventricle; next, dila- 
 
 
 over the 
 
 without a murmur, if the 
 
 tation of the right au- 
 
 
 apex, pre- 
 
 curtains are not adherent 
 
 ricle. 
 
 
 systolic in 
 
 at their sides; and on the 
 
 Finally, not often, 
 
 
 time. 
 
 other hand, Flint says that 
 
 but exceptionally, hy- 
 
 
 
 there may be, rarely, a 
 
 pertrophy or dilata- 
 
 
 
 mitral dir< ct murmur with- 
 
 tion of the left ven- 
 
 
 
 out obstruction when there 
 
 tricle. 
 
 
 
 is also free aortic regurgi- 
 
 Percussion signs ac- 
 
 
 
 tation. 
 
 cordingly. 
 
 
 
 The orifice is sometimes 
 
 
 
 
 too small to admit the end 
 
 
 
 
 of the little finger, whereas 
 
 
 
 
 in health t hree fingers can 
 
 
 
 
 be passed through it. 
 
 
 
 
 There cannot be much 
 
 
 
 
 mitral obstruction or re- 
 
 
 
 
 gurgitation so long as the 
 
 . 
 
 
 
 aortic and pulmonic second 
 
 
 
 
 sounds preserve their nor- 
 
 
 
 
 mal relative intensity.
 
 90 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 DISEASE. 
 
 AUSCULTATION. 
 
 Rhythm of 
 Murmur. 
 
 Maximum In- 
 tensity of 
 Murmur. 
 
 Murmur 
 also heard. 
 
 Other things 
 to be noticed. 
 
 
 Systolic. 
 
 At or near 
 
 Over the 
 
 Murmur general- 
 
 
 
 the apex. 
 
 s u p e rficial 
 
 ly soft, but some- 
 
 
 
 
 cardiac 
 
 times rough or mu- 
 
 
 
 
 space ; and 
 
 sical. 
 
 
 
 
 unless too 
 
 Aortic second 
 
 
 
 
 feeble, in the 
 
 sound won ken od, 
 
 
 
 
 left axilla 
 
 but pulmouic sec- 
 
 
 
 
 and behind, 
 
 ond sound (heard 
 
 
 
 
 near the 
 
 in the second left 
 
 
 
 
 lower angle 
 
 intercostal space) 
 
 
 
 
 of the left 
 
 often intensified. 
 
 
 
 
 scapula. 
 
 Where mitral ste- 
 
 
 
 
 
 nosis mid reiMirgi- 
 
 
 
 
 
 tation coexist, there 
 
 
 
 
 
 will lie one continu- 
 
 
 
 
 
 ous murmur, made 
 
 
 
 
 
 up of two elements, 
 
 
 
 
 
 ]'ivs\ siolic and sys- 
 
 MITRAL 
 
 
 
 
 tolic ; the lirst of 
 
 REGURGITA- 
 
 
 
 
 which will not be 
 
 T1ON. 
 
 
 
 
 conveyed to the left 
 
 
 
 
 
 and back. Besides, 
 
 (Insufficiency.) 
 
 
 
 
 they almost always 
 
 
 
 
 
 differ in pitch and 
 
 [1-] 
 
 
 
 
 
 quality.
 
 OF DISEASES OF THE HEART 
 TABLE NO. 11, Continued. 
 
 91 
 
 PERCUSSION. 
 
 INSPECTION. 
 
 PALPATION. 
 
 The same 
 changes take 
 place as in the 
 preceding ; and 
 besides, there is 
 always more or 
 less hypertrophy 
 or dilatation of 
 the left ventricle. 
 Percussion 
 dullness increased 
 in every direction. 
 
 Area of vis- 
 ible impulse in- 
 creased. 
 
 Impulse forci- 
 ble or diffused 
 according to the 
 proportion of hy- 
 pertrophy or dil- 
 atation. 
 
 Apex beat far- 
 ther to the left 
 than normal. 
 
 If hypertrophy 
 predominates, it 
 will be lower 
 than if dilatation 
 predominates. 
 
 Pulse variable 
 in volume, and in 
 the later stages 
 also irregular in 
 time. 
 
 The commonest of. 
 all valvular diseases, 
 especially among th 
 young. It often ex- 
 ists alone, but may 
 have mitral obstruc- 
 tion associated with it. 
 It is almost invaria- 
 bly attended by a 
 murmur, but a mitral 
 systolic non-regurgitunt 
 murmur may be pro- 
 duced by simple 
 roughening, c a 1 c a- 
 reous deposit, etc., 
 without insufficiency 
 of the valve. The 
 signs which especially 
 distinguish the n-rjiir- 
 gitant from the no-re- 
 gitrc/itant murmur are 
 the strong pulmonary 
 second sound, the 
 weak aortic second 
 sound existing even 
 with hypertrophy of 
 the left ventricle, the 
 diffusion of the mur- 
 mur to the left side 
 and to the back, and, 
 after the disea>e has. 
 made some progress, 
 the symptoms of pul- 
 monary congestion. 
 
 D y s p n 02 a and 
 dropsy are prominent 
 symptoms of mitral 
 obstruction and rc- 
 gurgiration. 
 
 Tricuspid regurgi- 
 tation is often found 
 as a secondary affec- 
 tion in connection 
 with mitral disease.
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 
 AUSCULTATION. 
 
 DISBASK. 
 
 Rhythm of 
 Murmur. 
 
 Maximum In- 
 tensity of 
 Murmur. 
 
 Murmur also 
 heard. 
 
 Other things to 
 be noticed. 
 
 
 Systolic. 
 
 Second or 
 
 Propagated 
 
 Second pulmonic 
 
 
 
 third left in- 
 tercostal 
 
 upwards for 
 
 a short dis- 
 
 sound impaired ia 
 iut( nsity. 
 
 
 
 space, near 
 
 t a n c e to- 
 
 Murmur super- 
 
 
 
 the sternum. 
 
 wards the 
 
 ficial and may be 
 
 
 
 
 left clavicle, 
 
 quite int. use. 'Must 
 
 
 
 
 but not over 
 
 be diagnosticated 
 
 
 
 
 the aorta or 
 
 from the / 
 
 
 
 
 carotid-;. 
 
 puimi'iiic murmur, 
 
 
 
 
 Remember 
 
 which is far more 
 
 
 
 
 that excep- 
 
 common than ihe 
 
 n. Right 
 
 
 
 tionally an 
 
 <> r L: a n i c. < it her 
 
 Heart. 
 
 
 
 aortic ob- 
 
 alone or with the 
 
 
 
 
 s t r u c t i v e 
 
 other inorganic 
 
 
 
 
 m u r m u r 
 
 m u r m u r t lie 
 
 PULMOXIC 
 
 
 
 mat/ be heard 
 
 aortic direct. 
 
 OBSTRUC- 
 
 
 
 with great- 
 
 Inorganic mur- 
 
 TION. 
 
 
 
 est inteiiMty 
 
 murs are always 
 
 
 
 
 at the second 
 
 systolic, and almost 
 
 (Stenosis.) 
 
 
 
 or third left 
 
 never occur except- 
 
 
 
 
 i nt ercostal 
 
 ing: at the aortic and 
 
 [6.] 
 
 
 
 space. The 
 
 puimonic orifices. 
 
 
 
 
 frequency of , 'I' li e inorganic 
 
 
 
 
 the aortic murmur is sot't and 
 
 
 
 
 murmur 
 
 feeble, with normal 
 
 
 
 
 and its other 
 
 heart sounds and 
 
 
 
 
 ch-iract e r s 
 
 no enlargement not 
 
 
 
 
 will gener- 
 
 constant, occurs in 
 
 
 
 
 ally suffice 
 
 anaemic persons, es- 
 
 
 
 
 for a diag- 
 
 pecially yotini: fe- 
 
 
 
 
 nosis. 
 
 males, and i> ac- 
 
 
 
 
 
 companied by ihe 
 
 
 
 
 
 bruit de diaile. 
 
 
 Diastolic. 
 
 Second or 
 
 Propagated 
 
 Pnlmonic second 
 
 
 
 third left in- ! downwards 
 
 sound impaired in 
 
 
 
 tercosta 1 
 
 towards the 
 
 intensify. 
 
 PULMONIC 
 
 
 space, near 
 
 e n s i f o r m 
 
 This murmur if 
 
 REGCRGITA- 
 
 
 the sternum. 
 
 cartilage. 
 
 it were more com- 
 
 TION. 
 
 
 
 
 mon, might easily 
 
 
 
 
 
 be confounded with 
 
 (Insufficiency.) 
 
 
 
 
 an aortic regurgi- 
 
 
 
 
 
 tant murmur, when 
 
 [7-] 
 
 
 
 
 the. pulmonary di- 
 
 
 
 
 
 rect murmur did 
 
 
 
 
 
 not co-exist.
 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11, Continued. 
 
 PERCUSSION. 
 
 INSPECTION. 
 
 PALPATION. 
 
 Hyper trophy 
 and dilatation of 
 the right ventri- 
 cle are produced. 
 
 Percussion 
 signs' accordingly. 
 
 See Hyper- 
 trophy and Dil- 
 atation of the 
 Right Ventricle. 
 
 See Hyper- 
 trophy and Dil- 
 atation of the 
 Right Ventricle. 
 
 Valvular diseases of 
 the right heart, \\ith 
 the exception of tri- 
 cuspid regurgitation, 
 are so infrequent as 
 to be almost unheard 
 of ; so much 'so, ihat 
 when the unqualified 
 term " valvular dis- 
 ease " is used, the left 
 heart is always meant. 
 
 When right-heart 
 lesions exist, they are 
 usually, but not inva- 
 riably, associated with 
 left-heart lesions, un- 
 less they are congen- 
 ital. 
 
 Contrary to the rule 
 which prevails after 
 birth, the right luart 
 is more commonly af- 
 fected in praenatal life 
 than the left. 
 
 Theoretically, 
 hypertrophy and 
 dilatation of the 
 right ventricle 
 are produced. 
 
 Percussion 
 signs accordingly. 
 
 See Hyper- 
 trophy and Dil- 
 atation of the 
 Right Ventricle. 
 
 See Hyper- 
 trophy and Dil- 
 atation of the 
 Right Ventricle. 
 
 Pulmonic regurgi- 
 tation is exceKlimjl;/ 
 rare, even more so 
 than pulmonic ob- 
 struction. C O II S ('- 
 quently, the annexed 
 physical signs of it 
 are, to a great extent, 
 theoretical. 
 
 Tricuspid insuffi- 
 ciency may follow 
 pulmonic obstruction 
 or regurgitation.
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 
 AUSCULTATION. 
 
 DISEASE* 
 
 Rhythm of 
 Murmur. 
 
 Maximum In- 
 tensity of Mur- 
 mur. 
 
 Murmur also 
 heard. 
 
 Other things to be 
 noticed. 
 
 4 
 
 TRICUSPID 
 OBSTRUCTION. 
 
 Presystolic. 
 
 At lower 
 part of ensi- 
 
 
 
 
 
 form carti- 
 
 
 
 (Stenosis.) 
 
 
 lage. 
 
 
 
 [8.] 
 
 
 
 
 
 
 Systolic. 
 
 At lower 
 
 Generally 
 
 A murmur is not 
 
 
 
 part of ensi- 
 
 limited to 
 
 present i n in a n y 
 
 
 
 forrn carti- 
 
 the superfi- 
 
 cases of actual tri- 
 
 
 
 lage. 
 
 cial cardiac cuspid regurg i t a- 
 
 
 
 
 space. 
 
 tion, even when 
 
 TRICUSPID 
 
 
 
 If trans- 
 
 there is a definite 
 
 REGURGITA- 
 
 
 
 mitt ed at 
 
 valvular lesion. 
 
 TION. 
 
 
 
 all, it is to 
 
 Rarely, if ever, 
 
 r 
 
 
 
 the right. 
 
 rough. 
 
 (Insufficiency.) 
 
 
 
 
 Pulmonic second 
 
 
 
 
 
 sound diminished in 
 
 [5.] 
 
 
 
 
 intensity. Mitral 
 
 
 
 
 
 or aortic murmurs, 
 
 
 
 
 
 or both, often coex- 
 
 
 
 
 
 ist, differing in pitch 
 
 
 
 
 
 and quality.
 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11, Continued. 
 
 95 
 
 PERCUSSION. 
 
 INSPECTION. 
 
 PALPATION. 
 
 REMARKS. 
 
 Theoretically, 
 
 
 
 The rarest of all. 
 
 hypertrophy and 
 
 
 
 
 dilatation of the 
 
 
 
 
 right auricle are 
 
 
 
 
 first produced. 
 
 
 
 
 First the right 
 auricle is dilated, 
 
 Jugular pul- 
 sation, synchro- 
 
 Indistinct apex 
 beat unless there 
 
 Primary tricuspid 
 regurgitation is very 
 
 then the right 
 
 nous with the 
 
 is considera b 1 e 
 
 rare; but secondary 
 
 ventricle is hy- 
 
 heart's systole, 
 
 hypertrophy o f 
 
 to mitral stenosis or 
 
 pertrophied and 
 
 a characteristic 
 
 the left ventricle. 
 
 regurgitation, it is 
 
 dilated. Then 
 
 sign of tricuspid 
 
 Distinct e p i- 
 
 not uncommon. 
 
 comes enlarge- 
 
 regurgi t a t i o n, 
 
 gastric p u 1 s a- 
 
 It not infrequently 
 
 ment of the left 
 
 unless the right 
 
 tion. 
 
 exists in cases where 
 
 ventricle on ac- 
 
 ventricle be very 
 
 
 there is no definite le- 
 
 count of its in- 
 
 weak from dila- 
 
 
 sion of the valve, but 
 
 creased work. 
 
 tation. 
 
 
 where, on account of 
 
 Per c u s s i o n 
 
 Larger area of 
 
 
 enlargement of the 
 
 signs accord- 
 
 visible impulse 
 
 
 right heart from mit- 
 
 ingly. 
 
 than with any 
 
 
 ral disease, the tricus- 
 
 
 other valvular 
 
 
 pid orifice is enlarged 
 
 
 lesion. 
 
 
 without a proportion- 
 
 
 
 
 ate enlargeme n t o f 
 
 
 
 
 the valve.
 
 96 
 
 THE PHYSICAL DIAGNOSIS 
 TABLE NO. 11, Continued. 
 
 AUSCULTATION. 
 
 PERCUSSION. 
 
 FATTY DEGEN- 
 ERATION OF THE 
 HEABT. 
 
 Both heart sounds are per- 
 manently weakened, especially 
 the Jirst. The second sound 
 over the apex is clearer and 
 louder than the first. First 
 sound often absent. When 
 present, it is short and valvu- 
 lar, the muscular element or 
 element of impulsion being 
 greatly impaired. This con- 
 dition is pemstent, not tempo- 
 rary; and several examina- 
 tions must be made before de- 
 ciding on the diagnosis. 
 
 Normal area of dullness 
 as a rule. 
 
 Sometimes a dilated or 
 hypertrophied heart un- 
 dergoes fatty degenera- 
 tion, when, of course, its 
 increased area of dullness 
 will remain. 
 
 CABDIAC NEUBO- 
 
 8E8. 
 
 (Nervous or func- 
 tional disorders of 
 the heart.) 
 
 Heart sounds healthy in 
 quality, but intensified, clearer, 
 and more abrupt than normal. 
 Occasionally the first sound is 
 metallic, and either may be re- 
 duplicated. 
 
 An inorganic anaemic mur- 
 mur is sometimes heard at the 
 base of the heart. It is systolic, 
 either aortic or pulmonic or 
 both, soft and feeble, often 
 propagated into the carotids, 
 and accompanied by a hum in 
 the veins of the neck. 
 
 Percussion dullness nor- 
 mal. 
 
 As a mere coincidence, 
 functional disease may ex- 
 ist in a hypertro p h i e d 
 heart.
 
 OF DISEASES OF THE HEART. 
 TABLE NO. 11, Continued. 
 
 97 
 
 INSPECTION. 
 
 PALPATION. 
 
 No visible im- 
 pulse as a rule, 
 even in thin per- 
 sons. 
 
 If there is any, 
 it is very indis- 
 tinct. 
 
 Very little or no apex 
 beat can be felt. If felt 
 it is generally in its nor- 
 mal position, and is irreg- 
 ular or intermittent. 
 
 If a hypertrop hied 
 heart becomes fatty, there 
 is a tumbling, rolling mo- 
 tion. 
 
 Valvular lesions may co-exist. 
 The diagnosis of fatty de- 
 generation of a hypertrophied 
 heart is very difficult. 
 
 Increased area 
 of visi b 1 e i m- 
 pulse, which may 
 be seen to be ir- 
 regular and in- 
 termittent at 
 times. 
 
 Apex beat in normal po- 
 sition. 
 
 Increased action, not 
 power. Beat abrupt and 
 brief. A violent blow, 
 not a powerful heaving. 
 
 Sometimes impulse 
 weaker than natural. 
 
 The physical signs are both 
 negative and positive, nega- 
 tive in excluding all organic 
 disease, and positive in show- 
 ing the healthy size, position, 
 and sounds of the heart. 
 
 Patients with functional dis- 
 ease complain much more of 
 heart symptoms than those with 
 organic disease. Inorganic pal- 
 pitation is increased by seden- 
 tary life, organic by exercise.
 
 INDEX. 
 
 -35gophony, 44. 
 Amphoric respiration, 28. 
 
 percussion resonance, 50. 
 
 voice, 44. 
 
 whisper, 44. 
 Anaemic murmurs, 87. 
 Aneurism, 76. 
 Aortic obstruction, 86. 
 
 regnrgitation, 88. 
 Asthma, 64. 
 
 Bronchial rales, 30. 
 
 respiration, 26. 
 
 whisper, normal, 40. 
 
 increased, 42. 
 Bronchiectasis, 74. 
 Bronchitis, acute and chronic, 64. 
 
 capillary, 66. 
 
 plastic or pseudo-membranous, 66. 
 Broncho-cavernous respiration, 28. 
 
 vesicular respiration, 26. 
 
 pneumonia, 70. 
 Bronchophony, 42. 
 
 whispering, 42. 
 Bubbling rales, 32. 
 
 Capillary bronchitis, 66. 
 Cardiac neuroses, 96. 
 Carcinoma of lung, 76. 
 Catarrhal pneumonia, 70. 
 Cavernous rales, 34. 
 
 respiration, 28. 
 
 whisper, 44. 
 
 Clicking. See SIBILANT RALES, 30. 
 Cogged-wheel respiration, 24. 
 Cracked-metal resonance, 50. 
 Crackling. See CREPITANT RALES, 34. 
 Crepitaut rales, 34. 
 Croupous pneumonia, 68. 
 
 Dilatation of the bronchi, 74. 
 
 heart, 84. 
 Diminished vocal fremitns, 42. 
 
 resonance, 42. 
 Dry or vibrating rales, 30. 
 Dullness on percussion, 46. 
 
 Emphysema, 62. 
 
 Empyema, 56. 
 
 Endocarditis, 80. 
 
 Exaggerated percussion resonance, 50. 
 
 respiration, 28. 
 Expiration prolonged, 24. 
 
 Fatty degeneration of the heart, 96. 
 Feeble respiration, 22. 
 Fibroid phthisis, 70. 
 Fine bubbling rales, 32. 
 Flatness on percussion, 46. 
 Fremitus, diminished vocal, 42. 
 
 increased vocal, 42. 
 
 suppressed vocal, 42. 
 Friction sounds, 36. 
 
 Gurgling rales, 34. 
 
 Harsh respiration, 26. 
 Healthy heart, 78. 
 Hippocratic succussion sound, 38. 
 Hydro-pericardium, 81. 
 Hydrothorax, 58. 
 Hypertrophy of the left heart, 82. 
 right heart, 82. 
 
 Increased bronchial whisper, 42. 
 
 respiration, 22. 
 
 vocal fremitus, 42. 
 
 vocal resonance, 42. 
 Inorganic murmurs, 87.
 
 100 
 
 INDEX. 
 
 Insufficiency, aortic, 86. 
 
 mitral, 90. 
 
 pulmonic, 92. 
 
 tricuspid, 94. 
 Intercostal neuralgia, 25. 
 Interrupted respiration, 24. 
 Interstitial pneumonia, 70. 
 Intra-thoracic tumors, 76 . 
 
 Jerking respiration, 24. 
 
 Laryijgeal rales, 30. 
 
 respiration, 20. 
 
 voice, 40. 
 
 Laryngophony, 40. 
 Left-heart hypertrophy, 82. 
 
 valvular lesions, 86. 
 Lobar pneumonia, acute, 68. 
 Lobular pneumonia, 70. 
 
 Metallic tinkling, 36, 44. 
 Miliary tuberculosis, 72. 
 Mitral obstruction, 88. 
 regurgitation, 90. 
 Moist rales, 30. 
 Morbid pleural sounds, 36. 
 Mucous rales, 32. 
 
 Nervous diseases of the heart, 96. 
 Neuralgia, intercostal, 25. 
 Neuroses, cardiac, 96. 
 Normal bronchial whisper, 40. 
 
 thoracic vocal resonance, 40. 
 
 vesicular percussion resonance, 46. 
 
 vesicular respiration, 20. 
 
 (Edema, pulmonary, 58. 
 Obstruction, aortic, 86. 
 
 mitral, 88. 
 
 pulmonic, 92. 
 
 tricuspid, 94. 
 
 Pectoriloquy, 44. 
 
 whispering, 44. 
 Pericarditis, 78. 
 Phthisis, 72. 
 Plastic bronchitis, 66. 
 Pleurisy, acute, 54. 
 
 chronic, 56. 
 Pleurodynia, 25. 
 
 Pneumo-hydrothorax, 60. 
 Pneumonia, acute lobar, 68. 
 
 catarrhal, 66, 70. 
 
 chronic, 70. 
 Pneumothorax, 62. 
 Prolonged expiration, 24. 
 Puerile respiration, 20, 22. 
 Pulmonary oedema, 58. 
 
 percussion resonance, 46. 
 
 respiration, 20. 
 Pulmonic obstruction, 92. 
 
 regurgitation, 92. 
 
 Kales, bronchial, 30. 
 
 bubbling, coarse, 32. 
 
 bubbling, fine, 32. 
 
 cavernous, 34. 
 
 clicking. See SIBILANT, 30. 
 
 crackling. See CKEPITANT, 34. 
 
 crepitant, 34. 
 
 dry, 30. 
 
 gurgling, 34. 
 
 laryngeal, 30. 
 
 moist, 30. 
 
 mucous, 32. 
 
 sibilant, 30. 
 
 sonorous, 30. 
 
 sub-crepitant, 32. 
 
 tracheal, 30. 
 
 vesicular, 34. 
 Regurgitation, aortic, 88. 
 
 mitral, 90. 
 
 pulmonic, 92. 
 
 tricuspid, 94. 
 
 Resonance on percussion, absence of, 
 46. 
 
 amphoric, 50. 
 
 cracked-metal, 50. 
 
 diminished, 46. 
 
 exaggerated, 50. 
 
 normal vesicular, 46. 
 
 pulmonary, 46. 
 
 tympanitic, 48. 
 
 vesiculo-tympanitic, 50. 
 Resonance, vocal, diminished, 42. 
 
 increased, 42. 
 
 normal thoracic, 40. 
 
 suppressed, 42. 
 Respiration, absence of, 22. 
 
 amphoric, 28.
 
 INDEX. 
 
 Respiration, bronchial, 26. 
 
 broncho-cavernous, 28. 
 
 broncho-vesicular, 26. 
 
 cavernous, 28. 
 
 cogged-wheel, 24. 
 
 feeble, 22. 
 
 harsh, 26. 
 
 healthy, 20. 
 
 increased, 22. 
 
 interrupted, 24. 
 
 jerking, 24. 
 
 laryngeal, 20. 
 
 puerile, 20, 22. 
 
 pulmonary, 20. 
 
 rough, 26. 
 
 rude, 26. 
 
 senile, 22. 
 
 suppressed, 22. 
 
 tracheal, 20. 
 
 tubular, 26. 
 
 tubule-vesicular, 26. 
 
 vesicular, 26. 
 
 vesiculo-bronchial, 26. 
 
 wavy, 24. 
 
 weak, 22. 
 Eight-heart hypertrophy, 82. 
 
 valvular lesions, 92. 
 
 Sibilant rales, 30. 
 Sonorous rales, 30. 
 Splashing, 38. 
 Stenosis, aortic, 86. 
 
 mitral, 88. 
 
 pulmonic, 92. 
 
 triru?pid, 94. 
 Sub-crepitant rales, 32. 
 Suppressed respiration, 22. 
 
 vocal resonance, 42. 
 
 Tinkling, metallic, 36, 44. 
 Tracheal rales, 30. 
 
 respiration, 20. 
 
 voice, 40. 
 
 whisper, 40. 
 Tracheophony, 40. 
 
 whispering, 40. 
 Tricuspid obstruction, 94. 
 
 regurgitation, 94. 
 Tuberculosis, acute miliary, 72. 
 Tubular respiration, 26. 
 Tubulo-vesicular respiration, 26. 
 Tympanitic resonance, 48. 
 
 Valvular lesions, 86. 
 Vesicular rales, 34. 
 
 respiration, 20. 
 
 resonance on percussion, 46. 
 Vesiculo-tympanitic resonance on per- 
 cussion, 50. 
 
 Vesiculo-bronchial respiration, 26. 
 Vibrating rales, 30. 
 Vocal resonance, diminished, 42. 
 
 increased, 42. 
 
 normal thoracic, 40. 
 
 suppressed, 42. 
 Voice in disease, 42. 
 
 laryngeal, 40. 
 
 tracheal, 40. 
 
 Wavy respiration, 24. 
 Weak respiration, 22. 
 Whispering bronchophony, 42. 
 
 pectoriloquy, 44. 
 
 tracheophony, 40. 
 Whisper, amphoric, 44. 
 
 cavernous, 44. 
 
 tracheal, 40.
 
 3 1970 00592 4623 
 
 SOUTHERN REGIONAL LIBRARY FACIUTY 
 
 A 000 501 566 
 
 WB278 
 
 C589t 
 1885 
 
 Glapp. Herbert C 
 
 Tabular handbook of auscultation and 
 oercussion. 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664