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r,^«.-    .HX641 39646 

RC941  .N791920  Diseases  of  the  ches 




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I  437  W.  59th  Street, 
11;^.       NEW  YORJ^^ITY. 

Assistant  Professor  of   Medicine   in  the  University  of  Pennsylvania;   Visiting 
Physician  to  the  Pennsylvania  Hospital;   Assistant  Visiting  Physician  to  the 
University  Hospital;  lately  Colonel,  M.  C,  U.  S.  Army 


HENRY  R.  M.  LANDIS,  A.  B.,  M.  D. 

Assistant  Professor  of  Medicine  in  the  University  of  Pennsylvania;  Director  of 
the  Clinical  and  Sociological  Departments  of  the  Henry  Phipps  Institute  of  the 
University  of  Pennsylvania;  Visiting  Physician  to  the  White  Haven  Sanatorium 

WITH    A    CHAPTER    ON    THE 




Assistant  Professor  of  Research  Medicine  in  the  University  of  Pennsylvania 





Copyright,  1917,  by  W.  B.  Saunders  Company.     Reprinted    August,  1918. 
Revised,  reprinted,  and  reeopyrighted,  Januaiy,  1920. 

Copyright,  1920,  by  W.  B.  Saunders  Company 

Printed  in  America. 


GEORGE  FETTEROLF,  A.  B.,  M.  D.,  Sc.  D. 






Digitized  by  tine  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


The  exhaustion  of  the  first  edition  of  this  book,  in  less  than  two 
years,  may  be  taken  as  evidence  that  it  supplied  a  need.  The  present 
edition  contains  descriptions  of  several  conditions  previously  omitted. 
Among  these  may  be  mentioned — Spirochetal  Bronchitis,  Influenza, 
Streptococcus  Empyema,  Chronic  Inflammatory  Conditions  of  the 
Lungs  of  Uncertain  Etiology,  Calcification  of  the  Lungs,  Pneumo- 
pericardium, etc.  In  addition  some  of  the  original  material  has  been 
recast,  in  part  or  completely  so.  In  every  instance  the  effort  has  been 
made  to  incorporate  in  the  original  text  such  additions  to  our  knowledge 
as  indicate  a  distinct  advance. 

The  authors  w^elcome  this  opportunity  to  express  to  old  and  new 
made  friends  their  gratification  over  the  cordial  reception  that  was 
accorded  the  first  edition;  and  also  to  venture  the  hope  that  the  second 
edition  will  merit  the  same  kindly  greeting. 

The  Authors. 
Philadelphia,  Penna. 
January,  1920 


To  write  a  practical  book  on  the  physical  diagnosis  of  the  heart  and 
lungs  in  health  and  disease,  has  been  the  aim  of  the  authors.  We  have  at- 
tempted to  omit  everything  not  of  practical  diagnostic  use,  and  to  con- 
dense methods  of  secondary  importance. 

More  than  is  the  custom  has  been  written  on  the  subject  of  diagnostic 
acoustics,  because  we  believe  that  only  through  the  comprehension  of  the 
laws  of  sound  production  and  transmission  can  the  results  of  percussion 
and  auscultation  be  intelligently  interpreted. 

We  have  endeavored  to  teach  as  much  as  possible  by  means  of  illus- 
trations. Of  these,  many  are  photographs  of  frozen  sections  from  the 
cadaver,  previously  hardened  in  formalin,  so  that  the  anatomic  relations 
of  the  tissues  remain  as  during  life.^  We  have  found  these  specimens 
invaluable  in  our  own  teaching;  and  the  book  has  been  written  in  the  hope 
that  the  photographic  reproductions  of  our  sections  may  be  useful  to 

We  take  pleasure  in  acknowledging  our  great  indebtedness  to  Dr. 
George  Fetterolf  for  the  frozen  sections;  to  Dr.  J.  Claxton  Gittings  for 
assistance  in  the  preparation  of  the  Section  on  Pediatrics;  to  Dr.  Edward 
B.  Krumbhaar  for  the  Chapter  dealing  with  the  electrocardiogram;  to 
Professor  Richard  Geigel,^  and  to  Dr.  Charles  M.  Montgomery,^ 
from  whose  articles  upon  acoustics  in  diagnosis,  much  information  has 
been  gleaned.  We  are  also  indebted  to  Miss  Eleanor  A.  Cantner  for  the 
production  of  some  of  our  drawings.  We  are  further  under  obligations 
to  Professor  William  M.  L.  Coplin  for  permission  to  photograph  numer- 
ous specimens  in  the  Museum  of  Pathology  of  the  Jefferson  Medical 
College,  as  well  as  to  Dr.  David  R.  Bowen  and  to  Dr.  Henry  K.  Pancoast 
for  our  radiograms. 

The  Authors, 
Philadelphia,  Penna. 

^The  photographs,  both  chnical  and  anatomical,  were  with  negligible  exceptions, 
made  by  Dr.  George  W.  Norris.  Many  of  the  pictures  illustrating; diseases  of  the 
heart  and  aorta  have  been  reproduced  from  "Studies  in  Cardiac  Pathology"  by 
George  W.  Norris. 

^  Geigel,  Richard:  "Leitfaeden  der  Diagnostischen  Akustik."     Stuttgart,  1908. 

^Montgomery  and  Eckhardt:  "Pulmonary  Acoustic  Phenomena."  Tenth 
Annual  Report  of  the  Henry  Phipps  Institute,  Phila.,  1915.  i 





By  George  W.  X orris,  A.  B.,  'M.  D. 



Physical  Diagnosis 17 

Inspection,  17;  General  inspection,  19:  Inspection  of  the  chest.  20;  The  ^ital 
capacity  of  the  lungs,  27;  Abnormal  thoracic  conformation,  33;  'Abnormal 
respiration,  40;  Visible  changes  in  respiratory  rhj-thm,  42. 


Palpatiox 43 

Object  of  palpation,  43;  Cutaneous  hyperesthesia,  44;  Pleural  pain  or  hj-per- 
esthesia,  45;  Tactile  or  vocal  fremitus,  46. 


AcorsTics  IX  Physical  Diagxosis 54 

Rhythmic  vibrations,  54;  L'nrh3i;hmic  vibrations,  55;  Vibrations  in  tense 
membranes,  55;  Sympathetic  vibrations,  55;  Interference  waves,  56;  Loaded 
strings,  56;  Resonators,  57;  Quahties  of  sound,  58;  Origin_of  sounds  heaid 
over  chest,  60. 


The  History  axd  Theory  of  Percussiox 64 

Percussion  sounds,  64;  Tjonpany,  64;  Resonance,  66;  Hj-per-resonance,  67; 
Dulness,  67;  Impaired  resonance,  69;  Flatness,  69;  Modified  tympany,  69; 
Metallic  ring,  70;  BeU  tjrmpany,  70;  Cracked-pot  sound,  70;  Special  percus- 
sion signs,  73. 

Anatomic  Coxsideratioxs 74 


Methods  and  Results  of  Percussion SO 

Immediate  or  direct  percussion,  SO;  Mediate  or  indirect  percussion,  SO; 
Results  of  percussion,  82;  Purpose  of  percussion,  87;  Technic  of  percussion, 
89;  Special  varieties  of  percussion,  90;  Conditions  modifjTug  percussion 
sounds,  93. 





Normal  Variations  of  Pulmoxart  Percussion  Souxds 95 

Individual  variations,  95;  Regional  variations,  95;  Other  variations,  102; 
Diaphragm,  102;  Some  physiologic  considerations,  103. 



Methods  of  auscultation,  103;  Influence  of  posture  on  physical  signs,  108; 
Stethoscopes,  109;  Breath  sounds,  111. 


Normal  axd  .\bxormal  Breath  Souxds 115 

Normal  vesicular  sound,   115;  Abnormal  breath  sounds,  115;  Changes  in 
respiratory  rh\i:hm,  12.3. 


Advextitious  Breath  Souxd.s 124 

Riles,  124;  Friction  sounds.  127;  Succussion  splash,  1-30;  Metallic  tinkle,  131. 


Voice  Sounds 132 

Vocal  resonance,   132;  Bronchophony,  134;  Pectoriloquy,  134;  Egophony, 


Physical  Findings  ix  Ixfaxts  ant)  Youxg  Children* 138 

Chest  inspection,  138;  Palpation,  138;  Percussion,  139;  Auscultation,  141; 
Pathologic  conditions,  143;  Practical  considerations,  146;  The  X-raj*,  149. 



By  George  W.  Norris,  A.  B.,  M.  D. 

The  Circulatory  System 151 

Inspection,  151;  The  heart — Anatomic  considerations,  153;  Palpation  of  the 
pulse,  157;  Pulse  rh^-thm,  158;  Pulse  volume,  1.58;  Pulse  tension,  158;  Equal- 
ity of  the  pulse,  159;  Normal  and  abnormal  types  of  arterial  pulse,  159. 



Blood-pressure  estimation.  163;  Venous  blood  pressure,  166;  Venous  pulse, 
166;  Sphygmographs,  167;  Interpretation  of  sph\-gmogram,  169. 




Cardiac  Arrhythmia 170 

Normal  rhythm,  170;  Sinus  arrhythmia,  172;  Heart  block,  173;  Extrasystole, 
174;  Paroxysmal  tachycardia,  176;  Auricular  flutter,  176;  Auricular  fibrilla- 
tion, 177;  Pulsus  alternans,  178;  The  effort  syndrome,  180;  Estimation  of 
vasomotor  efficiency,  182. 


The  Electrocardiograph  (By  Dr.  Edward  B.  Krtjmbhaar) 184 

The  principle,  184;  Normal  electrocardiogram,  185;  Preponderating  ventricu- 
lar hypertrophy,  187;  Cardiac  arrhythmias,  190. 

Palpation 199 

Cardiac  impulse,  199;  Thrills,  204. 


Percussion  of  the  Heart 206 

Methods  and  technic,  206;  Significance  of  cardiac  dulness,  210;  Records  of 
cardiac  dimensions,  213;  Orthodiagraph,  214. 


Auscultation 216 

Object  and  method  of  auscultation,  216;  Origin  and  character  of  heart 
sounds,  216;  Acoustics  of  heart  sounds,  218;  Individual  variation  of  the  heart 
sounds,  220;  Disproportionate  intensity  of  heart  sounds,  221;  Changes  in 
pitch  of  heart  sounds,  223;  Reduplication  of  heart  sounds,  223;  Changes  in 
rhythm  of  heart  sounds,  224. 

Heart  Murmurs 226 

Acoustics,  226;  Technic  of  cardiac  auscultation,  228;  Variations  in  intensity 
of  heart  sounds,  228;  Endocardial  murmurs,  229;  Individual  valvular  mur- 
murs, 232;  Functional  murmurs,  246;  Effect  of  respii-ation  on  endocardial 
murmurs,  248;  Special  murmurs,  249;  Exocardial  murmurs,  252;  Arterial 
sounds  and  murmurs,  253;  Venous  murmurs,  253;  Cardio-respiratory  mur- 
murs, 254;  Pericardial  friction  sounds,  255. 




By  H.  R.  M.  Landis,  A.  B.,  M.  D. 


Diseases  op  the  Bronchi 265 

Acute  bronchitis,  265;  Chronic  bronchitis,  267;  Fibrinous  bronchitis,  269; 
Spirochetal  bronchitis,  273;  Bronchiolitis  fibrosa  obliterans,  274;  Whooping 
cough,  276;  Bronchial  asthma,  279;  Bronchiectasis,  287;  Fetid  or  putrid  bron- 
chitis, 296;  Bronchiolectasis,  296;  Foreign  bodies  in  the  air  passages,  297. 




Diseases  op  the  Lixgs 303 

Tuberculosis  of  the  lungs,  303:  Chronic  tuberculosis  of  the  lungs,  303;  Acute 
tuberculosis  of  the  lungs,  372;  Fibroid  phthisis.  378;  Acute  miliary  tuber- 
culosis, 379;  Mycotic  infections  of  lungs,  38S;  Streptothricosis,  389;  Actino- 
mycosis, 392;  Blastomycosis,  39o;  Coccidioidal  granuloma.  398;  Aspergil- 
losis, 400;  Sporotrichosis,  401;  Acute  lobar  pneumonia,  402;  Friedliinder's 
bacillus  pneumonia,  425;  Psittacosis,  427;  Broncho-pneumonia,  428;  Influ- 
enza, 439;  Influenza  broncho-pneumonia,  454;  Pulmonary  fibrosis,  462; 
Chronic  inflammatory  conditions  of  lungs  of  uncertain  etiology,  469; 
Calcification  of  the  lungs,  471 ;  Pneumoconiosis, 472;  Atelectasis,  485;  Emphy- 
sema, 489;  Chronic  hypertrophic  emphj-sema,  480;  Senile  emphysema,  495; 
Acute  vesicular  emphysema,  495;  Interstitial  emphysema,  496;  Compensa- 
tory emphysema,  496;  Pulmonary  abscess,  498;  Pulmonary  gangrene,  507; 
Pulmonary  infarction,  511;  Pulmonary  congestion,  516;  Pulmonary  edema, 
518;  Effects  of  poisonous  gases  on  the  respiratory  tract,  521;  Hydatid  disease 
of  the  lungs  and  pleura,  528;  Pulmonary  distomatosis,  531;  Syphilis  of  the 
respiratory  tract,  534;  Intrathoracic  tumors,  542;  Intrathoracic  goitre,  557; 
Enlargement  of  the  thymus,  557;  Hernia  of  the  lung,  562;  Alternations  in 
the  extremities  due  to  chronic  pulmonary  disease,  564;  Changes  in  the  finger 
nails,  564;  Clubbing  of  the  fingers  and  toes,  564;  Hypertrophic  pulmonary 
osteo-arthropathy,  567. 


Diseases  of  the  Pleura 572 

Pleurisy,  572;  Dry  pleurisy,  578;  Fibrinous  pleurisy,  579;  Diaphragmatic 
pleurisy,  580;  Serofibrinous  pleurisj'  (Pleural  effusion),  580;  Chronic  pleurisy, 
589;  Empyema.  589;  Encysted  empyema,  600;  Hemorrhagic  pleural  effusions, 
605;  Hemothorax.  607;  Chylothorax.  612;  Hydrothorax,  614;  Pneumothorax, 


Diseases  of  the  Diaphragm 629 

Anatoni}-;  Normal  and  pathological  physiology  of  the  diaphragm,  629; 
Functional  disturbances  of  the  diaphragm,  632;  Diaphragmatic  hernia,  635; 
Evisceration  (Traumatic  or  spurious  hernia).  635;  Eventration  of  the  dia- 
phragm, 638;  Diaphragmatis,  641;  Subdiaphragmatic  abscess,  646. 


By  H.  R.  M.  Laxdis,  A.  B.,  M.  D. 


Diseases  of  the  Pericardium 653 

Acute  fibrinous  pericarditis,  653;  Tuberculous  pericarditis,  656;  Pericardial 
effusion,  657;  Pneumopericardium,  662;  Chronic  adhesive  pericarditis,  664. 




Diseases  of  the  Myocardium 670 

Hypertrophy,  670;  Dilatation,  677;  Myocarditis,  679;  Aneurism  of  heart, 
686;  Myocardial  changes  due  to  syphilis,  689;  Goitre  heart,  692;  The  heart 
and  uterine  myomata,  695. 


Endocarditis 696 

Acute  endocarditis,  696;  Acute  infectious  endocarditis,  700;  Subacute  infec- 
tious endocarditis,  707;  Chronic  valvular  disease,  710;  Mitral  insufficiency, 
717;  Mitral  stenosis,  725;  Aortic  insufficiency,  734;  Aortic  stenosis,  739;  Tri- 
cuspid insufficiency,  743;  Tricuspid  stenosis,  747;  Pulmonary  insufficiency, 
752;  Pulmonary  stenosis,  754. 


Congenital  Heart  Disease 756 


Angina  Pectoris 766 

Angina  pectoris  major,  766;  Incipient  angina  pectoris,  770;  Angina  pectoris 
vasomotoria  (pseudo-angina),  771. 


Diseases  op  the  Aorta 774 

Acute  aortitis,  774;  Syphilitic  aortitis,  776;  Chronic  aortitis,  779;  Essential 
hypertension,  788. 


Anex]rism  of  the  Thoracic  Aorta 791 

Dilatation  of  the  aorta,  813;  Arterio-venous  aneurism,  817;  Aneurism  of 
innominate  artery,  817;  Rupture  of  the  aorta,  818. 

Index '   : 821 



By  George  W.  Norris,  A.  B.,  M.  D. 



Physical  diagnosis  consists  in  employing  our  senses — sight,  touch,  and 
hearing — to  determine  the  condition  of  the  tissues.  These  are  altered  in 
character  by  many  pathologic  states.  They  may  become  more  solid  or 
less,  may  contain  more  or  less  of  fluid  or  of  air  than  normal,  their  elas- 
ticity may  be  increased  or  diminished.  Again,  it  may  be  that  organs  be- 
come larger  or  smaller  than  normal,  or  are  shifted  more  or  less  out  of 
place.  Such  alterations  we  can  often  demonstrate  by  means  of  physical 
signs.  The  data  thus  obtained,  used  in  conjunction  with  a  knowledge  of 
the  patient's  history,  and  symptoms,  together  with  a  familiarity  with  the 
pathology,  often  permit  us  to  estimate  very  accurately  the  nature,  charac- 
ter, location  and  extent  of  the  disease  from  which  the  patient  is  suffering. 
"The  significance  of  morbid  signs  relates  immediately  not  to  diseases,  but 
to  the  physical  conditions  incident  thereto.  Signs  are  not  directly  diag- 
nostic of  particular  diseases  "  (Flint) .  The  methods  employed  in  physical 
diagnosis  are:  inspection,  palpation,  percussion,  and  auscultation.  These 
methods  are  frequently  combined  with  mechanical,  chemical,  electrical, 
microscopic  and  bacteriologic  examination,  as  well  as  with  the  data 
obtained  by  means  of  the  X-rays. 


Although  seemingh^  the  most  obvious,  the  simplest  and  the  easiest  of 
the  four  methods  mentioned,  accurate,  useful  and  skilled  inspection  is 
in  reality  often  the  most  difficult  to  acquire  and  the  last  in  which  the 
practitioner  becomes  proficient.  It  is  in  this  method  especially  that 
the  seasoned  physician  far  excels  his  younger  confrere.  This  is  in  part 
due  to  carelessness  on  the  part  of  the  younger  man,  but  is  perhaps  even 
more  due  to  the  fact  that  the  senior  has  become  accustomed  to  make 
note  of  many  items  at  a  glance,  and  also  that  he  has  learned  not  only 
what  to  look  for,  but  where  to  look  for  it,  and  how  to  read  the  facts 
which  are  presented  before  his  ej^es.  He  has  acquired  the  faculty  of 
seeing  with  the  mind  as  well  as  with  the  eye.  "We  can  only  see  what 
we  have  learned  to  see."  Corrigan's  remark  is  still  as  apt  as  the  day  it 
was  uttered:  "The  trouble  with  most  doctors  isn't  so  much  that  they 
don't  know  enough,  as  it  is  that  they  don't  see  enough!"  We  feel 
2  17 



Fig.   1. — Clubbing  of  the  fingers  due  to  congenital  heart  disease. 

Fig.  2. — Radiogram  of  the  fingers  depicted  in  lit;.  1,  shuwini.:  not  only  hypertrophic 
changes  in  the  soft  tissues,  but  also  new  bone  formation  in  the  distal  phalanges  (pulmonary 
osteo-arthropathy).  "Simple  clubbing  of  the  fingers  and  secondary  hypertrophic^osteo- 
arthropathy  should  be  considered  as  identical,  the  former  representing  an  early  stage^of  the 



that  we  cannot  over-emphasize  the  importance  of  careful,  intelhgent 

The  Examination  of  the  Lungs. — For  the  purposes  of  examination, 
the  body,  especially  the  chest  and  abdomen,  must  be  stripped.  The  light 
should  be  good.  Its  source,  as  to  whether  it  falls  directly,  obliquely  or 
vertically,  upon  the  patient,  must  often  be  varied.  Many  physiologic 
and  pathologic  conditions  can  be  seen  only  with  oblique  illumination. 
It  is  therefore  desirable  to  have  the  patient  first  face  the  window,  later 
turn  his  side  toward  it.  In  the  latter  position  most  of  the  shadows 
become  intensified . 

The  following  points  are  especially  to  be  noted : 


General  appearance,  posture,  gait,  facial  expression,  nutrition,  color. 

Absolute  symmetry  is  unknown.     As  a  general  rule  the  right  side 

of  the  body  is  better  developed  than  the  left.     The  right  chest  is  about 

Fig.  3. — Pulmonaryrosteo-arthropathy  of  the  hands  and  forearms  in  a  case  of  sarcoma  of 

the  lung. 

1}>4  inches  larger  in  circumference  than  the  left.  The  spine  curves  to- 
ward the  right,  the  right  arm  is  longer  and  the  corresponding  shoulder 
is  often  narrower  and  lower.  There  are,  of  course,  well-marked  dif- 
ferences which  depend  upon:  (a)  Sex:  These  involve  the  bones,  the 
pelvis,  the  genitalia,  the  panniculus  adiposus,  etc.  (b)  Age:  In  the 
child,  the  ribs  are;^ more,  horizontal,  the  heart  and  liver  larger,  the  lungs 


smaller,  the  thymus  is  present,  the  bones  aie  more  cartilaginous  (see 
p.  138). 

The  Skin.- — (a)  The  color  (pallor,  cyanosis,  jaundice,  pigmentation, 
mottling,  etc.);  (b)  the  character  (texture,  moisture,  edema,  eruptions, 
gloss,  subcutaneous  fat,  wasting,  distended  blood-vessels). 

The  Muscles. — Development,  wasting,  tremors,  symmetry. 

The  Face. — ^Intelligence,  expression,  symmetry,  spasm,  paralysis, 
edema,  myxedema. 

The  Hair.- — Dryness,  sparsity,  distribution,  dyes,  parasites,  local 
discoloration,  the  presence  of  vermin. 

The  Eyes. — Prominence  of  the  eyeballs,  the  pupils  (size,  color  sym- 
metry, equality,  reaction  to  light,  etc.),  conjunctiva  (color,  ecchymosis, 
discharges),  cornea  (transparency,  arcus  senilis,  leucoma). 

The  Mouth. — Teeth,  gums,  tongue,  pharynx,  tonsils,  lips  (pyorrhea, 
cyanosis,  herpes,  ulcerations,  moisture,  deposits,  drooping,  rhagades). 

The  Ears. — Shape,  discharges,  tophi,  scars. 

The  Nose.- — -Discharges,  obstruction,  motionof  the  nostrils  (dyspnea), 
dilated  venules. 

The  Neck. — Pulsations — arterial  and  venous,  swelling — adenitis, 
thyroidal  enlargement,  scars. 

The  Hands. — Cyanosis,  curved  or  ridged  nails,  clubbed  fingers, 
joints,  deposits  (tophi,  Heberden's  nodes),  shape,  symmetry,  nutrition, 
capillary  pulse  (Figs.  1,  2,  3,  329,  330,  331). 

The  Abdomen.- — Shape,  clistention,  varicosities,  asymmetry,  pulsation, 
edema,  eruptions. 

The  Legs  and  Feet. — Edema,  clubbing  of  the  toes,  deformities,  vari- 
cosities, cyanosis,  scars,  pigmentation. 


This  method  of  physical  examination  is  too  frequently  omitted,  or 
made  so  hastily  and  cursorily  that  little  or  no  information  is  obtained. 
Inspection,  properly  done,  yields  more  valuable  information  than  any 
other  procedure  at  our  disposal,  with  the  exception  of  auscultation;  and 
furthermore,  it  has  this  to  commend  it,  namely,  that  no  special  training 
is  required,  and  the  beginner,  providing  he  is  taught  to  use  his  eyes  in- 
telligently, is  as  capable  of  seeing  defects  as  the  experienced  observer. 
This  is  in  marked  contrast  to  the  training  necessary  to  educate  the  ear 
to  differentiate  sounds,  particularly  those  produced  by  percussion,  the 
latter  method  often  requiring  years  of  practice.  Inspection,  on  the  other 
hand,  requires  no  special  technique;  the  only  requirement  is  that  one 
should  keep  in  mind  constantly  that  evei-y  abnormality,  hoivever  slight  it 
may  appear,  is  worthy  of  consideration. 

One  who  has  been  taught  to  make  a  proper  inspection  can,  in  many 
instances,  come  to  a  fairly  definite  conclusion  from  this  procedure  alone. 
Since  inspection  requires  no  special  training,  it  is  particularly  valuable  to 
the  student,  and  to  those  who  see  chest  cases  incidentally,  and  not 

In  order  that  inspection  should  yield  the  best  results,  it  is  absolutely 
essential  that  the  patient  be  stripped  to  the  waist.  "The  unpleasant- 
ness and  inconvenience  to  a  patient  of  undressing  for  this  purpose,  the 
time  occupied  in  so  doing,  the  trouble  it  gives,  and  a  sense  of  delicacy  in 



females"  are  no  longer  to  be  considered  the  serious  obstacles  Laennec 
believed  them  to  be.  An  examination  of  a  chest  which  has  not  been 
entirely  exposed  is  in  the  vast  majority  of  instances  worse  than  no  ex- 
amination at  all.  In  regard  to  women  it  can  be  safely  asserted  that  no 
difficulty  will  be  encountered  if  the  importance  of  the  procedure  is  ex- 
plained and  they  are  not  unnecessarily  exposed.  For  some  yeais  we 
have  used  the  following  method.  A  piece  of  linen  or  fine  muslin  a  yard 
square  is  slit  from  one  corner  to  the  center  and  the  free  edges  hemmed 
(see  Figs.  4  and  5).  This  is  thrown  over  the  shoulders.  In  examining 
the  anterior  aspect  of  the  chest  the  cape  is  loosened  over  the  shoulders. 
When  the  area  below  the  breasts  is  examined  the  cape  still  affords  pro- 
tection.    In  examining  the  back,  the  cape  may  be  pushed  up  exposing 

Figs.  4  and  5. — The  examining  cape  in  use. 

the  entire  back  as  no  objection  is  ever  offered  to  this.  As  the  capes  are 
inexpensive  a  number  can  be  kept  on  hand  and  a  fresh  one  used  for  each 

It  must  be  borne  in  mind  that  a  patient  stripped  to  the  waist  should 
not  be  subjected  to  the  discomfort  of  a  cold  examining  room. 

The  next  requisite  is  that  the  patient  shall  be  so  placed  that  the  light 
falls  directly  on  the  parts  under  inspection.  In  comparing  the  two  sides 
of  the  chest,  the  illumination  must  not  come  from  one  side  as  errors  may 
occur  if  one-half  of  the  chest  is  less  well  lighted  than  the  other.  The  chest 
should  be  inspected  not  only  from  the  anterior  and  posterior  aspects  but 
also  in  profile;  the  latter  method  is  of  value  in  estimating  the  depth  of  the 
chest  and  also  in  determining  the  presence  or  absence  of  pulsation.  In 
addition  the  chest  should  be  inspected  from  above  downward.  This 
is  done  by  the  examiner  standing  behind  the  patient  and  looking  down 
over  the  shoulders. 

The  Posture  of  the  Patient. — As  to  the  posture  of  the  patient,  the 
sitting  position  is  the  one  of  choice.     The  patient  should  be  instructed  to 



assume  a  natural  posture  and  not,  on  the  one  hand,  to  sit  too  rigidly,  or, 
on  the  other,  to  assume  a  slouching  position.  The  standing  position  may 
be  selected  if  the  examiner  prefers  it,  but  it  is  not  as  convenient  and  if  the 
examination  takes  much  time  is  tiring  both  for  the  patient  and  the 

Inspection  of  the  chest  in  patients  who  are  confined  to  bed  and  acutely 
ill  is  never  as  satisfactory'  as  in  those  who  can  sit  or  stand  up.  Further- 
more, only  the  anterior  aspect  of  the  chest,  as  a  rule,  is  available  for  the 
method.  Another  difficulty  is  that  in  private  houses  the  light  frequently 
comes  from  one  side  onh',  so  that  half  of  the  chest  is  in  a  shadow  which 
seriously  interferes  with  a  good  view.  In  very  ill  patients  this  method 
of  physical  examination,  in  common  with  the  other  procedures,  suffers 
from  a  lack  of  thoroughness  which  is  often  unavoidable.  If  the  exami- 
nation of  the  patient  in  the  recumbent  attitude  is  unavoidable,  care 

Fig.   6. — The  topography  of  the  chest  anteriorly.      For  purposes  of  description  the  chest  is 
divided  into  certain  regions  which  are  shown  in  this  and  in  the  following  figure. 

should  be  taken  to  see  that  the  body  rests  on  an  even  plane;  otherwise 
the  results  maj'  be  affected  very  materialh'  (see  p.  202). 

To  fix  a  standard  of  what  constitutes  a  normal  chest  which  shall 
serve  as  a  criterion  by  which  to  estimate  either  the  existence  of  or  the 
degree,  of  abnormal  variations,  is  not  possible.  Individuals  entirely 
free  from  thoracic  disease  present  the  greatest  variations  in  the  conforma- 
tion of  their  chests. 

The  Conformation  of  the  Normal  Chest. — -Providing  that  the  chest 
does  not  present  some  one  of  the  recognized  deformities,  it  is  assumed 
to  be  normal  if  it  is  sj'mmetrical,  not  onh'  generally  but  in  its  different 
parts.  The  shoulders  should  be  on  the  same  level  and  the  line  from  the 
neck  to  the  point  of  the  shoulder  slightly  convex.  In  men  the  clavicles 
are  usually  more  or  less  prominent  and  the  supraclavicular  spaces  a  little 
depressed.  In  women  the  clavicles  are  not  uncommonly  hidden  by 
adipose  tissue  and  there  are  no  depressions  above  the  clavicles.  Beneath 
the  clavicles  the  chest  wall  is  slightly  convex.     The  intercostal  spaces  are 



slightly  below  the  surface  unless  the  individual  is  well  covered  with  fat. 
Owing  to  the  progressively  increasing  obliquity  of  the  ribs  from  behind 
forward  the  intercostal  interspaces  are  broader  in  front  than  behind. 
In  the  majority  of  individuals  a  projection  of  the  sternum  is  visible  at 
the  level  of  the  second  costal  caertilags.  This  projection  or  angle  is  of 
variable  degree  and  is  formed  by  the  articulation  of  the  upper  and  middle 
portions  of  the  sternum.  It  is  known  as  the  Angulus  Sterni  or  Angle  of 
Louis.  In  certain  thoracic  conditions,  particularly  emphysema,  the 
bulging  forward  of  the  upper  ribs  tends  to  accentuate  this  angle.  The 
lower  part  of  the  sternum  just  above  the  ensiform  cartilage  is  normally 
slightly  depressed. 

Viewed  from  behind  the  angles  of  the  scapula  should  be  on  the  same 
level  (corresponding  to  the  spine  of  the  eighth  dorsal  vertebra)  and  closely 
approximated  to  the  chest  wall. 

Fig.  7. — The  topography  of  the  chest  posteriorly. 

The  spine  should  be  straight  and  slightly  concave  from  above  down- 
ward, slight  deviations  of  the  spine  are  not  uncommon,  however,  and 
may  or  may  not  be  an  indication  of  thoracic  disease.  They  are  frequently 
due  to  faulty  posture. 

The  points  especially  to  be  noted  in  inspecting  the  thorax  are:  the 
size  and  development,  the  contour  and  symmetry,  the  mobility  or  degree 
of  expansion,  the  type  of  breathing,  the  rate  of  respiration,  the  degree  of 
the  subcostal  angle,  local  bulging  or  pulsation,  and  the  prominence  of 
the  clavicles. 

The  Size  of  the  Chest. — -The  development  of  the  chest  depends  to  a 
considerable  degree  upon  the  general  health  and  activity  of  the  individual. 
Hence,  large,  deep,  well-muscled  thoraces  are  found  in  robust,  physically 
active  men.  Small  flat  chests  are  seen  as  the  result  of  early  disease  neces- 
sitating long  periods  spent  in  bed;  rachitis,  and  nasal  obstruction  (ade- 



noids)  are  also  common  causes.  Lack  of  thoracic  development  or  chest 
deformity  in  early  life  is  chiefly  due  to  these  causes.  In  adult  life  abnor- 
malities generally  result  from  tuberculosis,  pleuritis  or  emphj^sema. 

The  Contour  and  Symmetry  of  the  Chest. — It  is  especially  important 
that  the  two  sides  of  the  chest  be  compared  with  each  other.  There  is  of 
course  no  absolute  normal  standard,  but  merely  a  variable  range  of  the 
normal.  Disease  of  the  chest  is  so  frequently  unilateral  that  by  choosing 
the  "better"  side  we  are  enabled  to  estimate  a  given  individual's  normal. 
Asymmetry  of  the  thorax  is  often  due  to  abnormal  curvature  of  the 
spine — scoliosis,  kyphosis,  lordosis — which,  when  present  to  a  marked 
degree,  often  renders  examination  by  auscultation  and  percussion  very 
difficult  (Figs.  17,  26  and  36).  Inequality  in  the  size  or  expansion  of  the 
two  sides  of  the  chest  may  be  measured  by  sewing  two  tape  measures 

Fig.  8. — Position  of  the  bony  thorax  during  inspiration  and  expiration.  The 
emphysematous  chest  is  practically  that  of  a  chronic,  immobile,  forced  inspiration.  {After 

together,  placing  the  zero  point  over  the  spine  and  bringing  the  free 
ends  together,  horizontally  at  the  sternum. 

At  hirth  the  chest  is  cylindrical  (Fig.  19) ;  this  form  gradually  develops, 
beginning  at  the  second  year,  into  the  elliptic  shape  of  adult  life  (Fig.  20), 
to  revert  again  during  old  age  to  more  or  less  the  circular  contour  of 
childhood  (Figs.  25  and  33).  The  exact  contour  can  be  accurately  deter- 
mined by  means  of  the  cyrtometer — a  band  of  lead,  hinged  in  the  middle, 
which  is  firmly  applied  and  moulded  to  the  chest,  the  contour  of  which 
it  afterward  maintains. 

The  Mobility  of  the  Chest. — Chest  expansion,  the  difference  in  cir- 
cumference between  forced  inspiration  and  expiration  is  in  normal  men, 
about  2  inches.  Much  greater  degrees  of  mobility  are  found  in  indi- 
viduals accustomed  to  severe  physical  exercise.  Chest  expansion  can  be 
greatlj^  developed  during  adolescence  by  practice;  it  is  medically  of 
minor  importance  (Fig.  8). 



Inequality _  of  expansion  has  great  significance.  The  main  point  to  be 
determined  is  whether  both  sides  of  the  chest  expand  equally.  The  most 
important  cause  of  unilateral  diminished  or  delayed  expansion  is  tuber- 
culosis of  the  lungs  or  pleura,  but  such  a  condition  also  results  from  one- 
sided pneumonia,  pleuritis  (pain),  or  pleural  effusion,  pneumothorax,  etc. 
The  last  two  conditions  may  also  alter  the  shape  of  the  intercostal  spaces. 

ird^rvo^    ^^^^ 

Fig.   9. — Cross  section   of  the  right  lung  sho-nang  the  direction  of  expansion.      (Keith.) 


Fig.   10. — Right   lung   from    the   side   showing   the    direction   of   expansion.      {Keith.) 

In  chronic  cases^  inequality  is  generally  due  to  local  adhesions  and  con- 
tractions of  the  subjacent  tissues.  Unequal  expansion  maj'  rarely  be 
due  to  rachitis,  hemiplegia,  and  muscular  atrophy.  Diminution  or  delay 
of  apical  expansion  can  be  best  detected  by  standing  behind  the  seated 
patient  and  looking  downward  over  his  shoulders. 

A  great  deal  regarding  pulmonary  function  can  be  learned  by   in- 



spection.     In  order  to  determine  local  inequalities  of  movement   over 
the  upper  lobes  Hoover  recommends  the  following  procedure. 

t  The  examiner  standing  on  the  right  of  the  recumbent  patient  places 
the  tip  of  the  ring  finger  of  the  left  hand  upon  the  second  rib  in  the  mid- 
clavicular Hne;  the  tip  of  the  middle  finger  on  the  third  rib  midway 
between  the  anterior  axillar}^  and  the  midclavicular  lines;  and  the  index 
finger  on  the  fourth  rib  in  the  anterior  axillary  line.  If  the  patient 
breathes  deeply  and  somewhat  rapidly,  normally  the  relative  degree  of 
motion  should  increase  progressively  from  the  first  to  the  third  rib. 
In  other  words  normal  expansion  is  undulatory.  If  there  is  diminished 
ventilation  the  three  ribs  will  move  in  unison. 

Inspiratory  narrowing  of  the  subcostal  angle  and  retraction  of  the  whole 
of  both  costal  borders  is  noted  as  an  evidence  of  sub-ventilation  in 
emphysema,  which  may  appear  in  association  with  an  aggravation  of 
symptoms  such  as  dyspnea  and  cyanosis,  and  increased   carbon  dioxid 

Fig.   11. — Vertical  section  of  the  right  lung  showing  the  direction  of  expansion.     (Keith.) 

concentration  in  the  alveolar  air,  although  percussion  may  fail  to  show 
any  change  in  the  position  of  the  pulmonary  margins.  Such  observations 
may  enable  us  to  differentiate  an  access  of  dyspnea  due  to  emphysema 
from  that  due  to  cardiac  weakness,  for  in  the  latter  instance  although 
we  may  find  subcostal  inspiratory  narrowing,  we  will  not  find  inspiratory 
retraction  of  the  whole  costal  margin  (Hoover). 

Unilateral  variations  may  also  aid  us  diagnostically.  Thus  with 
left  ventricular  hypertrophy  the  median  portion  of  the  left  costal  margin 
will  be  retracted  or  move  less  in  an  outward  direction  during  inspiration 
than  the  corresponding  area  of  the  right  chest.  In  cases  of  mitral 
stenosis,  myocardial  disease,  and  enlargement  of  the  pericardial  sac 
there  will  be  sj^mmetrical  narrowing  or  constraint  of  the  subcostal 
angle  during  inspiration,  if  the  anterolateral  portion  of  the  diaphragm 
is  depressed  beyond  the  critical  point  by  the  enlarged  heart  or  peri- 



The  Vital  Capacity  of  the  Lungs. — The  amount  of  air  which  can  be  ex- 
pired after  a  forced  inspiration  varies  in  normal  individuals  with  sex  and 
height  as  well  as  with  muscular  development.  It  depends  largely  upon  the 
latter  factor  and  upon  proper  breathing.  It  can  therefore  be  increased, 
especially  in  youth,  by  training.  Low  values  mean  simply  poor  develop- 
ment and  improper  breathing,  and  are  of  practically  no  value  in  the 
diagnosis  of  pulmonary  lesions  such  as  tuberculosis.  In  heart  disease, 
however,  the  pulmonary  ''vital  capacity"  corresponds  more  or  less  to 
cardiac  efficiency.  The  degree  to  which  it  is  reduced  below  the  normal 
standard  corresponds  closely  to  the  tendency  to  dyspnea.  Thus  patients 
with  marked  decomposition  show  values  of  only  40  per  cent,  or  less  of 
the  normal,  while  patients  with  well  compensated  lesions,  who  have  no 
greater  dyspnea  on  exertion  than  normal  persons  yield  values  of  about 
90  per  cent,  of  the  normal.^ 

The  Type  of  Breathing. — In  men  respiration  is  mainly  diaphragmatic, 
in  women,  costal. 

"By  study  of  the  living  thorax  in  health  and  disease  we  learn — That  the  dia- 
phragm is  the  great  means  of  inspiration :  That,  in  quiet  breathing,  the  chief  use  .of 
the  intercostal  muscles  is  to  maintain  the  position  of  the  ribs  (or  the  expansion  of  the 
chest)  during  the  descent  of  the  diaphragm :  That,  when  the  descent  of  the  diaphragm 
is  hindered,  or  when  inspiration  becomes  more  laboured  than  natural,  the  intercostals 
contract  more  strongly,  so  as  to  dilate  the  chest  by  raising  the  ribs:  That,  when  in- 
spiration becomes  as  forcible  as  possible,  other  muscles,  which  act  by  raising  the  collar 
bones  and  first  ribs,  come  into  play,  namely,  the  sternomastoids,  scaleni,  omohyoids, 
and  upper  part  of  the  trapezii:  That  quiet  expiration  is  due  to  the  cessation  of  all 
muscular  contraction :  That  forced  expiration  is  performed  by  means  of  the  abdom- 
inal muscles  (especially  the  recti),  the  latissimi  dorsi,  and  lower  part  of  the  trapezii. 
Add  these  corollaries :  That  the  diaphragm  and  intercostals  are  antagonist,  although 
they  concur  to  produce  one  and  the  same  result:  That  forced  inspiration  tells  upon 
the  upper  chest  and  true  ribs :  That  forced  expiration  tells  upon  the  lower  chest  and 
false  ribs"  (Gee). 

"Whether  respiration  be  mainly  costal  or  mainly  abdominal  depends 
on  the  relative  part  taken  in  the  act  by  the  ribs  and  the  diaphragm." 
The  better  developed  the  abdominal  muscles  are,  the  more  easily  can  the 
diaphragm  elevate  the  ribs,  and  the  more  "thoracive"  the  type  of  respi- 
ration. It  also  depends  on  "the  order  in  which  different  parts  of  the 
body  wall  come  into  action.  If  the  w.ave  begins  in  the  abdomen  and 
passes  upward,  the  type  is  abdominal;  if  it  begins  above  and  passes 
down,  the  type  is  costal"  (Hutchison). 

The  types  of  breathing  are  often  modified  by  disease;  thus  the  pain  of 
an  acute  pleuritis  diminishes  expansion  especially  on  the  affected  side. 
Peritoneal  pain  diminishes  downward  movement  of  the  diaphragm  and 
prodjices  relatively  more  costal  breathing. 

^  The  vital  capacity  of  the  lungs  is  measured  by  means  of  the  spirometer.  Normal 
values  are:  Men;  Height  159.5-173.5  cm.,  4000  c.c;  from  173.5-182.5  cm.,  4800  c.c; 
182.5  and  above,  5.100  c.c.  Women:  Height  from  154.5-162  cm.,  2825  cc;  from 
162-167  cm.,  3050  c.c. ;  167  and  above,  3275  c.c.  (McClure,  C.  W.  &  Peabody,  F.  W. : 
Relation  of  Vital  Capacity  of  Lungs  to  Clinical  Condition  of  Patients  with  Heart 
isease.      J.  A.  M.  A.,  Dec.  8,  1917,  Ixix,  1954.) 



The  Rate  of  Respiration. — ^The  rate  of  respiration  in  adult  man  is 
from  16  to  20  per  minute.  In  healthy  adults  breathing  is  rhythmic  as 
long  as  they  are  unconscious  of  it.  In  infants,  in  whom  the  function  is 
imperfectly  established,  it  is  often  irregular.  To  insure  accuracy  the 
patient  should  never  know  that  we  are  observing  the  manner  and  the 
rate  of  his  breathing.  The  respiration  and  the  pulse  normally  bear  the 
relation  of  about  1  to  4. 

Fig.   12. — Radiogram  showing  tlie  position  of  the  diaphragm  during  expiration  and  in- 
spiration.    Note  the  effect  upon  the  position  and  shape  of  the  heart. 

A  constantly  increased  rate  of  resipiration  generally  indicates  disease 
of  the  heart  or  lungs,  but  disease  of  the  peritoneum  and  hysteria  may  also 
cause  rapidity.  A  decreased  respiratory  rate  occurs  in  sleep  (25  per  cent, 
slower),  in  obstruction  to  the  air  passages  and  in  opium  poisoning. 

Normal  Ratio  between  Age,   Pulse,  Inspiration  and  Temperature 

Birth  to  2 

2  to  5 

5  to  9 

9  to  12 

years      ] 





Pulse  rate.. 








T.  98° 




0  /  Respiratory 






1  Pulse 








0  /  Respiratory 

50     , 





\  Pulse 

149     1 





The  Subcostal  Angle. — By  this  is  meant  the  angle  at  which  the  ribs 
meet  at  the  ensiform  cartilage.  It  is  important  in  classifying  the  type 
of  chest  with  which  we  have  to  deal.  It  is  narrow  or  acute  in  the  long, 
flat  chest;  and  broad  or  obtuse  in  the  cylindrical  or  barrel-shaped  thorax 
(Fig.  13,  also  p.  2G). 

Local  Bulging  or  Pulsation. — Local  prominence  of  the  chest  is  often 
due  to  rachitis  in  childhood  and  to  spinal  curvature.     The  precordium 



(that  part  of  the  chest  which  overhes  the  heart)  is  often  normally  promi- 
nent, although  much  greater  degrees  of  bulging  are  seen  when  the  heart 
is  hypertrophied  (Fig.  15,  217),  especially  in  children.  The  most  im- 
portant pathologic  prominence  is  that  seen  at  the  base  of  the  heart  in 
aneurism  of  the  aorta  (Fig.  16).  Occasionally  disease  of  the  ribs  and 
empyema  cause  local  swelling.  In  emaciated  subjects  pulsation  of  the 
subclavian  arteries  may  be  visible.  Rhythmicity  practically  indicates 
that  a  pulsation  is  directly  connected  with  the  circulatory  apparatus. 
Pulsating  empyemata  are  very  rare. 

Fig.   13. — Illustrating  the  angle  of  the  ribs  in  the  barrel-shaped  and  in  the  long,  flat  chest. 

{Fowler  and  Godlee.) 

Prominence  of  the  Clavicles, — This  depends  largely  upon  the  shape 
of  the  chest.  It  is  marked  in  thoraces  conforming  to  the  "long,  flat" 
type  and  hence  is  common  in  enteroptotic  individuals.  It  is  often  seen 
in  tuberculosis  of  the  pulmonary  apices,  and  when  unilateral,  may  be 
regarded  as  an  index  of  the  degree  to  which  the  subjacent  tissues  have 
sunken  in  or  have  been  retracted  (Fig.  30). 

The  Diaphragmatic  Shadow. — {Phrenic  wave,  Litten's  phenomenon) 
(Fig.  18). — If  a  moderately  thin  person,  lying  on  a  bed  with  the  chest  ex- 
posed and  with  the  feet  pointing  directly  toward  the  window,  takes  slow, 
deep,  "abdominal"  inspirations,  a  shadow  will  be  seen  to  move  down  the 
lateral  aspect  of  the  chest  wall,  between  the  sixth  and  the  ninth  ribs. 
This  shadow  is  caused  by  the  fact  that  during  inspiration  the  diaphragm 
"peels  off"  from  the  inner  chest  wall  and  by  means  of  the  negative  pres- 
sure thus  produced,  causes  the  soft  tissues  to  fall  inward.  These  altera- 
tions of  pressure  correspond  with  in-  and  expiration  and  create  the  im- 
pression of  a  shadow  moving  down  the  chest  wall.  By  the  mobility  of 
the  shadow  and  by  the  extent  of  its  excursion,  we  are  enabled  to  deter- 
mine the  degree  of  diaphragmatic  motion  and  its  equality  on  the  two 
sides  of  the  body  (Fig.  18). 

Local  adhesions,  a  pneumonia,  or  a  pleural  effusion  would  diminish 
or  inhibit   the  shadow.     A  subdiaphragmatic   abscess    would,    on    the 



J'^.^  -JiM 

Fig.  14. — Bulging  of  the  left  lower  chest,  which  pulsated  synchronously  with  the  heart 
even  after  aspiration  of  the  pleura,  due  to  an  aneurism  of  the  left  ventricle.  The  dotted 
area  represents  approximately  the  degree  of  pulsating  excursion.  (Patient  of  Dr.  J.  N^ 

Fig.  15. — Bulging  of  the  precordium  due  to  an  hypertrophied  heart  (mitral  obstruction) 
in  a  boy  of  14  years.  Note  the  poor  nutrition  and  underdevelopment  often  caused  by 
cardiac  lesions  in  childhood 



Fig.   16. — Deformity  of  the  chest  due  to  thoracic  aneurism. 

Fig.  17. — Deformity  of  the  chest  resulting  from  kypho-scoiiosis.     Abnormal)physical; .signs 
must'ibe  construed  with  great  caution  in  these  cases.     (See^Figs.  26,^83,  84.) '-  °  *   ■ 



Fig.  18. — Diaphragm  phenomenon  (Litten's  sign),  from  a  patient  with  fibroid  phthisis 
of  left  lung  (New  York  City  Hospital).  The  linear  shadow  has  been  emphasized  in  the 
reproduction  of  the  photographs. 

1.  Full  Expiration. — Note  the  height  of  the  shadow  and  the  slight  concavity  of  the 
abdomen  corresponding  to  the  respiratory  phase. 

2.  Medium  Inspiration. — Note  the  descent  of  the  linear  shadow  and  the  slight  change  of 
contour  of  abdomen  corresponding  to  the  respiratory  phase. 

3.  Deep  Inspiration. — Note  the  further  descent  of  the  linear  shadow  and  the  rigid 
abdomen  corresponding  to  the  respiratory  phase. 

Although  the  artist  has  intensified  the  shadow  in  the  reproduction,  the  excursion  of  the 
right  lung  and  right  side  of  the  diaphragm  were  so  pronounced  in  this  patient  that  the  dis- 
tance between  the  shadows  in  the  extreme  positions  of  respiration  was  greater  than  has  been 
represented.  The  patient's  left  lung  was  practically  useless;  hence  the  abnormal  extent  of 
the  right  lung's  excursion.     (Sahli  and  Potter.) 



other  hand,  have  per  se  no  effect  on  the  excursion.  The  shadow  is  seen 
with  difficulty  in  (1)  obese  subjects,  (2)  if  there  is  more  than  one 
source  of  hght,  (3)  if  costal  breathing  is  practised.  The  extent  of 
the  normal  excursion  ranges  between  2}4  and  33^^  inches,  depending 
upon  the  depth  of  respiration.  The  observer  may  stand  between  window 
and  patient,  or  may  have  the  patient  between  himself  and  the  window. 
The  patient  should  be  told  to  ''breathe  with  his  belly." 

Diaphragmatic  mobility  can,  of  course,  be  much  more  accurately 
determined  by  means  of  the  fluoroscope  but  in  the  absence  of  such  an 
apparatus  the  shadow  test  may  be  of  considerable  diagnostic  utility. 
Unilateral  immobility  or  diminished  diaphragmatic  excursion  generally 
results  from  pleurisy.  Among  83  cases  studied  by  Pryor  53  showed  com- 
plete immobihty,  and  17[^some  restriction  of  motion,  in  patients  who  had 
previously  had  pleural  effusions. 


As  a  result  of  disease,  the  shape  of  the  chest  often  becomes  altered 
from  the  average  normal  type.  There  are,  of  course,  also  congenital 
tendencies  which  have  their  influence,  but  practically  the  shape  of  the 
chest  is  due  to  postnatal  influences.     Freund  and  others  maintain  that 

Fig.  19. — Transverse 
section  of  an  infant's  chest. 
Its  shape  is  cylindrical. 

Fig.  20. 

-An    adult's  chest,  elliptical   in 

thoracic  development  is  absolutely  determined  as  regards  its  ultimate 
form  by  the  rapidity  of  growth  and  time  of  calcification  of  the  first  rib. 

The  length  of  the  normal  first  rib : 

Male  Female 

According  to  Freund  is 3.8  cm.  3 . 1     cm. 

According  to  Hart  is 3.6  cm.  3 .  02  cm. 

In  flat-chested  (phthisical)  individuals  it  measures  from  3  down  to  2.2  cm.  This 
makes  the  upper  chest  much  narrower  and  since  the  rib  is  also  more  sloping,  makes  the 
whole  antero-posterior  thoracic  diameter  small.  The  first  costo-sternal  articulation 
is  frequently  ossified.  In  thoraces  having  this  conformation  the  pulmonary  apices 
are  more  slender  and  respiratively  less  mobile.  It  is  to  these  factors  that  the  pre- 
disposition to  tuberculosis  is  supposed  to  be  in  part  due. 

Pathologic  deformities  of  the  chest  may  be  classified  among  the  fol- 
lowing types : 

I.  The  Rachitic  Chest. — The  rickety  (rachitic)  chest  (due  to  unduly  soft 
bones  during  its  development)  is  typically  characterized  by  (1)  beading 



Fig.   21.— The    rachitic 

Fig.  22. — The  funnel-breasted  chest. 
(Compare  Fig.  30.) 

Fig.  23.— The  flat  chest. 

Fig.    24. — Unilateral    retraction  of    the 
chest  due  to  pulmonary  fibrosis. 

Fig.  25. — The'^emphysematous  chest. 
(Compare  Fig.  33.) 

Fig.  26. — The  chest  in  scoliosis. 
(Compare  Fig.  17.) 



of  the  costo-chondral  junctions  (rachitic  rosary),  (2)  a  transverse  fur- 
row corresponding  to  the  attachment  of  the  diaphragm  (Harrison's 
groove),  (3)  prominence  of  the  sternum  (pigeon  breast),  (4)  a  longitudinal 
groove  parallel  to  the  sternum  extending  to  the  costal  margin. 

During  infancy  respiration  is  mainly  abdominal,  because  the  thorax 
is^already  cylindrical  and  admits  of  but  httle  further  outward  expansion. 
The  negative  intrathoracic  pressure  occasioned  by  the  descent  of  the 
diaphragm  exerts  its  effects  mainly  on  the  lower  rilDS.  The  atmospheric 
pressure  causes  the  most  j-ielding  portion  of  the  thorax  to  cave  in  (costo- 
chondral   articulations)   and  thus   a   depressed  groove,   parallel  to  the 

Fig.  27. 

->sorinal  chest  with  excellent  conformation  and  muscular  development. 
pigmented  area  above  the  left  nipple  is  the  result  of  a  recent  blister. 


sternum  is  formed.  Such  deformities  maj^  result  from  normal  breathing, 
but  are  much  enhanced  in  case  of  inspirator}'  dj^spnea.  Forced  inspira- 
tion, which  overexpands  the  upper  chest,  causes  a  forward  protrusion  of 
the  sternum  which  results  in  ''pigeon  breast"  (Fig.  29).  This  may  be 
unequal  in  degree  on  the  two  sides  as  the  result  of  scoliosis.  The  chest 
is  usually  shortened,  and  the  costal  angle  acute.  OccasionaUy  there 
may  be  a  depression  of  the  sternum  extending  from  the  middle  of  the 
gladiolus  to  the  ensiform  cartilage  (funnel  breast,  trichter  briist,  pectus 
excavatum),  (Figs.  28  and  30).  Although  this  deformity  is  usually  con- 
genital, it  maj'  be   occupational  (schuster  brust,   cobbler's  breast)    due 



Fig.  28. — A  rachitic  deformity  of  the 
chest  which  produced  a  very  pronounced 

Fig.  29. — Pigeon  breast  in  a  cretinoid 
dwarf,  aged  23  years. 

Fig.  30. — Funnel  breast  due  to  rachitis,  Fig.  31. — Long,  flat  chest  with  marked 

in  a  patient  who  ultimately  developed  pul-  retraction    and    emaciation,  in    a   case  of 

monary  tuberculosis.      {Patient  of  Dr.  Ward  chronic   pulmonary   tuberculosis.      (Cour- 

Brinton.)      (Compare  Fig.  32.)  tesy  of  Dr.  Frescoln.) 



to  external  pressure  from  tools  of  trade.     A  transverse  section  of  a  pigeon 
breast  is  triangular  in  form  (Fig.  21). 

n.  The  Long  Flat  Chest. — The  flat  (phthisinoid,  paralytic)  chest  is 
commonly  met  with  in  pulmonary  tuberculosis,  and  while  apparent!}^ 
predisposing  to,  is  often  the  result  of,  this  disease.  It  is  a  chest  of  dimin- 
ished capacity  and  functionation.  The  thorax  is  elongated;  the  normal 
elhptical  shape  is  flattened  (antero-posterior  diameter  relatively  de- 
creased), the  subcostal  angle  is  acute,  and  the  obliquity  of  the  ribs 
increased.  In  association  we  often  see  faulty  posture  (stoop  shoulders, 
pot  bellies),  poor  expansion,  a  long  neck  with  a  prominent  larjmx  and 
the  head  carried  forward.     Increased  obliquity  of  the  ribs  makes  the 

Fig.  32. — Plaster  cast  of  a  long  flat,  and  a  normal  chest.      (Houseman.') 

scapulae  prominent  (winged)  and  in  such  cases  we  speak  of  the  "ptery- 
goid" or  '"alar"  chest,  especially  if  the  lateral  diameter  be  small.  The 
clavicles  are  prominent,  the  supra-  and  infraclavicular  fossae  exaggerated 
and  the  interspaces  wide.  Xot  infrequently  rachitic  deformities,  and 
especiaUj' unilateral  deformities  due  to  pulmonary  fibrosis  are  superadded 
(Figs.  30,  31,  and32j. 

III.  The  Barrel-shaped  Chest. — -In  the  emphysematous  (barrel- 
shaped)  chest  the  normal  elliptical  form  tends  to  become  cyhndrical  (the 
cylinder  has  a  greater  cubic  capacity).  The  ribs  are  elevated  and  everted 
(position  of  forced  inspiration) ;  as  a  result  of  this  the  costal  angle  en- 
larges, the  lower  ribs  flare  upward,  and  the  sternum  is  arched;  while 
Louis'  angle  becomes  prominent. 

These  changes  are  bilateral  and  result  from  enlarged  thoracic  con- 
tents— enlarged  lungs,  emphysema.  If  the  spine  is  also  involved  it 
becomes  bent  backward,  the  shoulders  are  thrown  forward  and  the  back 
is  rounded  (Figs.  8,  33,  34  and  35). 



Fio.  -V'i. — Barrel-shaped  chest,  a  case  of  long-standing  pulmonary  emphysema. 
(Compare  Fig.  25.) 

Fia.  34. — Emph3'sematous  chest  with  marked  kyphosis.     (Patient  of  Dr.  Ward  Brinton.) 


This  type  of  chest  is  the  result  of  prolonged  dyspnea — asthma, 
emphysema— owing  to  which  the  accessory  muscles  of  respiration  (sterno- 
mastoids,  serrati  postici  superiores,  serrati  antici  ma j ores,  trapezii, 
rhomboids,  levatores  scapulae,  and  the  pectoral  muscles)  hj-pertrophy. 
The  neck  becomes  thick  and  short,  the  thorax  being  drawn  upward. 
Inasmuch  as  the  expiratory  muscles  are  also  called  upon  for  increased 
effort  the  abdominal  muscles,  the  ciuadrati  lumbori.  and  serratus  anticus 
major  also  become  enlarged. 

Fig.  35. — Contrasted  Types.  The  young  man  on  the  left — a  case  of  advanced  pulmo- 
nary tuberculosis — has  a  long,  fiat  chest.  The  ribs  are  obliquely  placed,  the  antero-posterior 
diameter  is  decreased,  expansion  is  almost  nil.  The  neck  is  long,  the  larynx,  clavicles  and 
scapulae  prominent. 

The  old  man  on  the  right — a  case  of  pulmonary  emphysema — has  a  barrel  shaped  chest. 
The  ribs  are  horizontal,  the  spine  is  arched,  the  antero-posterior  diameter  is  increased,  the 
neck  is  short,  the  accessorj-  muscles  of  respiration  are  hjiDertrophied,  the  jugular  veins  are 

In  some  cases  only  the  upper  part  of  the  chest  is  involved.  The 
emphysematous  chest  is  in  varying  degree  a  normal  senile  change,  it 
is  also  seen  in  individuals  whose  occupations  require  habitual  stooping, 
especially  if  associated  with  great  respiratory  demands — -laborers,  sawyers. 
The  most  typical  examples  occur  in  sufferers  from  emphj'sema  especially 
if  associated  with  asthma.  The  supraclavicular  fossae  are  full  and  may 
actually  bulge  during  expiration  (see  Figs.  13,  25,  32,  33). 


Mixed  Deformities. — ■Various  combinations  of  the  foregoing  types 
may  sometimes  exist. 

There  may  also  be  unilateral  enlargement,  depression  or  Inilging. 
Such  changes  are  usually  due  to  spinal  abnormalities,  or  to  pleural  and 
pulmonaiy  fibrosis. 

Fig.   36. — Chest  deformity  resulting  frnm  k\iili<)-scoliosis.      (See  p.  9-3.) 
(Compare  Figs.  17,  2U,  o4.) 


Dyspnea.- — This  term  is  applied  to  various  types  of  "shortness  of 
breath."  It  generally  means  rapid,  labored  respiration  but  is  also  applied 
to  the  slow  difficult  breathing  which  occurs  when  the  larynx  or  the  trachea 
is  obstructed.  Dyspnea  may  occur  in  isolation,  during  either  phase  of 
respiration,  inspiration  or  expiration,  but  usually  both  acts  are  affected. 
It  is  due  to  either  (1)  lack  of  oxygen,  or  (2)  excess  of  carbon  dioxid  in  the 
blood.  As  a  general  rule  the  rate  and  the  depth  of  respiration  bear  an 
inverse  ratio  toward  each  other. 

Recent  investigations^  have  shown  that  increased  Hydrogen  ion  con- 
centration of  the  blood  (excess  of  CO-)  increases  the  depth  of  respiration, 
without  essentially  altering  its  rate,  whereas  anoxemia  (Oxygen  defi- 
ciency) produces  first,  a  peculiar  periodicity  of  the  respiratory  rhythm; 
and  secondly,  if  anoxemia  becomes  still  more  marked,  very  rapid  and 
shallow  breathing. 

Inspiratory  dyspnea  without  obstruction  simply  causes  increased 
thoracic  movement;  with  obstruction  it  causes  an  over  expansion  of  the 
upper,  and  a  recession  of  the  lower  chest.  This  in  rachitic  children 
produces  marked  deformities. 

iHaldane,  Meakins  and  Priestley:  J.  Physiol.,  1919,  lii,  420. 



Expiratory  dyspnea  occurs  in  asthma,  emphj^sema  and  edema  of  the 
glottis.  Expiration  is  prolonged  and  laborious,  the  accessory  expiratory 
muscles  are  called  into  activity. 

Orthopnea  is  exaggerated  dyspnea,  in  which  the  patient  is  no  longer 
able  to  breathe  in  recumbency,  but  is  forced  to  sit  up  and  frequently  add 
the  additional  support  of  his  hands,  in  order  to  fix  the  muscles  of  the 
shoulder  girdle  and  thus  assist  the  accessory  muscles  of  respiration.  It 
is  characteristically  seen  when  the  lungs  are  congested  as  the  result 
of  tricuspid  insufficiency,  and  indicates  that  the  last  line  of  reserve  force 
has  been  called  into  action. 

Asthma  is  an  intermittent  form  of  dyspnea  in  which  expiration  is 
chiefly  affected.  The  latter  is  often  audible  at  a  distance  from  the  patient 
as  a  musical  wheezing  sound.  When  marked,  it  is  accompanied  by 
cj^anosis,  a  sense  of  thoracic  constriction  and  of  suffocation.     It  is  due 




Fig.  37. — An  example  of  the  adult  type  of  Cheyne-Stokes  hreathing,  showing  the  large 
number  of  respirations  in  each  period,  the  relativelj'  short  apneic  pause  and  the  high  levels 
reached  by  the  expiratory  up-strokes  in  the  abdominal  trace.  In  this  and  the  following 
tracings  the  upper  line  represents  the  thoracic  tracing,  the  middle  line,  the  abdominal 
tracing,  and  the  bottom  line,  the  time  in  seconds.  The  down  strokes  record  the  inspiratory 
movements.      {Conner  and  Stillman.) 

to  obstruction  of  the  bronchi,  either  spasmodic  or  edematous  in  nature, 
and  is  accompanied  by  the  expectoration  of  tenacious  glairy  mucus. 
Asthma  is  frequently  an  anaphylactic  manifestation. 

Non-expansive  Dyspnea. — In  this  type  of  breathing  the  chest  is  ele- 
vated but  does  not  expand.  It  occurs  if  the  lung  is  impermeable  to  air 
(pneumothorax),  or  if  the  thorax  is  already  distended  to  the  limit  of  its 
capacity  (large  pleural  effusions,  extreme  emphysema)  or  if  expansion 
is  prevented  by  dense  pleural  adhesions  (pulmonary  fibrosis). 

Restricted  or  "catchy"  respiration  may  occur  in  acute  pleuritis  or 
intercostal  neuritis  as  a  result  of  pain. 

Siridulous  hreathing  is  characterized  by  a  noisy,  high-pitched,  crowing 
or  whistling  expiration.  It  is  due  to  a  spasmodic  condition  of  the  vocal 
cords  which  occurs  in  children. 



Stertorous  breathing  may  be  heard  at  a  distance  from  the  patient. 
It  occurs  in  comatose  and  moribund  patients,  and  consists  of  rattUng, 
snoring  or  bubbling  sounds.  Its  genesis  is  akin  to  that  of  snoring,  since 
it  is  often  due  to  vibrations  set  up  by  the  soft  palate,  glottis,  tongue  or 
vocal  cords.  Not  infrequently,  however,  it  is  due  to  exudate  in  the 
trachea  or  large  bronchi,  which  is  thrown  into  vibration  by  the  act  of 
breathing,  as  for  instance  in  case  of  pulmonary  edema. 

The  death  rattle  is  a  combination  of  stertorous  breathing  combined 
with  the  rattling  caused  by  the  vibration  of  exudate  (serum,  pus,  blood) 
in  the  large  bronchi  and  the  trachea. 


Cheyne-Stokes  Respiration. — This  is  characterized  by  visible  irregu- 
larity of  breathing.  The  respirations,  shallow  at  first,  gradually  increase 
in  depth  and  rapidity,  to  be  followed  after  gradually  diminishing  excur- 
sions by  complete  apnea,  lasting  sometimes  nearly  30  seconds  (Fig.  37). 
It  occurs  in  the  coma  of  uremia,  apoplexy,  meningitis,  opium  poisoning, 
etc.  Blood-pressure  is  higher  during  the  hyperpneic  periods,  in  cases 
associated  with  increased  intracranial  tension.  Chejme-Stokes  respira- 
tion is  due  to  an  obtunded  sensibilit}^  of  the  meduall  to  CO2     Deep 

inm/1  iY — !, 

A'l  ./""^^^^  "^fyn'^W '^/"'^'l^''; 'i  I ! !  f 


Fig.  38. — Tracing  from  a  child  of  8  years,  showing  typical  Biot's  breathing.  Note  the 
pauses  which  occur  at  irregular  intervals  and  vary  in  length,  the  frequent  deep  sighs,  and 
the  constant  irregularity  of  the  respirations  in  force  and  rhythm.      (Conner  and  Stillman.) 

breathing  carries  off  the  excess  of  this  substance  and  the  respiratoiy  center 
remains  inactive  until  another  over-accumulation  of  this  gas  has  taken 
place.  Cheyne-Stokes  respiration  is  of  grave,  but  not  necessarily  fatal, 
import.  In  children,  if  associated  with  other  suggestive  symptoms,  it 
points  gravely  toward  a  meningitis. 

Biot's  Breathing. — This  type  of  breathing  differs  from  that  just 
described,  in  that  a  series  of  rapid  but  equally  deep  respiratory  movements 
is  followed  by  a  sudden  apnea.  There  is  no  gradual  increase  and  decrease 
in  the  depth  of  respirations  (Fig.  38).  It  may  be  regarded  as  almost 
pathognomonic  of  meningitis  {Conner  and  Stillman^). 

^  Conner  and  Stillman:  "A  Pneumographic  Study  of  Respiratory  Irregularities 
in  Meningitis."     Arch.  Int.  Med.,  ix,  1912,  203. 



By  palpation  we  refer  to  the  use  of  the  sense  of  touch  for  the  determina- 
tion of  the  physical  character  of  the  tissues.     It  is  employed: 

1.  To  ehcit  tenderness,  or  rigichty. 

2.  To  ascertain  the  position  and  character  of  the  cardiac  impulse, 
pulsations  or  thiills,  and  to  feel  the  pulse  (see  Chap.  XIII). 

3.  To  determine  the  character  of  the  skin  (temperature,  moisture, 
texture,  edema). 

4.  To  discover  local  swelling,  induration,  softening,  etc.,  of  the  tissues, 
especially  as  regards  the  lymph  nodes. 

Fig.  39. 

Fig.  40. 

Figs.  39. — Palpation  to  determine  expansion  and  vocal  fremitus. 
^  Fig.  40. — Palpation  to  determine  bilateral  equalitj"  of  chest  expansion.     (Bethea.) 

5.  To  estimate  the  degree  and  equahty  of  chest  expansion. 

6.  To  ehcit  vocal  fremitus. 

7.  To  determine  the  presence  of  hepatic  or  splenic  enlargement, 
pulsation  of  the  liver,  etc. 

Chest  Expansion. — The  bilateral  equahty  of  chest  expansion  can 
often  be  satisfactorily  determined  by  laying  the  hands  lightly  upon  the 
patient's  chest  during  the  act  of  respiration.  Some  examiners  prefer  this 
method  to  simple  inspection. 





"  The  nerves  supplying  the  skin  and  skeletal  muscles  have  become  so 
educated  that  any  injury  to  them  is  accurately  located.  Such  is  not 
the  case  with  nerves  of  the  internal  organs.  A  painful  irritation  of  the 
viscera  finds  expression,  not  necessarily  over  the  site  of  the  organ,  but 
in  a  painful  area  of  the  skin  often  remote  from  it.  Head  has  shown  that 
the  painful  stimulus  in  the  organ  travels  in  a  centripetal  direction  to  the 
posterior  part  of  the  cord  and  there  sets  up  excitation  of  the  nerves  which 
in  the  same  and  in  the  adjoining  segments  supply  the  peripheral  surfaces 
with  sensation.  The  pain  is  referred  to  the  skin  because  therein  the  pain 
sense  reaches  its  highest  development."' 

Fig.  41. — Referred  pleural  pain.  The  horizontal  lines  indicate  the  location  of  inter- 
costal nerve  pain;  the  dots  represent  phrenic  nerve  pain,  on  the  anterior  surface  of  the 

"  Referred  pain  from  the  viscera  has  these  characteristics  to  differen- 
tiate it  from  pain  of  peripheral  origin:  (1)  It  is  often  remote  from  the 
site  of  irritation.  (2)  It  follows  the  hnes  on  the  skin  of  the  spinal  seg- 
mentation rather  than  the  course  of  the  peripheral  nerves.  (3)  It  is 
usually  associated  with  cutaneous  hyperesthesia  and  tenderness  to  pres- 
sure. (4)  Often  the  pain  fails  to  involve  the  whole  segmental  area  of  the 
skin,  but  finds  expression  in  one  or  more  points  of  maximal  tenderness 
and  spontaneous  pain." 

Examples. — The  pain  of  biliary  colic  is  felt  at  the  angle  of  the  scapula, 
that  of  renal  colic  in  the  testicles,  while  heart  pain  is  referred  to  the  arm 
or  the  neck. 

Hyperesthesia  of  the  skin  is  determined  by  light  pressure  with  a  dull 
object  such  as  the  head  of  a  pin,  or  by  slight  pinching.     Muscular  rigidity 

1  Capps:  Arch.  Int.  Med.,  December,  1911. 



or  spasm  which  may  have  a  similar  genesis  is  elicited  by  estimating  the 
degree  of  muscular  tonus  b}^  means  of  our  sense  of  touch. 

Cutaneous  hyperalgesia  was  found  in  only  3  per  cent,  of  all  pulmonary 
cases  or  in  13  per  cent,  of  those  who  complained  of  pain.  In  diseases 
of  ihe  heart  and  aorta  the  hyperalgias  was  noted  in  7  per  cent,  of  the  cases 
and  in  18  per  cent,  of  those  who  complained  of  pain.^ 


The  parietal  pleura  and  outer  part  of  diaphragm  receive  their  nerve 
supply  from  the  lower  six  intercostal  nerves.     Lesions  in  this  region 

Fig.  42. 

Fig.  43. 

Figs.  42  and  43. — Referred  cardiac  pain.  Showing  the  area  of  pain  and  cutaneous 
hyperesthesia  requently  met  with  in  angina  pectoris.  The  segmental  distribution  (third 
cervical,  to  the  third  dorsal)  is  indicated  by  the  Roman  numerals.  Other  segments  may, 
however,  be  involved,  the  sixth  dorsal  causing  epigastric  pain,  and  the  upper  cervical  roots, 
pain  in  the  neck  and  back  of  the  head.  The  characteristic  sense  of  thoracic  constriction  has 
been  explained  as  resulting  from  reflex  stimulation  of  the  intercostal  muscles,  and  the  sense 
of  impending  dissolution  has  been  likened  to  the  violent  stimulation  of  the  nervous  system 
produced  by  excitation  or  injury  of  other  viscera,  as  by  a  blow  on  the  testicles  or  over  the 
solar  plexus.      {Mackenzie.) 

In  pulmonary  disease  cutaneous  hyperalgesia  occurred  in  3  per  cent,  of  the  460  cases  studied  by 
Langstroth  and  in  13  per  cent,  of  those  who  complained  of  pain.  In  disease  of  the  heart  and  aorta  the 
hyperalgesia  was  noted  in  7  per  cent.;  and  in  18  per  cent,  of  the  cases  having  pain.  As  a  diagnostic 
aid  the  occurrence  of  Head's  hyperalgesic  zones  is  generally  disappointing,  owing  to  the  large  number  of 
areas  over  which  disease  of  a  given  viscus  may  cause  sensory  changes. 

produce  pain  in  the  overlying  skin,  which  may  be  regarded  as  the  result 
of  a  peripheral  neuritis.  Cutaneous  hyperesthesia  is  absent.  Irritation 
of  the  diaphragm  posteriorh^  produces  pain  in  lower  chest,  abdomen  or 
lumbar  region.     This  is  a  referred  pain — bj^  way  of  the  seventh  to  the 

^Laxgstroth:  Arch.  Int.  Med.,  1915,  xvi,  No.  2. 



twelfth  dorsal  segments.  The  visceral  pleura  is  devoid  of  the  pain  sense. 
The  central  diaphragmatic  pleura  is  supi)lied  by  the  phrenic  nerve.  Irrita- 
tion of  this  region  produces  pain  and  tenderness  in  the  neck,  especially 
along  the  ridge  of  the  trapezius  muscle,  often  with  a  surrounding  zone 
of  hyperesthesia  (Fig.  41).  This  is  a  true  referred  pain — by  way  of  the 
third  and  fourth  spinal  segments.  The  pericardial  pleura  when  irritated 
may  produce  similar  pain,  because  its  nerve  supply  is  mainly  if  not  en- 
tirely phrenic  in  origin  (Capps). 

Pleural  pain  may  be  referred  to  the  abdominal  wall  and  lack  of  a 
careful  examination  of  the  lungs  has  led  to  unwarranted  celiotomies  in 
patients  who  a  day  or  two  later  have  developed  well-marked  signs 
of  the  pneumonia  which  was  the  cause  of  the  original  abdominal  pain 
and  rigidity.  Vice  versa,  although  less  frequently,  abdominal  lesions 
may  occasionally  produce  thoracic  pain. 


Fremitus  is  the  tactile  perception  of  vibrations,  wliich  may  be  pro- 
duced by  (1)  phonation  (vocal  fremitus),  (2)  coughing  (tussive  fremitus), 

Fig.  44. — Ulnar  palpation.  The  lower  pulmonary  border  can  be  accurately  determined 
by  laying  the  ulnar  surface  of  the  hand  and  little  finger  against  the  chest  wall  while  the 
patient  counts  one — one — one — .     (See  Fig.  50.) 

(3)  breathing  (rhoncal  fremitus)  produced  by  exudation  into  or  stenosis 
of,  the  air  passages. 

These  actions  set  up  vibrations  within  the  bronchi  and  lungs,  which 
under  favorable  conditions  are  accompanied  by  objectively  sensible 
vibrations  of  the  chest  wall,  which  can  be  felt  when  the  hand  is  laid 
upon  it,  as  a  faint  vibration  or  trembhng  of  its  surface.     The  sensation 



thus  obtained  has  been  hkened  to  that  derived  from  a  purring  cat,  but 
in  the  case  of  human  fremitus  the  vibrations  are  much  finer  and  more 

Vocal  fremitus,  which  only  is  of  practical  utility,  is  eHcited  by  laying 
the  ulnar  surface  of  the  hand  or  fingers  upon  the  chest  or  in  the  inter- 
costal spaces,  while  the  patient  slowly  repeats  the  numerals,  "  one — one 
— one,"  or,  "ninetj'-nine"  in'a  clear,  low  tone.     SA'^mmetric  areas  of  the 

Fig.  45. — Diagram  illustrating  the  similarity  in  mechanism  between  voice  production 
in  the  human  body,  and  sound  production  in  an  organ.  From  above  downward  the- 
angulated  lines  indicate  respectively:  A,  the  resonator;  B,  the  reed;  C,  the  wind  pipe; 
D,  the  bellows.     (After  Barth.) 

chest  are  then  compared  in  regard  to  the  intensity  of  the  vibrations- 
which  are  felt.  In  order  to  appreciate  the  mechanism  and  significance 
of  fremitus  we  must  revert  for  a  moment  to  that  of  voice  production. 

The  Mechanism  of  Voice  Production. — The  larjmx  is  a  reed  instru- 
ment, the  pitch  of  which  is  determined  by  the  length  and  tension  of  the 
vocal  cords.  When  these  are  approximated  and  air  is  forced  upward 
from  the  lungs  by  means  of  the  diaphragm  and  other  respiratory  muscles, 
the  cords  are  thrown  into  A*ibration  and  a  sound  is  generated.     The  sounds- 



thus  produced  by  the  vocal  cords  and  glottis  pass  upward  through  a 
variable  resonator — mouth  and  nares — and  are  there  modified  as  regards 
their  overtones  by  the  hps,  tongue,  etc.,  and  thus  the  vowel  sounds 
originate.  A  further  modification  of  the  overtones  by  means  of  the 
lips,  teeth,  tongue,  etc.,  results  in  the  consonants  of  articulate  speech. 
The  laryngeal  sounds  are  further  reinforced  by  means  of  a  large  resonator 
— the  thorax — which  under  favorable  conditions  vibrates  in  unison  with 
the  larynx  and,  therefore,  amplifies  the  sonorous  waves  and  intensifies 
the  sound,  as  does  a  sound  box  those  of  the  tuning  fork.     Vocal  fremitus 

Fig.   46. — Illustration:   from  Gerhardt,  showing  a  sensitive  flame  as  affected  by  vibra- 
tions of  different  variety  and  intensity. 

1.  Gas  flame.     The  flame  is  most  sensitive  just  below  the  flaring  point. 

2.  The  same  on  a  rotating  mirror. 

3.  4,  and  5.     The  flame  while  the  vowel  U  is  loudly  pronounced  at  3,  the  mouth;  4,  the  traclioa;  5,  on 
the  anterior  chest  wall. 

(With  right-sided  pleural  effusion  would  get  2  on  the  right,  and  o  on  the  left  side.) 

6.  Vibrations  over  a  femoral  aneurism. 

7.  The  tympanitic  tracheal  tone,  with  a  half-closed  glottis. 

8.  The  tympanitic  tracheal  tone,  with  open  glottis  (rhythmic  vibrations). 

9.  The  resonant  non-tympanitic  note  of  the  chest  wall  (unrhythmic  vibrations). 

is,  therefore,  not  an  accidental  vibration  of  the  thorax  but  is  a  rhythmic 
vibration  due  to,  and  in  unison  with,  the  vocal  cords.  In  order  to 
produce  vocal  fremitus  we  must,  therefore,  have: 

1.  Functionally  efficient  vocal  cords. 

2.  A  sufficiently  resonant  voice:  the  resonator  (thorax)  must  bear 
definite  suitable  proportions  to  those  of  the  vocal  cords.  The  existence 
of  such  a  favorable  relationship  in  men,  and  its  usual  absence  in  women, 
explains  the  greater  intensity  of  fremitus  in  the  former.     The  great  indi- 



vidual  variations  met  with  in  apparently  similar  types  of   individuals 
have  a  like  explanation. 

3.  Open,  patulous  bronchi. 

4.  Comparatively  free  transmission  of  vibrations  from  the  lung  to  the 
chest  wall;  e.g.,  the  interposition  of  liquid,  as  in  the  case  of  a  pleural 
effusion,  diminishes  or  obliterates  fremitus,  unless  the  underlying  lung  is 
solidified,  in  which  case  fremitus  remains  present. 

Fremitus  is  NormaUy  Intense. — (a)  On  the  right  side,  especially  over 
the  upper  lobe,  because  the  trachea  lies  in  immediate  contact  with  the 
apex  of  the  lung,  whereas  on  the  left  side  it  is  separated  by  a  distance  of 
3  cm.  owing  to  the  interposition  of  the  aorta,  internal  carotid  artery, 
esophagus,  lymphatic  and  areolar  tissue  (Figs.  49,  52,  75,  95). 

Fig.  47 

Fig.  48. 

Figs.  47  and  48. — Diagrams  drawn  from  radiograms  of  the  bronchi  filled  with  a  fusible 
alloy  showing  the  relation  of  the  bronchi  to  the  chest  wall.  The  right  bronchus  is  larger, 
and  a  more  direct  continuation  of  the  trachea — which  slopes  toward  the  right.  Contrary 
to  what  is  usually  taught  it  is  not  more,  but  less  horizontal  than  the  left.  The  right 
bronchus  gives  off  a  branch  before  it  enters  the  lung.  The  trachea  bifurcates  at  Louis' 
angle  slightly  to  the  right  of  the  mid-sternal  line.  At  this  point  vocal  fremitus  and 
resonance  are  intense  and  the  breath  sounds  harsh. 

(6)  Posteriorly  between  the  scapulce,  because  of  proximity  to  large 
bronchi  (Figs.  48,  91). 

(c)  In  the  second  right  intercostal  space,  owing  to  the  nearness  of  the 
bronchial  bifurcation  (Figs.  47,  95,  104). 

{d)  It  is  more  intense  in  the  interspaces  (finger  tips  or  ulnar  surface 
of  little  finger  used)  than  over  the  ribs. 

Fremitus  is  Pathologically  Increased. — (a)  Over  'pulmonary  consolida- 
tion, because  of  better  conduction  of  the  vibrations  from  the  bronchi 
(see  Chap.  III). 

(6)  In  cases  of  atelectasis,  because  the  bronchi  are  nearer  to  the  chest 

(c)  Over  pulmonary  cavities  (as  a  rule)  because  of  surrounding  con- 

Increased  fremitus  is  generally  associated  with  bronchial  breathing  and 
bronchophony.  Of  course,  in  a  given  case  there  may  be  factors  working 
at  variance  with   one  another  as  regards  the  production   of  bronchial 



breathing,  bronchophony  and  increased  fremitus.  While  these  three 
signs  are  of  the  same  diagnostic  importance  we  must  determine  each 

Fremitus  is  theoretically   always  diminished  or  absent  over  cavities. 
There  is  little  or   no  fremitus  over  the  trachea,  because  air  does  not 

transmit  vibratory  waves  appreciable  to  the  hand,  and  because  there  is 
no  reinforcement  by  a  resonator  as  in  case  of  the  thorax.  But  practi- 
cally we  find  fremitus  in  the  majority  of  cases  increased  over  cavities  on 
account  of  (1)  an  overlying  area  of  consolidated  lung,  (2)  transmission 
by  well-organized  fibroid  walls,  (3)  general  sense  of  increased  fremitus 

.  437  W.  59tH  Street. 




Fig.  5U.  Fig.  51. 

Figs.  50  and  51. — The  dots  indicate  the  areas  of  the  chest  over  which  vocal  fremitus  and 
vocal  resonance  are  normally  most  intense.  The  solid  lines  indicate  the  lower  margins  of 
the  areas  over  which  these  phenomena  are  obtainable  (lower  pulmonary  border).  The 
dotted  lines  indicate  the  lower  margin  during  forced  inspiration,  the  lungs  having  expanded 
downward,  filling  the  complemental  space.  Downward  movement  of  the  percussion  reso- 
nance from  the  solid  to  the  dotted  lines  during  inspiration  also  indicates  pulmonary 

Fig.  52. — Advanced  bilateral  pulmonary  tuberculosis.  Both  upper  lobes  contain 
cavities  of  variable,  but  for  the  most  part  small,  size,  surrounded  by  completely  infiltrated 
lung  tissue.  The  lower  lobes  of  the  lung  are  relatively  uninvolved.  Fremitus  was  much 
increased  over  the  upper  lobes  and  was  associated  with  bronchophony  and  percussion  dul- 
ness,  having,  especially  in  the  left  axilla  (large  cavity)  a  tympanitic  quality.  Clear-cut 
metallic  rales  were  heard,  as  well  as  whispered  pectoriloquy.  The  lower  lobes''yielded  an 
impaired  note  with  diffuse  crackling  rales.  Expansion  over  the  upper  chest  was  almost 



from  suiTouiuliiig  consolidated  lung,  in  other  words,  failure  to  localize 
the  fremitus  directly  over  the  cavity. 

Fremitus  is  Normally  Feeble. —  (a)  As  the  result  of  overlying  fat  or 
mammary  glands  (vibratory  reflection). 

(6)  In  women  and  children  because  the  chest,  the  resonator,  is  not  in 
as  favorable  a  relation  with  vocal  cords  as  in  men  and  because  the  voice 
being  higher  in  pitch  the  vibrations  are  more  rapid  and  hence  less 
readily  felt. 

Fremitus  is  Pathologically  Decreased. —  (a)  In  obstruction  of  a 
bronchus — asthma,  compression,  occlusion.  (In  these  cases  it  may 
return  after  coughing.) 

Fig.  53. — Palpation  furnishes  the  most  satisfactory  method  of  examining  the  liver. 
The  patient  lies  on  his  back  with  the  knees  slightly  flexed,  and  is  told  to  breathe  slowly  and 
deeply  with  the  mouth  open.  If  the  liver  is  enlarged,  or  displaced  downward,  its  margin 
can  be  felt  to  push  against  the  right  hand  during  the  descent  of  the  diaphragm.  The 
examination  is  rendered  more  satisfactory  if  the  examiner's  left  hand  presses  upward  on 
the  posterior  costal  margin.      Splenic  enlargement  may  be  determined  in  a  similar  manner. 

(6)  From  increased  reflection  or  diffusion  (pleural  thickening,  effusion, 
or  pneumothorax). 

(c)  Over  cavities,  not  surrounded  by  consolidation. 

(d)  In  cases  of  dysphonia — weakness  or  paralysis  of  the  vocal  cords. 
Exceptionally  fremitus  may  he  'present  over  pleural  effusions;  this  is 

due  to  the  factors  which  are  discussed  on  pages  61,  62. 

The  most  intense  fremitus  is  encountered  in  robust,  deep-chested 
men.  The  lower  the  pitch  of  the  voice,  the  slower  the  sound  vibrations 
and  the  greater  their  amplitude,  and  hence,  provided  the  thickness  of  the 


chest  wall  remains  constant,  the  more  marked  the  fremitus.  This  is 
especially  the  case  on  the  right  side,  for  the  reasons  already  mentioned. 

Tactile  vibrations  may  also  be  produced  by: 

(a)  Flowing  liquids — ^thrill. 

(6)  Movements  of  fluid — fluctuation,  succussion. 

(c)  Mechanical  friction — friction  fremitus,  pleural  or  pericardial 

The  costal  and  visceral  pleurae  during  respiration  glide  with  smooth, 
mirror-like  surfaces  over  each  other.  The  greatest  degree  of  excursion 
is  vertical  (3  cm.).  They  also  move  horizontally,  their  motion  being 
downward  and  forward  during  inspiration  (see  Figs.  9,  10,  11).  In 
health  no  palpable  thrill  or  audible  sound  is  produced.  But  the  pleural 
surfaces  roughened  by  disease  may  produce  palpable  vibrations  as  well 
as  sounds  (friction  fremitus  and  friction  sounds),  both  being  most  marked 
in  the  mid-  and  lower-axillary  regions. 


For  the  ready  comprehension  of  physical  diagnosis  a  superficial 
knowledge  of  acoustics  is  necessary.  The  phenomena  of  percussion, 
auscultation  and  to  a  considerable  extent  palpation,  cannot  otherwise 
be  grasped  or  properly  interpreted.  We  have  therefore,  been  led  to 
briefl}'  review  some  of  the  more  important  laws  of  sound.  Phj'sical  diag- 
nosis is  for  the  most  part  based  upon  a  foundation  of  acoustics.  Our 
interpretation  of  the  signs  elicited  from  both  healthy  and  diseased  tissues 
is  but  a  manifestation  of  the  fact  that  physical  alterations  of  the  tissues 
cause  corresponding  changes  in  the  vibrations  which  the}'  are  capable  of 
assuming  or  transmitting.  The  fact  that  all  the  phenomena  met  with 
cannot  as  yet  be  satisfactorily  explained  is  due  to  the  limitations  of  our 
knowledge  and  is  not  to  be  attributed  to  any  mj'sterious  manifestations. 
Acoustics  has  not  developed  into  such  a  loft}',  rich,  well-rounded  form  as 
has  her  sister  science.  Optics. 

Rhythmic  Vibrations.- — When  the  equilibrium  of  an  elastic  body  is 
momentarily  displaced,  it  vibrates  back  and  forth  until  its  equilibrium 
is  regained.  Thus  a  bass  viol  string  when  on  a  stretch,  if  plucked,  can  be 
seen  to  vibrate.  The  motion  imparted  to  a  localized  area  is  gradually 
transmitted  throughout  its  whole  length.  The  rate  of  the  vibration  is 
increased  as  the  string  is  rendered  more  taut,  until  separate  vibrations 
can  no  longer  be  seen.  At  the  rate  of  16  per  second  the  lowest  audi- 
ble tone  is  produced.^  For  the  human  ear  the  highest  perceptible 
note  corresponds  to  36,000  vibrations  per  second.  The  vibrations 
are  perceptible  to  touch  (vocal  fremitus)  as  well  as  hearing,  but  touch 
perceives  the  slow,  and  hearing  the  rapid,  vibrations  more  readily.  The 
musical  range  of  vibrations  lies  between  40  and  4000  per  second.  The 
greater  the  tension,  the  more  rapid  the  vibrations,  and  the  higher  the 
pitch.  When  an  elastic  tissue  (e.g.  violin  string),  vibrates  rh}i:hmically 
and  with  sufficient  rapidity  a  tone  is  produced. 

But  a  string  vibrates  both  as  a  whole,  and  simultaneously  in  its  ali- 
quot parts,  at  its  nodal  points,  each  of  which  represents  an  octave  of  the 
fundamental  note  (the  note  of  string  vibrating  as  a  whole).  These  par- 
tial vibrations  produce  additional  tones  which  are  known  as  overtones. 
Overtones  bear  a  simple  relation  to  the  fundamental  note:  2,  3,  4,  5,  7, 
etc.  The  first  six  overtones  are  harmonious,  above  this  they  are  generally 
not  so.  The  combination  of  the  fundamental  note  plus  the  overtones 
produces  what  is  known  as  klang  (timbre).  Klang,  then  (the  musical 
quality)  results  from  rhythmic  vibrations  such  as  occur  when  the  fundamen- 
tal note  vibrates  together  with  harmonious  overtones. 

^  Not  only  the  rate  and  amplitude  of  the  vibrations,  however,  determines  their 
audibility,  their  duration  is  perhaps  of  even  greater  importance.  Recent  investiga- 
tions (Gianfranceschi)  have  shown  that  vibrations  must  last  one-fortieth  of  a  second 
to  be  audible,  and  that  duration  is  a  much  more  constant  factor  in  perceptibility  than 




On  different,  though  accurately  attuned  instruments — ^flute,  violin, 
clarionet — the  same  fundamental  note  may  be  sounded,  yet  the  indi- 
viduality of  each  instrument  remains  distinct;  we  can  distinguish  one  from 
the  other.  Now  this  individual  difference — timbre,  klang,  quality — is 
dependent  upon  the  character  of  the  overtones.  The  individual  quality 
of  different  voices  is  dependent  upon  similar  factors. 

Unrhythmic  Vibrations. — Theoretically  if  a  string  could  be  struck  at 
a  minute  point,  by  a  hard  hammer,  in  0  time,  the  vibrations  would  tend 
to  remain  localized,  and  those  points  of  the  string  which  had  not  been 
directly  struck  would  begin  to  vibrate  slowly  and  unrhythmically.  As 
a  result  the  overtones  and  especially  the  higher  overtones — ^the  unhar- 
monious  ones — would  disproportionately  increase  in  strength  and  an 
unpleasant  metallic  note  result  (Helmholtz).  In  the  case  of  the  piano 
this  is  obviated  by  having  the  strings  struck  by  soft  broad  hammers, 

Fig.   54. — Diagrammatic  illustrations  of  a  vibrating  string.     First,  as  a  whole;  second,  with 
one  nodal  point;  third,  with  two  nodal  points;  fourth,  with  three  nodal  points. 

which  remain  in  contact  long  enough  to  ensure  a  continuous  vibration  of 
the  whole  string,  and  are  so  placed  as  to  dampen  the  unharmonious  over- 
tones by  eliminating  their  nodal  points.  If  in  any  sound-producing  body 
the  elastic  equilibrium  be  briefly  and  locally  disturbed,  unrhythmic 
vibrations  result.  Very  unrhythmic  vibrations  allow  the  distant  overtones 
to  preponderate,  and  a  metallic  quality  is  produced.  This  occurs  regard- 
less as  to  whether  we  are  practicing  auscultation  or  percussion,  and  regard- 
less as  to  whether  these  higher  overtones  are  heard  together  with  the 
fundamental  (amphoric  breathing)  or  separately.  All  the  metallic 
sound  phenomena,  of  auscultation  and  percussion  are  thus  produced 
(metallic  ring,  bell  tympany,  amphoric  breathing,  cracked-pot  sound) 
(see  Fig.  55). 

Vibrations  in  Tense  Membranes. — Tense  membranes  such  as  a 
kettle  drum  or  the  distended  stomach,  tend  to  vibrate  with  very  diverse 
and  variable  nodal  points,  and  hence  the  relationship  between  the  funda- 
mental note  and  the  overtones  is  a  very  variable  one.  This  may  be 
illustrated  by  throwing  stones  into  a  pool  of  water.  Each  stone  will 
produce  its  own  circle  (vibrations)  and  these  circles  will  mingle  and 
interweave  without  losing  the  original  identity. 

Sympathetic  Vibrations.- — Vibrations  may  be  set  up  in  neighboring 
tissues  not  only  by  the  direct  conduction  of  the  sound-producing  impact, 
but  also  by  what  is  known  as  sympathetic  vibration.  It  has  been 
stated  that  overtones  accompany  the  fundamental  note,  but  it  is  also 



true  that  if  an  overtone  be  produced  the  fundamental  note  which  corre- 
sponds to  it  will  begin  to  vibrate.  Thus  if  a  certain  note  on  a  piano  be 
struck  and  suddenly  damped,  certain  other  strings  can  be  heard  to  vibrate. 
If  iodide  of  nitrogen  be  painted  upon  the  "G"  string  of  a  bass  viol  and 
allowed  to  dry,  a  violent  detonation  will  occur  if  a  similarly  pitched 
string  of  another  instrument  in  the  neighborhood  is  set  in  vibration; 
while  vibrations  of  the  "E"  string  are  without  effect.  It  is  also  a  well- 
known  fact  that  the  vocal  or  instrumental  production  of  certain  musical 
notes  may,  to  the  chagrin  of  the  musician,  crack  glass  vases  on  the  nearby 
mantelpiece.  How  important  a  role  sympathetic  vibrations  play  in 
physical  diagnosis  cannot  be  stated,  but  that  they  have  some  bearing 
cannot  be  questioned. 




Rhythmic  vibrations 

Unrhythmic  vibrations 

Very  unrhj-thmic  vibrations 

f)f\(]  n  (\  i)  (](]  n  n  n  r 


Loud  sound 

(large  wave  amplitude) 

Feeble  sound 

(small  wave  amplitude) 



Low  pitch 
(slow  vibrations) 

High  pitch 
(rapid  vibrations) 

Fig.   55. — Diagram  illustrating  the  difference  in  the  sounds  produced  by  vibrations  of 

different  kinds. 

Interference  Waves. — When  two  waves  travel  through  a  vibrating 
string  in  opposite  directions,  they  tend  to  nullify  each  other  if  their 
nodal  points  be  similar.  This  phenomenon  has  been  used  to  explain 
some  phvsical  signs. 

Loaded  Strings. — If  a  piece  of  wa.x  be  attached  to  one  of  two  tuning 
forks,  or  to  musical  strings  of  a  similar  pitch,  the  vibrations  of  the  struc- 
ture thus  treated  become  slower  than  those  of  its  fellow  and  the  note 
which  it  gives  forth,  correspondingly  lower  in  pitch.  A  bottle  filled  with 
soapsuds  gives  forth  a  much  lower  note  when  percussed,  than  a  similar 
body  when  empty.     Here  the  suds  act  as  a  "load"  and  retard  the  vibra- 



tions.  In  lungs  under  normal  tension  the  pulmonary  septa  act  as  a  load, 
and  tend  to  localize  and  delay  the  vibrations.  The  relaxed  lung  in  which 
the  septa  are  no  longer  under  tension  yields  a  tympanitic  note  of  much 
higher  pitch  than  the  normal  organ,  and  vibrates  as  a  whole;  not  merely 
where  it  is  percussed,  as  does  the  normal  lung. 

7'-"  Ot^ERTONE 




.mg^^^m^emm^  ■3Kj>  overtone 




Fig.  56. — The  production  of  overtones.  Opposite  the  drawings  are  reproduced  (from 
actual  photographs  obtained  by  means  of  the  improved  Koenig  manometric  flame  appa- 
ratus) the  vibrations  of  the  fundamental  note  and  the  overtones.  {From  the  Scientific 

Resonators. — Sound  waves  are  transmitted  readily  from  solid  to 
solid  bodies,  as  from  a  tuning  fork  to  the  skull,  but  not  so  readily  from 
vibrating  bodies  to  the  air — a  violin  string  vibrating  between  the  fingers 
produces  little  sound.  To  increase  the  volume  of  sound,  therefore,  we 
resort  to  the  use  of  sound  boxes  or  resonators,  as  when  a  tuning  fork 
rests  on  a  table.  The  resonators  used  for  musical  instruments  readily 
assume  all  varieties  of  simple  and  compound  vibrations  which  are  im- 


parted  to  them,  that  is  they  vibrate  in  unison  with  the  source  of  the 
sound  (sympathetic  vibration)  and  thus  amphfy  the  waves.  Indeed, 
it  is  in  part  due  to  certain  vibratory  habits  which  they  have  acquired 
that  old  viohns  owe  their  mellow  richness  of  tone.' 

Resonators  are  also  used  to  analyze  sou7ids — to  resolve  a  complex 
sound  into  its  component  elements  to  a  degree  which  is  not  otherwise 
possible.  Such  resonators  are  hollow  bodies,  with  a  smooth  lining, 
stiff  walls  and  two  openings.  The  most  powerful  tj^pes  are  spherical 
in  shape,  but  many  forms  are  used,  as  in  case  of  the  viohn.  For  the 
purpose  of  analyzing  the  sounds  met  with  in  physical  diagnosis,  simple 
telescopic  tubes  2  meters  in  length  have  proved  sufficient.  Resonators 
are  characterized  by  the  fact  that  when  a  sound  is  produced  thej^  cause 
the  fundamental  note  to  predominate,  while  the  overtones  remain  weak 
and  unharmonic. 

The  large  end  of  the  resonator  is  brought  into  proximit}'  with  the 
sound  to  be  anah'zed,  the  small  end  is  connected  with  the  ear  by  means  of 
rubber  tubing.  By  varjang  the  length  of  the  tube  to  the  point  which 
produces  the  loudest  sound  for  a  given  note,  the  wave  length  of  that  note 
can  be  computed  and  its  position  in  the  musical  scale  established. 

In  the  human  body  the  thorax,  a  distended  stomach,  a  pneumo- 
thorax, etc.,  ma}^  act  as  resonators.  The  more  elastic  the  material  of 
which  the  resonator  is  composed,  the  longer  its  vibration.  Thus  a  bell 
sounds  longer  than  a  glass,  and  a  glass  longer  than  a  wooden  bowl. 
A  resonator  15  to  30  cm.  in  length  is  sufficient  to  amplify  the  sound  of 
pure  bronchial  breathing  (httle  "D"  to  "E"  on  the  musical  scale),  but 
for  normal  vesicular  breathing  a  length  of  from  1  to  2  meters  ("A"  to 
"F")  is  required.  The  latter  is,  therefore,  from  two  to  three  octaves 
lower  in  pitch  than  the  former. ^ 

While  inferior  to  the  resonator  in  point  of  accuracj^,  very  com- 
plex sounds  can  be  resolved  by  the  human  ear  into  their  component 
elements.  The  expert  leader  can  volitionally  single  out  the  notes  of 
any  individual  instrument  of  bois  orchestra,  and  it  is  the  unconscious 
analysis  of  sound — the  separation  of  the  fundamental  note  from  the 
overtones — which  enables  us  to  distinguish  individual  voices,  and  to 
recognize  tympan}^,  resonance,  metalhc  sounds,  etc.,  in  percussion  and 
auscultation.  With  percussion  of  equal  force,  the  high  notes  are  more 
acutely  perceived  b}'  the  human  ear,  than  the  low  ones,  which  are  apt 
to  be  overshadowed  by  their  overtones.  It  is  evident,  therefore,  that 
the  individual  who  is  the  possessor  of  a  good  musical  ear  will  much  more 
readily  acquire  efficiency  in  auscultation  and  percussion,  and  will  derive 
much  more  information  from  the  employment  of  these  methods,  than  he 
who  is  more  or  less  tone-deaf. 


The  qualities  of  sound  are  as  difficult  to  describe  as  are  colors  to 
the  blind,  hence  we  are  forced  to  use  similes  and  comparisons.  Sounds 
are  classified  according  to  their  component  quahties;  which  are  intensity, 
duration,  quality  and  pitch. 

1  Wooden  resonators,  especially  those  made  of  spruce  (which  is  made  up  of  very- 
long,  straight,  regular  fibers,  and  stretched  taut  like  a  string)  are  chosen  for  most 
musical  instruments,  since  their  vibrations  result  in  much  richer,  mellower  tones  than 
do  those  of  other  wood  or  metal. 

2  Mueller,  F.  :  Zeitschr.  f.  Aertzliche  Fortbildung,  ix,  1912,  No.  14. 


Intensity. — This  depends  upon  the  amphtude  of  the  sound  waves; 
not  only  on  the  force  of  the  blow,  but  also  on  the  number  of  air  columns 
set  in  vibration.  Hence  the  importance  of  percussion  of  equal  force 
(Fig.  55). 

Duration. — The  more  air  in  a  vibrating  column  the  longer  the  dura- 
tion of  the  sound.  The  "fullness"  and  the  "leerness"  of  Skoda,  terms 
which  are  still  occasionalh^  employed  in  German  hterature,  although 
compound  perceptions,  depend  mainly  upon  the  duration  of  the  vibra- 
tions. Resonant  and  tympajiitic  notes  are  long;  dull  and.  flat  notes  are 

Quality. — Bj-  this  term  we  mean  that  a  sound  either  is  or  is  not 
musical.  If  it  has  a  musical  quality,  we  say  that  the  sound  possesses 
timbre  or  klang,  attributes  which  depend  upon  the  number  and  quality 
of  the  overtones.  It  must,  of  course,  be  remembered  that  in  physical 
diagnosis  we  shall  find  no  pure  musical  notes,  but  only  varpng  degrees 
of  tone  dulling.  The  difference  between  resonance  and  tj^mpany,  be- 
tween a  wooden  bowl  and  a  glass,  is  due  to  the  fact  that  the  last  named 
in  each  instance  possesses  many  and  harmonious  overtones  (Fig.  56j. 

Pitch. — Pitch,  as  was  first  notabh'  emphasized  by  Austin  Fhnt,  is 
from  a  medical  standpoint  probably  the  most  im'portant  element  in  the 
analysis  of  sound.  It  depends  on  the  rate  of  the  vibrations — the  more 
rapid  the  rate,  the  higher  the  pitch.  The  longer  the  air  column  set  in 
motion,  the  slower  the  \'ibration  and  the  lower  the  pitch.  Long  organ 
pipes  or  long  instrumental  strings  of  equal  caliber  give  forth  the  lowest 
sounds.  The  adult  chest  yields  a  lower  note  than  that  of  the  infant. 
Increase  in  pitch,  loss  of  resonance,  and  shortness  of  duration  go  hand 
in  hand,  (pulmonary''  consolidation).  Auenbrugger  wrote:  "  Ubi  sonus 
est  altior,  ibi  est  morbus."  Our  recognition  of  the  degree  of  pulmonary 
consolidation  depends  largely  upon  the  high-pitched  note  which  such 
tissue  yields  when  percussed. 

All  sounds  possess  the  qualities  of  intensity  (loudness)  and  duration, 
some  in  addition  the  qualities  of  pitch  and  tone  (klang). 

In  medical  parlance  we  speak  of  '"tones"  and  apply  the  term  to  more 
or  less  distinct  resonances,  but  it  must  be  remembered  that  none  of  them 
are  tones  as  defined  by  phj'sics,  nor  in  the  musical  sense.  In  the  latter 
a  tone  is  a  sound  of  definite  pitch  which  cannot  be  further  resolved  into 
simpler  sounds.  "No  pure  tone  can  have  timbre  (klang)."  Percussion 
sounds  are  always  more  or  less  muffled,  impure  and  dull.  In  a  strict 
sense  there  is  no  sharp  distinction  between  a  noise  and  a  tone.  Each 
can  be  resolved  by  the  ear  into  simpler  tones  (Fig.  55). 

Extremes  are  easily  recognized,  but  there  are  many  gradations  which  cannot  be 
definitely  analyzed.  Even  the  typical  tympany  of  an  air-distended  abdomen  is 
far  from  having  the  rhythmic  relations  between  the  fundamental  note  and  the  over- 
tones which  is  met  with  in  pure  musical  tones.  Again  tympanitic,  and  non-tym- 
panitic  notes  often  merge  so  gradualh'  into  each  other  that  an  absolute  differentiation 
is  impossible.  In  the  case  of  a  tympanitic  sound,  the  fundamental  note  is  readily 
appreciable — we  can  sing  it,  but  with  a  non-tympanitic  note  this  is  not  the  case. 
Practically  the  boundary  between  the  two  Ues  at  the  point  at  which  the  ear  fails  to 
distinguish  any  one  pitch,  on  account  of  the  interference  of  the  "overtones, "  and  this 
in  turn  is  largely  a  question  of  the  individual  ear. 

For  example,  if  we  strike  a  key  on  the  piano  a  tone  results,  but  if  we  strike  a ' 
number  of  adjacent  keys,  musical  notes  blend  to  form  a  noise.     Certain  of  the  modern 
"harmonics"  are  mere  noises  to  the  uneducated  ear.^ 

^  Geigel:  Deut.  Arch.  /.  1:1.  Med.,  vol.  Ixxxviii,  p.  598. 



The  act  of  speaking  or  breathing  produces  sounds  in  the  upper  respira- 
tory tract — larynx,  vocal  cords,  glottis,  mouth,  nares — which  are  con- 
ducted downward  into  the  chest  mainly  bj-  the  air  columns  in  the  lumen 
of  the  bronchi.  The  moving  column  of  air  sets  the  pulmonary  tissues 
into  vibration,  and  vibrations  of  certain  kinds  produce  audible  sounds. 

These  sounds  are  conducted  through  the  overlying  tissues  to  the  ear 
of  the  examiner,  and  the  character  of  the  sound  we  hear  depends  upon 
the  character  of  the  tissues  in  their  effect  upon  the  following  acoustic 
factors:  (1)  diffusion,  (2)  absorption,  (3)  reflection,  (4)  resonance,  and 
perhaps  (5)  interference. 

The  Diffusion  of  Sound.^ — By  this  is  meant  a  loss  of  intensity  due  to 
conduction  over  a  wide  area — a  dilution  of  energy.  In  spreading  from  a 
sphere  of  a  given  size  to  one  double  its  size,  the  intensity  on  the  surface 
of  the  second  sphere,  the  vibratory  energy  per  unit  area,  will  be  halved. 
The  function  of  the  stethoscope  or  of  a  megaphone  is  to  diminish  diffu- 
sion (lateral  radiation).  Diffusioji  appears  to  he  the  most  important  factor 
in  reducing  the  intensity  of  sound  heard  over  the  chest  (Montgomery). 

The  Absorption  of  Sound. — By  this  term  we  refer  to  the  annihilation 
of  sound  as  such,  and  its  conversion  into  forms  of  energy  such  as  heat,  of 
which  the  ear  takes  no  cognizance.  It  plays  but  a  small  role  if  sounds 
travel  such  short  distances  as  is  the  case  in  the  chest.  Its  effects  are  sepa- 
rate and  distinct  from  those  of  diffusion. 

The  Reflection  of  Sound. — Sound  waves  may  be  reflected  backward 
toward  the  direction  from  which  they  come.  This  is  especially  apt  to 
occur  ivhen  vibrations  pass  through  tissues  of  different  densities,  as  for 
instance  when  air-borne  vibrations  pass  from  the  lumen  of  a  bronchus  to 
its  walls  or  from  the  alveoli  to  fluid  or  to  the  chest  wall.  The  degree  of 
loss  of  sound  depends  "upon  the  differences  in  density  and  elasticity  of 
the  two  media,  irrespective  of  whether  the  sound  is  passing  from  the 
heavier  to  the  lighter,  or  from  the  lighter  to  the  heavier  medium,  pro- 
vided the  sound  passes  from  one  medium  to  another  at  the  normal  inci- 
dence, and  provided  that  plane  surfaces  come  into  contact  or  separate 
two  media,  and  provided  that  the  two  media  are  homogeneous  and  infinite 
in  extent"   (MontgomerjO- 

Resonance. — By  resonance  we  mean  tone  reinforcement,  due  to  the 
fact  that  amplifying  vibrations  are  set  up  in  a  second  medium  so  that 
the  two  media  vibrate  in  unison  and  a  louder  sound  results. 

Although  playing  a  less  important  role  in  modifjdng  the  acoustic 
phenomena  in  the  chest  than  do  diffusion  and  reflection,  yet  resonance  at 
times  is  an  important  factor.  It  is  to  be  noted  that  whereas  diffusion, 
absorption  and  reflection  modify  all  sounds  in  like  degree  providing  that 
intensity  is  constant,  resonance  is  selective,  and  amplifies  sounds  of  differ- 
ent pitch  (vibratory  rate)  in  very  different  degree.     "Conditions  favor- 

FiG.  57. — Diagrammatic  representation  of  how  reflection  and  diffusion,  the  most  impor- 
tant factors  that  diminish  sounds  on  their  way  tlirough  the  chest,  may  operate  in  some 
pulmonary  and  pleural  conditions.  {After  Montgomery  and  Eckhardt,  "  Pulmonary 
Acoustic  Phenomena,"  10th  Report,  Henry  Phipps  Institute,  Phila.,  1915.) 

The  continuous  lines  indicate  surfaces  of  special  reflection;  the  broken  lines  indicate  the 
surfaces  of  no  special  reflection  except  those  common  to  all  the  conditions,  namely,  the  outer 
chest  surface  and  the  internal  bronchial  surface.  Fluid-tissue  junctions,  and  the  junctions 
between  relaxed  lungs  and  air,  are  not  specially  indicated,  because  the  changes  in  density  at 
these  junctions  are  not  specially  great. 



Fig.  --i. — Xorynal  lung.  Reflection  occurs 
at  lung-chest  junction,  at  junction  of  tense 
membranous  tissues  of  lung  with  air,  and  at 
surface  of  contact  between  bronchi  and  sur- 
rounding air  in  the  vesicles  (a  somewhat  ques- 
tionable factor).  Diffusion  much  as  in  Fig.  B. 
Vocal  fremitus  and  resonance  normal.  Breath 
sounds  "vesicular." 

Fig.  D. — Pleural  effusion.  Lung 
air-bearing,  but  membranous  tissue 
relaxed.  Special  reflection  at  lung- 
fluid  junction,  and,  to  some  extent,  at 
surface  of  contact  between  bronchi 
and  surrounding  intravesicular  air. 
Special  diffusion  between  lung  and 
chest  wall.  Vocal  fremitus  and  reso- 
nance diminished.  Breath  sounds 
feeble  or  absent. 


^i Trachea 

I.  1 


Fig.  B. — Solid  lung.  No  special  reflection 
after  the  sounds  enter  the  bronchial  walls. 
Diffusion  an  important  factor,  but  no  special 
diffusion  present  that  is  absent  in  other  condi- 
tions. Vocal  fremitus  and  resonance  increased. 
More  sound  retained  within  the  bronchi  than 
normalh".     Bronchial  breathing. 

Fig.  E. — P neumothorax .  Lung 
solid.  Special  reflection  at  air-chest- 
wall  junction  and  lung-air  junction. 
Special  diffusion  between  lung  and  chest 
wall.  Vocal  fremitus,  resonance  and 
breath  sounds  diminished  or  absent. 


/    /FLUID 

\     /.'"—-.  . 
L-"! ^ 


Fig.  C. — Pleural  effusion.  Lung  solid.  No 
special  reflection.  Special  diffusion  between 
lung  and  chest  wall.  Vocal  fremitus  and  re- 
sonance may  be  increased. 

Fig.  F. — P  neumothorax.  Lung 
air-bearing.  Special  reflection  at  air- 
chest-wall  junction,  and,  to  some  extent, 
at  outer  bronchial  surface.  Special 
diffusion  between  lung  and  chest  wall. 
Vocal  fremitus,  resona^ice  and  breath 
sounds  diminished. 


able  to  the  lesonance  of  sounds  of  one  pitch  may  actually  diminish  sounds 
of  another  pitch.  In  addition  sounds  from  different  sources  maj^  come 
together,  and  thus  sounds  will  be  superimposed  upon  one  another,  and  a 
condition  known  as  interference  may  result,"  causing  blurring  of  sound. 
As  an  example  of  this  we  have  the  fact  that  vocal  resonance  may  be 
diminished,  and  yet  the  whispered  voice  sounds  present,  over  a  pleural 

The  importance  of  resonance  or  vibratory  amplification  in  regard  to 
vocal  fremitus  has  been  considered  in  the  preceding  chapter. 

"Normal  Lung. — The  diminution  of  sounds  on  their  way  through  the 
normal  chest  is  due  chiefly  to  the  factors  of  diffusion  and  reflection.  The 
latter  acts  particularly:  (1)  As  the  sound  within  the  air  in  the  bronchi 
comes  into  contact  with  the  bronchial  walls,  especially  of  the  larger 
bronchi;  (2)  as  the  sound  passes  from  bronchial  wall  to  the  air  in  the 
surrounding  vesicles;  (3)  as  the  sound  comes  into  contact  with  the  tense 
pulmonary  membranes;  and  (4),  as  the  sound  passes  from  the  air  in  the 
lung  to  the  chest  wall  (Fig.  57,  A). 

"Consolidation.- — ^Apart  from  the  marked  loss  in  intensity  of  the 
sounds  as  they  pass  from  within  the  bronchi  to  the  bronchial  walls,  the 
chief  loss  of  sound  in  consolidation  as  it  passes  to  the  periphery  of  the 
chest  is  due  to  diffusion.  It  is  not  due  to  absorption.  One  can  readily 
see  whv  the  solid  lung  ordinarily  gives  louder  sounds  than  the  normal 
lung  (Fig.  57,  B). 

"Pleural  Effusion. — In  cases  with  diminished  or  absent  vocal  reso- 
nance the  chief  source  of  sound  loss  after  the  vibrations  have  entered  the 
fluid  is  due  to  diffusion,  and  not  to  absorption  or  reflection.  Diminution 
of  sound  is  impeded,  and  there  7nay  be  an  actual  increase  in  vocal  reso- 
nance when  the  lung,  instead  of  being  collapsed  and  air-bearing,  is  actually 
solid,  because  there  is  comparatively  little  sound  lost  at  the  lung-fluid 
junction  when  the  lung  is  solid,  just  the  reverse  of  what  occurs  when  the 
lung  contains  air  (Figs.  57,  C  and  D). 

"Pneumothorax. — The  conditions  here  are  roughly  parallel  to  those 
encountered  in  pleural  effusion,  provided  the  lung  is  air-bearing  and  is 
equidistant  from  the  chest  wall  in  each  case,  except  that  with  pneumo- 
thorax a  marked  loss  in  sound  intensity,  instead  of  occurring  at  the  lung- 
fluid  junction,  is  met  with  at  the  air-chest-wall  junction.  If- the  lung 
in  the  case  of  pneumothorax  is  solid,  a  very  serious  loss  in  sound  intensity 
will  take  place  at  the  lung-air  junction.  If  an  open  fistula  between  a 
bronchus  and  the  pleural  cavity  exists,  the  vocal  resonance  will  be 
increased"  (Montgomery)  (Figs.  57,  E  and  F). 

The  inspiratory  vesicular  sound  arises  within  the  lungs  at  the  'point  at 
which  the  air  passes  from  the  smallest  bronchioles  into  the  alveoli.  It  is 
ordinarily  independent  of  the  sounds  arising  in  the  upper  respiratory  tract. 

The  expiratory  vesicular  sound  arises  partl}^  if  not  entirely  in  the 
upper  respiratory  tract  (nares,  mouth,  glottis,  larynx)  (Fig.  56,  96). 

The  sounds  which  we  hear  in  bronchial  breathing  arise  mainlj'"  in  the 
upper  tract.  The  solidified  lung,  though  causing  no  new  sounds  may 
modify  those  already  produced  above.  The  same  facts  apph--  to  caver- 
nous and  amphoric  breathing;  the  cavities  which  yield  them  modify  an 
already  existent  sound  by  acting  as  resonators.  New  sound  production 
due  to  the  air  entering  or  leaving  an  excavation  is  generally  if  not  always 
a  negligible  factor. 


The  preceding  facts  explain  why  the  physical  signs  over  what  appear 
clinically  to  be  identical  conditions  at  times  vary  diametrically.  Thus 
some  cases  of  'pleural  effusion  yield  diminished,  or  absent,  fremitus,  vocal 
resonance,  breath  sounds  and  whispered  sounds,  while  in  other  clinically 
identical  cases  these  signs  may  not  only  be  present  but  at  times  actually 
increased.  These  discrepancies  are  mainly  due  to  the  fact  that  in  the 
former  instance  the  lung  is  air-bearing — merely  relaxed,  while  in'' the 
latter  the  lung  is  sohdified,  either  as  a  result  of  compression  or  consolida- 
tion. Analogous  variations  occurring  in  cases  of  pneumothorax  are  to 
be  explained  upon  the  same  basis. 

The  effects  of  these  differences  in  the  density  of  the  tissues  upon  sound 
reflection  and  diffusion  are  accountable  for  the  difference  in  the  findings. 


The  theoiy  of  percussion  is  based  upon  the  fact  that  when  elastic 
matter  which  is  capable  of  adequate  vibration  is  struck,  a  sound  will  be 
produced.  Thus  by  striking  a  blow  on  the  chest  wall  a  sound  is  generated 
which  varies  with  the  character  of  the  tissues  within  the  thorax.  Per- 
cussion although  practised  from  early  Grecian  times  for  the  differentia- 
tion of  ascites  from  tympanites,  was  not  used  for  thoracic  diagnosis  until 
1755.  Leopold  Auenbrugger  (b.  Gratz,  1722)  was,  when  about  thirty 
years  of  age,  put  in  charge  of  a  Spanish  Military  Hospital  in  Vienna,  and 
while  doing  his  duties  there,  invented  the  art  of  percussion." 

The  principles  of  Auenbrugger's  discovery  are  mainly  two:  first, 
that  percussion  sounds  are  simply  vianife stations  of  acoustic  phenomena 
which  should  he  expressed  in  corresponding  terms;  second,  that  the  varia- 
tions of  sounds  are  due  to  a  physical  variation  of  the  tissues. 

In  1826  Piorry,  in  Paris,  erroneously  tried  to  establish  the  identity 
of  sounds  as  specific  of  certain  tissues,  e.g.,  a  pulmonal,  cardial,  osteal, 
or  intestinal  note.  The  subject  was  put  upon  a  permanently  fixed  basis 
by  Skoda  of  Vienna,  who  in  1839  wrote:  "  We  must  first  determine  every 
possible  variety  of  percussion  sound  and  ascertain  the  conditions  on  which 
each  variety  depends;  and  then  endeavor  to  reconcile  our  observations 
with  the  well-ascertained  laws  of  sound." 


If  we  percuss  the  chest  a  sound  will  be  produced,  the  character  of 
which  will  depend  upon  the  amount  of  air,  fluid  and  elasticity  in  the 
lung.  The  sounds  which  are  thus  elicited  are  arbitrarily  classified 
according  to  their  acoustic  properties  as:  (1)  tympany,  (2)  hyper- 
resonance,  (3)  resonance,  (4)  dulness,  (5)  flatness. 

No  sharp  line  of  distinction  can  be  drawn  between  these  sounds. 
They  merge  gradually  into  each  other.  What  for  instance  one  examiner 
might  consider  tympany,  another  of  equal  experience  might  declare  to 
be  hyperresonance.  As  a  general  rule,  however,  distinctions  suffi- 
ciently accurate  for  clinical  purposes,  which  will  be  concurred  in  by  other 
reasonably  skilled  examiners,  can  readily  be  established. 

Tympany. — Tympany  is  a  musical  note  in  which,  although  rich  in 
overtones,  the  fundamental  note  can  be  more  or  less  clearly  recognized. 
We  can  sing  a  note  to  correspond  with  its  pitch.  Its  name  is  derived 
from  the  tympanum — kettle  drum.     It  occurs: 

1  Students  and  practitioners  of  medicine  who  are  interested  in  physical  diagnosis 
should  read  the  translation  of  Auenbrugger's  and  Laennec's  articles,  which  are 
readily  available  in  Camac's  "Epoch-making  Contributions  to  Medicine,  Surgery 
and  the  Allied  Sciences,"  Philadelphia,  1909;  as  well  as  Flint's  "  Auscultation  and  Per- 
cussion," a  recent  edition  of  which  has  been  revised  by  H.  C.  Thatcher,  M.  D. 



(.4)  When  air  in  closed  chambers  vibrates  in  unison  with  an  elastic 
membrane  (in  an  air-filled  stomach  or  intestine). 

(B)  When  air  columns  vibrate  in  smooth-walled  chambers  which 
communicate  with  the  atmosphere  (open  pneumothorax). 

(C)  In  relaxed  lung  tissue  (when  the  lungs  are  removed  from  the 
body,  or  when  their  tension  is  relaxed  by  a  pleural  effusion,  or  by  upward 
displacement  of  the  diaphragm).  The  lung  under  these  conditions 
vibrates  as  a  whole,  not  merely  locally,  the  percussion  stroke  produces 
rhythmic  vibrations.  A  non-tympanitic  (normal)  lung  becomes  tympanitic 
when  the  internal  air  tension  is  relaxed. 

Percussion  of  a  stale  loaf  of  bread  yields  tympany;  of  a  fresh  loaf, 
resonance.  An  air-inflated  bladder  under  moderate  tension  yields  a 
long  tympanitic  sound;  a  tensely  inflated  bladder  gives  forth  a  shorter, 
higher  pitched,  more  metalUc,  less  tympanitic  note. 

"The  tympanitic  character  of  the  note  in  the  first  instance  {A)  is  due  to  the  fact 
that  the  comparatively  relaxed  and  yielding  wall  permits  a  sufficiently  long  duration 
of  the  contact  between  the  wall  and  the  percussing  instrument,  for  the  movement  to 
be  transmitted  to  the  whole  bladder,  so  that  it  vibrates  primarily  as  a  whole,  as  does  a 
string  struck  with  a  cushioned  hammer.  If,  on  the  contrary,  the  bladder  be  markedly 
distended,  contact  is  so  short  as  to  give  rise  to  a  circumscribed  undulation  of  the 
surface,  before  the  movement  has  reached  the  more  distant  parts  of  the  bladder.  In 
this  case  so  many  diif erent  portions  of  the  bladder  vibrate  independently  that  a  vast 
number  of  overtones  are  produced  and  the  sound  is  a  mere  noise"  (Sahli)  (Fig.  58). 

Lungs  removed  from  the  body  yield  a  tympanitic  note,  because  they  have  lost  their 
tonicity  and  diminished  their  bxilk.  Pulmonary  tone  is  mainly  due  to  stretched  elastic 
tissue,  also  in  part  to  activity  of  the  bronchial  muscular  fibers.^  Relaxation  or  loss  of 
tone  allows  the  lung  to  vibrate  as  a  whole.  It  is  not  the  air  that  vibrates  as  a  whole, 
because  ligation  of  the  trachea  under  these  conditions  does  not  alter  the  pitch,  nor  yet 
the  elastic  tissue  as  a  whole,  for  this  is  relaxed  and  does  not  vibrate  at  all.  _ 

If  we  reinflate  the  lung  removed  from  the  body  it  becomes  non-tympanitic  (relaxa- 
tion has  given  place  to  tension)  unless  the  lung  be  emphysematous  and  have  lost  its 
elasticity.  This  is  because  with  tension  present,  unrhythmic  vibrations  are  more 
readily  produced,  which  permit  the  overtones  to  predominate  and  render  the  funda- 
mental note  less  perceptible,  and  hence  the  pitch  is  less  recognizable. 

A  lung  section  held  free  in  ^he  air  gives  a  lower  note  than  when  laid  in  a  plate, 
because  the  weight  of  the  lung  of  itself  causes  an  increase  in  tension.  If  a  lung  be  cut 
in  longitudinal  sections  the  pitch  of  each  will  be  higher,  the  smaller  the  section.  If 
these  sections  are  again  laid  in  apposition  a  lower  pitch  will  result  than  the  note  of  any 
one.  The  rate  of  vibrations  in  each  section  is  roughly  approximate,  inversely,  to 
the  square  of  the  thickness  (Zamminer  and  Seitz). 

It  is  impossible  either  by  strong  or  light  percussion  to  alter  the  pitch  of  a  tym- 
panitic lung.  The  only  difference  is  that  of  loudness,  because  the  lung  under  these 
conditions  always  vibrates  as  a  whole.  We  must  not  imagine,  therefore,  that  by  light 
percussion  over  a  relaxed  lung,  as  in  pleural  effusion  we  are  eliciting  only  the  note  of  the 
superficial  lung  tissue. 

A  tympanitic  note  is  one  in  which  unrhythmic  vibrations  are  impossible.  It  is 
evident,  therefore,  that  accurate  topographic  percussion  (the  outlining  of  dull  areas) 
is  possible  only  in  the  absence  of  tympany.  This  explains  why  small  broncho-pneu- 
monic areas  or  tuberculous  consolidations  are  so  difficult  to  demonstrate  by  percussion 
in  emphysematous  subjects  in  whom  more  or  less  tympany  is  always  present.  For  a 
similar  reason  dull  areas  under  the  abdominal  wall,  etc.,  cannot  be  outlined  by 

Tympany  is  normally  heard  on  percussing  the  abdomen,  larynx  or 
trachea,  and  over  the  lower  anterior  and  lateral  margin  of  the  left  lung 
owing  to  the  proximity  of  stomach  and  intestines. 

Pathologically  tympany  is  heard : 

[1  West:  Trans.  Med.  Chir.  Soc,  1898,  p.  273. 


1.  In  consolidation  overh/ing  air  chambers  (bronchi,  cavities) — a 
dull,  high-pitched  tj-mpan}-  (Fig.  61). 

2.  Over  cavities  (air-containing  and  at  least  the  size  of  a  walnut)  as 
in  tuberculosis  or  bronchiectasis:  also  often  over  a  pneumothorax 
(Fig.  236). 

3.  Over  relaxed  lung  tissue:  in  the  neighborhood  of  pulmonarj'  infil- 
trations, and  above  pleural  or  near  pericardial  exudates  (Skodaic  tympany) 
(see  Fig.  107,  339).  Occasionally  also  in  incomplete  pulmonaiy  consoli- 
dation— air  and  fluid,  e.g.,  edema  of  lungs. 

4.  Over  areas  of  subcutaneous  emyhysema.  In  such  cases  if  this  con- 
dition overlies  the  lungs,  no  satisfactory  percussion  or  auscultation  data 
regarding  the  state  of  the  lungs  can  be  obtained. 

Fig.  58. — Diagram  to  illustrate  the  difference  in  effect  of  large  and  small  pleximeters,  as 
well  as  of  tense  and  of  flaccid  membranes. 
In  A  the  membrane  Ls  stiff  and  tense,  the  pleximeter  small,  the  percussion  stroke  staccato        The 
vibrations  tend  to  remain  localized  and  are  very  unrhythmic.  hence  metallic  sounds  are  produced. 

In  B  the  membrane  is  6accil,  the  pleximeter  broad  and  the  percussion  blow  of  average  duration. 
The  vibrations  w.hich  result  are  widespread,  as  well  as  rhythmic,  and  hence  the  sound  is  musical  (tym- 

The  pitch  of  t\'mpany  varies,  but  as  a  genei'al  rule,  it  is  higher  than 
that  of  resonance.  Percussion  of  the  stomgch,  for  instance,  produces 
very  rhythmic,  regularly  recurrent  vibrations  at  a  rate  of  320  to  450 
per  second.  The  note  is,  therefore,  much  higher  than  that  of  the  lung — 
108  to  54  per  second  (F.  Mueller).  In  either  case  the  pitch  depends 
largely  upon  the  size  and  tension  of  the  organs  in  question. 

Resonance  is  a  long,  clear,  low-pitched  non-tympa7iitic  sound.  It  is 
due  to  amplification  of  the  sound  waves,  reinforcement  of  tone  (see 
Resonators).  The  percussed  lung  yields  the  fundamental  note  and  the 
thorax  acts  as  the  resonator.  When  the  two  vibrate  in  unison  resonance 
is  produced,  mere  reflection  of  the  waves  is  insufficient.  The  tissues 
must  possess  more  or  less  rh3'thmic  vibrations  with  the  reflected  waves 
in  order  to  produce  resonance.  Pulmonary  resonance  is  best  elicited  in 
normal  lungs  in  the  left  infraclavicular  region  and  at  the  angles  of  the 
scapulae.  It  has  been  likened  to  the  sound  of  a  drum  covered  by  a 
blanket  (Auenbrugger),  and  to  the  upper  crust  of  a  loaf  of  fresh  bread 

Resonance  j'ields  both  a  longer  and  a  louder  note  than  dulness:  R.  0.42,  D.  0.28 
second.  (Resonance  is  not  due  to  vibrations  in  the  bronchi;  these  structures  may  be 
filled  with  gelatin  and  yet  resonance  persists.  Not  so  the  alveoli.)  The  note  over  a 
normally  distended  healthy  lungnn  the  regions  in  which  it  is  neither  unduly  encroached 
upon  by  organs,  or  overlaid  by  tissues,  is  resonance.  This  can  be  more  or  less  fixed  in 
the  mind  by  frequent  e.xaminations  of  normal  chests,  with  the  reservation,  however, 


that  there  is  no  absolute  normal  standard,  but  merely  relatively  normal  variations. 
In  disease  the  sound  side  if  such  there  be,  must  always  be  compared  with  the  side 
which  is  diseased. 

Selling  has  proved  by  means  of  resonators  that  the  pulmonary  note  is  a  very  com- 
plex one,  made  up  of  many  overtones  of  which  the  lower  ones  predominate.  The  range 
of  pitch  of  normal  resonance  is  from  low  F  to  high  C.  In  healthy  adults  it  goes  down 
to  about  low  A;  in  children  to  middle  F,  in  emphysema  to  low  F.  A  dull  note  on  the 
contrary  is  higher  in  pitch  since  the  deeper  tones  are  subdued  through  the  decreasing 
vibratability  of  the  lung. 

The  upper  range  of  the  pulmonary  percussion  note  represents  the  pleximeter,  the 
lower  range  is  the  lungs'  own  note.  The  latter  varies  with  the  amount  of  air  and 
elasticity.  The  fact  that  the  note  between  the  large  right  and  smaller  left  lung  is  not 
more  noticeable,  is  probably  due  to  the  fact  that  when  the  note  is  low,  a  considerable 
difference  in  volume  must  occur  before  an  appreciable  change  of  the  whole  note  is 
produced.  When  infiltration  of  lung  tissue  becomes  complete  we  -practically  hear  only  the 
note  of  the  pleximeter  ( finger) . 

In  the  lungs  the  pulmonary  septa  modify  the  sound  by  limiting- 
localizing — the  sound  waves;  not,  however,  by  acting  at  nodal  points 
— ^they  are  too  closely  spaced — but  by  acting  as  a  "load"  on  a  vibrating 
string  (see  p.  56).  If  the  lung  is  under  normal  tension,  the  vibrations 
remain  localized  in  the  area  percussed.  If  it  is  relaxed,  both  lung  and 
its  contained  air  vibrate  as  a  whole  and  tympany  results. 

Resonance  occurs  only  over  the  lungs  (elastic  air-containing  organs). 
The  larger  the  quantity  of  air,  the  more  resonant  the  note,  especially  if 
its  deep  diameter  lies  in  the  vertical  plane  of  the  percussion  stroke. 

Hyperresonance. — By  this  term  we  understand  a  sound  which 
acoustically  lies  between  resonance  and  tympany,  having  some  of  the 
qualities  of  each  but  failing  to  be  identical  with  either.  It  may  be 
produced  by  percussing  the  normal  chest  during  forced,  deep,  held 
inspiration  (increased  tension,  and  increased  air),  but  is  most  character- 
istically heard  in  cases  of  pulmonary  emphysema  (increased  air  and 
diminished  tension).  The  same  concept  may  be  expressed  by  "resonance 
with  a  tympanitic  quality." 

Dulness. — A  dull  note  is  a  short,  high-pitched,  non-musical  sound. 
Percussion  resonance  disappears  over  the  lung,  and  dulness  takes  its 
place  as  the  result  of  the  following  physical  conditions:  (1)  Absence  of 
tone-producing  material  (consolidation  of  pneumonia,  tuberculosis, 
infarction,  atelectasis).  (2)  Poor  tone  conduction.  (3)  Poor  conduc- 
tion of  the  percussion  stroke  (exudation  between  the  lung  and  the  plexi- 
meter-— ^pleural  thickening,  effusions,  edema  of  the  skin).  Dulness  is 
"the  sound  of  both  fluids  and  solids,  that  of  the  airless  viscera — ^liver, 
heart,  spleen"  (Da  Costa). 

Pulmonary  dulness  (lack  of  resonance)  indicates  an  abnormally  large 
proportion  of  solids  or  liquids  in  proportion  to  the  amount  of  air  in  the 
pulmonary  vesicles.  With  the  appearance  of  dulness  there  is  always 
an  increase  in  the  elevation  of  the  pitch,  and  an  increased  sense  of  resistance. 
Acoustically,  dulness  is  a  condition  in  which  the  fundamental  note 
preponderates,  and  but  few  overtones  are  heard. 

A  hand  placed  on  a  vibrating  glass  deadens  the  overtones.  Its  musical  quahty 
disappears,  we  hear  only  the  fundamental  note.  Air-containing  organs  such  as  the 
intestines  are  more  elastic,  vibrate  more  readily  and  more  complexly,  furnish  more 
overtones  which  produce  a  clearer,  louder,  longer,  higher  pitched,  more  intense  and 
more  musical  sound  (tympany).  Solid  organs  on  the  other  hand — hver,  spleen, 
thigh — yield  but  few  overtones,  hence  the  sound  is  shorter,  weaker  and  more  mufHed. 
Percussion  of  normal  lung  produces  a  larger  wave  amplitude — louder  sound — than 
that  of  airless  structures. 



The  dull  note  obtained  by  percussing  pulmonary  consolidation  is 
characterized  by  the  predominance  of  high-pitched  sounds,  those  of 
lower  pitch  being  weak  or  inaudible,  and  since  high-pitched  sounds 
fade  out  more  rapidly  than  do  low-pitched  ones,  the  sound  is  not  only 
high-pitched  but  also  short,  and  does  not  carry  far.  The  metallic, 
crackling  rales  heard  in  the  neighborhood  of  pulmonary  consolidation  are 
even  higher  in  pitch  than  the  bronchial  breathing  which  accompanies 
them  (F.  ^lueller).     The  normal  lung,  under  normal  tension  (inflation), 

Fig.  5!'. — S-howmg  difierent  degrees  ot  pi  rcu--'--^ion  rlulncss  in  a  case  of  pnhtionary  tuber- 
culosis. The  left  upper  lobe  contains  several  ca\-ities  filled  with  blood  clot  and  surrounded 
by  consolidated  lung,  j-ields  a  verj-  dull  note.  The  right  upper  lobe  is  diffusely  infiltrated, 
jnelds  moderate  dulness.  The  left  lower  lobe  is  slightly  infiltrated  and  yields  an  "impaired  " 
note.      The  right  lower  lobe  is  relatively  free  fronz  disease  and  yields  a  resonant  note. 

yields  on  percussion,  a  long,  low-pitched,  resonant,  non-musical  note. 
The  pleximeter  finger  recognizes  distinct  elasticity  (normal  resistance). 
The  breath  sounds,  except  near  the  large  bronchi  or  the  trachea,  are 
"  vesicular" — soft,  breezy  and  low  in  pitch.  Expiration  is  much  shorter 
than  inspiration.  Over  the  lower  lobes  the  percussion  note  is  longer  and 
lower-pitched  than  over  the  upper  lobes  because  of  (1)  the  greater  mass 
of  lung  tissue  thrown  into  vibration;  and  (2)  thinner  overlying  tissues. 
The  liver  on  the  right  and  the  stomach  on  the  left  tend  to  add  respec- 
tively a  dull,  and  a  tympanitic,  quality  to  the  lower  pulmonary  margin. 


Impaired  resonance  or  impairment  is  a  term  sometimes  used  to  indi- 
cate slight  dulness.  It  is  somewhat  shorter,  high-pitched  and  less 
intense  than  resonance  and  is  produced  by  the  same  causes,  in  lesser 
degree,  which  produce  dulness — slight  pulmonary  infiltration,  etc. 

Flatness  is  a  term  which  is  applied  to  extreme  or  absolute  dulness. 
The  note  of  the  thigh  or  of  a  fluid — pleural  effusion — is  flat.  Some 
physicians  prefer  to  use  the  expressions  slight,  marked  and  absolute 
dulness,  to  those  just  discussed.  Efforts  have  been  made  to  numerically 
classify  or  standardize  different  degrees  of  dulness  as  dulness  number 
1,  2,  3,  4. 

Thus  some  examiners  classify  lack  of  resonance  as  1-  2-  3-  4-line  dulness,  using 
these  terms  to  indicate  respectively  impaired  resonance,  dulness,  marked  dulness 
and  flatness.  This  method  of  recording  has  not  been  satisfactory,  owing  to  lack  of 
standardization.  The  3-line  dulness  of  one  examiner  might  be  called  2-  or  4-line  dul- 
ness by  another.  It  has  been  suggested^  that  since  these  different  degrees  of  dulness 
represent  varying  degrees  of  pitch,  they  might  be  standardized  according  to  a  musical 
scale,  i.e.: 

1.  Normal  resonance  =  F  or  F  sharp  below  middle  C. 

2.  1-Une  dulness  =  A    below    middle    C    to    the    latter. 

3.  2-line  dulness  =  E  flat  to  F  above  a  middle  C. 

4.  3-Une  dulness  =  B  flat  to  intermediate  C. 

5.  4-hne  dulness  =  E-F  above  intermediate  C. 

While  such  standardization  would  be  most  desirable,  we  cannot  but  question 
tis  feasibility  especially  among  "non-musical"  examiners.  , 


The  tympanitic  or  musical  sound  already  described  sometimes  under- 
goes certain  modifications  which  give  it  distinct  and  separate  quahties, 
producing  what  are  known  as  (1)  metallic  ring;  (2)  hell  tympany;  (3) 
cracked  pot  sound.  We  have  already  learned  that  if  vibrations  are  im- 
parted to  an  air-containing  cavity  by  a  steady  stroke  applied  to  a  large 
surface,  rhythmic  vibrations  will  be  set  up  throughout  the  structure. 
If,  on  the  other  hand,  a  quick,  sudden,  locahzed  blow  be  struck,  the 
vibrations  will  tend  to  remain  localized,  will  be  unrhythmic  and  will 
produce  a  harsh,  metallic,  unpleasant  sound.  This  may  be  illustrated 
b}^  striking  a  piano  string  with  a  knife  blade. 

The  conditions  necessary  for  the  production  of  markedly  unrhythmic 
vibrations,  and  hence  metallic  sounds  (a  sudden  localized  blow,  and  a 
quick  rebound)  are  most  nearly  fulfilled  in  the  case  of  a  large,  tense, 
superficial  cavity.  Long  before  an  explanation  of  the  genesis  of  these 
sounds  was  forthcoming,  Wintrich  pointed  out  that  metallic  sounds  could 
be  more  easily  demonstrated  by  quick,  forcible  percussion,  and  when  a 
hard,  artificial  pleximeter  was  employed.  To  produce  metalhc  sounds 
we  must  have  a  stiff  walled  resonator  which  reflects  better  than  it  trans- 
mits. If  the  cavity  is  deeply  situated,  too  much  lateral  radiation  of  the 
vibrations  will  occur  before  the  cavity  is  reached,  and  vibrations  instead 
of  locally,  will  be  set  up  generally,  throughout  it,  producing  a  tympanitic 
note.  If  the  cavity  is  small,  the  fundamental  vibrations  will  be  very 
rapid,  and  the  overtones  still  more  so.  It  is  possible  that  a  smallcavity 
may  actually  yield  a  metallic  sound  which  we  merely  appreciate  as 

1  Wood,  N.  K.:  "Percussion  of  the  Lung."  Jour.  Amer.  Med.  Assn.,  Ixiii,  1914, 


tympan}'  because  the  unharmonious  overtones  are  above  our  auditory 
range  (36,000  per  second). 

Metallic  ring  is  a  term  which  is  applied  to  a  percussion  note  having 
a  metallic  quality.     It  may  be  heard: 

1.  Over  cavities  not  less  than  4  cm.  in  diameter,  with  smooth,  tense 
walls,  especiall}'  if  superficially  located  (Fig.  61). 

2.  Over  a  tense  pneumothorax  (Fig.  106). 

3.  Occasionally  over  intense  apical  infiltration.  In  this  case,  espe- 
ciallv  if  right-sided,  the  trachea  acts  as  the  "large  cavitv  with  tense 

4.  At  times  over  a  greatly  distended  stomach. 

Metallic  ring  is  best  heard  with  staccato  percussion  and  if  stetho- 
scopic  auscultation  be  simultaneously  practised. 

Metallic  ring  occurs  onh'  over  fairh'  large  cavities  because: 

1.  Small  cavities  vibrate  too  readil}^  as  a  whole,  and  because  their 
overtones  are  too  rapid — high-pitched — to  be  perceptible. 

2.  ^Metallic  ring  is  often  associated  with  a  short,  high-pitched  note 
which  is  closely  allied  to  flatness. 

Examples:  Percussion  of  a  thin  tumbler  yields  tympany.  Percus- 
sion of  a  thick  bottle  yields  metallic  ring.  The  fundamental  note  grows 
deeper  as  the  size  of  the  bottle  is  increased  and  its  opening  diminished. 
The  metallic  quality  is  especially  noted  if  the  ear  be  held  near  to  the 
open  mouth  of  the  bottle  (or  of  the  patient,  in  case  of  a  patulous  cavity). 

Percussion  of  a  moderately  inflated  pig's  bladder,  the  cheeks,  or  the 
stomach  yields  tympanv;  with  extreme  inflation  the  note  becomes 

Bell  Tympany. — Bell  tympany  is  a  clear,  vibrant,  metallic  sound  which 
may  be  heard  by  ausculting  over  tense  pneumothoraces  while  percussion 
is  practised  on  the  opposite  side  of  the  lung,  using  silver  coins  as  plexor 
and  pleximeter.  A  clear-cut.  slighth'  echoing  sound  is  thus  produced 
which  has  been  likened  to  the  sound  of  a  gold  coin  dropped  upon  a 
marble  slab,  or  the  sound  of  a  distant  trolley  bell.  Acoustically  the 
sound  owes  its  character  to  the  fact  that  sustained  high-pitched  overtones 
vibrate  together  with  a  deep  fundamental  note,  and  fade  out  slowlj'. 
Coins  are  used  for  percussion  since  being  small,  hard  and  metallic  thej- 
tend  to  impart  unrhythmic  vibrations  to  the  tissues  beneath. 

Cracked-pot  Sound. — This  is  a  metallic  note,  followed  by  a  stenotic 
murmur,  caused  by  the  rapid  expulsion  of  air,  through  a  slit-like  opening, 
as  the  result  of  the  percussion  blow. 

"  Though  obviously  related  to  metallic  resonance,  the  nature  and 
causation  of  cracked-pot  sound  are  essentially  different.  The  expulsion 
of  air  through  a  narrow  opening  plays  a  part  in  causing  it.  Apparently 
the  edges  of  the  opening  are  set  in  vibration,  and  an  opportunity  is  thus 
given  for  the  production  of  high  overtones  by  interference"  (Sahli). 

Cracked-pot  sound  (bruit  de  pot  fele)  then  is  heard:  (1)  when  air  is 
forced  through  a  stenotic  opening  as  in  the  case  of  a  superficial  cavity 
communicating  with  a  bronchus  (vibrations  of  the  tissues  at  the  mouth  of 
the  cavity);  (2)  over  the  chest  of  a  crying  child  (glottic  vibrations);  (3) 
occasionally  over  relaxed  and  infiltrated  lung  tissue.  It  is  most  marked 
if  the  examiner's  ear  be  close  to  the  patient's  open  mouth  and  during 
expiration.  It  is  best  heard  over  a  superficial  cavity  near  the  pulmonary 
apex,  with  tense  but  resilient  walls  and  a  stenotic  outlet.     The  sound 


may  be  imitated  by  striking  the  loosely  clasped  hollowed  palms  of  the 
hands  together  against  the  knee,  or  by  suddenly  percussing  a  perforated 
rubber  ball.  All  metallic  sounds  are  best  elicited  if  forcible  staccato  per- 
cussion is  employed. 

Thus  we  find  that:  Rhythmic  vibrations  produce  tympanitic  sounds, 
Unrhythmic  vibrations  produce  non-tympanitie 

Markedly  unrhythmic  vibrations  produce  metallic 

Fig.  60. — The  coin  test. 

Summary. — 1.  Resonance  is  a  long,  low-pitched,  non-musical  note, 
heard  on  percussing  normal  lung,  due  to  unrhythmic,  more  or  less  local- 
ized^vibrations.  It  may  be  imitated  by  percussing  a  loaf  of  fresh  bread. 
It  ,^is  associated  with  a  sense  of  resiliency. 

2.  Tympany  is  a  long  musical  note  of  variable  pitch,  produced  by  per- 
cussing elastic,  air-containing  viscera.  It  is  due  to  widespread  rhythmic 
vibrations  and  may  be  heard  over  the  stomach,  intestines,  over  relaxed 
lung  tissue,  and  over  many  cases  of  pulmonary  cavitation  and  pneumo- 
thorax. It  may  be  imitated  by  percussing  a  loaf  of  stale  bread  or  towel 
folded  many  times  upon  itself,  or  the  inflated  cheeks. 

3.  Dulness  is  a  short,  non-musical,  invariably  high-pitched  sound, 
heard  when  percussing  structures  containing  little  or  no  air.     It  is  due 



Fig.  61. — Section  through  the  posterior  parts  of  lungs  showing  advanced  pulmonary 

The  right  upper  lobe  shows  several  empty  cavities,  one  of  which  is  superficial,  large,  and 
surrounded  by  stiff  fibrous  walls.  High  up  in  the  axillary  region  one  should  expect  to 
find  metallic  tympany;  amphoric  breathing;  clear-cut,  metallic  rales;  whispered  pectorilo- 
quy, and  if  the  bronchus  leading  into  the  cavity  is  stenotic,  cracked-pot  sound. 

The  left  upper  lobe  shows  diffuse  infiltration  which  would  yield  the  following  physical 
signs:  diminished  expansion,  dulness,  increased  vocal  fremitus  and  resonance,  broncho- 
vesicular  breath  sounds,  crepitant  and  crackling  rales. 

The  position  of  the  liver  and  spleen  in  relation  to  the  chest  wall,  lung  and  stomach  is  well 


to  lack  of  vibratability  and  may  be  imitated  by  percussing  the  inner 
surface  of  the  tibia.  It  is  the  note  heard  over  consoHdated  lung  tissue. 
It  has  less  volume  (wave  amphtude)  than  resonance  and  does  not  carvj 

4.  Flatness  is  absolute  dulness.  It  is  a  very  short,  high-pitched  non- 
musical  note,  with  very  little  carrying  power  (intensity).  It  is  heard  in 
percussion  of  viscera  such  as  the  heart  and  the  liver  in  regions  not  covered 
by  lung  tissue  and  may  be  exemplified  by  percussing  the  thigh.  It  is  the 
note  of  liquids  and  is  heard  over  pleural  or  pericardial  effusions.  It  is 
invariably  associated  with  a  marked  sense  of  resistance. 


Wintrich's  Change  of  Note. — This  consists  of  a  change  of  pitch  during  percussion, 
which  varies  according  to  whether  the  mouth  be  opened  or  closed,  the  note  being 
higher  in  the  former,  and  lower  in  the  latter  instance.  In  a  pipe  open  at  one  end,  anj' 
constriction  of  the  opening  lowers  the  pitch  of  the  sound  (IBernoulli).  It  may  be 
demonstrated  by  percussing  the  trachea  with  the  mouth  open,  and  closed.  This 
phenomenon  may  occur  pathologicalh'  if  a  pulmonary  cavity  or  a  pneumothorax 
communicates  with  an  open  bronchus.  It  occurs  rarely  in  pneumonia  and  is  to  be 
explained  by  conduction  of  the  percussion  stroke,  through  the  consolidation  to  a  large 
bronchus.  If  noted  in  recumbency  only,  this  may  be  due  to  temporary  occlusion  of 
the  bronchus  by  fluid.     This  sign  is  of  but  httle  practical  value. 

Gerhardt's  Change  of  Note. — This  consists  of  a  change  of  the  percussion  sound, 
with  a  change  of  the  patient's  posture,  and  is  dependent  upon  an  alteration  in  the 
direction  of  the  long  axis  of  a  cavity,  which  contains  both  air  and  fluid.  This  was 
formerly  explained  as  resulting  from  a  change  in  the  length  of  the  air  columns.  This 
is  incorrect  since  the  greatest  possible  differences  in  lung  cavities  are  too  small  to 
account  for  such  changes  in  sound.  The  real  explanation  must  be  sought  in  the  change 
in  tension  which  as  a  result  of  the  contained  fluid,  the  cavity  undergoes  (Geigel). 

Friedreich's  Change  of  Note. — This  phenomenon  consists  of  a  lowering  of  the  pitch 
of  percussion  note  over  a  cavity  during  forced  inspiration,  due  to  an  increased  volume 
of  air.     It  is,  therefore,  supposed  to  indicate  a  patulous,  flexible  cavity. 

Biermer's  Change  of  Note. — This  phenomenon  is  practically  the  same  as  Ger- 
hardt's, except  that  the  former  described  the  metallic  resonance  sometimes  heard  over 
a  pneumothorax.  The  pitch  is  lower  on  sitting  up,  due  to  an  increased  volume  of  the 
pleural  cavitj',  caused  by  a  sagging  of  the  diaphragm  owing  to  the  weight  of  the 

None  of  the  foregoing  changes  of  note  are  of  much  practical  importance.  They 
are  rarely  demonstrable,  and  even  when  so  are  often  of  doubtful  significance. 

The  Lting  Reflex. — Local  irritation  of  the  skin,  b\'  cold,  mustard,  or  continued 
percussion,  maj-  temporarily  produce  a  reflex  dilatation  of  the  subjacent  lung  tissue 
— a  relative  emphysema — which  may  be  sufficient  to  obscure  slight  degrees  of  per- 
cussion dulness.  Thus  too-prolonged  percussion  of  a  pulmonary  apex  may  tem- 
porarily cause  the  disappearance  of  a  slight  impairment  of  resonance  which  was 
readily  demonstrable  at  the  beginning  of  the  examination.  It  should  not  be  forgotten, 
however,  that  aural  fatigue  on  the  part  of  the  examiner  may  account  for  a  similar 
result.  When  such  an  occurrence  is  suspected,  the  examiner  may  proceed  to  some 
other  step  in  the  examination  and  revert  to  the  examination  of  the  doubtful  region 
after  some  time  has  elapsed.      \ 


The  right  ribs  are  longer,  the  right  hmg  larger  (but  shorter),  the  right 
shoulder  often  lower  and  narrower,  the  right  breast  is  higher  and  further 
from  the  mid-sternum,  than  the  left. 

The  Lungs. — ^The  apices  extend  from  1  to  13>-^  inches  (2.5  to  4  cm.) 
above  the  clavicles.  The  right  apex  is  slightly  smaller  than  the  left,  its 
conical  shape  is  due  to  encroachment  of  the  right  innominate  vein.  This 
vessel,  unlike  the  left,  pursues  an  almost  vertical  course,  and  with  the 
superior  vena  cava,  occupies  the  space  which  on  the  left  is  filled  by 
the  anterior,  inner  margin  of  the  pulmonary  apex.  In  addition  to  this  the 
subclavian  artery  pursues  a  course  more  anterior  and  less  mesial,  to  the 
right  apex  than  the  left.  The  left  apex  is  more  dome-like  and  slightly 
larger.  There  is  practically  no  difference  in  the  height  of  the  apices 
on  the  two  sides. 

The  percussion  note  from  the  right  upper  apex  to  the  second  interspace 
is  slightly  higher-pitched,  less  resonant,  and  at  times  has  a  slightly  tympanitic 
quality  because:  (1)  The  right  apex  is  smaller.  (2)  The  superior  vena  cava 
lies  in  front  of  the  inner  part  of  it.  (3)  The  right  subclavian  artery 
occupies  a  more  anterior,  the  left,  a  more  mesial  position.  These  con- 
ditions account  for  the  diminished  resonance  and  higher  pitch.  (4) 
The  right  apex  lies  in  immediate  contact  with  the  trachea  (Figs.  49, 
52,  76,  77,  97) .  This  accounts  for  the  tympanitic  element  and  in  part  for 
the  elevation  of  pitch.  (5)  A  slight  influence — with  light  percussion — is 
sometimes  exercised  by  increased  thickness  of  the  right  pectoral  muscles. 


The  Right  Lung  The  Left  Lung 

Turns  out  at  the  6th  costo-sternal  articu-     Turns  out  at  the  4th  costo-sternal  articu- 
lation (sternal  line).  lation. 

Turns  out  at  the  5th  costal  space. 
Crosses  the  6th  and  7th  intercostal  space     Crosses  at  the  5th  costal  space, 
(mid-clavicular  line).  Turns  out  at  the  6th  costal  space. 

Crosses  the  6th  and  7th  costal  space. 
Reaches  8th  rib  in  axillary  line.  Reaches  the  8th  in  the  axillary  line. 

Reaches  10th  rib  in  scapular  line.  Reaches  the  lower  border  of  10th  dorsal 

Reaches  upper  border  of  the  10th  dorsal         vertebrae  in  scapular  line, 

Louis'  angle ^  (the  junction  of  the  manubrium  with  the  gladiolus) 
marks  the  sternal  attachment  of  the  second  rib.     It  is  opposite  to  the 

1  Louis'  angle,  not  Ludwig's  angle.  It  was  not  described  by  Ludwig,  the  German, 
but  was  named  after  Louis,  the  great  French  clinician,  Ludwig  being  the  German  for 
Louis.  The  angle  was  originally  described  by  Louis  as  a  unilateral  prominence  of 
the  ribs  noted  in  certain  cases  of  emphysema  on  the  most  affected  side. 

(E.  H.  Goodman:  "Historical  Note  on  the  So-called  Ludwig's  Angle  or  Angle  of 
Louis."     Medical  Record,  July  23,  1910.) 



Fig.  62. — Mediastinal  surface  of  lungs  hardened  before  removal.  This  photograph 
shows  (a)  the  groove  produced  in  the  right  apex  by  the  trachea;  (6)  the  relatively  anterior 
position  of  the  vessels  on  the  right  side;  and  (c)  the  smaller  size  of  the  right  apex.  AG, 
azygos  groove,  VG,  grooves  for  superior  vena  cava,  innominate  vein,  and  subclavian  vessels; 
TG,  tracheal  groove;  SG,  subclaAnan  groove;  AAG,  aortic  groove;  CI,  cardiac  impression. 

Fig.  63. — Lateral  view  of  lungs  hardened  before  removal.     This  photograph  shows  the 
deeper  vascular  groove  and  the  smaller  size  of  the  right  apex  as  compared  with  the  left. 




Fig.  64. — Anterior  view  of  lungs  hardened  before  removal.  This  photograph  shows 
the  anterior  position  of  the  groove  for  the  subclavian  vessels  on  the  right  side,  compared 
with  the  more  superior  position  on  the  left.     SG.  subclavian  groove. 

''"  Fig.  65. — The  lungs  normally  meet  and  frequently  overlap  at  Louis'  angle.  This 
previously  hardened  dissection  shows:  an  infant's  chest,  displaying  a  shrunken  thj-mus 
gland  between  the  apices  of  the  lungs.      (Fetterolf  and  Gxttings.) 




Qg Showing  prominent  angle  of  Louis,  also  small  areas  of  absolute  cardiac  and 

hepatic  dulness  in  a  case  of  emphysema. 

Fig.  67.  Fig-  68. 

Figs.  67  and  68. — The  solid  lines  indicate  the  position  of  the  pulmonary  margins  and  of 
the  interlobar  fissures.  The  dotted  lines  mark  the  anterior  and  lower  confines  of  the  pleural 
cavities — the  spaces  into  which  the  lung  expands  during  forced  inspiration.  This  space  at 
its  lower  margin,  which  is  bounded  by  the  diaphragiA  on  the  inside  and  the  thoracic  wall  on 
the  outside,  is  known  as  the  complemental  space  of  Gerhardt.  It  is  in  this  space  that  smail 
pleural  effusions  first  accumulate,  thus  causing  the  disappearance  of  the  diaphragmatic 
shadow  (see  Fig.  12),  slight  dulness  on  percussion  and  diminished  vocal  fremitus,  reso- 
nance and  breath  sounds. 



level  of  the  fifth  thoracic  vertebra,  indicates  the  level  at  which  the  trachea 
bifurcates,  and  anteriorly  the  upper  point  at  which  the  lungs  meet,  to 
diverge  again  at  the  fourth  costal  cartilage.  It  marks  the  upper  boundary 
of  the  cardiac  auricles,  and  the  point  at  which  the  veins  of  the  hand  col- 
lapse while  the  arm  is  being  raised  upward  from  its  lowest  to  its  highest 
position  (Gaertner's  test  of  venous  blood  pressure).  It  forms  a  con- 
venient landmark  from  which  to  count  ribs. 

Fig.  69. — An  approximate  knowledge  of  the  location  of  the  pulmonary  fissures  is  espe- 
cially important  in  the  diagnosis  of  interlobar  empyema.  Right  lung.  The  fissure  between 
the  upper  and  the  lower  lobe  corresponds  to  a  line  drawn  from  the  fourth  dorsal  vertebra  to 
the  fifth  or  sixth  costo-sternal  articulation.  The  upper  border  of  the  middle  lobe  is  marked 
by  a  line  drawn  from  the  middle  of  that  just  described,  to  the  third  costo-sternal  articula- 
tion.     {After  Doyen,  Bouchon  and  Doyen.) 

Fig.  70.— Left  lung.  The  interlobar  fissure  may  be  located  by  drawing  a  line  from  the 
fourth  dorsal  vertebra  to  the  sixth  costo-sternal  articulation.  These  relations  are  not  ab- 
solutely fixed,  but  are  subject  to  individual  variations.      {After  Doyen,  Bouchon  and  Doyen.) 

The  vertebral  spines  correspond  to  the  level  of  the  rib  below.  The 
first  rib  begins  and  is  in  direct  articulation  with,  the  seventh  cervical 
vertebra.  The  second  rib  articulates  with  the  second  and  third  verte- 
brae, the  third  rib  with  the  third  and  fourth  vertebrae,  etc.,  but  the 
eleventh  and  twelfth  ribs  articulate  directly  with  their  respective  verte- 
brae. The  scapulce  overlie  the  second  to  the  seventh  or  the  third  to 
the  eighth  ribs.  The  hilus  of  the  lung  lies  opposite  to  the  spines  of  the 
fourth,  fifth  and  sixth,  and  the  bodies  of  the  fifth,  sixth  and  seventh, 



Fig.  71. — Vertical  section  of  the  body,  showing  the  shape  of  the  lower  lobes,  the  upper 
lobes  having  been  removed.  Note  the  higher  position  of  the  right  phrenic  dome,  which 
causes  the  lower  border  of  pulmonary  resonance  to  be  slightly  higher  on  the  right  side.  On 
the  left  the  stomach  imparts  a  tympanitic  quality  to  the  lower  portion  of  the  lung.  If 
filled  with  food  it  diminishes  pulmonary  resonance  and  may  simulate  consolidation  or  a 
small  pleural  effusion. 


The  Immediate  or  Direct  Method.^ — The  hand  or  the  finger  tips  are 
struck  directly  against  the  object  in  which  we  desire  to  set  up  vibrations. 
This  was  the  method  of  Auenbrugger,  who,  however,  covered  the  fingers 
with  a  soft  glove  to  diminish  the  finger  element  of  the  sound,  especially 
the  overtones.  The  direct  method  is  still  occasionally  employed  to 
determine  the  resonance  of  the  upper  lobes  of  the  lung  (by  using  the 
clavicle  as  the  pleximeter),  or  that  of  the  lower  lobes  as  a  whole,  by 
striking  the  patient's  back  with  the  edge  of  the  hand. 

The  Mediate  or  Indirect  Method. — This  was  suggested  by  Piorry, 
who  interposed  a  hard  object — the  plexirneter— between  the  plexor  (the 
object  striking  the  blow)  and  the  part  to  be  percussed. 

Artificial  plexors  and  pleximeters  are  sometimes  used,  especially  for 
class  demonstration.  They  generally  consist  respectively  of  a  small 
light  rubber-tipped  hammer,  and  of  a  narrow  piece  of  bone  or  vulcanite 
of  variable  shape  (Fig.  72).  The  fingers  are  nearly  always  used  as  plexor 
and  pleximeter. 

The  middle  finger  of  the  left  hand  is  pressed  firmly  against  the  chest 
wall,  in  a  direction  parallel  to  the  ribs,  while  the  middle  finger  of  the  right 
hand  strikes  upon  it,  just  behind  the  nail,  a  short,  light,  quick,  vertical 
blow,  delivered  from  the  wrist  (Figs.  73  and  74). 

The  Pleximeter. — Despite  the  fact  that  a  hard  pleximeter,  a  quick 
rebound  and  a  short  time  of  impact  are  advantageous,  we  cannot  use 
an  unpadded  plexor  of  hard  material  because  in  such  a  case  a  high-pitched 
sound  would  be  produced,  due  to  the  overtones  of  the  pleximeter  which 
would  overshadow  the  low-pitched  fundamental  note  of  the  lung.  We 
therefore  use  a  soft  plexor  or  the  finger,  just  as  we  use  felt  pads  in  a  piano 
in  order  to  let  the  basic  note  preponderate  and  to  drown  out  the  unhar- 
monious  overtones.  The  vibrating  area  equals  in  size  the  percussed  area 
plus  a  radiation  during  the  course  of  transit.  Hence  the  smaller  the 
pleximeter  and  the  more  superficial  the  tissue  percussed,  the  more  accurate 
our  topographic  results  (see  Fig.  75). 

Half  the  diameter  of  the  pleximeter  must  always  be  allowed  as  the 
unavoidable  margin  of  error  in  estimating  the  boundaries  between  an 
air-containing  and  an  airless  structure  as  the  heart  and  lung,  even  when 
the  pleximeter  is  applied  in  a  direction  parallel  to  the  anticipated  bound- 
ary line.  Based  upon  these  facts  some  very  narrow,  wedge-shaped  plex- 
imeters (Ziemmsen)  have  been  devised  for  limiting  the  lung  apices,  cardiac 
boundaries,  etc.  The  results  derived  from  their  employment,  however, 
have  been  disappointing  (Fig.  72). 

The  percussion  blow  may  be  delivered  either  lightly  or  forcibly,  and 
accordingly  we  speak  of  light  or  heavy — superficial  or  deep- — percussion. 
The  latter  terms  are  used  because  with  heavy  percussion  a  deeper  pene- 
tration of  the  vibrations  is  ensured — ^the  sphere  of  the  blow  is  larger — • 
greater  masses  of  tissue  are  set  in  vibration  and  a  louder  sound  is  produced. 




Fig,  72.— 1,  Plexor  or  percussion  hammer;  2,  ivory  pleximeter;  3  and  4,  Hirschfelder's 
pleximeter;  5,  Sansom's  pleximeter. 

Fig.  75.  Fig.  74. 

_  Figs.  73  and  74. — The  method  of  percussion.  The  percussion  blow  is  struck  from  the 
wrist  only,  the  forearm  being  practically  stationary.  The  impact,  which  is  delivered  just 
behind  the  nail  of  the  middle  finger,  should  be  quick  and  brief  in  duration,  the  force  of  the 
blow  should  fall  as  vertically  as  possible.  Fig.  73  shows  the  beginning,  Fig.  74  the  end 
of  the  percussion  stroke.  In  order  to  deliver  a  vertical  blow  with  the  terminal  phalanx,  the 
nail  of  the  second  finger,  which  is  generally  used  as  plexor,  must  be  short. 


The  fingers  are  preferable  to  artificial  plexors  and  pleximeters 
because  of  the  important  information  cierived  from  the  sense  of  resist- 
ance. It  is  a  relatively  easy  task,  for  one  practised  in  percussion, 
to  outline  accurately  dull  areas  by  this  means  alone.  It  is  a  useful  method 
when  we  are  forced  to  make  our  examination  in  the  presence  of  extraneous 


As  the  result  of  a  percussion  stroke  on  the  chest  wall,  the  equilibrium 
of  the  underhung  tissues  is  locally  disturbed,  they  are  thrown  into  "^"ibra- 
tion,  and  a  sound  results.  This  sound  is  produced  by  \-ibrations  arising 
from  three  sources: 

1.  Frotn  the  Pleximeter. — This  element  of  the  composite  sound  is 
high-pitched,  of  short  duration  and  dull. 

2.  From  the  Thoracic  Wall. — This  element  also  ^-ields  a  short,  dull, 
high-pitched  (osteal)  note.  When  the  costal  cartilages  are  ossified  much 
of  the  percussion  blow  is  absorbed  by  the  arch-like  structure  of  the  ribs, 
penetration  is  diminished,  and  a  more  or  less  tympanitic  note  is  produced. 

3.  From  the  Underlying  Tissues  (Lungs,  etc.). — That  portion  of  the 
sound  which  is  contributed  by  the  \'ibrations  of  a  healthy  lung  under 
normal  tension  is  long,  low-pitched  and  resonant,  because  of  the  thin- 
ness and  elasticity  of  the  pulmonary  tissue,  and  the  large  amount  of  air 
it  contains.     The  greater  the  depth  of  the  lung,  the  lower  the  note. 

Sound  travels  radially  from  point  struck  and  gradually-  fades.  It  is 
conducted  through  tubes  (bronchii.  stethoscope)  to  much  greater 
distances  because  lateral  rachation  is  minimized. 

Sound  waves  in  traveling  through  the  body  meet  with  media  of 
varying  density  and  are  in  part  (oi  reflected;  (6)  transmitted  (by  setting 
up  ^■ibrations  in  the  second  medium).  In  jmssing  through  media  of 
different  densities  much  sound  is  lost  by  refledian. 

In  percussing  the  chest  the  overhing  tissues  in  different  s^Tiimetrical 
regions  are  much  the  same  (skin,  fat,  bone,  etc.)  and,  therefore,  com- 
parisons of  the  underhnng  tissues  can  readily  be  made.  But  when  fat 
or  edema  are  excessive,  percussion  data  are  obtained  with  difficulty. 

Sound  is  conducted  better  if  its  waves  impinge  vertically  upon  the 
di^Tding  point  of  two  media  than  if  they  reach  it  obliquely.  Hence  the 
percussion  sH'oke  must  fall  vertically  in  order  to  penetrate  deeply. 

Although  percussion  sets  up  vibrations  in  the  entire  lung,  yet  it  does 
so  in  the  deeper  portions  insufficiently  to  set  up  audible  sounds.  Prac- 
tically, therefore,  in  case  of  a  normally  distended  lung  with  light  or  moderate 
percussio^n.  the  inbrations  tend  to  remain  localized  both  as  regards  lateral 
radiation  and  vertical  penetration. 

It  has  been  shown  orthodiagraphically  that  the  heart  may  be  accurately  outUned 
both  by  forcible  and  by  very  Ught  percussion.  It  was  questioned  whether  threshold 
percussion  had  sufficient  penetration  to  traverse  the  lung  overh-ing  the  heart  or 
whether  the  alterations  of  sound  were  not  simply  the  result  of  altered  pulmonary- 
tension  due  to  the  nearby  solid  organ.  Weil's  statement  made  years  before  and 
generallj-  accepted  was  to  the  eflfect  that  percussion  -v-ibrations  penetrated  only  5 
to  7  cm.,  thus  only  -t  to  5  cm.  into  the  lung  itseK.  This  beUef  was  founded  on  the  fact 
that  liver  dulness  could  not  be  demonstrated  when  more  than  4  to  5  cm.  of  lung  tissue 
overlay  it.  The  following  experiments  show  that  even  light  percussion  has  a  deep 

I.  Moritz  and  Rihl  beat  up  into  a  spongy  froth,  a  solution  of  stiflfening  gelatin  to 
which  formalin  and  carbohc  acid  had  been  added,  this  closeh*  resembling  lung  tissue  in 



structure.  This  was  poured  into  a  glass  cylinder  4  cm.  in  width  and  70  cm.  m  length. 
Before  the  gelatin  had  "set"  a  small  rubber  balloon  was  placed  m  its  midst,  not  m 
contact  with  the  glass,  and  connected  by  means  of  a  tube  with  a  sensitive  flame.  The 
lightest  possible  percussion  produced  vibrations  in  the  flame. 

II.  A  cylinder  20  by  20  cm.  gave  the  same  tone  whether  light  or  heavy  percussion 
was  used,  showing  that  in  either  case  the  same  mass  of  air  vibrated. 


the  penetration  of  audible  percussion. 

Very  heavy — 3  finger  or  fist  percussion — at  P  produces  audible  vibrations  throughout  the  triangle 

This  tends  to  bring  out  the  note  of  the  lung  as  a  whole. 
Heavy  percussion  at  P  sets  up  audible  vibrations  throughout  the  triangle  aPb. 
Average  percussion  at  P'  sets  up  audible  vibrations  throughout  the  area  C'P'D'. 
Very  light  percussion  at  P'  causes  audible  vibrations  only  throughout  the  area  CP'D. 

III.  Wintrich  showed  that  percussion  of  the  clavicles  in  the  corpse  was  readily 
palpable  by  the  hand  held  beneath  the  diaphragm.     Here,  of  course,  bony  conduction 

IV. If  1  ung  tissue  be  immersed  in  water  whose  surface  is  percussed,  the  pulmonary 
resonance  can  be  elicited  if  percussion  be  performed  directly  over  the  lung,  but  not  if 
the  stroke  is  delivered  beyond  its  margin.     But,  of  course,  percussion  vibrations  are 


more  directly  conducted  by  water  than  by  air  or  lung  tissue,  especially  when  in  case 
of  the  latter  the  bony  thoracic  arch  is  interposed. 

V.  Moritz  and  Rihl  further  showed  by  modifications  of  the  gelatin  experiment  and 
by  attention  to  physical  laws  such  as  that  regarding  the  parallelogram  of  force,  that 
the  laterally  radiating  percussion  waves  in  media  denser  than  air  lose  much  of  their 
penetration  power.  .        .         '  . 

An  ovoid  cylinder  yields  a  lower  note  when  percussed  in  the  direction  of  its  long 

It  is  evident,  therefore,  that  the  physical  character  of  lung  tissue  is  such  that  a 
vibration  of  the  entire  mass  always  occurs  even  with  the  lightest  percussion.  Never- 
theless it  reacts  to  percussion  in  such  a  manner  that  a  louder  note  is  produced  when  a 
larger  mass  of  pulmonary  tissue  is  directly  exposed  to  the  impact  than  when  only  a 
thin  layer  of  lung  tissue  underlies  the  area  of  the  percussion  blow.^ 

The  following  points,  therefore,  deserve  to  be  emphasized.  Light 
'percussion  is  esserilial  for  topographic  diagnosis;  with  heavy  percussion  too 
much  lateral  radiation  occurs.  Heavier  percussion  must  he  used  where 
the  superficial  tissues  are  thick,  in  order  to  set  up  audible  pulmmiary  vibra- 
tions, but  at  the  same  time  the  accurate  delimitation  becomes  more  difficult. 
Very  heavy  percussion  may  give  us  a  general  idea  as  to  the  amount  of  air- 
bearing  tissue  in  the  lung  as  a  whole.  It  is  absolutely  useless  for  the  purpose 
of  outlining  of  organs  or  for  the  detection  of  small  areas  of  pulmonary  in- 

For  practical  purposes  then,  in  so  far  as  audible  sound  production  is 
concerned,  the  penetration  of  the  percussio7i  wave  is  about  6  cm.  (2^^ 
inches).  Of  this,  2  to  3  cm.  is  consumed  in  penetrating  overlying  tissues 
so  that  only  3  or  4  cm.  il}/'2  inches)  are  left  to  enter  the  underlying  organ. 
Hence  percussion  is  practised  from  all  directions.  The  heart  could  not 
be  outlined  from  behind,  nor  deeply  placed  pulmonary  lesions  from  in 
front.  The  fact,  however,  that  consolidations  the  size  of  a  cherry,  and 
deeper  than  2^  inches  cannot  be  located  by  light  percussion  does  not 
prove  that  sound  waves  may  not  penetrate  deeper.  Deep  percussion 
tends  to  bring  out  note  of  lung  in  its  entirety,  and  drowns  out  slight  degrees 
of  dulness. 

For  light  percussion  the  pleximeter  must  be  lightly  but  snugly 
applied  to  the  chest  wall,  the  stroke  must  be  gentle  and  its  duration 
short,  so  as  to  include  only  a  small  sphere  of  blow  (Fig.  75).  We  should 
percuss  so  as  to  evoke  practically  no  note  over  the  dull  areas.  Light  per- 
cussion is  more  accurate  because  with  it  there  is  less  lateral  radiation. 
For  deep  percu,ssion  the  plexor  is  applied  more  firmly,  the  blow  is  some- 
what longer  and  more  intense.  Too  strong  a  blow  is  transmitted  too 
far  laterally  and  renders  exact  localization  impossible.  Deep  percussion 
is  not  necessarily  loud  percussion.  Percussion  should  be  of  such  strength 
and  duration,  as  to  make  the  difference  between  resonance  and  dulness  as 
great  as  possible. 

"  The  deep  dulness  of  organs  depends  only  on  the  volume  of  the  air- 
containing  parts  in  the  region  of  the  sphere  of  the  blow"  (Weil)  and  not 
as  was  formerly  taught  upon  the  dulhng  influence  of  the  neighboring 
solid  organs  upon  those  filled  with  air.  Such  a  dulling  influence  does  not 
exist  (Sahli).  The  strength  of  percussion  must  vary  with  the  size  and 
character  of  the  organs  and  neighboring  tissues:  e.g.,  in  children  (thin 
chest  walls,  superficial  organs)  light  percussion  is  necessary;  in  corpulent 
adults  (thick  chest  walls,  deeply  placed  organs)  heavier  percussion  is 

1  Moritz  and  Rihl:  Deul.  Arch.  f.  kl.  Med.,  1909. 



As  has  been  stated,  the  percussion  note  obtained  over  the  lung  is  a 
compound  sound,  consisting  of  the  note  of  the  pleximeter,  the  chest  wall, 
and  lung.  In  heavy  percussion  it  is  the  lower,  and  in  Hght  percussion 
the  higher,  range  of  this  complex  to  which  our  chief  acoustic  attention  is 
directed.  Both  have  the  higher  range — the  pleximeter  note — in  com- 
mon, but  there  is  relatively  more  of  the  pleximeter  note  in  the  sound 
produced  by  light  percussion.  Lessening  of  the  amount  of  pulmonary 
air  is  manifested  by  a  lack  of  the  deeper  tones. 

Fio.  76. — 8ection  through  the  upper  part  of  the  thorax,  viewed  trum  below.  The  line 
of  section  is  not  exactly  horizontal,  a  slightly  lower  plane  being  reached  on  the  right  side 
than  on  the  left.  In  order  to  show  the  apical  parietal  pleura,  the  pulmonary  apices  have 
been  removed.  There  can  be  noted  in  this  specimen  the  beginning  contact  of  the  right 
pleura  with  the  trachea,  and  the  anterior  position  of  the  innominate  artery,  whose  bifurca- 
tion is  well  shown.  On  the  left  side,  the  wide  separation  of  the  pleura  from  the  trachea  by 
means  of  the  large  arteries,  esophagus,  and  areolar  tissue  can  readily  be  seen.  The  deep 
position  of  origin  and  the  obliquely  anterior  course  of  the  left  subclavian  artery  is  plainly 
visible.  T,  trachea;  E,  esophagus;  R.A.P.,  right  apical  pleura;  L.A.P.,  left  apical  pleura; 
I. A.,  innominate  artery,  dividing  into  R.S.A.,  right  subclavian  artery  and  R.C.A.,  right 
common  carotid  artery;  L.S.A.,  left  subclavian  artery;  L.C.A.,  left  common  carotid  artery; 
R.S.V.,  right  subclavian  vein;  L.I.V.,  left  innominate  vein. 

If  one  lung  becomes  infiltrated,  its  percussion  note  becomes  higher  in  pitch,  not 
by  virtue  of  any  nevi^  sound  element  added,  but  on  account  of  the  loss  of  the  deeper 
tones.  The  note  of  consolidation  is,  therefore,  to  speak  accurately,  not  actually 
higher  but  relatively  less  low.  It  is  the  prominence  of  the  low-pitched  notes  which 
causes  what  we  know  as  resonance.  The  difference  between  a  resonant  and  a  dull 
note  lies,  however,  not  only  in  the  rate  of  the  vibrations  (pitch)  but  also  to  some  extent 
in  their  amplitude  (intensity).     In  other  words,  the  resonant  note  is  louder  and  carries 



further.  For  this  reason  slight  degrees  of  duhiess  can  sometimes  be  more  readily 
perceived  at  a  slight  distance  from  the  patient  than  by  the  percussor  himself.  This 
is  due  to  the  fact  that  sound  waves  lose  much  of  their  amplitude  in  transit,  and  the 
difference  between  1  and  0  seems  greater  than  that  between  1  and  2.     Low-pitched 

Fig.  77. — Horizontal  section  of  the  thorax  just  above  the  sternoclavicular  articulation 
viewed  from  beneath.  The  pleura  has  been  dissected  away.  This  photograph  shows  (a) 
the  anterior  position  of  the  innominate  artery,  (b)  the  posterior  position  of  the  left  sub- 
clavian artery,  and  (c)  the  anterior  position  of  the  right  innominate  vein.  R,  first  rib; 
R.I. v.,  right  innominate  vein;  E,  esophagus;  T,  trachea;  /.A.,  innominate  artery;  L.S.V., 
left  subclavian  vein;  L.C.A.,  left  common  carotid  artery;  L.S.A.,  left  subclavian  arterj'. 

It  also  shows  the  thickness  of  the  dorsal  muscles  through  which  the  percussion  vibrations 
must  penetrate  in  order  to  set  up  vibrations  in  the  lung,  even  above  the  level  of  the  scap- 
uliE.  Percussion  must,  therefore,  be  more  forcible  than  on  the  front  of  the  chest.  This 
section,  although  from  a  different  bodj'',  shows  the  same  anatomic  disposition  of  the  large 
vessels  in  relation  to  the  upper  lobes  as  does  Fig.  76.  It  is  in  part  due  to  the  more  anterior 
position  of  the  vessels  in  case  of  the  right  upper  lobe  that  the  percussion  note  on  this  side 
is  normally  less  resonant  than  that  of  its  fellow. 

sounds  having  a  great  vibrator}'  excursion  carrj'  further.  In  listening  to  a  distant 
orchestra  we  hear  the  drums  and  bassoons,  not  the  stringed  instruments  or  the  fifes; 
we  hear  the  distant  pounding  of  the  surf,  not  the  swish  of  the  waves. ^ 

^  Selling:  Deui.  Arch.  f.  kl.  Med.,  vol.  xc. 


The  skilled  examiner  can  be  accurate  in  topographic  percussion  within 
a  range  of  from  0.5  to  1.0  cm.  Whichever  method  we  employ,  the  finger 
which  strikes  the  blow  (plexor;  must  fall  verticallj^,  not  obliqueh",  upon 
the  tissues  to  be  percussed  for  thus  greater  penetration  is  ensured.  Fur- 
thermore, it  must  be  quickly  withdrawn,  for  thus  lateral  deviation  and 
radiation  of  ^dbration  is  minimized,  and  deeper  penetration  ensured. 
In  other  words,  unrh^.'thmic  vibrations  are  produced,  in  contradistinction 
to  rhythmic  ones,  in  which  the  lung  tends  to  vibrate  as  a  whole,  and  in 
which  topographic  delimitation  is  impossible. 


Percussion  is  practised:  ('1;  to  elicit  ■sound;  (2)  to  d.etermine  resistance. 

Percussion  is  based  upon  the  fact  that  when  the  equilibrium  of  an 
elastic  body  is  briefly  disturbed,  it  is  thrown  into  Adbrations,  which  in 
ttu-n  produce  sounds  which  vary  in  intensity,  quality,  duration  and  pitch, 
such  A'ariations  depending  on  the  character  of  the  vibrating  tissue — the 
amount  of  air  and  the  degree  of  elasticity — and  on  the  nature  of  the  blow. 

The  bodily  organs  are  of  unhomogeneous  structure  and  for  the  most 
part  not  good  tone  producers,  but  sounds  can  be  produced  in  air-contain- 
ing chambers  and  in  liquid-containing  organs.  The  former  vibrate  more 
easily  and  for  a  longer  time. 

The  vihratory  capacity  of  tissues  depends  upon: 

1.  The  size  and  character  of  the  air-contoAning  spaces — lungs,  intestines, 

2.  The  amount  of  elastic  tissue.  The  skin  and  the  lung  have  a  good 
deal,  the  hver  little.  In  the  lungs  it  is  under  tension,  hence  a  better 
tone  than  that  of  the  skin. 

3.  The  degree  of  tension.  The  greater  the  tension,  the  higher  the  pitch 
— tympanitic  beU3\  Human  tissues^the  lung,  intestines,  etc. — vary 
greatly  in  the  degree  of  tension  they  possess.  They  may  be  so  relaxed 
as  to  A-ield  no  note:  or  thej'  maj^  be  so  tense  as  to  jdeld  metaUic  soimds. 

4.  The  thickness  of  the  tissue.  The  thinner  the  tissue,  the  better  the 
^dbration,  the  higher  the  note. 

Various  tissues  vibrate  differently,  and  the  same  tissues  when  altered 
hj  disease  in  their  physical  consistencies  yield  an  altered  note.  Percus- 
sion teaches  us  only  physical  differences.  Before  we  can  make  a  diag- 
nosis we  must  add  the  data  obtained  by  inspection,  palpation,  ausculta- 
tion, etc.,  as  wen  as  the  knowledge  we  possess  regarding  the  history  and 
symptoms  of  the  patient  and  the  pathology  of  the  disease. 

For  example,  a  dull  note  obtained  over  lung  tissue  teaches  us  that  the 
tissues  are  less  ^dbratile — contain  less  aii' — than  is  normally  the  case. 
The  sound  of  the  pleximeter  being  constant,  we  are  justified  in  attribut- 
ing variations  in  the  sound  to  physical  alterations  in  the  underhing 
tissues.  Such  a  dull  note  generally  indicates  consolidation,  but  even  if 
we  are  correct  in  this  assumption  we  have  no  means  of  determining  by 
percussion  with  which  of  the  diverse  types  of  pulmonary  consolidation 
we  are  deahng. 

Percussion  is  also  used  to  outline  the  boundMries  of  organs  when 
neighboring  ^dscera  possess  different  phj^sical  quahties,  as  for  instance 
the  heart  and  the  lung.  The  most  brilliant  triumphs  of  topographic 
percussion  are  manifested  when  unrhythmic  "^-ibrations  Twhich  remain 



more  or  less  localized)  are  set  up,  and  when  the  tissues  directly  under- 
lying the  point  of  percussion  yield  different  vibrations  than  the  neighbor- 
ing structures,  i.e.,  in  the  normally  distended  healthy  lung.  We  can 
accurately  outline  the  heart  or  the  liver  from  the  lung  since  they  have 
very  different  vibratory  qualities,  but  not  the  liver  from  the  heart,  since 
their  acoustic  properties  are  much  the  same.  Neither  can  we  be  accurate 
in  differentiating  between  the  stomach  and  the  colon,  owing  to  their 


Slight   dulness 

Flat    (absolute 



Fig.  78. — lllustratiug  the  different  percussion  sounds  normally  obtained  on  the  right 
anterior  and  the  lateral  aspects  of  the  chest,  as  well  as  the  anatomic  reasons  therefor. 
(Compare  Fig.  88.) 

vibratory  similarity,  nor  can  we  accomplish  much  in  outlining  a  tumor  of 
the  intestine  because  rhj^thmic  vibrations  (tympanitic  sounds)  are  set 
up,  which  cannot  be  localized. 

The  Sense  of  Resistance. — Hard  and  soft  are  terms  which  we  apply 
to  objects  according  as  their  parts  are  displaceable  with  difficulty  or  with 
ease.  We  derive  our  judgments  from  the  pressure  sense  of  the  skin  and 
the  muscle  sense.  Thus  we  speak  of  a  board-like  resistance,  which  we 
are  accustomed  to  meet  with  in  massive  consolidations. 

The  attributes  which  give  us  the  impression  of  hardness  or  softness 


depend  essentially,  first,  upon  the  elasticity  of  the  percussed  object.  The 
more  elasticity,  the  greater  the  displacement  possible.  Second,  upon  the 
length  of  time  during  which  the  percussed  object  is  out  of  contact.  The 
longer  the  plexor  and  pleximeter  remain  in  contact  the  softer  the  object 
seems  and  vice  versa.  Now  we  noted  under  the  discussion  of  tympany 
that  heavy  and  prolonged  percussion  strokes  were  unfavorable  to  bringing 
out  unrhythmic  vibrations — -non-tympanitic  notes.  And  we  find  that  an 
increased  tactile  impression  is  most  common  in  association  with  dulness. 
A  sense  of  increased  resistance  is  not  compatible  with  pure  tympany;  the 
note  which  goes  hand  in  hand  with  such  increased  resistance  is  non-tym- 
panitic, of  slight  intensit}^,  of  brief  duration,  and  high  in  pitch  (flatness). 
Thus  pulmonary  consolidation  and  more  especially  liquid  exudates,  as  a 
pleural  effusion,  produce  a  marked  increase  in  resistance  which  is  readily 
felt  by  the  underlying  (pleximeter)  finger,  and  which  is  associated  with  a 
short,  high-pitched,  flat  percussion  note. 

Not  infrequently  we  are  able  to  state  positively  whether  a  given  note 
is  either  resonant  or  flat,  even  with  our  ears  closed,  simply  by  our  sense 
of  touch.      Anything  which  diminishes  elasticity  will  increase  resistance. 


The  patient  may  be  sitting,  standing  or  lying,  the  preference  being  in 
the  order  named.  The  chest  must  be  exposed  or  covered  only  by  an 
examining  cape  (see  p.  21).  Muscular  relaxation  must  be  secured.  A 
revolving  low-backed  chair  or  stool  is  useful,  since  it  renders  change  of 
position  from  front  to  back  easy  and  expeditious. 

The  examiner  proceeds  to  percuss  alternately  corresponding  areas  of 
the  right  and  left  sides  of  the  body  and  to  note  differences  in  the  sound 
and  resistance  encountered.  Many  of  these  differences  are  due  to  normal 
anatomic  causes  and  these  must  of  course,  be  borne  in  mind. 

Although  it  is  generally  the  custom  to  begin  at  the  top  and  percuss 
to  the  bottom  of  the  chest,  this  method  is,  as  has  been  pointed  out  by 
N.  K.  Wood,  especially  for  beginners,  much  more  difficult,  and  for  the 
following  reasons  more  fraught  with  the  possibility  of  error. 

It  is  much  easier  for  the  ear  to  single  out  a  high  note  from  among 
low  ones,  than  is  the  reverse.  In  tuberculosis  especially,  it  is  the  upper 
part  of  the  lung  which  is  first  and  most  extensively  diseased.  By  begin- 
ning at  the  base,  therefore,  we  are  more  likely  to  have  a  normal  resonance 
and  resistance  to  begin  with.  In  other  words,  it  is  better  to  progress 
from  a  normal  finding  to  pathologic  change,  than  work  from  the  abnormal 
to  the  normal.  This  applies  to  both  the  percussion  sound  and  to  the 
sense  of  resistance. 

The  upper  border  of  the  liver  may  be  very  accurately  determined 
by  marking  on  the  chest  wall  a  line  at  the  point  at  which,  while  percussing 
downward,  the  first  slight  impairment  of  resonance  occurs.  Percussion 
is  then  begun  from  the  costal  margin  upward  and  the  point  marked  at 
which  with  threshold  percussion  an  audible  sound  is  produced.  X-ray 
studies  have  shown  that  the  upper  hepatic  border  corresponds  to  a  point 
midway  between  the  two  lines  (Laporte).  The  lower  border  may  better 
be  determined  by  palpation  since  tympany  due  to  the  hollow  viscera 
renders  localization  of  vibrations  impossible. 

Percussion  and  auscultation  of  the  apex  of  the  axilla  will  often  reveal 
physical  signs  which  may  be  sought  in  vain  elsewhere.     This  is  especially 



the  case  in  the  early  stages  of  pneumonia,  in  pulmonary  tuberculosis  and 
in  interlobar  empyema.  The  accompanying  illustration  (Fig.  79) 
depicts  the  position  in  which  the  patient's  arm  should  be  held  for  such 
an  examination.     The  muscles  being  retracted  examination  is  facilitated. 


Spinal  Percussion. — Percussion  of  the  spine  wiiile  not  generally  practised,  is  be- 
lieved by  some  physicians  to  have  a  value  in  the  diagnosis  of  deep-seated  aneurisms 
and  tumors,  mediastinal  lymphadenitis,  etc.  There  is  normally  dulness  from  the  first 
to  the  fourth  dorsal  vertebrse;  and  an  "osteal"  note  extends  thence  to  the  last  dorsal  spine; 
the  lumbar  region  yields  an  impaired  note,  and  the  sacral  vertebrae,  tympany.  We 
have  never  been  able  to  convince  ourselves  of  the  value  of  this  method  of  examination 
<see  Fig.  91). 

Pjq_   79_ — Position  of  the  patient  while  the  axillary  region  is  being  examined. 

Threshold  Percussion.— This  is  simply  the  lightest  of  light  percus- 
sion. It  must  be  done  in  an  absolutely  silent  room.  The  pleximeter  is 
laid  lightly  against  the  chest  wall,  only  in  the  interspaces,  the  blow  is 
delivered  upon  the  proximal  end  of  the  second  or  of  the  distal,  phalanx 
which  is  bent  at  right  angles  to  its  fellow,  and  in  a  vertical  direction  upon 
the  chest  (orthopercussion).  If  this  is  impossible,  a  stump  of  lead  pencil 
may  be  substituted.  In  other  words,  the  pleximeter  is  not  only  small  but 
vertically  placed.  The  blow  struck  by  the  plexor  is  so  light  that  only 
resonant  tissues  produce  any  audible  sound;  when  dull  tissues  are 
struck  their  note  is  below  our  auditory  threshold  (Fig.  80). 



,  The  Coin  Test.- — In  performing  this  test  silver  coins  are  used,  as  the 
plexor  and  pleximeter  respectively.  Percussion  is  practised  over  the 
front  of  the  chest,  auscultation  over  the  back.  The  object  of  using  coins 
is  to  favor  the  genesis  of  very  unrhythmic  vibrations  (metallic  sounds). 
If  a  pneumothorax  is  present,  the  sounds  heard  through  the  stethoscope 
will  have  a  clear,  vibrant,  bell-like  quahty,  owing  to  the  resonating 
quality  of  a  large  cavity.  In  such  a  case,  the  coin  test  is  said  to  be 
present  and  the  presence  of  pneumothorax  is  practicallj^  established. 

Fig.  80. — Orthopercussion.  Generally  employed  in  conjunction  with  a  very  light  per- 
cussion stroke.  The  pleximeter  surface  being  small  and  the  blow  vertical,  great  accuracy 
may  be  obtained.  This  method  is  especially  recommended  for  outlining  the  left  border  of 
the  heart. 

Normal  lung,  solidified  lung  and  simple  effusions  yield  only  a  dull,  short 
metallic  note  closely  similar  to  that  heard  over  the  healthy  lung  (see 
Fig.  60). 

Auscultatory  Percussion. — This  is  occasionally  of  use  in  outlining 
organs.  The  bell  of  the  stethoscope  is  placed  over,  let  us  say,  the  heart. 
It  is  held  in  position  by  the  patient  or  an  assistant  while  the  examiner 
percusses  lightly  the  surrounding  regions  in  a  circular  direction. 

We  begin  at  a  distance  from  the  heart  and  percuss  toward  it  in  a 
series  of  circles.  The  tissues,  the  sound  of  which  is  to  be  compared,  must 
be  equally  distant  from  the  stethoscope,  as  under  normal  conditions 
the  sound  will  increase  in  intensity  in  approaching  the  point  ausculted. 
As  soon  as  the  organ  is  reached  by  the  percussion  blow  the  sound  will 
greatly  increase  in  intensity  and  we  know  that  its  outer  boundary  has 
been  reached.  Instead  of  percussing  some  examiners  use  a  vibrating 
tuning  fork,  placing  the  butt  of  the  same  against  the  chest  wall  in  order 
to  set  up  intrathoracic  vibrations. 



Fig.  81. — Auscultatory  percussion. 

Fio.   82. — Auscultatory  percussion.     The  bell  of  the  stethoscope  is  placed  at  B  and  per- 
cussion is  performed  in  gradually  narrowing  circles  toward  the  heart. 




1.  Any  thickening  of  the  superficial  tissues  tends  to  diminish  pene- 
tration of  the  percussion  blow  and  to  deaden  sound.  The  commonest 
causes  are:  adiposity,  large  muscles,  or  mammary  glands  and  edema. 

2.  When  the  bony  thorax  is  large  and  deep,  we  have  a  more  powerful 
resonator.  This  tends  to  cause  a  note  of  lower  pitch.  When  the  costal 
cartilages  are  ossified,  the  thorax  becomes  more  rigid,  and  less  penetra- 
tion of  the  percussion  blow  occurs  because  a  greater  portion  of  the  impact 
is  transferred  laterally  by  the  arch-like  structure  of  the  ribs,  accurate 
topographic  percussion  is,  therefore,  more  difficult. 

Fig.  83.  Fig.  84. 

Figs.  83  and  84. — Showing  the  areas  over  which  the  percussion  note  is  shorter,  higher 
pitched  and  less  resonant  than  normal  in  dextro-convex  scoliosis.  These  changes  are  most 
marked  over  the  area  I,  and  least  marked  over  the  area  IV.  {After  E.  A.  Gray,  Jour.  Am. 
Med.  Assn.,  1912,  LIX,  2249.)     (See  Figs.  17,  34,  36.) 

3.  Thickening  of  the  pleura,  or  exudation  or  effusion  into  the  pleural 
cavity  cause  both  a  diminished  penetration  of  the  percussion  blow  and  a 
lessened  resonance  of  sound,  because  the  vibrations  lose  much  of  their 
amplitude  in  passing  through  media  of  different  density. 

4.  Changes  in  the  pulmonary  tissue — the  degree  of  tension,  the  amount 
of  air,  elasticity  and  density — produce  marked  and  important  alterations 
of  sound. 

I.  Changes  in  pulmonary  tension  may  be  uni-  or  bilateral. 

(a)  Increased  tension  occurs  during  forced  inspiration  and  in  emphy- 
sema.    This  causes  more  rapid  vibrations  and  a  higher-pitched  note. 

(6)  Decreased  tension. 

(1)  General,  may  arise  from  pleural  effusions,  increased  intra-ab- 
dominal pressure  (ascites,  tumors);  it  also  occurs  in  senility  (less  elastic 
and  more  rigid  thorax).  Decreased  tension  allows  the  lung  to  vibrate 
as  a  whole.     This  adds  a  tympanitic  quality  to  the  percussion  note. 


The  high-pitched  tympany  which  occurs  above  pleural  effusions  and 
around  consolidations  is  known  as  Skodaic  tijm'panij  (Figs.  107,  320). 

(2)  Local  decrease  of  tension  occurs  around  consolidated  areas 
(pneumonia,  tuberculosis,  etc.). 

II.  Changes  in  the  Amount  of  Air  in  Lung  Tissue.— (a)  An  increase 
occurs  in  emphj^sema,  asthma  and  during  compensatory  (forced)  breath- 
ing, also  in  cases  of  cavitation.  In  the  first  case  the  percussion  note 
is  hyperresonant,  in  the  last,  tympanitic,  provided  that  the  cavity  is 
sufficiently  large,  not  too  deeply  placed,  and  that  it  is  filled  with  air. 
In  the  first  instance  the  vibrating  tissues  are  thinner  under  greater  ten- 
sion and  contain  more  air.  In  the  latter  the  walls  of  the  cavity  vil^rate 
in  unison  with  the  air  columns  it  contains.  During  forced  inspiration 
deep  percussion  fields  a  lower;  light  percussion,  a  higher  note,  than 
during  forced  expiration. 

(h)  Decreased  air  bearing  lung  tissue  occurs  in  consolidation  (pneu- 
monia, tuberculosis,  fibrosis,  atelectasis  with  compression,  cavities 
filled  with  exudate,  etc.).  The  percussion  note  becomes  less  resonant 
in  proportion  to  the  consolidation,  because  the  vibrating  tissues  are 
thicker,  less  elastic  and  contain  less  air.  The  sound,  therefore,  becomes 
short,  liigh-pitched  and  dull,  and  resistance  is  increased. 

Even  minor  degrees  of  spinal  curvature  ma}'  produce  lack  of  resonance 
over  certain  areas  of  the  chest.  This  is  due  to  the  fact  that  abnormal 
convexities  of  the  thorax  produce  an  increased  rigiditj-  of  the  more  con- 
vex rib  which  tends  to  prevent  penetration  of  the  percussion  blow,  whereas 
a  flattened  rib  has  the  opposite  effect  (Sahli)  (Figs.  17,  26,  36,  83,  84). 

In  order  to  detect  spinal  deformities  the  patient  should  be  sitting, 
muscularly  relaxed,  and  the  examiner  should  note  especiallj':  the  relative 
height  of  the  shoulders  and  of  the  scapulae,  the  depth  of  the  supra- 
clavicular fossae,  and  in  women  the  height  of  the  breasts.  The^spine 
itself  is,  of  course,  also  inspected  both  from  a  lateral  and  from  an  antero- 
posterior aspect.  Small  degrees  of  scoliosis  may  be  emphasized  by  mark- 
ing the  skin  over  the  spinous  processes  of  the  vertebrae  with  a  pencil. 





There  is  no  invariable  normal  standard.  Actual  values  must  be 
determined  largely  by  the  variation  of  the  two  sides  of  the  chest,  while 
the  normal  range  must  be  learned  by  experience.  Percussion  sounds 
will  vary  with:  (a)  the  soft  parts  overlying  the  lungs;  (6)  the  flexibility 
of  the  thorax;  (c)  the  size  and  shape  of  the  lungs,  and  their  state  of 
tension;  (d)  the  region  percussed. 

Fig.  85. — Showing  normal  areas  of  dulness  and  flatness  caused  by  and  outlining  the 
anatomici  position  of  the  heart  and  the  liver.  The  lower  border  of  the  heart  cannot  be  out- 
lined since  it  overlies  the  liver  and  these  organs  have  acoustically,  in  so  far  as  percussion  is 
concerned,  identical  qualities.  The  heavy  shading  indicates  the  part  of  these  organs  which 
are  uncovered  by  lung  tissue  and  therefore  yield  a  fiat  note.  The  arrows  indicate  the  di- 
rection in  which  percussion  should  proceed.  The  light  shading  shows  the  areas  over  which 
clear  pulmonary  resonance  is  replaced  by  slight  dulness  owing  to  the  proximity  of  the  under- 
lying liver  and|heart.     (See  Figs.  86,  167.) 


Anteriorly. — The  clearest  pulmonary  resonance  is  encountered  below 
the  clavicles  and  at  the  angles  of  the  scapulae.  In  women  a  diminution 
of  resonance  and  an  elevation  of  pitch — owing  to  the  mammcB — begins 
below  the  second  interspace.  On  the  left  side  cardiac  dulness  begins  at 
the  upper  border  of  the  third  rib,  and  on  the  right,  the  hepatic  dulness, 
below  the  fourth  interspace.  The  note  on  approaching  these  organs 
becomes  progressively  less  resonant  until  absolute  flatness  is  encountered 




— no  lung  tissue  intervening  between  the  organ  and  the  chest  wall. 
Diminished  resonance  is  also  encountered  in  the  splenic  region,  but  the 
spleen  cannot  be  accurately  outlined  by  percussion  (Figs.  61,  87).  There  is 
less  resonance  at  the  sterno-clavicular,  than  at  the  sterno-acromial  angle, 
and  less  resonance  over  the  second  rib  than  over  the  second  interspace. 
Over  the  upper  sternum  the  osteal  qualit}^  predominates,  below  the  second 
rib  more  pulmonary  resonance  may  be  elicited,  especially  on  hght 

Shortly  before  the  lower  costal  margin  is  reached  the  note  becomes 
slightly  tympanitic  owing  to  the  underlying  air-containing  viscera — 

Fig.  86. —  Window  disset-tion  of  the  chest  from  in  front,  showing  the  position  of  the  heart 
and  liver  which  causes  the  dull  areas  charted  in  Fig.  85.  The  pericardium  has  been  re- 
moved. The  area  of  absolute  (superficial)  cardiac  dulness  is  larger  than  normal,  because 
the  lungs  were  frozen  in  the  position  of  expiration.  The  amount  of  heart  exposed  is  there- 
fore unusually  large.  Not  infrequently  the  anterior  pulmonary  margins  overlap  in  front, 
leaving  very  little  of  the  heart  exposed.     (See  Fig.  85.) 

stomach  and  intestines  (Figs.  78,  107).  On  this  account  hver  dulness, 
especially  to  the  right  of  the  right  para-sternal  line,  often  does  not  ex- 
tend to  quite  the  lower  margin  of  the  ribs  unless  the  organ  is  enlarged. 

On  the  left  side  near  the  lower  costal  margin  a  tympanitic  area — 
Traube's  semilunar  space — is  encountered.  The  tympany  is  caused  by 
that  area  of  the  stomach  which  lies  between  the  left  lower  margin  of  the 
lung,  the  right  border  of  the  spleen  and  the  left  border  of  the  liver. 
It  disappears  when  the  stomach  is  filled  with  food  and  in  cases  of  peri- 
cardial effusion.     It  is  diagnostically  of  little  importance  (Fig.  89). 

Dulness  over  the  left  lateral  pulmonary  margin  may  be  caused  by  a 


full  stomach,  and  tympany  in  this  region  is  often  due  to  gaseous  disten- 
tion. These  facts  must  be  borne  in  mind  or  diagnostic  errors  will  be 
made  (Fig.  90). 

Posteriorly. — The  supraspinous  fossae  despite  the  thickness  of  the 
overlying  muscles,  gives  a  certain  amount  of  pulmonary  resonance, 
especially  in  women  and  in  emaciated  individuals  (Figs.  76,  77,  91). 
The    upper  scapular  region  is  less  resonant  than  the  lower,  especially 

Fig.  87. — Splenic  duiness  Percussion  of  the  spleen  has  but  little  value  unless  the 
organ  is  enlarged,  and  when  this  is  the  case  palpation  is  a  more  satisfactory  method;  of 
examination.     (Compare  Figs.  61  and  70.) 

over  the  spine.  The  interscapular  region  lies  between  the  range  of  these 
two.  The  infrascapular  region  gives  a  clear  resonance  on  light  percus- 
sion as  far  downward  as  the  eleventh  interspace,  but  forcible  percussion 
brings  out  the  dulling  due  to  the  liver,  as  high  as  the  ninth  or  even  the 
eighth  rib  on  the  right  side.  On  the  left  side  the  note  is  variably  modified 
by  the  neighboring  influence  of  the  stomach  and  spleen  (Fig.  61).  In  the 
axillary  region  hyperresonance  is  often  encountered;  in  the  lower  por- 
tions, the  stomach  imparts  a  tympanitic,  and  the  liver  a  dull  quality  as  we 
approach  the  level  of  the  diaphragm. 




The  percussion  outlines  of  the  king  vary  with  the  phase  of  respiration. 
One  can  map  out  the  superior,  inferior,  and  precordial  margins.  Respira- 
tion changes  the  percussion  note,  by  altering  the  volume,  tension  and 
density  of  the  pulmonary  tissue  and  by  displacing  organs. 

The  superior  margin  of  the  lung  extends  2  to  3  cm.  (1)^  inches) 
above  the  clavicles  at  the  end  of  a  quiet  respiration. 

There  has  been  much  discussion  as  to  whether,  and  to  what  extent  the  apices  move 
during  respiration.  It  seems  definitely  established  that  only  the  anterior  and  lateral 
aspects  can  move  and  that  there  is  a  slight  upward  movement  during  inspiration. 
Over  the  anterior  slope  of  the  apex  lies  a  lid  consisting  of  fibrous  fascia,  the  first  rib, 

Pleura    oth  rib    Int.  mammary  artery 

Descending  aorta         Inf.  vena  cava 

Fig.  88. — Transverse  section  through  the  thorax  from  the  lowest  part  of  the  ensi- 
form  cartilage  to  the  bottom  of  the  ninth  dorsal  vertebra.  The  following  points  are  to  be 

1.  Liver  dulness  is  demonstrable  by  percussion  on  the  right  side  of  the  chest  only;  on  the  left  side 
this  organ  is  too  deeply  placed.     (Compare  Fig.  78.) 

2.  The  liver  extends  even  further  to  the  left  than  does  the  heart  which  rests  upon  it,  only  the  dia- 
phragm separating  these  two  structures.  In  case  of  abdominal  distention  (ascites,  meteorism)  the  dia- 
phragm encroaches  even  more  upon  the  pleural  cavity  than  in  the  normal  case  here  shown.  For  this 
reason  the  pulmonary  bases  may  yield  a  dull  note  on  percussion  in  cases  of  ascites,  even  in  the  erect 
position  and  in  the  absence  of  pulmonary  congestion  or  hydrothorax  (upward  displacement  of  the 

iver) . 

3.  This  section  passes  through  the  heart  2  cm.  above  its  lowest  level,  the  pericardium  which  con- 
tained half  an  ounce  of  serous  fluid  extended  2  cm.  below  the  level  of  the  heart.  In  the  performance 
of  paracentesis  pericardii  there  is  less  danger  of  puncturing  the  pleura  if  the  trochar  is  introduced  in  the 
fifth  interspace  on  the  left,  close  to  the  sternum.  At  this  point  both  the  pleura  and  the  internal 
mammary  vessels  will  be  avoided.     (Figure  redrawn  after  Braune.) 

the  subclavian  artery  and  vein.  This  Ud  is  hinged  from  behind.  \Mien  its  anterior 
part  is  lifted  up  durfng  inspiration,  it  is  the  anterior  part  of  the  apex  which  feels  the 
movement;  the  posterior  portion  lying  in  front  of  the  neck  of  the  first  rib,  being  nearer 
the  axis,  is  affected  only  indirectly  (Fig.  93)  (Keith,  Journal  of  Anatomy  and  Physi- 
ology, May,  1903.     Appendix,  Proc.  Anat.  Sac.  Gr.  Brit.  &  Ireland,  May,  1903). 

Percussion  of  the  Supraclavicular  Fossa: — The  idea  that  a  failure  of  the 
percussion  resonance  to  move  upward  during  forced  inspiration  indicates 
apical  adhesions  or  infiltration  is  erroneous.  Such  an  increase  in  reson- 
ance is  not  always  present  under  normal  conditions,  and  when  so,  is 


Fig.  89. — Traube's  semilunar  space. 

Fig.  90. — Dulness  due  to  a  full  stomach. 

100  THE    EXAMIXATIOX    OF    THE    Ll'NGS 

mainly  an  indication  that  the  apex  of  the  lung  has  become  broader, 
deeper.  As  has  been  stated  above,  there  is  practically  no  upward  move- 
ment. Since  the  clavicles  move  with  respiration,  they  cannot  be  taken 
as  accurate  fixed  points,  from  which  to  judge  of  apical  expansion. 

The  Inferior  Pulmonary  Margin. — During  forced,  held,  inspiration,  the  percussion 
note  becomes  slightly  higher-pitched,  because  of  the  increased  tension  of  the  pul- 
monarj-  tissue.     The  lower  border  of  the  pulmonarj-  resonance  should  be  noted  during 

Fig.  91. — "Window  dissection  of  the  back,  showing:  1.  Thickness  of  dorsal  muscles  through 
which  the  percussion  vibrations  must  penetrate  before  reaching  the  pulmonary  tissue.  2. 
The  bronchial  bifurcation  over  which  area  the  breath  sounds  are  normally  broncho-vesicular, 
the  fremitus  and  vocal  resonance  intense.  A,  aorta;  B,  bronchial  bifurcation;  L. A.,  left 
auricle;  T.A.,  thoracic  aorta;  £■,  esophagus.  Forcible,  two-finger  percussion  is  sometimes 
necessary  to  eUcit  pulmonary  resonance  at  the  level  of  the  shoulder  girdle.  3.  This  dissec- 
tion further  illustrates  the  reason  why  spinal  percussion  has  practically  no  value.  The 
distance  of  the  mediastinal  viscera  from  the  point  percussed  and  the  thickness  of  the  spinal 
column  render  the  localization  of  percussion  vibrations  well-nigh  impossible. 

quiet  breathing  and  its  distance  from  the  level  of  the  seventh  cervical  vertebra  noted. 
The  patient  is  then  asked  to  take  as  deep  an  inspiration  as  possible  and  hold  it.  The 
line  of  pulmonary  resonance  will  move  downward  several  centimeters  during  this 
procedure.  The  absence  of  this  phenomenon  may  be  due  to  pleural  adhesions  or 
effusion,  pulmonary  fibrosis  or  infiltration  (see  Fig.  50 j. 

During  quiet  respiration  the  margins  of  the  lungs  move  but  little.  In  the  dorsal 
position,  the  anterior  margin  moves  downward  about  2  cm.  (%  inch)  lower  than  in 
the  erect  posture.     In  lateral  decubitus  the  edge  of  the  lung  on  the  upper  side  moves 



Fig.  92. — Oblique  view  of  the  mediastinal  viscera  from  the  right  posteriorly,  showing 
A,  aortic  arch;  A',  thoracic  aorta  (reflected);  R,  recurrent  laryngeal  nerve;  L.A.,  left 
auricle;  L.V.,  left  ventricle;  L.P.A.,  left  pulmonary  artery;  L.S.V.P.,  left  superior  pul- 
monary vein;  L.Z.P.F.,  left  inferior  pulmonary  vein;  E,  esophagus  (reflected).  The  left 
recurrent  laryngeal  nerve  is  not  infrequently  compressed  in  aneurisms  of  the  arch  of  the 
aorta.  This  results  in  a  localized  neuritis  which  is  clinically  manifested  by  a  husky  voice,  a 
"brassy"  cough  and  sometimes  "rattling  in  the  throat."  The  nerve  may  be  compressed 
indirectly  in  some  cases  of  mitral  stenosis.  *  The  right  auricle  being  greatly  dilated  presses 
the  left  pulmonary  artery  upward,  squeezing  the  nerve  between  this  vessel  and  the  aortic 

*  Fettbrolf,  G.  and  Norris,  G.  W.:  "The  Anatomic  Explanation  of  the  Paralysis  of  the  Left  Re 
current  Laryngeal  Nerve  Found  in  Certain  Cases  of  Mitra'  Stenosis."    Am.  Jour.  Med.  Sc,  May  1911 


down  3  to  4  cm.  During  forced  lireathing  the  excursion  may  amount  to  9  cm.  (3J^ 

Respiratory  displacement  of  the  lung — which  occurs  through  a  filling  of  the  com- 
plemental  space — is  most  marked  in  the  axillar.y  line.  The  lower  pulmonary  border 
never  descends  nearer  to  the  lower  costal  margin  than  7  cm.  {2%  inches)  on  the  right, 
and  5  cm.  (1.96  inches)  on  the  left  side  (see  Figs.  9,  10,  11). 

Pathologic  Displacement. — Dowtncard  displacement  of  the  lower  lung  border  may 
be  permanent  (emphysema)  or  temporary  (asthma).  Upward  displacement  of  the 
lower  pulmonary  border  occurs  in  cases  of  pleural  or  pulmonary  contraction  (fibrosis), 
and  in  intraperitoneal  enlargement. 


'■"■•-  \ 

Fig.   93. — A  figure  to  show  the  relationship  of  the  first  rib  and  manubrium  sterni  to  the 
apex  of  the  lung  (1)  in  expiration,  (2)  in  inspiration.      (Keith.)      (See  p.  97.) 


Sex. — In  women  the  upper  chest  is  more  resonant  as  compared  to 
the  lower,  than  in  men,  due  to  the  habit  of  upper  thoracic  breathing. 
The  mammary  region  is  often  difficult  to  percuss  on  account  of  the  thick- 
ness of  the  tissues. 

Age. — In  old  age  the  costal  cartilages  become  ossified,  resulting  some- 
times in  a  higher-pitched,  less  resonant  note.  In  other  cases  a  more 
tympanitic  qualitj'  is  heard.  These  alterations  are  in  part  due  to  tho- 
racic rigidity,  and  in  part  to  the  condition  of  the  lungs,  depending  upon 
whether  senile  pulmonary'  atrophy,  or  emphj^sema  has  occurred.  The 
rigid  thorax  tends  to  prevent  deep  penetration  of  the  percussion  blow. 


The  position  of  the  diaphragm  may  be  determined  by:  (a)  percussing 
the  lower  border  of  the  lungs ;  (6)  percussing  the  upper  border  of  the  liver 
and  spleen;  (c)  observing  Litten's  phenomenon;  {d)  Harrison's  groove 
if  present;  and  (e)  by  means  of  the  X-ray. 

The  lungs  do  not  fill  the  pleural  sac  during  quiet  respiration,  but  leave  a  semi- 
circular space — the  complimental  space  of  Gerhardt,  between  the  chest  wall  and  the 
shelving  diaphragm.  The  right  phrenic  dome  is,  as  a  rule,  1  inch  higher  than  the  left, 
but  both  may  be  equal  or  the  normal  difference  even  reversed  (see  Fig.  59).  During 
inspiration  a  recession  downward  is  noted,  but  hardly  any  appreciable  flattening, 
except  with  forced  inspiration.  The  extent  of  the  excursion  in  quiet  breathing  is 
^4  inch;  in  forced  respiration  2J-^  to  5  inches.  The  diaphragm  is  normally  lowest 
while  sitting,  intermediate  in  standing  (active  abdominal  muscles)  and  highest  in 
recumbency.  In  the  right  lateral  decubitus,  the  right  dome  is  higher  (greater  weight 
of  the  abdominal  contents),  and  vice  versa,  notwithstanding  this  fact  the  excursion  is 


greater  on  the  dependent  side  (muscles  act  more  forcibly  against  resistance),  the  upper 
side  remains  relatively  motionless  (decreased  excursion  because  of  approximation 
of  the  diaphragmatic  origin  and  insertion). 

Alterations  in  arching  and  -mobility  are  almost  a  constant  factor  in  pulmonarj^  tuber- 
culosis, especially  if  there  is  fibrosis  or  basal  pleural  adhesions.  In  unilateral  cases, 
the  fluoroscope,  generally  shows  a  high,  well-arched  dome  on  the  affected  side  which 
moves  only  slightly,  and  a  low  flattened  dome  on  the  sound  side  (compensatory 


The  diaphragm  is  the  chief  means  of  inspiration.  In  quiet  breathing 
the  main  function  of  the  intercostals  is  to  fix  the  ribs,  and  maintain  expan- 
sion during  the  descent  of  the  diaphragm.  When  the  latter  is  hindered 
or  inspu'ation  becomes  labored  the  intercostals  act  more  strongly,  so  as 
to  raise  the  ribs  and  dilate  the  thorax.  In  very  forcible  inspiration  other 
muscles  act  also:  sternomastoid,  scaleni,  omohyoids,  upper  part  of  the 
trapezii.  The  scaleni  simply  supply  an  anchorage  for  the  first  ribs. 
The  rotation  of  the  ribs,  from  the  second,  downward  is  accomplished 
solely  by  the  intercostal  muscles  (Hoover).  These  muscles  hypertrophy 
from  overuse — emphysema. 

Elevation  of  the  ribs  is  also  in  part  produced  by  the  diaphragm 
(normal  position  is  one  of  arched  tension)  which  acts  by  contracting 
over  the  liver  and  the  abdominal  viscera  as  a  fulcrum.  The  latter  are 
pressed  upward  by  the  abdominal  muscles.  If  "the  ribs  remain  fixed 
the  diaphragm  cannot  be  pushed  upward,  but  if  the  abdominal  muscles 
pull  the  ribs  inward,  then  the  tension  of  the  diaphragm  is  relaxed  and 
the  abdominal  viscera  under  the  pressure  of  the  abdominal  muscles, 
can  drive  it  upward  and  expel  the  supplemented  air"  (Hutchison). 
The  diaphragm  and  intercostals  are  antagonists  although  they  concur 
to  produce  the  same  result.  The  liver  and  the  intercostal  muscles  pre- 
vent the  diaphragm  from  drawing  the  chest  in. 

When  the  line  of  traction  and  the  plane  of  the  diaphragm  coincide — 
when  it  is  neither  arched  upward  nor  downward — the  diaphragm  over- 
powers the  intercostal  muscles  and  the  costal  margin  is  drawn  toward 
the  median  line.  But  if  the  diaphragm  is  arched,  either  upward  or 
downward,  the  intercostal  muscles  gain  the  upper  hand  and  the  rib  margin 
moves  awaj^  from  the  median  line  during  inspiration.  For  the  pre- 
ponderance of  either  the  intercostals  or  the  diaphragm  depends  not 
upon  the  height  of  the  latter  but  upon  its  curve  and  line  of  traction. 

"The  direction  of  movement  and  comparative  movements  of  the  median 
and  lateral  portions  of  the  costal  margins  on  the  two  sides  give  us  valuable 
information  on  activation  of  the  diaphragm  and  the  position  of  its  median 
and  lateral  parts.  The  direction  in  which  any  portion  of  the  costal 
margin  may  move  is  determined  by  the  resultant  of  two  forces.  One 
is  the  expression  of  the  action  of  the  intercostal  muscles,  which  always 
widens  the  subcostal  angle  and  spreads  the  hypochondria;  the  other 
force  originates  in  activation  of  the  diaphragm  and  always  draws  the 
costal  margin  toward  the  median  line.  When  the  resultant  of  these 
two  forces  causes  narrowing  of  the  subcostal  angle,  the  subcardial  or 
median  portion  of  the  diaphragm  is  less  convex  than  normal.  When  the 
entire  costal  margin  is  drawn  toward  the  median  line,  the  entire  phrenic 
leaf  has  lost  a  large  part  of  its  convexity.  The  movement  of  the  costal 
margins  has  nothing  to  do  with  excursion  of  the  diaphragm;  it  is  merely 


the  resultant  of  activation  of  the  intercostal  muscles  and  of  the  dia- 
phragm. The  onh^  subphrenic  sign  of  phrenic  excursion  is  protrusion 
of  the  epigastrium  and  lateral  portions  of  the  abdomen." 

In  order  to  determine  whether  the  costal  border  remains  stationary 
or  diverges  from,  or  is  drawn  toward  the  median  line,  Hoover  gives  the 
following  directions:  The  examiner  should  place  his  thumbs  symmetri- 
cally along  the  costal  borders  to  serve  as  indicators  as  inspection  alone 
may  lead  to  confusion  between  elevation  of  the  thoracic  cage  and  widen- 
ing of  the  subcostal  angle.  In  obese  individuals  the  movements  of  the 
costal  borders  are  usually  obscured  and  can  be  detected  only  by  palpation. 

"The  significance  of  the  slight  arch  of  the  anterolateral  portions  of  the 
diaphragm  is  illustrated  very  nicely  in  cases  of  acute  cardiac  dilatation 
due  to  myocardial  incompetence  from  arterial  sclerosis.  It  is  a  common 
experience  to  see  these  patients  brought  to  the  hospital  with  dilatation 
of  both  sides  of  the  heart.  During  this  period  there  will  be  sj^mmetrical 
inspiratory  narrowing  of  the  subcostal  angle,  but  the  lower  and  lateral 
portions  of  the  costal  margins  move  awaj^  from  the  median  line  during 
inspiration.  As  the  heart  recovers  from  its  acute  dilatation,  the  upper 
and  inner  half  of  the  right  costal  margin  will  resume  its  outward  move- 
ment during  inspiration,  but  the  left  side  of  the  subcostal  angle  will  be 
restrained  in  its  outward  movement  or  may  continue  to  move  toward 
the  median  line  during  inspiration.  This  is,  of  course,  due  to  the  fact 
that  the  left  ventricle  is  permanently  enlarged  and  depresses  the  left 
sternocostal  portion  of  the  diaphragm.  The  symmetry  and  asymmetry 
of  movement  of  the  two  sides  of  the  subcostal  angle  and  the  lower  and 
outer  halves  of  the  costal  margins  give  much  valuable  information  con- 
cerning the  total  volume  of  the  lungs,  and  form  and  size  of  the  heart 
and  heart's  sac.  Furthermore,  an  exact  analysis  of  the  respiratory 
movement  of  each  part  of  the  thoracic  cage  is  essential  to  form  an  adequate 
estimate  of  the  ventilatory  function  of  the  different  parts  of  the  lungs. 
Such  an  analysis  is  also  necessary  to  form  an  exact  idea  about  the  factors 
in  supraphrenic  and  infraphrenic  diseases  which  may  modify  the  curve 
in  any  part  of  the  diaphragm."^ 

Forced  inspiration  exerts  its  effects  mainly  upon  the  upper  chest  and 
the  true  ribs. 

Quiet  expiration  is  due  not  merely  to  cessation  of  muscular  contrac- 
tion— a  passive  act,  the  result  of  elastic  recoil — but  also  to  active  relaxa- 
tion (of  the  inspiratory  muscles).  The  muscular  effort  required  by  an 
inspiration  is  equivalent  to  raising  100  pounds;  a  forced  inspiration  to 
raising  300   pounds   (Hutchison). 

Forced  expiration  is  due  to  the  activity  of  the  abdominal  muscles, 
the  latissimi  dorsi,  and  lower  part  of  the  trapezii.  It  exerts  its  effect 
mainly  upon  the  lower  chest  and  false  ribs. 

Paralysis  of  the  diaphragm  causes  bilateral  enlargement  of  the  chest, 
inspiratory  A\adening  of  the  subcostal  angle  and  flaring  of  the  hypo- 
chondria. Paralysis  of  the  intercostal  muscles  produces  bilateral 
diminution  in  size  with  subcostal  narrowing. 

Respiratory  pressure  changes  are  most  marked  in  the  lower  part  of 
the  pleural  sac,  and  least  marked  between  the  tracheal  bifurcation  and 
the  heart  (Meltzer  and  Auer). 

1  Hoover,  C.  F.  :  "  Diagnostic  Signs  from  the  Scaleni,  Intercostal  Muscles  and 
the  Diaphragm  in  Lung  Ventilation."     Arch.  Int.  Med.,  Nov,  1917,  xx,  701. 


During  inspiration  the  interspaces  are  pushed  inward  by  the  atmos- 
pheric pressure.     This  is  most  evident  in  the  lower  interspaces. 

The  visceral  pleura  is  retained  in  contact  with  the  parietal  pleura  bj^ 
an  ''atmospheric  ligament"  (Keith)  due  to  the  atmospheric  pressure 
(15  pounds  to  the  square  inch),  by  way  of  the  bronchii  exerting  its  force 
against  the  negative  intrathoracic  pressure.  "The  weight  required  to 
separate  the  \dsceral  from  the  parietal  pleura  over  both  lungs  amounts 
to  about  a  ton"  (Hutchison),  a  far  greater  force  than  can  be  brought 
to  bear  bj^  the  respirator}^  muscles,  hence  the  two  pleural  membranes 
remain  in  contact.  But  if  one  lung  collapses  owing  to  a  pneumothorax 
or  a  pleural  effusion,  it  is  dragged  toward  the  opposite  side  by  its  fellow 
even  before  the  presence  of  an  exudate  causes  displacement  by  means 
of  actual  pressure.  The  negative  pressure  exerted  by  the  lungs  upon  the 
pleura  favors  exudation  (hydrothorax)  when  the  vascular  engorgement 
of  the  pleura  exists.  Very  considerable  exudation  must  occur  before 
the  pressure  becomes  positive.  This  fact  is  a  strong  argument  in  favor 
of  the  early  aspiration  of  pleural  effusions.     The  greater  the  elasticity 

Fig.  94. — Diagram  illustrating  the  direction  of  the  "pull"  of  the  lungs  which  is 
due  to  their  elasticity  and  which  occurs  when  they  are  relaxed  as  in  pneumothorax. 
{After  Hutchison.)     Compare  Figs.  9,  10  and  11. 

or  tonus  of  the  lung,  the  greater  will  be  its  traction  when  the  opposing 
lung  is  collapsed.  Hence  pneumothorax  occurring  with  relatively  healthy 
lungs,  free  from  pleural  adhesions,  will  cause  greater  mediastinal  displace- 
ment and  shock,  than  if  the  lungs  have  partially  lost  their  elasticity  or 
are  bound  fast  by  adhesions  (Hutchison)  (see  p.  625). 
The  negative  intrathoracic  pressure  is  about  as  follows: 

Mg.    Hg. 

Normal  inspiration —   10 

Normal  expiration —     7 

Deep  inspiration —  40 

Deep  expiration —     0 

Deep  inspiration  with  air  passages  closed — 100 

Deep  expiration  with  air  passages  closed +100 



Auscultation,  the  discover}-  of  which  we  owe  to  Laennec,  is  the  act 
of  listening  for  sounds  produced  within  'the  bodj',  chiefly  those  of  the 
heart  and  the  lung. 

I.  Immediate  or  direct  auscultation  is  performed  b}-  placing  the  ear 
against  the  chest  wall.  This  method  is  still  much  used  for  listening  to 
the  sounds  produced  in  the  lung.  By  its  employment  we  get  more  bone, 
than  air  conduction.  The  sounds  heard  are  generally  less  loud  and  clear 
than  those  heard  through  the  stethoscope,  and  accurate  localization  is 
not  as  readily  possible.  If,  and  this  should  but  rarely  happen,  the  ex- 
amination must  be  made  through  garments,  the  unaided  ear  is  preferable 
to  the  stethoscope.  Vocal  resonance  may  sometimes  be  better  appreciated 
by  the  immediate  method. 

II.  Mediate  or  indirect  auscultation  is  practised  b}-  interposing  some 
sound  conducting  material — a  stethoscope — between  the  ear  and  the 
body.  This  method  is  now  generally  emploj'ed,  especially  in  ausculting 
the  heart.  It  has  the  following  advantages.  The  examiner  can  localize 
sound  more  sharply,  he  can  assume  a  more  comfortable  position,  he  comes 
into  less  intimate  contact  with  the  patient,  he  can  auscult  certain  regions 
such  as  the  supraclavicular  fossge,  and  the  axillary  apices  which  would 
otherwise  remain  inaccessible. 


It  is  essential  that  both  patient  and  examiner  be  in  as  comfortable 
a  position  as  possible.  The  former  will  then  relax  his  muscles  and  breathe 
more  regularly,  the  latter  will  be  better  able  to  concentrate  his  entire 
attention  upon  what  he  hears.  The  sitting  posture  should  be  chosen  when 

For  a  satisfactory  examination  it  is  essential  that  the  part  to  be 
ausculted  be  bared  to  the  skin.  After  having  been  put  both  mentally 
and  physically  at  ease,  the  patient  should  be  told  to  breathe  a  trifle  more 
deeply  than  is  normally  the  case,  with  the  mouth  open.  All  raucous, 
throaty  sounds  or  voluntary  expiration  must  be  avoided  since  thej' 
vitiate  the  results  of  the  examination.  It  is  a  waste  of  time  to  attempt 
auscultation  of  the  lungs  until  the  patient  breathes  properh*.  A  begin- 
ning may  be  made  at  the  top  or  bottom  of  the  chest  and  the  stethoscope 
gradually  moved  from  one  interspace  to  another  until  the  entire  chest 
has  been  ausculted;  at  each  step  comparing  the  sounds  of  a  similar  area 
on  the  opposite  side  of  the  chest,  in  the  anterior,  lateral  and  posterior 
regions.  The  supraclavicular  fossae  and  the  axillary  apices  must  not 
be  overlooked. 

The  bell  of  the  stethoscope  is  placed  firmly  against  the  skin  so  as  to 
exclude  external  sounds,  but  too  great  pressure  is  to  be  avoided,  since 
it  increases  skin  tension,  diminishes  elasticity  and  deadens  sound.  Con- 
siderable pressure  maj-  occasionally  be  necessary  in  order  to  bring  the 
bell  nearer  to  the  source  of  the  sound,  as  in  the  case  of  ausculting  the 




fetal  heart  sounds,  also  at  times  to  elicit  pleural  or  pericardial  friction 
sounds  by  bringing  the  inflamed  serous  surfaces  into  more  intimate 

Auscultation  is  sometimes  rendered  difficult  by  the  presence  of 
cutaneous  hair,  edema  or  emphysema.  In  the  first  instance  the  crackling 
of  the  hair  may  be  obviated  by  shaving  or  by  simply  wetting  the  hair. 
The  loud  crackling  sounds  produced  by  subcutaneous  emphysema 
render  auscultation  of  the  intra-thoracic  organs  quite  unreliable  if  not 
absolutely  impossible. 

R.S.A.     R.C.A. 

L.C.A.  L.S.A.A. 



Fig.  95. — Broncho-vesicular  breath  sounds  are  often  due  to  stenosis  of  the  upper  air 
passages.  If  the  patient's  neck  is  sharply  turned  toward  either  side,  if  he  has  hypertrophied 
tonsils,  adenoids,  etc.,  such  sounds  may  be  produced  in  normal  lungs.  They  are  to  be  differ- 
entiated from  pathologic  sounds  bj^  the  fact  that:  1.  The  harshness  is  bilateral,  is  often 
audible  at  a  distance  when  the  patient  breathes  deeply.  2.  They  may  be  greatly  modified 
by  opening  the  mouth.  .3.  They  are  [unassociated  with  other  physical  signs  indicative 
of  pulmonary  consolidation. 

The  illustration  shows  a  stenotic  trachea  due  to  enlargement  of  the  thyroid  gland. 
Also  the  intimate  contact  of  the  right  pulmonary  apex  with  the  trachea,  in  contrast  to  the 
marked  separation  of  these  structures  on  the  left  side.  A,  aorta;  D.A.,  descending  aorta; 
R.S.A.,  right  subclavian  artery;  R.C.A.,  right  carotid  artery;  L.S.A.,  left  subclavian  artery) 
L.C.A.,  left  carotid  artery;  L.M.A.,  left  mammary  artery;  E,  esophagus;  R.V.N'.,  right  vagus 

Extraneous  Sounds,  etc. — Practice  enables  us  to  concentrate  our 
attention  on  a  particular  element  of  a  complex  sound  and  to  disregard 
the  rest.  Thus  when  we  listen  to  the  heart  we  ignore  the  perfectlj^ 
audible  respiratory  sounds  and  vice  versa.  Furthermore,  certain  other 
noises  must  be  prevented  or  equally  eliminated  from  our  consciousness, 
e.g. :  (a)  noises  in  the  room;  (b)  sounds  produced  by  friction  of  the  stetho- 
scope against  the  examiner's  finger  or  patient's  skin  during  the  act  of 
breathing  or  by  the  rhythmic  encroachment  of  a  neighboring  rib,   or 


by  the  fact  that  some  part  of  the  rubber  tubing  comes  into  contact  with 
the  garments,  etc. ;  (c)  sounds  produced  by  the  interposition  of  garments 
between  the  ear  and  the  chest.  Needless  to  say  it  is  useless  to  attempt 
to  auscult  through  stiff  materials  such  as  starched  linen,  (d)  Contract- 
ing muscle  produces  a  sound,  hence  any  muscular  tremor  or  voluntary 
stiffening  of  muscles  on  the  part  of  the  patient  must  be  prevented.  The 
examining  room  must  not  be  cool  enough  to  produce  shivering.  Muscle 
sounds  are  especially  common  over  the  pectoralis  major  in  the  anterior 
axillary  region  and  over  the  trapezius  muscle,  (e)  Occasionally  the 
physician  may,  when  the  stethoscope  has  been  placed  in  the  auditory 
meatus,  become  subjectively  conscious  of  his  own  circulatory  sounds. 

In  ausculting  the  chest,  sounds  are  frequently  heard  which  to  the 
beginner,  sound  like  rales.  If  the  patient  swallows  while  one  is  listening 
over  the  chest  the  sound  produced  resembles  very  clearly  that  produced 
by  a  rale.  This  is  especially  apt  to  occur  when  the  patient  coughs  and 
then  takes  a  moderately  deep  breath.  As  this  procedure  is  employed 
especially  to  elicit  latent  rales,  the  patient  should  be  cautioned  not  to 
swallow.  In  ausculting  the  apices  care  must  also  be  taken  not  to  confuse 
joint  crepitations  with  rales.  The  scapulae,  the  costo-sternal,  sterno- 
clavicular and  shoulder  joints  may  produce  such  sounds.  These  fictitious 
rales  can  be  identified  by  manipulating  the  articulations  named. 

Occasionally  when  ausculting  the  axillary  regions  fine  rales  are  heard 
during  the  first  moderately  deep  inspiration.  They  are  of  no  significance 
unless  they  persist  during  succeeding  inspiratory  acts. 

At  this  place  mention  might  be  made  of  the  transmission  of  sounds 
from  the  diseased  to  the  healthy  side.  Very  often  the  sound  produced 
by  large  bubbling  or  resonating  rales  as  well  as  exaggerated  voice  sounds 
and  loud  cavernous  or  bronchial  breathing  on  one  side  may  be  heard  on 
the  opposite  side.  When  this  occurs  it  is  always  over  the  upper  and 
posterior  portion  of  the  chest  near  the  large  bronchi.  Mistakes  may  be 
avoided  by  noting  the  character  of  the  percussion  note  and  the  breathing, 
and  especially  by  tracing  the  sounds  from  their  point  of  maximum  inten- 
sity across  to  the  opposite  side.  If  the  sounds  are  not  due  to  bilateral 
lesions  they  will  gradually  diminish  in  intensity. 


The  posture  of  the  patient  has  certain  definite  modifying  influences 
upon  the  results  of  the  physical  examination.  A  sitting  position  is 
always  preferable.  If  the  patient  hes  upon  the  side,  percussion  of  the 
lower  lung  yields  a  slightly  impaired  note  with  a  tympanitic  quality. 
The  former  results  from  the  lessened  amount  of  air  which  the  lung  con- 
tains, the  latter  from  diminution  of  pulmonary  tension  and  from  the 
resonating  property  of  the  mattress.  The  resonating  property  of 
extraneous  objects  must  be  borne  in  mind.  For  example,  pulmonary 
resonance  is  greater  if  the  patient  is  percussed  immediately  in  front  of  a 
door  (sounding  board)  then  if  he  stand  in  the  middle  of  the  room.  Shght 
dulness  over  one  pulmonary  apex  which  may  be  readily  demonstrable 
when  the  patient  sits  up,  may  disappear  if  percussion  is  performed  in 
recumbency  while  the  thorax  rests  upon  pillows  or  a  soft  mattress 

In  the  lateral  decubitus  the  breath  sounds  in  the  lowermost  lung  tend 
to  become  mufl9[ed  and  feeble,  owing  to  the  decrease  of  tidal  air.  In  the 
uppermost  lung,  on  the  contrary  their  intensity  may  be  increased. 



The  main  functions  of  the  binaural  stethoscope  are  (1)  to  prevent 
lateral  radiation  of  the  vibrations  with  which  the  air  it  contains,  is  charged, 
thus  conducting  a  larger  proportion  to  the  ear,  and  (2)  to  exclude  extra- 
neous sounds.  A  large  bell  furnishes  more  sound  than  a  small  one,  be- 
cause it  covers  a  larger  area  of  vibration-emitting  surface.  The  bell 
may  also  act  as  a  resonator  and  reinforce  certain  vibrations.  Thus  a 
bell  2  inches  in  diameter  enables  us  to  judge  accurately  regarding  inten- 
sity and  rhythm,  but  is  inferior  to  a  bell  of  ordinary  size  or  to  the  unaided 
ear  in  the  judging  of  equality  and  pitch  (Flint).  Furthermore  it  is 
evident  that  depending  upon  its  shape  and  the  elasticity  of  the  material 
of  which  it  is  made,  the  resonating  quality  of  the  bell  must  vary  consider- 
ably. A  small  bell  is  also  advantageous  since  it  enables  us  to  localize 
sound  more  sharply,  this  being  especially  important  in  ausculting  the 
heart  and  the  supraclavicular  apices,  as  well  as  in  children  and  emaciated 
individuals  in  whom  the  projecting  ribs  interfere  with  close  application 
of  the  bell. 

The  importance  of  the  thoracic  wall  in  acting  as  a  resonator  of  the 
laryngeal  vibrations  has  already  been  alluded  to  under  vocal  fremitus 
(p.  47).  The  sounds  that  we  hear  are  due  to  both  visceral  and  mural 
vibrations.  The  latter  sometimes  preponderate  in  intensity  and  having 
a  lower  pitch  have  a  greater  volume;  whereas  the  higher  range  due  to  the 
fundamental  note  is  often  medically  of  greater  importance.  Mural 
vibrations  can  to  a  certain  extent  be  eliminated,  and  the  visceral  vibra- 
tions studied  in  isolation  by  exerting  marked  pressure,  with  the  bell  of  a 
a  binaural  stethoscope  equipped  with  rubber  tubing. 

In  case  of  the  mon-aural  stethoscope  made  with  a  hollow  or  solid  stem 
of  metal,  vulcanite  or  wood,  transmission  occurs  both  through  the  stem 
and  through  its  contained  air.  The  thinner  the  walls  of  the  stem  and  the 
bell,  the  more  easily  will  sympathetic  vibrations  be  set  up  and  trans- 
mitted to  the  ear.  A  large  part  of  the  sound  is  thus  transmitted  by  the 
solid  stem.  This  applies  to  a  slight  extent  also  to  the  modern  binaural 
stethoscope,  in  which  some  sound  is  conducted  by  the  rubber  tubing, 
which  tends  to  reinforce  the  aerial  vibrations.  Nor  "is  it  immaterial 
what  thickness  of  tubing  we  employ.  It  must  be  neither  too  flexible 
nor  too  rigid.  High-pitched  sounds  are  conducted  along  tubes,  especially 
soft  tubes  much  less  readily  than  low-pitched  sounds,  because  of  their 
smaller  mass." 

In  using  the  binaural  stethoscope  with  rubber  tubing,  the  results  of 
pressure  on  the  thoracic  wall  are  quite  different.  In  case,  for  instance, 
that  the  bell  is  thick-walled,  and  possessed  of  a  high  fundamental  note 
it  will  be  much  less  affected  by  the  damped  mural  vibrations  than  is  the 
case  with  the  monaural  stethoscope. 

"A  solid  body  laid  upon  the  chest  wall  takes  up  and  transmits  accord- 
ing to  its  own  elastic  properties  the  vibrations  emanating  from  the  latter. 
When  the  pressure  of  the  solid  body  upon  the  surface  is  sufficiently  in- 
creased, the  sensible  vibrations  of  the  latter  are  damped,  but  their  energy 
is,  of  course,  transferred  to  the  body  which  extinguished  them.  When,  for 
example,  the  mon-aural,  solid  stethoscope  is  applied  to  the  chest,  the  sounds 
heard  through  it  are  not  deadened  by  increasing  the  pressure  of  contact; 
on  the  contrary,  they  tend  to  become  more  intense,  and  are  brought 


nearer  the  ear.''i  The  diaphragmatic  type  of  instrument  yields  louder 
sounds  than  a  simple  bell,  because  it  covers  a  large  area  of  sound 
emitting  surface  and  because  the  diaphragm  prevents  the  encroachment 
of  the  soft  tissues  upon  the  lumen  of  the  receiver  (^Montgomery).  Per- 
haps also  the  sound  waves  are  amplified  by  the  vibrations  of  the  disc. 
At  all  events,  this  tj^pe  of  instrument  should  be  used  as  a  magnifying  lens 
to  study  detail  and,  especially  by  the  beginner,  not  as  the  sole  method 
of  auscultation.  The  sounds  heard  are  Jiot  merely  intensified,  often  they 
are  distorted  because  the  instrument  disproportionately  magnifies  certain 

"Binaural  stethoscopes  and  to  a  minor  degree  phonendoscopes  are 
less  well  adapted  for  the  auscultation  of  faint,  high-pitched  murmurs, 
wheezy  sounds  and  the  metallic  phenomena.''^ 

Pulmonar}'  sounds  are  often  heard  better  with  the  unaided  ear, 
applied  directly  to  the  chest  wall,  because  in  such  cases  we  get  bone 
conduction  as  well  as  ear  conduction.  The  early  stages  of  pulmonary 
consolidation,  the  tubular  quality  of  bronchial  breathing,  and  at  times  the 
diastolic  aortic  murmur  are  also  better  appreciated  without  a  stethoscope. 

On  the  other  hand,  the  vesicular  element  of  the  respiratory  murmur, 
heart  sounds,  and  generally  speaking  murmurs,  also  certain  rules  are  more 
easily  analyzed  uyith  a  stethoscope.  This  is  perhaps  due  to  the  fact  that 
certain  wave  lengths  bear  a  definite  reinforcing  relation  to  the  size  of  the 
receiver  and  the  length  of  the  stethoscope  tubing.- 

With  a  small  bell  we  can  localize  more  sharply  but  we  get  less  volume. 
Therefore,  wider  bells  give  better  results  for  feeble  sounds — weak  mur- 
murs, fetal  heart  sounds,  etc.  For  the  latter  deep  pressure  on  the  abdo- 
men is  also  requisite. 

If  a  stethoscope  with  a  spring  is  used,  the  curvature  of  the  metal  parts 
and  ear  pieces  should  correspond  to  that  of  the  external  auditory  meatus, 
since  the  opening  in  the  ear  piece  should  point  directly  toward  the  drum 
and  not  toward  the  cartilaginous  meatus.  Owing  to  differences  in  the  angle 
of  individual  ears,  stethoscopes  with  metal  ear  pieces  must  have  adjust- 
able angulations.  It  is  partly  for  this  reason  that  the  author  prefers 
simple  rubber  tubing  without  any  spring  attachment  whatever. 

The  Choice  of  a  Stethoscope.— This  is  largely  a  question  of  personal 
preference.  A  small  minority  still  prefer  the  mon-aural  type,  perhaps  as 
a  matter  of  habit.  Certainly  two  ears  are  better  than  one,  especially 
when  one  is  hampered  by  extraneous  noises.  In  a  choice  between  many 
binaural  types  certain  factors  must  be  considered: 

1.  The  ear  pieces  must  fit  the  external  auditory  meatus  exactl,y,  not 
only  in  order  to  exclude  outside  noises,  but  also  so  that  the  instrument 
can  be  used  indefiniteh'  without  discomfort  or  pain.  A  little  time  con- 
sumed in  filing  the  ear  pieces  to  the  proper  shape  and  dimensions  is  well 

2.  Instruments  of  the  phonendoscope  type— those  with  diaphragms 
— should  never  be  used  by  beginners.  They  not  only  magnify,  but  also 
distort,  sounds.  Their  habitual  use  even  bj-  more  experienced  clinicians 
establishes  a  false  standard  of  normality,  and' often  renders  the  examiner 
more  or  less  helpless  in  case  they  are  temporarily  unavailable. 

^  Sewall,  Hexry:  "The  Role  of  the  Stethoscope  in  Physical  Diagnosis.''  Amer. 
Jour.  Med.  Sci.,  February,  1913,  p.  234. 

2  Conner:  A".  Y.  Med.  Jour.,  Julv  13.  1907. 


3.  The  tubing  should  not  be  smaller  than  the  caliber  of  the  metal 
parts,  and  should  be  sufficiently  heavy  to  prevent  kinking. 

4.  An  extra  bell  (receiver)  smaller  than  the  usual  size  is  desirable, 
especially  in  the  practice  of  pediatrics. 

5.  The  instrument  should  be  light  and  compact  so  that  it  can  be 
readily  carried  in  the  pocket. 

The  author  personally  prefers  the  Sansom  instrument  with  two  bells,. 
and  furnished  with  an  extra  diaphragmatic  receiver  for  occasional  use. 


The  act  of  breathing  causes  certain  sounds  which  are  known  as  the 
breath  sounds  or  the  respiratory  murmur.  The  breath  sounds  may  be 
heard  when  the  ear  is  applied  to  an  area  of  the  thorax  overlying  lung 
tissue.  They  are  composed  of:  (1)  the  laryngeal  or  "bronchial,"  and 
(2)  the  vesicular,  elements. 

The  Laryngeal  Element. — During  both  inspiration  and  expiration 
certain  sounds  are  produced  in  the  nose,  mouth,  glottis,  larjmx  and 
trachea.  They  are  due  to  sonorous  vibrations  caused  bj-  a  column  of 
air  moving  through  the  structures  in  ciuestion  (Fig.  96). 

If  we  listen  over  the  trachea  during  the  act  of  respiration  we  generally 
hear  high-pitched  sounds,  having  a  tubular  quality,  with  expiration 
lasting  as  long  or  longer  than  inspiration;  the  former  having  a  higher 
pitch  than  the  latter  and  being  separated  from  it  by  a  distinct  interval. 
When  we  listen  over  the  lung  these  sounds  have  undergone  a  great  modi- 
fication. The  sounds  are  softer,  lower  in  pitch,  expiration  is  very  short, 
and  faint,  indeed  often  it  is  inaudible,  while  the  pause  separating  inspira- 
tion has  practically  disappeared. 

Stenosis  of  any  portion  of  the  upper  respiratory  tract,  such  as  by  nasal 
or  faucial  adenoids,  markedlj^  increases  the  intensity  of  the  larjmgeal 
element  of  the  respiratory  murmur.  Such  obstruction  may  cause 
broncho-vesicular  breathing  over  the  pulmonary  apices,  thus  simulating 
infiltration  of  the  lung.  It  is  to  be  distinguished  from  the  latter  by  its 
bilateral  character,  disappearance  when  the  obstruction  is  removed  and 
by  the  absence  of  percussion  dulness  (Fig.  95). 

The  primary  sound  producing  vibration  in  the  respirator}^  system 
arises  in  the  vibrations  of  tissues,  not  of  the  air.  The  moving  air  sets 
the  tissues  in  motion;  this  produces  a  sound,  which  is  in  turn  conveyed  or 
conducted  by  the  air,  as  well  as  by  the  tissues  which  surround  them — 
the  bronchi  and  pulmonary  tissue. 

The  relationship  is  that  of  the  bow,  to  the  violin  strmg,  the  former  being 
represented  by  the  air  current,  the  latter  hj  the  tissues.  Furthermore, 
the  rapidity  of  the  current  affects  the  intensity  of  the  sounds  (ampHtude 
of  the  vibrations).  When  the  air  current  is  rapid,  more  intense  breath 
sounds  are  produced.  Just  as  the  voice  sounds  produced  in  the  larynx 
are  carried  downward  into  and  through  the  pulmonary  tissues,  where 
they  are  heard  as  "vocal  resonance."  so  are  the  breath  sounds,  which 
arise  at  the  same  source  and  are  spoken  of  as  the  "vesicular  murmur." 

"  The  chief  effect  of  the  bronchial  wahs  is  to  prevent  diffusion,  thus 
allowing  the  good  conducting  properties  of  the  air  to  operate  at 

The  voice  and  breath  sounds  lose  much  of  their  intensity  as  we  hear 
them  over  the  chest  wall,  (1)  as  a  result  of  diffusion,  although  this  loss 


is  more  or  less  offset  by  the  deep  penetration  of  the  bronchi  into  the 
puhnonary  tissue;  (2)  owing  to  reflection  which  occurs  when  the  air- 
borne vibrations  pass  through  the  walls  of  the  bronchi;  (3)  because  in 

FiQ.  96. — This  antero-posterior  section  through  the  head  and  thorax  depicts  the  struc- 
tures concerned  in  the  production  and  modification  of  the  "laryngeal"  element  of  the  breath 

Auscultation  over  the  area  "A"  during  nasal  breathing,  the  mouth  being  closed,  yields 
pure  cavernous  breathing  (low-pitched  sounds  with  a  hollow  or  reverberating  quality,  and 
expiration  longer  than  inspiration).  The  outgoing  air  strikes  the  nares  more  directly  than 
when  the  mouth  is  open;  the  vocal  cords  are  more  closely  approximated  during  expiration 
and  vibrate  considerably.  The  nares  and  the  mouth  furnish  the  cavity  for  the  reverbera- 
tion of  sound,  and  the  occipital  bone  is  a  good  conductor. 

Auscultation  over  the  area  "B."  If  the  mouth  is  open,  the  air  passes  directly  out  of  it, 
the  nasal  resonator  has  been  eliminated  and  the  cavernous  quality  as  well  as  the  intensity  of 
the  breath  sounds  almost  entirely  disappear.  The  results  of  tracheal  auscultation  are  also 
greatly  modified  by  oral  and  nasal  breathing.      (Barach.) 

passing  from  the  bronchial  walls  into  the  pulmonary  septa  more  wave 
energy  is  lost  by  reflection;  (4)  as  similar  loss  occurs  in  passing  through 
the  air  chambers  of  a  normally  distended  lung;  (5)  since  they  meet  with 
reflection  again  in  passing  from  the  lung  to  the  chest  wall,  because  here 


again  a  distinct  "break"  occurs  in  passing  from  a  very  light  to  a  fairly 
heavy  medium,  as  well  as  (6)  diffusion  in  passing  through  the  chest  wall. 

The  breath  sounds  as  heard  over  the  chest  become  altered  in  the 
character  they  possess  at  their  source  of  origin,  in  regard  to  intensity, 
quality  and  pitch.  The  change  in  intensity  results  mainly  from  diffusion 
and  reflection  although  absorption,  resonance,  and  perhaps  interference 
also  plays  a  part.  "  Changes  in  pitch  and  quality,  although  explicable 
to  some  extent  in  the  elimination  of  the  weaker  vibrations  as  the  whole 
sound  becomes  more  feeble,  appear  to  be  due  chieflj^  to  the  factors  of 
resonance  and  interference  affecting  certain  vibrations,  while  exerting 
little  or  no  influence  on  other  vibrations  which  go  to  form  the  complex 
group  of  vibrations  which  we  ordinarily  term  a  single  sound" 
(Montgomery)  (see  p.  60). 

The  Vesicular  Element. — In  addition  to  the  laryngeal  sound  just 
described,  a  vesicular  element  is  added  which,  when  auscultation  is 
practised  over  the  chest,  furnishes  most  of  the  inspiratory  pulmonary 
breath  sound.  It  is  due  to  the  separation  and  distention  of  the  alveoli 
by  the  inrushing  current  of  air.  The  expiratory  portion  appears  to  arise 
in  the  upper  respiratory  tract.  The  fact  that  the  sound  heard  over  the 
chest  wall  is  more  muffled,  weaker  and  lower  in  pitch  than  that  audible 
experimentally  over  the  actual  periphery  of  the  lung  is  due  to  loss  of 
vibratory  intensity  in  passing  from  the  lung  to  the  chest  wall  and  from 
the  chest  wall  to  the  stethoscope  (vibratory  reflection). 

The  Basis  for  the  Assumption  of  Alveolar  Sound  Production. — The 
cubic  capacity  of  an  alveolus  is  0.00494  mm.   (Zuntz), 

In  long-necked  animals,  such  as  the  ruminants,  the  respiratory  murmur  is  much 
less  loud  than  in  the  short-necked  ones,  such  as  the  carnivora. 

The  estimated  total  of  the  alveoli  is  400  million.  As  the  average  lung  volume  is 
4000  cm.,  1  cm.  would  include  100,000  alveoli.  If  we  assume  that  in  ausculting  we 
hear  sound  from  a  depth  of  3  cm.,  we  would  perceive  sound  yielded  by  half  a  sphere  14 
cm.  in  circumference.  In  other  words,  we  would  hear  the  combined  sound  of  1,400,000 
alveoli.  Since  a  normal  deep  inspiration  takes  2  seconds,  we  should  hear  the  sound  of 
700,000  alveoli  per  second.  Now  we  cannot  recognize  as  separate  sounds,  vibrations 
occurring  with  a  rapidity  of  700  per  second,  as  would  be  the  case  if  1000  alveoli  gave 
forth  sound  simultaneously.  But  alveolar  distention  is  gradual  and  when  a  sufBcient 
number  of  sequent  groups  produce  sound,  it  is  extremely  plausible  to  assume  that  an 
audible  sound  is  thus  engendered. 

Only  on  such  a  hypothesis  can  we  assume  that  sound  is  produced  in  the  alveoli. 
The  dimensions  of  an  alveolus  are  so  small  that  there  is  no  possibility  of  sound 
production  after  the  manner  in  which  it  occurs  in  the  trachea  or  bronchi.  "There 
can  be  no  question  of  inspirator}'  vibration,  reflexion,  interference,  or  the  formation 
of  horizontal  waves  where  there  is  no  reflective  wall  because  the  relationship  between 
the  size  of  the  waves  and  the  chambers  is  too  disproportionate"  (Geigel,  p.  172). 

"The  total  alveolar  surface  of  the  lung  amoimts  to  no  less  than  90  square  meters, 
or  100  times  the  body  surface."^  The  interlobar  bronchioles  end  in  narrow  alveolar 
ducts  and  these  "expand  in  turn  into  comparatively  wide  infundibuli  lined  by  air 
cells.  This  sudden  widening  out  of  the  air  passage  is  believed  to  aid  in  the  produc- 
tion of  the  inspiratory  sound  heard  in  ausculting  the  lungs,  eddies  being  set  up  in 
the  passage  of  the  air  from  the  narrower  to  the  wider  cavity"  (Hutchison). 

Sahli  found  in  a  case  of  pulmonary  hernia  due  to  a  sternal  fissure  that  character- 
istic vesicular  breathing  could  be  heard  over  the  hernia  during  the  performance  of  the 
Valsalva  experiment,  in  which  of  course  all  laryngeal  and  glottic  sounds  were  elimi- 
nated, and  proving  that  at  least  a  part  of  the  vesicular  sound  originated  in  the  ves- 
icles themselves.  The  vesicular  sound  is  also  noted  in  cases  of  cardio-pulmonarj-  mur- 
murs, a  factor  which  further  corroborates  the  foregoing  statement  (Sahli,  Corre- 
spondenzblatt  f.  Schweizer  Aertze,  1892). 

1  R.  Hutchison:  "Applied  Physiology,"  1908. 


The  greater  part  of  the  expiratory  sound  is  produced  by  the  passage 
of  air  over  the  vocal  cords  and  through  the  glottis.  It  contains,  as  well, 
certain  sounds  arising  in  the  oral  and  nasal  ca^'ities  and  some  contributed 
by  the  trachea  and  the  bronchi. 

The  greater  part  of  the  inspiratory  portion  arises  in  the  vesicles.  In 
as  much,  therefore,  as  both,  but  especially  the  expiratorj-  portion,  have  a 
composite  genesis  it  is  not  surprising  to  find  that  the  breath  sounds  heard 
over  the  chest  may  var}-  in  different  individuals,  and  even  in  the  same 
person  under  varying  conditions,  in  regard  to  intensity,  qualit}',  dura- 
tion and  pitch. 



The  sound  normally  heard  over  pulmonary  tissue  during  the  act  of 
breathing — the  vesicular  murmur — is  regular  in  rhythm,  low  in  pitch,  and 
soft,  breezy  or  rustling  in  character.  It  is  heard  throughout  respiration, 
but  progressively  diminishes  in  intensity  during  expiration,  the  end  of 
which  is  inaudible.  There  is  only  a  very  brief  pause  between  in-  and 
expiration.  It  is  to  be  noted  that  although  the  duration  of  these  two 
physiologic  phases  of  respiration  is  as  5  to  6,  the  audible  duration  is  as 
5  to  1,  respectively.  In  other  words  the  expiratory  sound  is  much  shorter 
than  that  of  inspiration,  and  sometimes  it  is  barely  audible.  Being  a  purely 
passive  act,  which  results  from  the  elastic  recoil  of  the  distended  lung 
tissue,  it  is  less  harsh,  and  lower  in  pitch,  as  well  as  shorter  than  inspira- 
tion. The  elastic  recoil  is  greatest  at  the  end  of  inspiration,  hence 
the  beginning  of  expiration  is  more  intense  than  its  end.  Furthermore, 
the  glottis  is  more  widely  opened  during  inspiration  and  the  air  leaves 
the  chest  less  rapidly  than  it  enters.  The  vesicular  sound  may  be 
imitated  by  breathing  deeply  with  the  lips  set  in  the  position  which  pro- 
duces a  soft  "F. "  In  ausculting  the  lungs,  the  beginner  especially, 
should  note  the  character  of  the  expiration,  for  it  is  in  this  phase  particularly 
that  pathologic  abnormalities  are  most  apt  to  occur. 


The  vesicular  murmur  may  become  abnormal  owing:  (1)  to  a  change 
in  its  character  (intensity,  quality,  duration,  pitch  or  rhythm) ;  or  (2)  to 
the  introduction  of  new  or  adventitious  sounds,  i.e.,  (a)  rales;  (5)  fric- 
tions; (c)  succussion  splash;  {d)  metallic  tinkle. 


Abnormal  breath  sounds  are  more  or  less  arbitrarily  classified  as  (1) 
exaggerated,  (2)  broncho-vesicular,  (3)  bronchial,  (4)  cavernous,  and  (5) 

Changes  in  the  Intensity  and  Quality  of  the  Breath  Sounds. — Exagger- 
ated Breathing. — (a)  A  mere  increase  in  the  intensity  of  the  respiratory 
murmur  is  known  as  exaggerated  breath  sounds,  and  is  due  to  increased 
vesicular  activity — more  air  entering  in  a  given  unit  of  time  than  is  nor- 
mally the  case.  Such  a  condition  is  normal  in  children,  hence  the  name 
puerile  breathing.  It  may  occur  in  any  individual  who  is  breathing  hard, 
as  for  instance  after  physical  exertion.  In  women  the  respiratory  sounds 
are  louder  than  in  men,  especially  in  the  upper,  anterior  thoracic  region, 
and  during  expiration  (costal  breathing).  In  exaggerated  breathing 
both  in-  and  expiration  are  harsh  and  prolonged  because  the  glottic 




sounds  are  louder,  and  on  account  ol'  the  increased  pulmonarj'  tension 
(vicarious   "  emphysema  ") . 

(h)  Decreased  breath  sounds  (feeble,  senile,  emphysematous,  breath 
sounds)  are  characterized  by  the  fact  that  the  sounds  are  faint  or  short; 
expiration  may  be  inaudible.  This  may  be  due  to:  (1)  diminished  sound 
conduction — bronchial  obstruction  (increased  diffusion  and  reflection) — 
pleural  effusion  or  thickening  (increased  reflection)  cutaneous  adiposity 
or  edema,  etc.;  or  to  (2)  diminished  sound  production — shallow  breath- 
ing arising  from  pain,  muscular  weakness,  thoracic  rigidity,  pulmonary 

Fig.  97. — Diagram  to  illustrate  tlu-  incurrence  and  non-occurrence  of  bronchial 
breathing  in  pneumonia.  On  the  right  aide  the  consolidation  spreading  inward  has 
reached  the  bronchus  and  as  a  result  bronchophony  and  bronchial  breathing  are  heard. 

On  the  left  side  there  is  still  a  break  in  the  continuity  of  consolidation  between  the 
periphery  and  the  large  tubes,  and  although  dulness  is  marked,  bronchial  breathing  and 
bronchophony  are  absent.  The  breath  sounds  are  feeble  or  absent.  This  partial  or  entire 
suppression  of  the  breath  sounds,  especially  of  the  vesicular  clement,  associated  with  percussion 
dulness,  and  occasional  rales  on  deep  breathing,  occurs  in  the  early  days  of  a  pneumonia  much 
more  frequently  than  bronchial  breathing. 

In  the  early  stages  of  pneumonia  and  of  pulmonary  tuberculosis  the 
sounds  are  often  indistinct  and  muffled. 

(c)  Breath  sounds  may  be  absent  in  pleural  effusion,  closed  pneumotho- 
races  with  atalectasis,  or  from  occlusion  of  a  bronchus — pressure  or 
exudation.  "Diffusion  of  sound  between  the  lung  surface,  free  from 
adhesions,  and  the  chest  wall,  shares  the  honors  with  reflection  of  sound 
from  the  fluid  back  into  the  air  in  the  lung,  in  reducing  the  intensitj^  of 
sounds  in  their  passage  from  lung  to  chest  wall  in  ordinary  cases  of  pleural 
effusion"  (Montgomery). 


Pleural  effusions  sometimes  yield  normal  or  actually  increased! 
fremitus,  voice  and  breath  sounds  even  below  the  level  of  the  fluid.[ 

This  phenomenon  is  ascribed  by  Montgomery  to  the  fact  that  the  lung  is 
solid  either  as  the  result  of  exudation,  infiltration  or  compression  and 
being  such  imparts  its  vibrations  readily  to  the  surrounding  fluid  without 
much  of  a  "break"  due  to  reflection.  This  state  of  affairs  is  only  inade- 
quately offset  by  the  loss  of  sound  through  diffusion  in  the  effusion,  so 
that  the  end  result  is  at  least  ''normal"  if  not  actually  an  increased  inten- 
sity of  transmission.  A  similar  effect,  although  less  in  degree,  may  be 
exerted  upon  fluid  by  a  collapsed  lung.  It  is  furthermore  evident  that 
anything  which  tends  to  bring  the  lung  near  to  the  chest  wall — adhesions, 
large  lungs  and  small  thoraces  (in  infants) — would  further  tend  to  prevent 
the  disappearance  of  fremitus,  resonance  and  breath  sounds,  in  cases  of 
pleural  effusion. 

Broncho -vesicular  Breathing. — This  is  a  combination  of  the  vesicular 
and  the  bronchial  types,  both  the  soft  vesicular  and  the  harsh  bronchial 
elements  being  present,  either  one  of  which  may  predominate.  Some 
authorities  prefer  to  use  the  term  vesiculo-bronchial  if  the  vesicular 
sound  is  preponderant,  and  broncho-vesicular  when  the  bronchial  sound 
is  the  greater.  Others  prefer  to  include  both  these  types  under  one  head- 
ing, and  modify  the  term  by  adding  such  adjectives  as  slight,  marked, 
harsh,  intense,   etc. 

Physiologic  broncho-vesicular  breathing  is  heard  over  definite  locations 
at  which  it  is  normal  and  can  be  explained  on  anatomic  grounds.  It  is 
considerably  influenced  by  opening,  narrowing  or  closing  the  mouth  or 
the  glottis;  and  tends  to  become  moi-e  intense  as  a  main  bronchus  is  ap- 
proached. It  is  normally  heard  below  the  right  clavicle  especially  at 
the  second  costo-sternal  articulation  and  posteriorly  at  the  tracheal 
bifurcation.  Auscultation  over  the  manubrium  yields  a  soft  vesicular 
murmur.  Bronchial  breathing  over  this  area  may  occur  if  the  anterior 
mechastinum  is  encroached  upon  by,  (1)  persistent  thymus;  (2)  sub- 
sternal thyroid  enlargement;  (3)  edema  of  the  mediastinal  tissues;  (4) 
glandular  enlargement;  (5)  dilatation  or  aneurism  of  the  aorta;  (6) 
tumors.  (Warfield.)  The  pathologic  type  of  hroncho-vesicular  breathing 
may  occur  over  any  portion  of  the  lung  and  is  relatively  uninfluenced  by 
alterations  in  the  oral  resonator  (breathing  through  the  mouth  or  nose). 
It  occurs  when  both  normal  vesicles  and  infiltrated  pulmonary  tissue 
exist  together,  as  in  incomplete  consolidation.     (Figs.  98  and  99.) 

BrOiichial  Breathing. — By  this  term  which  is  synonymous  with  tubular 
breathing,  we  understand  a  loud,  harsh,  high-pitched,  snorting  type  of 
breath  sound,  with  a  distinct  pause  betiveen  inspiration  and  expiration,  the 
latter  being  even  longer,  more  harsh  and  higher-pitched  than  the  former. 
The  soft,  low-pitched,  rustling  or  breezy  vesicular  element  is  entirely 
absent.  The  breath-sounds  normally  heard  over  the  trachea  are  often 
used  as  an  example  of  bronchial  breathing,  but  the  tracheal  sound  is 
generally  more  harsh  and  lower  in  pitch  than  that  which  occurs  patho- 
logically over  consolidated  lung  tissue.  As  in  normal  breathing,  the 
primary  sound  originates  in  the  upper  respiratory  tract.  Bronchial 
breathing  is  characteristic  of  consolidated  lung  because  conditions 
are  less  unfavorable  for  sound  transmission  than  is  the  case  in  normal 
lungs.  The  vibrations  pass  from  the  bronchial  wall  to  the  surrounding 
consolidated  lung  and  thence  to  the  chest  wall  without  undergoing  a 



Fig.  98. 

Fig.  99. 

Figs.  98  and  99. — These  figures  illustrate  the  areas  over  which  breath  sounds  are  nor- 
mally harsh.  The  term  vesiculo-bronchial  as  here  used  signifies  vesicular  breathing  with  a 
very, slight  degree  of  the  bronchial  element.  In  other  words,  the  sound  heard  is  just  a  trifle 
more  harsh  and  high  pitched  than  over  the  corresponding  area  on  the  opposite  side.  The 
degree  of  harshness  which  is  subject  to  considerable  individual  variation,  is  mainly  due  to 
the  proximity  of  the  right  upper  lobe  to  the  trachea  anteriorly,  and  posteriorly,  in  addition, 
to  the  tracheal  bifurcation.      (Compare  Figs.  49,  52,  75,  95,  104.) 



serious  "break"  in  the  process  of  transmission.  This  is  so  because 
bronchus,  soHd  lung  and  chest  wall  are  acoustically  more  or  less  identical 
and  there  is,  therefore,  not  much  chance  for  diffusion  or  reflection  of  the 
vibrations  at  the  different  tissue  junctions. 

Montgomery  has  shown  that  lung  under  normal  tension  transmits 
sound  much  less  well  than  either  relaxed  or  consolidated  pulmonary  tissue. 
"The  occurrence  of  weaker  sounds  over  the  normal  chest  than  over  the 
chest  where  there  is  consohdation  is  due  not  only  to  favorable  conditions 
on  the  diseased  side,  but  also  to  unfavorable  transmission  facilities  on  the 
normal  side.  These  are  the  main  factors  in  explaining  why  the  side  con- 
taining the  larger  amount  of  air  3delds  weaker  sounds  at  the  periphery  of 
the  chest  than  that  containing  the  greater  amount  of  solid  tissue." 

The  term  bronchial  breathing  is  sanctioned  by  usage,  but  is  not 
descriptive  as  signifying  the  sound  normally  heard  over  the  bronchi. 

Pure  bronchia 


Fig.   100. — Diagram  illustrating  different  types  of  the  breath  sounds  in  various 
pathologic  conditions. 

The  type  of  bronchial  breathing  heard  above  and  sometimes  directly 
over  pleural  effusions  has  a  similar  genesis  and  is  due  to  associated  com- 
pression or  consolidation  of  the  lung. 

Bronchial  breathing  occurs  characteristically  over  large  areas  of 
complete  pulmonary  consolidation  such  as  in  pneumonia.  It  frequently 
is  not  demonstrable  until  the  third  or  fourth  day  after  the  onset.  The 
consolidation  begins  at  the  periphery  and  gradually  spreads  inward 
toward  the  hilus  and  although  dulness  occurs  quite  early,  bronchial 
breathing  and  bronchophony  do  not  appear  until  the  entire  fan-shaped 
area  of  lung  tissue  lying  between  the  pleura  and  the  large  bronchi  has 
become  consohdated  (see  Fig.  97). 

Bronchial  breathing  is  never  heard  over  normal  lu7ig  tissue.  It  maj''  be 
imitated  by  a  harshly  whispered  "Ha"  or  by  a  guttural  "Ch." 



Cavernous  Breathing. — This  type  of  breathing  may  be  heard  over 
cavities  and  open  pneumothoraces.  It  is  low  in  pitch,  and  has  a  hollow 
reverberating  quality.  Frequently  the  expiration  is  even  lower-pitched 
than  the  inspiration,  the  relations  of  bronchial  breathing  being  thus 
reversed.  As  pointed  out  by  Flint,  it  is  more  apt  to  be  confused  with 
normal  vesicular  breathing,  than  with  the  bronchial  type,  and  is  to  be 

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differentiated  from  the  former  ''only  by  the  absence  of  the  vesicular 
quality  in  the  inspiratory  sound"  (Flint).  The  expiration  is  always  pro- 
longed and  puffing  (Loomis).  Phonetic  equivalent  =  whispered  "Who." 
Some  authors  deny  the  existence  of  cavernous  breathing  altogether, 
classing  it  as  a  variety  of  bronchial  breathing — low-pitched  bronchial. 
Cavernous  breathing  may  be  imitated  by  breathing  into  the  hollowed 


hands  It  is  heard  normally  over  the  occiput,  especially  if  the  mouth  be 
closed  (see  Fig.  96). 

Like  bronchial  breathing,  cavernous  breathing  has  its  origin  in  the 
upper  respiratory  tract.  In  the  former,  however,  we  are  dealing  not 
merely  with  ordinary  bronchi  but  also  with  excavations  which  possess 
resonating  properties. 

Only  rarely  is  the  genesis  of  this  sound  due  to  the  fact  that  the 
respiratory  air  current  actually  enters  a  cavity  and  sets  up  vibrations 
within  it.  VVhat  generally  occurs  is  that  vibrations  in  the  neighborhood 
of,  and  external  to  the  cavity,  set  up  sympathetic  vibrations  within  the 
cavity,  which  then  acts  as  resonator,  reinforcing  and  modifying  the  original 
sound;  imparting  to  it  the  hollow  reverberating  quality  which  we  recog- 
nize as  "cavernous"  or  the  higher-pitched  metallic  sound  which  we  desig- 
nate as  amphoric  breathing. 

It  is  hardly  necessary  to  point  out  the  fact  that  even  large  cavities 
may  exist  without  revealing  their  presence  by  cavernous  or  amphoric 
breathing.  When  more  or  less  filled  with  mucus,  pus,  or  blood,  the 
cavity  may  be  "silent"  or  only  manifested  by  localized  rales. 

Amphoric  Breathing. — 1  his  is  a  high-pitched  form  of  cavernous  breath- 
ing, with  high  ringing  overtones  which  impart  a  metallic  quality.  It  may 
be  heard :  over  tense,  smooth,  stiff-walled  cavities,  in  size  not  less  than  a 
walnut,  especially  if  superficially  placed;  and  over  pneumothoraces. 
It  is  analogous  to  the  metallic  ring  of  percussion  (see  p.  70). 

Fig.  102. — Diagram  illustrating  tho  production  of  metallic  breath  sounds — amphoric 
breathing — in  large  stiff-walled  cavities. 

If  we  blow  into  a  cylinder  such  as  a  test-tube,  in  such  a  way  as  to  cause  sound  waves 
by  reflection,  we  get  a  strong  fundamental  note,  with  weak  harmonious  overtones,  but 
if,  as  with  the  bottle  we  add  a  neck  relatively  small  in  proportion  to  the  size  of  the 
cylinder,  and  sufficiently  long,  we  get  a  peculiar  high  metallic  quality.  This  is  the 
result  of  unrhythmic  vibrations,  due  either  to  the  angle  of  reflection  or  to  the  force  of 
the  blow,  by  virtue  of  which  the  air  in  the  lee  of  the  neck  (see  Fig.  102)  does  not  begin 
to  vibrate  until  after  that  beyond  has  been  set  in  vibration.  In  the  former  instance 
we  produce  cavernous,  in  the  latter  amphoric,  sounds. 

Amphoric  sounds  may  be  heard  over  a  closed  cavity,  or  a  closed 
pneumothorax;  in  these  cases  the  metallic  quality  is  due  to  a  quick,  local 
percussion  of  their  walls  by  means  of  the  neighboring  air  columns. 

Although  amphoric  breathing  is  more  intense,  and  generally  of  higher 
pitch  than  cavernous  breathing,  the  essential  difference  lies  in  the  metallic 
quality  of  the  former.  If  we  blow  softly  across  the  neck  of  a  bottle  the 
sound  will  be  cavernous,  if  intensely,  it  becomes  amphoric.  The  pitch 
depends  on  the  length  of  the  air  columns  and  on  the  size  of  the  opening. 
The  metallic  quality  depends  on  the  generation  of  very  unrhythmic 
vibrations — on  the  suddenness  of  the  entrance  or  impact  of  the  vibrations. 
It  is  for  this  reason  that  the  amphoric  quality  is  often  only  apparent  dur- 
ing forcible  breathing,  just  as  a  metallic  percussion  note,  and  cracked-pot 
sound  can  generally  only  be  elicited  by  quick,  forcible  percussion. 



Fig.  103.- — Cardiac  IIyukothurax.  A  ciiae  of  rheumatic  mitral  and  tricuspid  disease, 
with  marked  cardiac  dilatation,  auricular  fibrillation,  etc.,  under  observation  for  many  yeara. 
Died  in  a  state  of  anasarca.     Body  frozen  in  the  recumbent  posture. 

The  diaphragm  is  depressed.  The  effusion  reaches  to  the  uppermost  limits  of  the 
pleural  cavity.     The  lung  is  compressed,  and  the  dilated  heart,  displaced  downward. 

The  pericardium  contains  a  small  effusion.     The  following  physical  signs  were  noted: 

Over  the  back  and  the  sides  of  the  chest:  A  flat  percussion  note,  with  absent  vocal  frem- 
itus and  resonance  and  breath  sounds.  Over  the  front  of  the  chest:  A  short,  high-pitched, 
slightly  tympanitic  note  (Skodaic) ;  exaggerated  breath  sounds,  increased  vocal  fremitus 
and  resonance  (compression) ;  subcrepitant  rales  (congestion  and  serous  exudation) ;  in  some 
areas  distant  broncho-vesicular  breath  sounds.  In  others  suppressed,  breath  sounds 
(compression  of  vesicles  or  of  bronchi).  In  the  upper  anterior  axillary  line  egophony 
was  elicited. 


Metamorphic  Breathing. — This  term  is  sometimes  applied  to  different 
varieties  of  mixed  breath  sounds.  Thus,  breath  sounds  with  a  feeble 
indistinct  beginning  may  end  as  the  pure  bronchial  tj^pe,  or  the  pitch  of 
the  bronchial  element  maj^  change,  or  inspiration  may  begin  as  a  broncho- 
vesicular  and  end  as  an  amphoric  sound.  The  change  is  generally  attrib- 
uted to  opening  of  an  occluded  or  occlusion  of  an  open  bronchus. 

Asthmatic  Breathing. — This  form  of  the  respiratory  murmur  is  heard 
during  paroxj^sms  of  asthma,  frequently  in  emphysematous  subjects. 
Both  inspu"ation  and  expiration  are  increased  in  intensity,  especially  the 
latter,  which  is  high-pitched,  prolonged  and  wheezing  in  character,  and 
generally  associated  with  musical  rales.  It  is  frequently  audible  at  a 
distance  from  the  patient. 


Cog-wheel  Respiration. — In  this  type  of  breathing,  inspiration  in- 
stead of  producing  a  soft,  continuous  sound,  as  is  normally  the  case,  is 
interrupted,  so  that  it  occurs  as  a  series  of  jerks  or  puffs  and  pauses. 
This  occurs  chiefly  in  the  upper  lobes  or  at  the  anterior  margins  of  the 
lungs.  It  is  due  to  irregular  inflation  and  expansion  of  the  pulmonary 
lobules.  It  may  result  from  pleural  adhesions  and  is  a  frequent  phe- 
nomenon in  tuberculous  cases,  but  maj^  also  occur  as  a  result  of  asthma, 
pain  or  fatigue  of  the  respiratory  muscles.  (For  visible  changes  in 
respiratory  rhythm  see  p.  41.)  It  is  sometimes  met  with  in  healthy 
people  with  apparently  normal  lungs. 



Rales  are  more  or  less  musical  sounds  which  originate  in  the  vibration 
of  exudate  in  the  respiratory  passages.  The  exudate  practically  acts 
like  a  reed  in  a  wind  instrument.  Genetically  all  rales  are  moist,  but 
sometimes  they  are  classified  as  "moist"  and  ''dr}-."  These  are 
undesirable  terms  however,  and  should  not  be  used. 

If  a  rale  is  described  simply  as  a  "dry  rale"  or  a  "mucous  rale"  it  connotes  nothing 
definite  and  further  is  not  along  the  lines  of  scientific  accuracy'.  Further,  the  term 
"dry"  as  applied  to  rales  seems  paradoxical,  for  it  is  almost  impossible  to  conceive  of  a 
"rale"  that  does  not,  to  some  extent  at  least,  depend  on  moisture  or  increased  turges- 
cence  for  its  causation. 

Rales  vary  in  quality,  size,  pitch,  time,  intensity,  duration,  distribu- 
tion, according  to  the  size  of  the  air  chambers  (bronchi-l^ronchioles)  and 
the  character  of  the  exudate. 

Rales  are  arbitrarily  classed  in  five  groups,  a  classification  based  on 
their  primary  auditory  characteristics. 

1.  Sonorous  rales,  loud,  snoring  and  low-pitched. 

2.  Sibilant  rales,  whistling,  piping,  squeaking,  hissing,  humming. 

These  two  varieties  constitute  what  is  known  as  the  musical  rales. 
Their  sound  is  longer  and  more  continuous  than  that  of  the  other  varieties. 
They  are  generally  caused  by  a  thin,  tenacious  exudate,  and  are  most 
characteristically  heard  in  cases  of  asthma.  The}'  are  considerably 
influenced  by  coughing. 

3.  Crepitant  rales  are  verv  fine,  chiefl}'  inspiratory,  constant,  clear- 
cut,  high-pitched,  uninfluenced  by  coughing,  probably  alveolar  in  origin. 
They  are  also  known  as  consonating  rales.  They  are  heard  in  associa- 
tion with  bronchial  breathing,  and  seem  to  originate  close  to  the  ear. 
They  may  be  imitated  by  rubbing  a  lock  of  hair;  or  bj-  separating  the 
fingers,  which  have  been  moistened  b}^  saliva.  They  often  have  a 
metallic  quality,  especially  when  associated  with  cavitation,  or  consolida- 
tion. They  may  be  heard  in  the  early  and  the  late  stages  of  pneumonia 
(crepitus  indux  and  redux).  Also  in  broncho-pneumonia,  infarction, 
pulmonary  tuberculosis.  They  are  the  only  rales  produced  in  the  alveoli 
and  indicate  parenchymatous  involvement  of  the  lung. 

4.  Subcrepitant  (Crackling)  Rales. — ^These  are  coarser  and  lower- 
pitched  than  crepitant  rales.  They  may  be  simulated  by  rolling  a  dry 
cigar  between  fingers,  or  sprinkling  salt  on  a  hot  stove.  They  originate 
in  the  bronchioles,  and  are  heard  in  cases  of  bronchitis,  pulmonary 
congestion  and  edema.  Crepitant  and  crackling  rales  maj'  be  closely 
simulated  by  friction  sounds. 




5.  Bubbling  and  Gurgling  Rales. — These  are  also  known  as  mucous 
or  liquid  rales.  They  are  coarser  and  lower-pitched  than  crackhng 
rales.  They  are  generally  heard  over  the  large  bronchi,  or  cavities,  and 
in  cases  of  pulmonary  edema.  The  so-called  "death  rattle"  is  due  to 
liquid  exudation  in  the  trachea,  and  belongs  to  this  class. 


-t=  +i  o  o 

Bubbling  rales  are  due  to  fluid — serum,  mucus,  pus  or  blood  in  the 
bronchi.  When  the  fluid  is  thin,  we  get  a  bubbling  quality,  when  thick 
a  certain  sharpness  or  stickiness.  The  quality  depends  on  the  surround- 
ing lung  tissue.  In  consolidations  a  clear,  ringing  quality  is  noted. 
Bubbling  rales  vary  in  size,  with  the  site  of  production,  and  with  the 
quantity  and  character  of  the  exudate. 



No  phrenic 

Fig.  105. — Pyothorax.  Large  post-pneumonic  empyema.  The  whole  right  pleural 
cavity  was  filled  with  a  thick  purulent  exudate,  some  of  which  may  still  be  seen  adherent  to 
the  costal  pleura.  The  right  lung  is  completely  atelectatic,  and  has  been  compressed  into  a 
small  fibrous  mass.  The  heart  is  displaced  to  the  left,  and  the  diaphragm,  downward.  The 
left  lung  in  its  lateral  aspect  is  compressed  by  the  heart.  The  body  was  received  in  the  dis- 
secting room  from  the  Anatomical  Board,  the  clinical  diagnosis  having  been  "pneumonia." 


The  significance  of  rales  lies  mainly  in  their  (a)  quality  and  (&)  dis- 
tribution, as  indicating:  (1)  the  area  of  activity  of  the  pathologic  process; 
(2)  the  character  and  stage  of  the  lesion;  (3)  the  localization — in  the  lung 
or  pleura. 

The  primary  terms  crepitant,  crackUng,  bubbling,  sibilant  and 
sonorous,  should  be  further  qualified  by  descriptive  adjectives  indicating 
their  size,  pitch,  number,  location  and  association  with  the  phases  of 
respiration,  e.g.,  "numerous,  fine,  high-pitched,  clear-cut,  metallic  rales 
heard  mainly  at  the  end  of  inspiration." 

Friction  Sounds. — These  are  also  spoken  of  as  friction  rales.  They 
may  be  heard  over  inflamed  serous  membranes  and  are  due  to  mechanical 
attrition  of  the  roughened  surfaces.  They  occur  in  the  pleura,  peri- 
cardium, and  rarely  peritoneum.  They  are  characteristically  described 
as  dry  and  leathery  (like  a  sound  produced  by  riding  on  a  new  saddle). 

They  differ  from  rales  in  that  they  tend  to  be  (1)  localized  (in  the  case 
of  pleuritis  to  the  axilla),  (2)  unilateral,  (3)  heard  both  with  in-  and  ex- 
piration. (4)  They  do  not  disappear  with  coughing,  (5)  thej^  are  in- 
creased by  pressure,  (6)  they  sound  close  to  the  ear,  (7)  they  are  attended 
by  pain  and  often  tenderness.  They  may  be  synchronous  with  the 
heart,  even  if  only  the  pleura  is  involved. 

It  is  by  no  means  always  possible  to  differentiate  between  an  intra- 
pulmonary  rale  and  a  pleuritic  friction,  but  the  following  points  often  aid 
in  arriving  at  a  correct  conclusion. 

Rales  Frictions 

(a)  Affected  by  coughing,  or  breathing,  (a)  Constant,  not    altered   by  coughing 

and  vary  spontaneously.  or  breathing. 

(6)  Sounds  are  often  "moist."  (b)   Sounds  are  more    "dry,"    leathery, 


(c)  Seem  more  distant.  (c)   Seem   closer  to  the  ear. 

(d)  Uninfluenced  by  pressure  on  the  chest  (d)  Increased  by  pressure,  accompanied 
wall.     Unaccompanied  by  local  pain.  by  pain,  which  is  also  increased  by 


(e)  Distribution  more  general,  more  (e)  Localized  in  extent,  generally  uni- 
widely  diffused.  Usually  bilateral.  lateral.  Most  common  in  axillary 
Commonly  heard  posteriorly  or  near  region. 

(/)    May  be  musical.  (/)    Rarely  musical. 

{g)   Occur  in  showers,  are  uniform  in  size,     (g)   Size    and    character    of    component 

sound  elements  vary. 

Both  rales  and  frictions  may  be  closely  simulated  bj^  (1)  muscle 
sounds,  (2)  hair  on  the  chest  (see  p.  105). 

Method  of  Eliciting  Rales. — If  rales  are  suspected  to  be  present  but 
are  not  heard  in  the  course  of  ordinary  breathing,  the  patient  should  be 
asked  to  breathe  more  deeply;  or  to  cough,  and  afterward  breathe  deeply. 
The  crepitant  rales  of  early  tuberculosis  may  thus  be  elicited  (latent 
rales).  They  are  also  more  apt  to  be  heard  before  or  during  the  period 
of  the  morning  cough,  when  such  is  present.  Owing  to  the  faintness  of 
their  sound,  rales  are  only  rarely  heard  at  a  distance  from  the  seat  of 
their  origin,  although  it  is  said  that  they  are  occasionally  conducted  along 
the  ribs  and  may  even  be  heard  in  the  opposite  lung. 

Certain  tinkling,  gurgling  and  splashing  sounds  may  be  heard  over 
the  chest,  especially  near  the  spinal  column,  as  the  result  of  liquid  passing 
down  the  esophagus  when  the  patient  swallows.  These  sounds  are  often 
marked  and  delayed  in  the  presence  of  a  diverticulum. 



— .  V.  frem- 
itus O-  V 
O. tympany 
+  ,  Breatli 
O,  metallic  | 
tinkle   +, 
splash  +, 
bell  tym- 
pany +  , 
full.     Ex- 
panison  —  , 
wave  'O.  V. 
fremitus  O- 
V.  reso- 
[nance  O- 
dulness  + 
-t-.    Breath 
sounds  O, 
tinkle  -|-  J 

Fig.  1D6. — Hyuho-pneumothorax.  The  right  pleural  cavity  is  represented  as  partly 
filled  with  fluid,  partly  with  air.  The  rupture  of  the  lung  has  occurred  below  the  present 
fluid  level,  so  that  the  fistulous  tract  opens  into  the  effusion  and  bubbles  are  given  off  during 
respiration.  The  right  lung  is  collapsed.  The  left  lung  is  functionating  compensatorily 
despite  its  compression.  Siiccussion  splash  may  be  elicited  because  both  air  and  liquid  are 
present  in  a  large  cavity.  Metallic  tinkle  is  due  to  bubbles  from  the  fistulous  tract  passing 
up  through  the  effusion,  not  to  drops  of  liquid  falling  upon  the  surface  of  the  effusion. 



— .     Vocal 
+  .    Vocal 
+  .  Percus- 
sion: high 
sounds  :, 

— .     Inter- 
spaces full. 
fremitus  O- 
Vocal  reso- 
nance O-  , 
percussion  | 
dulness  ' 
+  +  +. 
sounds  O- 
shadow  O- 

Fig.  107. — Large  Right-sided  Empyema.  The  diaphragm  is  flattened  and  depressed, 
forcing  the  liver  downward.  The  heart  is  pushed  to  the  left,  compressing  the  left  lung, 
which  is  contracted  and  exposes  the  heart  more  than  is  normally  the  case.  The  right  lung  is 
compressed  and  atelectatic,  and  in  part  adherent  to  the  chest  wall.  The  right  pleural 
cavity  contained  a  large  quantity  of  thick  purulent  exudate,  depressing  the  diaphragm  and 
liver  on  that  side.  On  the  left  side  the  diaphragm  is  pushed  upward  and  flattened  against 
the  chest  wall  by  the  colon.  Note  how  a  distended  stomach  or  colon  may  mechanically 
embarrass  the  heart.  This  has  an  important  bearing  upon  symptomatology  an^l  treatment 
in  cases  of  cardiac  decompensation  and  angina  pectoris.  {Specimen  the  property  of  Dr. 
T.  T.  Thomas.) 




This  may  be  heard  on  ausculting  over  large  tense  chambers  which 
contain  both  Hqiiid  and  air.  It  is  eUcited  by  having  the  patient  cough, 
suddenly  move  the  body  from  side  to  side,  or  shake  his  chest. 

Succussion  splash  Hke  the  other  metalUc  auscultatory  phenomena 
owes  this  quality  to  the  suddenness  with  which  the  liquid  is  thrown  into 
motion,  unrhythmic  vibrations  being  thus  originated.  For  its  production, 
a  stiff-walled  cavity  of  considerable  size  is  necessary.  It,  therefore, 
rarely  occurs  in  the  chest  except  in  hydro-pne,umothorax.     Pulmonary 

Fig.  108.4.. — The  currently  accepted  but  erroneous  explanation  of  the  genesis  of 

metallic  tinkle. 

Fig.  108.B. — The  true  mechanism  of  metallic  tinkle. 

cavities  are  generally  too  small,  too  flaccid  and  their  contents  too  viscid, 
to  produce  the  characteristic  sound.  It  may  be  simulated  by  imparting 
motion  to  the  liquid  in  an  atonic  stomach,  or  by  shaking  a  small  quantity 
of  water  in  a  bottle.  It  can  sometimes  be  heard  at  quite  a  distance  from 
the  patient,  especially  if  the  pneumothorax  communicates  with  a  bronchus 
and  the  mouth  be  "open.  It  is  often  noted  in  cases  of  diaphragmatic 
evisceration  or  hernia.     It  is  said  also  to  occur  over  very  large  pulmonary 


cavities.     It  never  occurs  in  simple  serous  or  jnirulent  effusion,  as  no  air 
is  present. 

Succussion  splash  and  metallic  tinkle  are  the  most  pathognomonic 
signs  of  hydro-pneumothorax,  but  they  only  occur  in  about  30  or  40 
per  cent,  of  the  cases  (Cruice). 


This  is  a  clear,  vibrant,  musical  sound  which  may  be  heard  in  many 
cases  of  hydro-pneumothorax.  It  has  been  likened  to  the  distant  tinkling 
of  a  clear,  high-pitched  s;'lver  bell. 

The  genesis  of  metallic  tinkle  may  be  illustrated  by  the  following  ex- 
periment (Fig.  108).  If  we  attach  a  stethoscopic  tubing  to  the  mouth 
piece  of  a  wash  bottle  and  listen  while  air  is  being  forced  through  the 
other  glass  tube  into  the  hquid,  the  phenomenon  of  metallic  tinkle  can 
be  accurately  reproduced.  It  will  further  be  noted  that  the  sound  occurs 
at  the  moment  the  bubble  is  given  off  and  not  at  the  time  at  which  it 
reaches  the  surface.  If,  on  the  other  hand,  we  listen  while  water  is 
allowed  to  fall  from  a  pipette  upon  the  surface  of  the  water  only  a  dull, 
indifferent  sound  wiU  be  heard. ^ 

It  is  evident  both  from  this  and  for  anatomic  reasons,  that  metallic 
tinkle  is  due  to  air  bubbles  ascending  through  an  effusion  from  a  fistulous 
tract  in  the  lung  below  the  level  of  the  liquid,  and  not,  as  was  formerly 
taught,  to  liquid  dropping  from  a  moist  pleura  upon  the  effusion  beneath. 

Metallic  tinkle  may  also  be  produced  by  the  bursting  of  bubbles  in 
a  bronchial  tube  which  communicates  with  a  pneumothorax  or  bj^  a  bub- 
ble in  the  surface  of  a  moist  perforated  lung  above  the  level  of  the  fluid 
if  the  bubble  is  expelled  with  sufficient  force.  In  either  case  the  musical 
quality  is  due  to  the  rhythmic  vibration  of  the  air,  and  the  reverberation 
is  due  to  the  large  air-filled,  stiff-walled  resonator — the  pleural  cavity 
(Fig.  106). 

1  Baeach:  Arch.  Diag.,  .January,  1910. 


The  voice  sounds  consist  of: 

1.  Vocal  resonance :  the  voice  sounds  heard  upon  the  chest. 

2.  Bronchophony :  increased  vocal  resonance. 

3.  Pectoriloquy:  bronchophony  with  articulated  overtones — syllabic 
speech.     Whispered  pectoriloquy. 

4.  Egophony :  a  variety  of  bronchophony^  having  a  nasal  or  bleating 

These  signs  are  elicited  bj^  ausculting  over  different  areas  of  the  chest 
wall,  while  the  patient  speaks  or  whispers.  In  the  former  case  the  patient 
should  be  told  to  slowly  and  loudly  pronounce,  "one — one — one,"  or 
"  ninet\^-nine "  in  the  lowest  range  of  his  natural  speaking  voice.  The 
examiner  should  note  an}^  differences  in  clearness  or  intensity  which  may 
exist  over  symmetrical  areas  of  the  thorax. 


The  vibrations  produced  in  the  larynx  during  phonation  are  increased 
in  intensity  (larger  wave  amplitude)  by  (1)  the  thorax  and  to  a  minor 
degree  by  the  trachea  and  bronchi,  (2)  by  the  air  chambers  above  the 
vocal  cords — the  mouth  and  nares.  These  structures  act  as  resonators, 
sympathetic  vibrations  being  set  up  in  them.  But  inasmuch  as  resona- 
tors act  selectivel}^,  amplifying  only  certain  wave  lengths,  the  original 
sound  as  produced  in  the  larynx  undergoes  certain  changes  not  only  in 
intensity  but  also  in  quality  and  pitch.  This  explains  why  whispered 
pectoriloquy  viay  he  heard  when  vocal  resonance  is  actually  diminished. 
Under  normal  conditions  the  vocal  sounds  heard  over  the  chest  are  much 
less  loud  and  clear  than  when  we  listen  over  the  larjmx.  They  seem  dis- 
tant and  diffused,  are  lower  in  pitch,  and  the  distinct  articulations  of  the 
trachea  are  replaced  by  indistinct,  rumbling  sounds.  The  spoken  word 
is  lower  in  pitch  when  heard  through  the  chest  than  when  heard  at  the 
mouth,  owing  to  the  fact  that  the  lung  (resonator)  which  is  large,  rein- 
forces the  lower  notes.  When,  however,  the  lung  is  consolidated,  the 
sounds  heard  through  the  chest  wall  seem  higher-pitched  than  at  the 
mouth  because  the  pulmonary  tissue  being  infiltrated,  only  the  bronchi  re- 
main to  act  as  resonators,  and  also  being  small  in  size,  only  the  higher  notes 
are  amplified  (Mueller),  It  is  thus  evident  that  vocal  resonance  is  due 
to  somewhat  the  same  causes,  and  is  governed  by  the  same  laws  as  the 
breath  sounds.  Vocal  resonance  and  vocal  fremitus  have  the  same  origin. 
They  generally  vary  in  the  same  direction  and  in  like  proportions. 
Discrepancies  between  the  two  methods  of  examination  may  be  due  to  the 
fact  that  the  ear  perceives  vibrations  better  when  they  are  rapid;  the 
hand  when  they  are  slow.  Vocal  resonance  may  be  (1)  increased — more 
intense  and  clearer;  (2)  decreased — less  intense  and  muffled.     Here  clear- 



ness  is  used  in  a  double  sense:  (a)  in  regard  to  the  fundamental  note — 
the  amount  of  sonorous  laryngeal  character;  or  (b)  in  regard  to  the  articu- 
lated overtones — syllabic  speech.  These  two  qualities — clearness  and 
loudness — do  not  necessarily  run  parallel,  they  may  be  diametrically 

Normal  Vocal  Resonance. — Vocal  resonance  is  normally  most  in- 
tense over  those  areas  of  the  chest  over  which  broncho-vesicular  breath- 
ing is  normallj^  heard — the  interscapular  region,  the  upper  sternum  and 
the  supraclavicular  apices.  But  even  here  no  distinct  articulate  speech 
can  be  appreciated;  only  an  indistinct  humming,  buzzing,  fluttering 
sound  not  unlike  that  of  a  voice  heard  at  the  distant  end  of  a  long  hall. 
The  sounds  of  both  the  spoken  and  the  whispered  voice  are  normally 
more  intense  on  the  right  side,  especially  over  the  upper  lobe,  both  an- 
teriorly and  posteriorly.  This  is  due  to  the  fact  that  the  right  pulmonary 
apex  lies  in  direct  contact  with  the  trachea,  and  also  because  the  right 
bronchus  is  almost  a  direct  continuation  of  the  trachea  which  points 
to  the  right  (Fetterolf)  (see  Figs.  75,  95,  103). 

In  women  vocal  resonance  is  feeble  because  the  fundamental  note  of 
the  larjmx  does  not  stand  in  a  favorable  relationship  with  the  thorax — 
the  resonator.  (Small  tuning  forks  require  small  resonators.)  In  men 
the  relationship  is  generally  more  favorable,  although  even  here  we  meet 
with  great  degrees  of  difference.  In  singing  an  ascending  scale  from  one's 
lowest  base  to  one's  highest  treble,  both  vocal  fremitus  and  resonance 
will  become  progressively  less  intense,  and  at  a  given  point  chsappear 
entirely.  Children  often  have  a  more  intense  fremitus  than  women  be- 
cause the  aforesaid  relationship  is  more  favorable,  although  as  a  rule 
vocal  fremitus  and  resonance  are,  in  small  children  determined  with 
difficulty  (see  p.  142).  For  the  same  reason  these  signs  may  vary  with 
the  degree  of  inspiration  or  expiration  at  which  the  patient  speaks.  If 
the  sounds  heard,  remain  intense  even  with  marked  stethoscopic  pressure 
— which  tends  to  blot  out  the  sympathetic  vibrations  of  the  chest — we 
have  even  greater  reason  for  believing  that  loss  of  elasticity  and  infiltra- 
tion of  the  lungs  has  occurred  (Sewall). 

Vocal  resonance  may  be  diminished  or  absent  in  conditions  which 
interfere  abnormally  with  the  conduction  of  vibrations  from  the  larynx 
to  the  chest  wall,  such  as  obstruction  of  a  bronchus,  pleural  effusions, 
edema  of  the  chest  wall  or  excessive  subcutaneous  fat.  These  conditions 
act  through  their  effects  of  diffusion,  reflection  and  resonance  (see  p.  60). 

Vocal  resonance  is  generally  diminished  OYer^pleural  effusions  because 
vibrations  are  not  readily  transmitted  from  an  air-bearing  lung  to  the 
effusion.  //,  however,  the  loiver  part  of  the  Ivng  ivhich  is  in  contact  with 
the  effusion,  is  solidified,  either  as  the  result  of  infiltration  or  compression, 
vocal  resonance  {as  well  as  fremitus  and  breath  sou7ids)  will  be  intensely 
transmitted  to  the  chest  wall. 

Vocal  resonance  may  be  diminished  in  some  rare  cases  of  pulmonary 
fibrosis  which  would  appear  contradictory  to  what  has  been  stated  re- 
garding normal  and  abnormal  sound  transmission,  since  solid  lung,  solid 
pleura  and  bronchus  have  relatively  the  same  density  and  we  should, 
therefore,  expect  what  we  usually  find — increased  voice  and  breath  sounds. 
Montgomery  suggests  that  diminished  sounds  may  be  due  to  (1)  "heavy 
strands  of  fibrous  tissue  alternating  with  air-bearing  lung  or  small  cavi- 
ties" thus  offering  a  "break"  in  transmission;  or  (2)  the  fact  that  the 


bronchi  are  further  removed  from  the  chest  wall  by  the  thickened  pleura 
and  obliterated  peripherally,  or  that  their  lumen  is  actually  diminished. 
Vocal  resonance  may,  however,  be  diminished  in  some  uncomplicated 
cases  of  pulmonary  consolidation:  (1)  owing  to  bronchial  obstruction 
due  to  (a)  secretion  (mucus,  pus,  blood,  serum),  (h)  to  pressure  from  with- 
out or  (c)  a  malignant  growth  from  within.  In  the  first  instance  es- 
pecially, the  phenomenon  may  be  temporarily  dissipated  by  coughing 
or  deep  breathing.  (2)  Cases  not  explainable  upon  this  basis  may  be  due 
to  the  variable  effects  of  resonance  or  wave  interference  already  referred 
to  (p.  55)  (Montgomery). 


By  this  term  we  understand  vocal  resonance  increased  in  intensity 
and  clearness.  Over  normal  pulmonary  tissue  the  voice  sounds  are  even 
more  muffled  and  indistinct  than  when  we  listen  near  a  primary  bron- 
chus.l  If  the  lung  tissue  is  pathologically  altered  so  that  it  becomes  a 
better  conductor  of  sound  than  is  normally  the  case,  we  hear  an  increased 
vocal  resonance — bronchophony.^  In  other  words,  the  sounds  are  louder, 
higher-pitched,  clearer  and  more  amphoric  than  those  we  expect  to  hear 
in  the  locality  in  question,  or  than  those  we  do  hear  in  the  corresponding 
area  of  the  opposite  (healthy)  side. 

Bronchophony,  therefore,  occurs  in:  (1)  Pulmonary  solidification — 
pneumonia,  tuberculosis,  atelectasis,  compression,  glandular  enlarge- 
ment especially  if  these  conditions  exist  near  to  a  large  bronchus,  etc. 
(2)  Pulmonary  cavitation — tuberculosis,  abscess,  gangrene,  etc.  In 
the  latter  instance  the  existence  of  bronchophony  is  in  part  due  to  the 
consolidation  which  accompanies  and  often  surrounds  the  cavities. 
Bronchophony  is,  therefore,  generally  encountered  in  association  with 
increased  vocal  fremitus,  bronchial  breathing,  percussion  dulness  and  metallic 
sr  consonating  rales. 


Pectoriloquy  is  exaggerated  bronchophony.  It  is  an  increased  vocal 
resonance  in  which  syllabic  speech  (the  articulated  overtones)  can  be 
more  or  less  distinctly  recognized.  In  the  ordinary  speaking  voice,  as 
heard  through  the  chest  wall,  the  syllables  tend  to  be  drowned  out  by  the 
more  intense  and  lower-pitched  rumble  of  the  vowel  sounds,  hence  pec- 
toriloquy can  be  better  determined  during  the  act  of  whispering. 

The  Whispered  Voice  Sounds. — Whispering  is  the  result  of  articulate 
speech  in  which  the  glottis  plays  no  part.  Over  the  normal  chest  the 
whispered  voice  is  scarcely  audible,  since  whispering  does  not  set  up 
sympathetic  vibrations  of  the  thoracic  wall.  Over  areas  near  to  the 
primary  bronchi  one  hears  an  indistinct  swishing  sound.  The  transmis- 
sion of  syllabic  speech — whispered  pectoriloquy — is  pathologic. 

Our  judgment  must  be  based  not  on  the  loudness  but  on  the  dis- 
tinctness of  syllables.     The  actual  recognition  of  individual  syllables  is 

1  Bronchophony  as  the  derivation  of  the  word  impUes,  suggests  the  emanation  of 
a  sound  from  the  bronchus.  We  receive  the  impression  that  the  source  of  the  sound 
is  very  near  to  the  end  of  the  stethoscope,  or  as  if  someone  were  talking  directly  into 
the  latter.  Some  authorities  speak  of  a  ' 'normal ' '  and  a  ' ' pathologic ' '  bronchophony, 
using  the  former  term  as  synonymous  with  vocal  resonance. 



Fig.  109. — Htdhothorax.  The  lung,  which  is  atelectatic,  is  surrounded  by  serum  which 
being  frozen  appears  as  ice  crj^stals.  The  dome  of  the  diaphragm  is  flattened  and  beneath  it 
are  seen  a  filled  stomach  and  a  portion  of  the  left  lobe  of  the  liver. 




I^ML -i} 

Fig.  110. — Sagittal  section,  viewed  rom  the  left,  of  the  body  of  a  nexv-horn  child,  the 
plane  of  section  being  2  cm.  to  the  right  of  the  midsteriial  line.  Owing  to  adhesions  the 
horizontal  fissure  is  not  shown.  L.  liver;  R.M.L.,  middle  lobe  of  right  lung;  R.U.L.,  upper 
lobe  of  right  lung;  O.F.,  oblique  fissure;  72.L.L.,  lower  lobe  of  right  lung.  (Feiterolf  and 


not  a  sine  qua  non.  The  sound  is  rarely  sufficiently  distinct  to  enable  us 
to  recognize  every  individual  word. 

The  whispered  voice  is  elicited  by  ausculting  the  chest  while  the 
patient  whispers  such  words  as  ''one,"  "two,"  "three,"  "sixty-six." 
Over  the  lung,  soft,  indistinct  sounds  are  heard. ^  We  hear  "a 
feeble,  low-pitched,  blowing  sound,  these  characters  corresponding  with 
those  of  the  expiratory  sound  in  forced  breathing"  (Flint).  Sometimes 
no  audible  sound  is  produced.  Near  to  areas  of  consolidation  over  which 
bronchial  breathing  is  heard,  the  sounds  become  more  distinct  so  that 
some  syllables  can  be  recognized,  and  over  cavities  or  consolidations  near 
a  bronchus  or  cavities  communicating  with  a  bronchus,  the  acoustic 
impression  is  often  nearly  that  of  a  person  whispering  directly  into  the 
stethoscope.  In  women  and  children  the  voice  is  higher-pitched  and  in 
the  latter  the  large  bronchi  are  nearer  to  the  chest  wall,  thus  the  whispered 
voice  is  often  more  intense  than  in  men.  Whispered  pectoriloquy  is  an 
important  sign  of  pulmonary  consolidation  or  cavitation.  What  has 
already  been  stated  in  regard  to  vocal  resonance  and  bronchial  breathing 
applies  to  it.  It  is  much  less  taxing  to  the  patient  than  speaking,  and  is 
often  a  useful  method  of  determining  pulmonary  infiltration  if  a  patient 
breathes  so  badly  that  bronchial  breathing  cannot  be  elicited.  Whispered 
pectoriloquy  is  sometimes  more  distinct  than  spoken  bronchophony, 
and  may  be  elicited  when  the  latter  is  absent,  owing  to  the  resonating 
properties  of  the  tissues. 

The  whispered  voice  test  further  has  the  advantage  over  that  of  the 
spoken  voice  that  does  not  set  up  sympathetic  vibrations  in  the  chest  wall 
(resonator)  and  that  an  increase  in  intensity,  therefore,  speaks  more 
strongly  in  favor  of  actual  change  in  the  pulmonary  tissue. 

The  whispered  voice  is  normally  heard  most  clearly  from  the  right  apex 
to  the  second  intercostal  space.  Posteriorly  it  is  less  intense  and  never 
extends  below  the  scapular  spine.  On  the  left  side  its  intensity  is  much 
less  and  its  extent  much  more  limited. 


Egophony  is  a  modified  bronchophony  characterized  by  a  tremulous, 
high-pitched,  bleating  quality.  It  has  been  compared  to  the  bleating 
of  a  goat,  the  speech  of  a  person  with  a  cleft  palate,  or  to  the  voice  of  a 
ventriloquist.  It  may  be  imitated  by  attempting  to  throw  the  voice 
through  the  nares,  while  speaking  with  the  nostrils  occluded, ^  or  by  the 
interposition  of  a  thin  cork  between  the  larynx  and  the  stethoscope. 
It  may  be  heard  just  below  the  upper  level  of  pleural  effusions  while  the 
patient  is  being  examined  for  vocal  resonance,  and  when  present  is  a 
valuable  sign  of  pleural  exudation.  It  is  perhaps  due  to  the  abnormal 
relationship  between  the  bronchi  (which  become  shorter  when  the  lung  is 
collapsed)  and  the  compressed  lung  in  pleural  effusions  that  the  necessary 
physical  conditions  are  brought  about  which  will  reinforce  the  high- 
pitched  nasal  sounds. 

1  Some  people  have  never  learned  to  whisper,  some  whisper  during  inspiration, 
which  greatly  modifies  the  sounds  produced. 

2  Egophony  was  formerly  attributed  to  (a)  flattening  of  non-cartilaginous  bronchi 
by  pressure  of  the  effusion,  so  that  they  acted  like  reeds  (Laennec) ;  (6)  vibrations  of 
the  walls  of  small  bronchi  by  actual  collision — interruption  of  the  air  current  ( Wintrich) ; 
(c)  the  articulation  of  overtones — only  the  higher  harmonics  passing  through  the  effu- 
sion (Stone);  (d)  to  vibrations  passing  through  a  thin  layer  of  fluid. 



Chest  Inspection. — ^The  antero-posterior  diameter  is  relatively  in- 
creased in  infants  (under  two  j^ears).  The  sternum  is  prominent  and  the 
ribs  more  horizontal.  Breathing  is  of  the  abdominal  type  for  the  first 
five  or  six  years  or  even  longer  (see  Fig.  17).  The  chest  loall  is  thin  and 
resilient  and  readilv  transmits  sound  vil)rations.     Auscultation  should 

Fig.  111. — Body  of  a  rn  a-bom  child  from  which  the  median  portion  of  the  anterior  chest 
wall  has  been  removed.  R.L.,  right  lung;  R.T.,  right  lobe  of  thymus;jR.J.F.,  right  internal 
jugular  vein;  R.C.A.,  right  common  carotid  artery;  T,  trachea;  L.C.A.,  left  common  carotid 
artery ;  L.J.  F.,  left  internal  jugular  vein;!/.  T.,  left  lobe  of  thymus  ;Z,.L.,  left  lung;  P,  pericar- 
dium.     {Fetterolf  and  Gittings.) 

be  practised  before  palpation  or  percussion,  lest  ciying  interfere  with  the 

Palpation. — Exqiansion  is  shght  and  vocal  resonance  less  marked  than 
in  adults  (see  vocal  resonance).  The  apex  heat  is  in  the  fourth  interspace, 
just  within  or  even  to  the  left  of  the  left  mid-clavicular  line. 

1  For  assistance  in  the  preparation  of  the  following  paragraphs,  we  are  indebted  to 
Dr.  J.  C.  Gittings. 



Percussion. — Percussion  must  be  extremely  light — finger  percussion  is 
often  necessary.  If  a  forcible  stroke  be  employed  the  whole  lung  as  well 
as  the  neighboring  abdominal  viscera  will  be  thrown  into  vibration  and 
topographic  percussion  will  become  impossible.  The  child  must  be 
placed  in  the  sitting  or  standing  position — or  prone  or  supine — never  on 
one  side.  Owing  to  the  flexibility  of  the  thoracic  cage  the  lowermost 
lung  when  the  infant  lies  upon  one  side  becomes  compressed  and  yields  a 
less  resonant  note.  The  posterior  portion  of  the  thorax  should  be  ex- 
amined while  the  infant  held  in  the  nurse's  arms,  looks  backward  over 
her  shoulder.     The  general  percussion  note  is  resonant,  sometimes  hyper- 

FiG.  112. — Thymus  in  situ.  The  am  i-ii.ji  ijulnionaiyiiiurjiin^  are  pushed  aside.  The 
lower  border  of  the  thymus  gland  overlies  the  greater  portion  of  the  heart.  {After  Fetterolf 
and  Gritting s.)      (Compare  Fig.  309.) 

resonant  (higher  pitched  than  in  adults)  from  the  clavicle  to  the  fourth 
rib  on  right  side  anteriorly;  to  eighth  rib  posteriorly  (on  account  of  high 
dome  of  liver).  Below  these  levels  the  note  shades  into  liver  dulness  at 
the  sixth  and  tenth  ribs,  respectively. 

In  the  axilla  and  posteriorly  on  the  left  side  gastric  tympany  may 
affect  the  normal  note,  as  high  as  the  sixth  rib.  This  tympanitic  quality 
may  sometimes  be  eliminated  or  at  least  diminished  by  the  method  of 
lateral  limitation — three  fingers  down,  percuss  the  middle  one. 

On  the  left  side  below  the  inner  third  of  the  clavicle  the  note  is  impaired 
or  dull,  shading  into  the  area  of  cardiac  dulness  (Hamill),  owing  to  poor 
expansion  of  left  apex  over  the  great  vessels,  possibly  in  part  to  left  lobe 


of  thymus.  Crying  produces  a  rigid  chest  and  ma}-  cause  dulness  over 
the  lower  lobes.  Percussion  during  ciying  ma}'  .yield  a  cracked-pot 
sound  (p.  69) .  Percussion  is  generally  less  satisfactory  than  auscultation. 
The  sense  of  resistance  is  often  a  valuable  criterion  in  deciding  between 
consolidation  and  liquid  effusion. 

The  heart  is  large,  lies  higher  in  the  thorax,  as  well  as  more  horizon- 
tally. Cardiac  dulness,  therefore,  normally  extends  relatively  further  to 
the  left  than  in  adults.  It  may  normally  extend  >^  inch  beyond  the  mid- 
clavicular line.  Dulness  due  to  the  right  auricle,  however,  rarely  extends 
beyond  the  sternal  line.  The  great  vessels  are  relatively  large.  This, 
together  with  the  possibility  of  a  persistent  thymus  gland  renders  a 
determination  of  the  upper  border  difficult.     This  difficulty  is  further 

Fig.   113. — Lcxgs  of  a  child.     In  infancy  and   childhood  the  lungs   often   completely 
envelop  the  heart,  there  being  in  such  cases  no  absolute  (superficial)  heart  dulness. 

enhanced  by  the  normal  dull  area  at  the  inner  third  of  the  left  clavicle 
already  alluded  to. 

During  the  first  year  the  apex  beat  is  usualh'  found  in  the  fourth 
intercostal  space.  This  may  be  so  until  the  thirteenth  year,  after  which 
in  normal  children,  it  is  always  in  the  fifth  interspace.  As  in  adults,  the 
existence  of  cardiac  hypertrophy  can  usually  be  satisfactorily  determined 
by  inspection  and  palpation  alone.  If  the  left  ventricle  is  chiefly  in- 
volved, a  hea^'ing  systolic  thrust  is  felt  outside  of  the  mid-clavicular  line. 
In  case  the  right  ventricle  is  chiefly  affected,  the  thrust  is  diastolic  in  time 
and  most  marked  in  the  epigastrium  because  the  right  ventricle  retracts 
from  the  chest  wall  to  rebound  in  diastole  (Talley).  Since  compensatory 
and  reparative  changes  in  j'outh  are  good,  marked  degrees  of  cardiac 
h^'pertrophyare  often  seen  in  children  with  valvular  lesions  (Figs.  15, 122). 

Cardiac  Arrhythmia. — Sinus  arrhythmia,  or  juvenile  arrhythmia  as  it  is 
often  called,  is  as  the  latter  name  implies,  ver}'  common  in  infants  and 



children,  especiallj^  in  high  strung  youngsters  and  following  infections 
(seep.  172). 

Extrasystoles  are  also  common,  more  so  indeed  in  children  with  ap- 
parently normal  hearts  than  in  those  with  definite  valvular  lesions. 
Tachycardia  is  frequent  after  five  years  of  age  and  bradycardia  may  occur 
during  convalescence  from  fevers  and  in  association  with  jaundice. 

Auricular  fibrillation  is  rarely  met  with  and  when  encountered  is 
usually  only  noted  in  fatal  cases  of  diphtheria  or  rheumatic  pancarditis. 


Fig.  114. — Horizontal  section  of  a  new-horn  infant' s  thorax  at  the  upper  level  of  the 
ensiform  cartilage:  showang  its  cylindrical  shape.  L.L.,  left  lung;  P. A.,  pulmonary  aorta; 
L.T.,  left  lobe,  and  R.T.,  right  lobe  of  thymus  body;  A. A.,  ascending  part  of  aortic  arch; 
S.V.C.,  superior  vena  cava;  R.L.,  right  lung;  B.T.,  bifurcation  of  trachea;  E  ,  esophagus; 
A.,  descending  part  of  aortic  arch.     {After  Fetterolf  and  Gittings.) 

Auricular  flutter  is  even  more  unusual,  although  Ritchie  has  reported  two 
cases  in  children  under  ten  years.  Heart  block  'also  has  been  observed  in 
association  with  diphtheria. 

The  prognostic  significance  of  arrhythmia  in  children  is  essentially 
the  same  as  in  adults.^ 

Auscultation. — Respiration  in  infants  and  young  children  is  irregular 
in  rhythm  and  very  irregular  in  depth.  (Respiration  being  entirely  a 
postnatal  function,  development  of  this  function  is  relatively  retarded. 
It  does  not  become  fully  developed  until  the  child  has  become  active  upon 
its  feet.  This  early  irregularity  of  breathing  accounts  in  great  part  for 
the  difficulty  in  interpreting  the  auscultatory  phenomena.) 

1  For  more  detailed  information  see  Talley,  J.  E.:  "The  Physical  Examination 
of  the  Heart  in  Children."  Arch.  Pediatrics,  September,  1915,  to  which  article  I  am 
indebted  for  some  of  the  foregoing  facts. 



In  early  life,  the  breath  sounds  are  relatively  harsh,  and  loud.  Expira- 
tion is  clearly  heard,  and  in  comparison  with  an  adult  relatively  pro- 
longed. Exaggerated  or  vesiculo-bronchial  breathing  is,  therefore,  a 
normal  finding  (puerile  breathing) . 

The  areas  overlying  the  bifurcation  of  the  bronchi  anteriorly  extend- 
ing 1  to  3  cm.  to  the  right  of  the  sternal  margin,  and  1  to  2  cm.  to  the  left 
(at  level  of  the  first  interspace  and  the  second  rib)  yield  broncho-vesicular 

Fig.  115. — The  infant's  chest  is  circular  in  outline.  The  abdominal  viscera  are  large. 
The  proximity  of  the  stomach  and  colon  to  the  lower  portion  of  the  lungs  imparts  a  tympan- 
itic quality  to  the  lower  lobes,  especially  the  left,  and  renders  very  light  percussion  ssential. 
The  heart  lies  almost  horizontally,  hence  cardiac  dulness  extends  relatively  furter  to  the 
left  than  is  the  case  in  adults.    It  also  lies  about  one  interspace  higher  in  infants.he 

breathing.  Posteriorly  this  is  also  found,  especially  on  the  right  side. 
Vocal  resonance  in  young  children  is  hard  to  elicit  as  child  cannot  be  con- 
trolled. Whispered  pectoriloquy  can  often  be  heard,  normally,  over  the 
areas  of  broncho-vesicular  breathing. 

Owing  to  tardy  development  of  the  accessor}^  muscles  of  respiration 
and  of  the  laryngeal  and  pharyngeal  muscles,  a  slight  hypersecretion  of 
mucus  in  the  pharynx,  naso-pharynx  or  larynx,  often  produces  coarse 



moist  7'dles  which  may  be  heard  all  over  chest.  The  heart  sounds  tend  to  be 
embryocardial  in  character,  the  first  sound  having  a  valvular  quality, 
and  the  diastolic  pause  being  brief.  The  pulmonic  second  sound  is 
loud  and  more  intense  than  the  aortic  (retracted  lungs,  more  superficial 
position).     Heart  sounds  and  murmurs  are  loud. 

Fig.  116. — Horizontal  section  of  an  infant  thorax  showing  its  cylindrical  contour  as 
well  as  the  relatively  large  size  and  horizontal  position  of  the  heart.  L.  =  left  ventricle. 
R.   =  right  ventricle. 


Small  serous  effusions  in  the  pleural  cavities  usually,  but  not  in- 
variably, produce  a  dull  note  on  percussion.  Large  serous  effusions  may 
produce  a  dull  or  even  a  flat  sound,  as  in  adults,  but  quite  often,  a  slightly 
tympanitic  note  results,  due  to  relaxation  of  pulmonary  tension  and  to 
abdominal  tympany.  The  note  over  empyemas  is  more  apt  to  be  dull 
or  flat,  but,  for  the  same  reasons,  this  is  not  invariable.  In  serous  or 
purulent  effusions  as  a  general  rule,  therefore,  we  do  not  find  as  flat  a 
note  as  in  adults,  under  the  same  conditions. 

In  ausculting  over  a  pleural  effusion  (serum  or  pus)  the  breath  sounds 
often  persist  and  in  some  cases  the  diagnosis  can  be  definitely  established 
only  by  the  exploring  needle.  In  the  case  of  large  effusions,  especially  if 
purulent  and  causing  marked  compression  of  lungs,  we  may  find  bronchial 
or  cavernous  breathing,  with  whispered  pectoriloquy,  from  the  clavicle 
down  as  far  as  the  third  or  even  the  fourth  rib.  An  erroneous  diagnosis 
of  cavity  is  sometimes  made.     Cavities  in  children  are  rare. 

The  second  pulmonic  sound  is  actually  and  relatively  louder  than  the 
second  aortic — this  difference  persisting  throughout  childhood.     Organic 



Fig.  117. — Sagittal  section  of  the  hwdx  i.i  :i  //.  </ ///  '<.<//(  child  vicwi'tl  fiwiii  the  right,  the 
plane  of  the  section  being  0.25  cm.  to  the  left  of  the  mid-sterual  line.  M.V.,  mitral  valve; 
L.A.,  left  auricle;  L.A.A.,  left  auricular  appendage;  L.V.P.,  orifices  of  the  left  pulmonary 
veins;  R.P.A.,  right  pulmonary  artery;  L.B.,  left  bronchus;  L.S.A.,  left  subclavian  artery; 
I. A.,  innominate  artery;  L.C.A.,  left  common  carotid  artery;  L.I.V.,  left  innominate  vein; 
A. A.,  aortic  arch;  A.L.,  aortic  leaflets;  T.L., tricuspid  leaflets;  R.V.,  right  ventricle;  D,  dia- 
phragm: L.  liver. 





I^^HH ' 







I^RBB     : 

Fig.  118. — Sagittal  section  of  the  body  of  a  neivly  born  infant,  tje iced  from  the  left. 
The  plane  of  section  being  0.75  em.  to  the  left  of  the  mid-sternal  line,  i-,,  liver;  R.A.,  right 
auricle;  R.A.A.,  left  auricular  appendage;  A.L.,  aortic  leaflets;  R.P.A.,  right  pulmonary 
artery;  L.I.V.,  left  innominate  vein;  I. A.,  innominate  artery;  T,  trachea;  .-1.-4..,  aortic^arch; 
L.B.,  left  bronchus;  R.S.V.,  right  superior  pulmonary  vein;  L.A.,  left  auricle;  R.I.V..  left 
inferior  pulmonary  vein;  T.A.,  thoracic  aorta. 


systolic  murmurs,  produced  at  the  mitral  orifice,  usually  can  be  heard 
clearly  all  over  the  area  of  the  heart  and  posteriorly,  on  the  left  side.  This 
is  true  to  a  lessened  extent  of  aortic  systolic  murmurs  in  double  aortic 
disease.  Aortic  diastolic  mu,rmurs,  even  more  frequently  than  in  adults, 
are  heard  best  near  the  apex  or  at  the  fourth  left  costal  cartilage. 

Functional  murmurs  are  very  common  in  childhood  and  often  simulate 
organic  murmurs  in  quality,  but  are  heard  loudest  over  the  base  and  in  the 
reclining  position.  They  become  much  less  marked  when  the  child  sits 
up — an  important  distinction,  since  venous  hums  are  intensified  by  this 

Compression  of  the  left  lung  by  an  enlarged  heart  or  a  pericardial 
effusion  gives  the  signs  of  consolidation  posteriorly — dulness  and 
bronchial  breathing — and  must  be  differentiated  from  pneumonia. 

In  addition  to  the  detailed  anatomic  relations  the  preceding  figures 
illustrate  the  following  facts: 

1.  The  large  amount  of  space  in  the  antero-posterior  direction  occu- 
pied by  the  heart,  enlargement  of  which  (dilatation,  pericardial  effusion) 
would  compress  the  upper  part  of  the  lower,  and  the  lower  part  of  the 
upper  pulmonary  lobes,  causing  bronchial  breathing  over  the  correspond- 
ing areas  of  the  chest. 

2.  The  superior  vena  cava  enters  the  auricle  at  a  plane  posterior  to 
that  of  the  inferior  cava,  so  that  the  blood  stream  from  the  latter  is 
directed  upward  by  the  Eustachian  valve  and  not  to  the  left  as  is 
commonly  stated. 

3.  The  tricuspid  orifice  is  practically  vertical,  not  horizontal,  and 
opens  toward  the  left  and  slightly  forward.  The  lower  part  of  the  right 
ventricle  is  so  near  the  level  of  the  right  auricle  that  gravity  can  play  but 
an  inconspicuous  part  in  the  filling  of  the  ventricle. 

4.  The  mitrU  and  tricuspid  orifices  lie  in  planes  almost  at  right  angles 
to  each  other.  ^. 

5.  The  two  posterior  aortic  leaflets  are  attached  to  the  base  of  the 
mitral  leaflet  (see  Flint's  murmur). 

6.  The  mitral,  tricuspid  and  aortic  valves  are  practically  contiguous 
structures.  This  fact  together  with  the  actually  small  size  of  the  heart, 
and  the  thinness  of  the  chest  wall,  explains  why  sounds  produced  at  these 
areas  are  often  differentiated  with  difficulty.  A  systolic  aortic  murmur 
can  only  be  identified  with  certainty  if  heard  in  the  neck.^ 


In  examining  the  lungs,  the  chest  must  be  exposed  and  the  patient 
must  not  be  in  a  recumbent  position  if  the  greatest  possible  accuracy  is 
a  desideratum.  The  importance  of  inspection,  especially  in  chronic  pul- 
monary disease,  cannot  be  over-emphasized.  Symmetric  areas  of  the 
chest  must  be  examined  and  compared  step  by  step.  In  determining 
fremitus  it  is  well  to  bear  in  mind  that  the  ulnar  nerve  distribution  is 
more  sensitive  than  the  radial  and  hence  the  hand  should  be  slightly 
rotated  toward  the  outer  side. 

In  practising  percussion  the  beginner  usually  employs  far  too  much 
force.     This  is  always  disagreeable  and  often  painful  to  the  patient;  it  is 

1  Fetterolf  and  Gittings:  Am.  Jour.  Dis.  Children,  I,  1911,  6. 



also  hard  on  the  examiner's  fingers.  As  a  general  rule,  the  more  experi- 
enced the  examiner  the  Kghter  the  percussion  stroke  he  employ's.  Force 
and  accm-ate  limitation  are  not  compatible.  The  blow  must  be  dehvered 
from  the  wrist  (not  the  arm),  it  must  fall  vertical!}^  and  the  striking 
finger  must  be  ciuickly  withdrawn.  Good  percussion  is,  and  should  be, 
a  "gentle  art. '" 

Before  ausculting,  see  to  it  that  the  patient  breathes  properly.  Res- 
pirations should  be  a  trifle  deeper  than  is  normally  the  case,  and  the  mouth 
slightly  open.  ''Throaty"  sounds  must  be  eliminated  and  expiration 
must  be  purely  passive.     The  areas  over  which  the  breath  sounds  may 


Hyper- re  30  nance; 


Noraal  Breathing: 

Vfeai  breatiiing: 

Exaggerated  'breathing: 

Bronoiio-vssicular  breathing: 


Bronchial  breathing: 
CavernouB  breathing: 

Cog-wheel  breathing: 


Crepitant  rales: 

Crackling  rales: 
.Bubbling  rales: 
Sibilant  or   sonorous  rales: 

Fig.  119.- — For  the  sake  of  conser\-iiig  time  in  the  recording  of  physical  signs  various 
ss'stems  of  graphic  registration  have  been  suggested.  That  which  follows  is  modified 
after  Barach's  plan.  Unfortunately  no  uniform  system  has  thus  far  been  adopted  by 

If  roles  occur  during  inspiration  they  are  charted  before,  if  during  expiration,  after  the 
symbol  which  stands  for  the  type  of  breathing. 

normally  be  somewhat  harsh,  must  be  borne  in  mind,  and  examination  of 
the  supracla%'icular  and  suprascapular  portions  of  the  lung  as  well  as  the 
apex  of  the  axilla  must  not  be  omitted. 

A  diagnosis  of  incipient  tuberculosis  based  upon  a  single  examination 
is  always  a  questionable  procedure.  Repeated  examinations  and  fur- 
ther observation  are  usually  advisable.  In  really  early  pulmonary  tuber- 
culosis, abnormality^  in  the  physical  signs  is  veiy  slight  and  may  be  absent. 
A  careful  consideration  of  the  patient's  history  and  an  observation  of  his 
temperature  and  pulse  are  often  more  reHable  than  slight  abnormality 
of  his  physical  signs. 

The  physical  signs  of  pleural  effusion  and  pulmonary  consohdation 
are  variable,  and  the  classical  text-book  method  differentiation  often 
fallacious.  Consolidation  may  yield  absent  breath  sounds;  an  effusion, 
bronchial  breathing,  bronchophony  and  fremitus.     The  reasons  for  this 




Heart  and  Abdominai, 

Vw-Cvvvovvvc.  'i.    i- 

-Wtt  tv<X^  ,  S  H^^ti'^C 


Slight  dulness 

Moderate    ** 


Marked        " 




Pectoriloquy  outlined 
Hyperresonance    '* 

D  red  ink. 
'  purple  iak. 

Fig.  120. — The  accompanying  chart,  which  is  the  type  used  at  the  Phipps  Institute, 
depicts  the  physical  signs  encountered  in  a  case  of  right-sided  pulmonary  tuberculosis  with 
cavitation  in  the  upper  lobe,  and  of  left-sided  pleural  effusion.  In  addition  to  furnishing 
excellent  graphic  records  the  details  of  which  can  be  grasped  at  a  glance,  the  method  is 
invaluable  for  students  since  they  are  required  to  describe  exactly  the  signs  occurring  in 
every  region  of  the  chest.  This  encourages  care  for  detail  and  eliminates  "negative" 
r  >sults.     Red  shading  indicates  tympany. 



variation  of  phj^sical  signs  have  already  been  discussed  (p.  60,  Fig.  107). 
The  exploring  needle  should  be  unhesitatingly  emploj^ed  in  doubtful 
cases.  Properly  performed,  this  procedure  is  unattended  by  risk,  or  any 
considerable  degree  of  pain. 

The  explanation  of  abnormal  phj^sical  signs  as  "thickened  pleura" 
should  be  made  only  as  a  last  resort.  In  this  condition  physical  signs 
are  slight  or  entirely  absent,  unless  the  lung  is  also  involved. 

With  obscure  pulmonary  symptoms,  especially  in  men  past  thirty-five 
years,  the  possibilitj-  of  aortic  aneurism  must  ever  be  borne  in  mind, 
especially  if  associated  with  cough,  chest  pain,  or  d^^spnea  for  which 
symptoms  no  evident  cause  can  be  demonstrated. 

Fig.  121. — The  graphic  signs  here  depicted  would  be  construed  as  follows:  Right  upper 
lobe:  high-pitched  tympany,  surrounded  by  dulness,  cavernous  breathing,  inspiratorj^  bub- 
bling rales.     Right  axilla:  friction  and  below  this  area  weak  breath  sounds. 

Left  upper  lohe:  slight  dulness,  broncho-vesicular  breathing,  subcrepitant  inspiratory 
and  crackling,  expiratory  rales.  Left  axilla:  cog-wheel  breathing,  below  this  area,  exaggerated 
breath  sounds. 


The  X-ray,  especially  as  a  fluoroscope,  has  become  a  useful  adjunct 
in  intrathoracic  diagnosis.  It  enables  us  to  "control"  our  percussion 
and  often  definitelj^  establishes  the  presence  or  absence  of  deep-seated 
mediastinal  lesions — aneurism,  lymphadenitis,  central  pneumonia,  tu- 
mors, foreign  bodies,  mediastinal  displacement,  pulmonary  abscess,  etc. 
- — in  cases  in  which  ordinary  physical  diagnosis  onlj^  permits  us  to  "sus- 
pect" the  lesion.  The  same  statement  applies  to  some  cases  of  localized 
pneumothorax  and  of  pulmonary  fibrosis  involving  the  diaphragmatic 
pleura,  as  well  as  to  small  pleural  effusions. 

On  the  other  hand,  the  ordinary  methods  of  diagnosis  are  far  superior 
to  the  X-ray  in  cases  of  incipient  or  early  pulmonary  tuberculosis  and  in 
congestion  of  the  lungs.  In  these  instances  the  mistakes  are  usualty  on 
the  side  of  the  radiographer.  The  X-raj-  is  rarely  of  much  use  as  an  early 
diagnostic  method  in  cardiac  or  pulmonary  disease. 


By  George  W.  Norris,  A.  B.,  M.  D 



The  most  important  signs  to  be  looked  for  are:  dj'spnea,  orthopnea, 
paUor,  flushing  or  cyanosis;  distention  or  pulsation  of  the  superficial 
arteries  or  veins,  especially  in  the  neck;  edema,  especiallj^  of  the  dependent 
portions  of  the  bodj^  and  of  the  face;  clubbing  of  the  fingers,  inequality 
of  the  pupils;  normal  or  abnormal  pulsations,  especially  of  cardiac  apex 
and  the  epigastrium;  distention  of  the  abdomen,  fulness,  in  the  hepatic 
region,  and  in  the  flanks. 

OrtJwpnea,  the  state  in  which  the  patient  has  to  sit  up  in  order  to  get 
his  breath — indicates  that  the  heart  is  drawing  on  its  last  reserves. 
Circulatory  pallor  is  seen  in  connection  with  low  blood-pressure  and  periph- 
eral anemia.  Flushing  "Of  the  face  may  be  seen  in  fevers,  excitement 
also  in  aortic  insufficiency  and  at  times  in  arterial  hypertension.  Cyano- 
sis indicates  insufficient  oxygenation  of  the  blood,  and  is  seen  chiefiy  in 
mitral;  pulmonary  and  tricuspid  lesions  associated  with  pulmonary 
congestion.  It  is  most  marked  in  the  face,  hands,  and  feet.  Distention 
of  the  superficial  veins  indicates  high  venous  pressure,  generally  a  weak 
right  heart;  or  local  obstruction  to  the  venous  circulation  and  an  effort 
to  establish  collateral  circulation.  Circulatory  edema  occurs  character- 
istically at  the  end  of  the  day,  and  in  the  dependent  portions  of  the  body; 
renal  edema  occurs  in  the  morning  and  upon  the  face.  Cluhhing  of  the 
fingers  indicates  long-standing  stasis  of  the  pulmonary  circulation — 
chronic  cardiac  or  pulmonarj^  disease.  Anisocoria — -pupillary  inequality — 
may  result  from  pressure  of  a  thoracic  aneurism  upon  the  cervical  sym- 
pathetic. Pulsation  of  the  cervical  vessels  may  be  arterial  or  venous.  In 
the  former  instance  it  may  be  due  to  marked  alternations  of  blood-pres- 
sure and  an  hypertrophied  heart,  or  to  a  local  aneurism.  Venous  pulsa- 
tions may  be  seen  in  the  jugular  veins  of  recumbent  subjects.  Normally 
three  small,  faint  waves  can  be  made  out.  These  are  stasis  waves;  thej' 
are  not  due  to  regurgitation  from  the  right  heart.  A  single  large  sj^stolic 
pulsation  may  result  from  (a)  a  transmitted  impulse  from  a  contiguous 
artery,  (6)  tricuspid  insufficiency,  (c)  aneurismal  varix.  A  capillary 
pulse  (Quincke's  pulse)  consists  in  an  alternate  flushing  and  blanching 
of  a  flnger  tip  when  slight  pressure  is  made  upon  the  lower  portion  of  the 




finger  nail.     It  may  occur  in  cases  of  aortic  insufficiency.     It  is  not'^an 
early  sign  and  is  elicited  with  difficulty. 

The  patient  who  suffers  from  mitral  and  tricuspid  disease  is  apt  -  to 
complain    of  orthopnea,  cough,  cyanosis,  and  hemoptysis    (pulmonary 

Fig.   122. — Stunted  growth  and  bulging  of  the  precordium  resulting  from  mitral  obstruction 
and  insufficiency  in  a  boy  of  fifteen  years. 


Anrtic  valve 

Fig.    iL'.'i. — showing  partial  overlapping  of  the  aortic  and  pulmonic  valvular  orifices.      The 
'        pulmonic  is  the  most  superficial  of  all  the  cardiac  valves. 

stasis),  digestive  disturbances  (portal  congestion)  and  edema.  Aortic 
lesions  are  characteristically  associated  with  dyspnea  on  exertion,  vertigo, 
flushing,  palpitation,  precordial  oppression. 




The  heart  lies  obliquely  placed  behind  the  lower  two-thirds  of  the 
sternum.  It  rests  upon  the  upper  surface  of  the  diaphragm,  two-thirds 
of  its  bulk  being  placed  to  the  left  of  the  mid-sternal  Hne.  The  base  ex- 
tends from  the  lower  border  of  the  second  left  costal  cartilage  to  the  upper 


Fig.  124. — Normal  position  of  the  heart.  A.  =  aorta;  P. A.  =  pulmonary  artery; 
R.A.  =  right  auricle;  »S.C  =  superior  vena  cava;  T.  =  trachea;  E.  =  esophagus;  -S. A. .sub- 
clavian artery;  S.V.   =  subclavian  vein;  ^.   =  spinal  cord;  C.   =  clavicle. 

border  of  the  third  right  costal  cartilage.  The  apex  lies  in  the  fifth  left 
intercostal  space,  about  8  cm.  to  the  left  of  the  mid-sternal  line.  The 
aorta  arises  at  the  level  of  the  third  costal  cartilage  behind  the  sternum. 
It  reaches  halfway  up  the  manubrium,  and  is  nearest  the  surface  at  the 
second  right  costal  cartilage. 



The  Valves. — The  aortic  valve  lies  behind  the  third  left  costo-sternal 
junction.  It  is  one-fourth  overlapped  by  the  pulmonary  valve.  The 
pulmonary  valve  lies  a  little  higher  and  more  to  the  left.  The  mitral  valve 
lies  behind  the  third  intercostal  space  about  1  inch  to  the  left  of  the  ster- 
num.    The  tricuspid  valve  lies  below  and  slightly  to  the  left  of  a  line 

Fig.  125. — Radiogram  showing  the  relatict  position  of  the  cardiac  vahes  in  relation  to 
each  other  and  to  the  anterior  bony  thorax.  The  pulmonarj-,  in  part  overlies  the  aortic, 
valve.  It  is  the  most  superficially  placed  of  all  the  heart  valves.  The  mitral  valve  is  the 
farthest  from  the  anterior  chest  wall.  The  large  size  of  the  tricuspid  orifice  is  well  shown. 
This  valve  is  structurally  a  much  less  perfect  mechanism  than  is  the  mitral. 

The  valves  were  covered  with  lead  paint  before  making  the  radiogram.  (After  Norris 
and  Fetterolf.^) 

drawn  from  the  inner  end  of  the  third  left,  to  the  sixth  right  costal  carti- 
lages. The  aortic,  mitral  and  tricuspid  valves  are  anatomically  practi- 
cally contiguous  structures.  The  mitral  is  the  furthest  from,  the  pul- 
monic the  nearest  to,  the  anterior  chest  wall  (Figs.  123,  128). 

Posteriorly. — The  base  of  the  heart  lies  at  the  level  of  the  fifth  dorsal 

1  XoRRis  and  Fetterolf:  "The  Topography  of  the  Cardiac  Valves  as  Revealed 
bv  the  X-ravs. "     Am.  Jour.  Med.  Sc,  cxlv,  191.3,  225. 



Left  innom- 
inate vein 

Right  auricle 

Papillary  -^ 


Right  ventricle 

Right  pulmo- 
nary artery 
Left  bronchus 

Aortic  leaflets 

Left  lunc 

Fig.  12G. 



Right  pul.  artery 

Left  super,  pul.  vein  .. 

L.auricular  appendix s  ^ 

L.  infer,  pul.  vein 

Left  auricle 

Mitral    valve   ante-  " 

rior  leaflet  v>. 


Aortic  leaflets 

Left  ventricle 
Right  ventricle 

Fig.  127. 

Figs.  126  and  127. — These  sections  show  the  deeply  placed  position  of  the  left  auricle 
which  may  be  topographically  described  as  the  "posterior  auricle."  They  also  depict  the 
relatively  large  amount  of  mediastinal  space  which  is  occupied  in  an  antero-posterior  di- 
rection by  the  heart.  The  rear  view  of  the  heart  is  shown  in  Figs.  91  and  92.  the  anterior 
aspect  in  Figs.  86  and  163. 


vertebra.  The  apex  of  the  heart  Hes  at  the  level  of  the  eighth  dorsal  ver- 
tebra. The  aorta  reaches  the  spine  at  the  level  of  the  fourth  dorsal 
vertebra.  The  pulmonary  artery  bifurcates  at  the  level  of  the  fourth 
dorsal  vertebra.  Practically  the  whole  anterior  surface  of  the  heart  is 
right  heart  (see  Fig.  163).  The  left  auricle  lies  posteriorly.  Of  the  left 
ventricle  only  the  tip  is  seen  from  in  front. 

— -A- 

Fig.  128. — Diagram  illustrating  the  relative  position  of  the  heart  valves  as  seen  from 
above;  1,  pulmonary;  2,  aortic;  3,  mitral;  4,  tricuspid.  The  pulmonary  is  the  most  super- 
ficial, and  the  mitral  the  most  deeply  placed  of  the  cardiac  valves  (comp.  Fig.  123). 


The  pulse  is  generally  examined  by  palpation  of  the  radial  artery. 
When  the  patient's  hands  are  not  accessible,  as  during  sleep,  the  temporal 
artery  is  often  selected.  Under  certain  circumstances  it  may  be  neces- 
sary to  feel  the  pulse  elsewhere  as,  for  instance,  in  the  tibial  arteries  or 
in  the  dorsalis  pedis.  The  pulse  should  be  palpated  with  the  tips  of  the 
fingers,  not  with  the  palmar  surface.  The  thumb  must  not  be  used 
because  a  subjective  pulse  can  often  be  felt.  When  examining  the  pulse 
two  conditions  are  to  be  determined:  (1)  the  character  of  the  arterial  wall 
(arterio-sclerosis,  etc.) ;  and  (2)  the  character  of  the  pulse. 

1 .  Arterial  thickening  is  determined  (a)  by  rolling  the  emptied  artery, 
in  which  the  blood  flow  has  been  temporarily  occluded  by  pressure  above 
and  below  the  point  of  palpation,  under  the  ball  of  the  finger;  (6)  by  allow- 
ing the  end  of  the  finger  nail  to  slip  across  the  arterial  wall.  Normal 
arteries  are  barely  palpable. 

An  important  source  of  error,  however,  lies  in  the  state  of  vascular 
tonus.  When  blood-pressure  is  high  the  artery  may  readily  be  rolled 
under  the  finger,  and  the  tactile  sensation  received  may  be  similar  to  that 
produced  by  actual  arterial  sclerosis.  Increased  tonus  may  sometimes 
be  temporarily  abated  by  local  massage  of  the  artery.  On  the  other 
hand,  a  definitely  thickened  artery  may  escape  detection  when  tonus  is 

If  arterio-sclerosis  is  suspected,  examination  must  not  be  limited  to 
the  radial  arteries  but  should  include  the  brachials,  femorals,  temporal 
and  retinal  arteries  as  well. 

2.  The  character  of  the  pulse  is  judged  by  noting  the  rate,  rhythm, 
volume,  tension  and  equality.  Both  radial  arteries  should  be  habitually 
palpated  synchronously  in  order  to  determine  bilateral  equality. 


The  Pulse  Rate. — The  normal  rate  in  adults  is  for  men  72,  for  women 
80.  With  advancing  years  the  rate  often  becomes  slower.  Certain 
individuals  in  perfect  health  may  have  by  nature  a  rapid  (90)  or  a  slow 
(60-70)  pulse.  The  latter  rate  is  not  infrequent  in  advanced  years.  In 
the  new-born  the  rate  averages  about  140,  and  at  fourteen  years  about  90. 
The  pulse  rate  is  increased  by  excitement,  anger,  fear,  exercise,  digestion, 
deep  inspiration,  low  blood-pressure,  fever,  etc.  The  pulse  increases 
about  ten  beats  for  every  degree  Fahrenheit  above  the  normal  body 
temperature.  It  is  more  rapid  in  short,  high-strung  individuals  than  in 
people  with  a  large  frame  and  a  phlegmatic  disposition.  The  peripheral 
pulse  rate  does  not  always  indicate  the  cardiac  rate.  Notable  discrep- 
ancies may  occur  in  auricular  fibrillation,  extrasystolic  arrhythmia  and 
pulsus  alternans.  The  complete  bodily  circuit  of  blood  flow  requires 
normally  about  23  seconds  and  is  accomplished  by  about  27  systoles. 
The  pulse  wave  travels  9  to  10  m.  per  second,  it  therefore  reaches  the 
dorsalis  pedis  artery  ^  second  later  than  the  aorta — about  the  middle 
of  ventricular  systole.  The  time  required  to  reach  the  radial  artery  is 
approximately  6.17,  and  the  interval  between  the  carotid  and  the  radial 
pulses,  is  0.08  second. 

Tachycardia. — This  term  is  generally  applied  to  a  pulse  rate  above 
130  per  minute.  It  may  occur  in  exophthalmic  goitre,  in  cardiac  disease, 
in  vasomotor  collapse,  etc.,  but  is  most  characteristically  seen  in  "  paroxys- 
mal tachycardia,"  a  condition  due  either  to  extrasj^stoles  or  to  a  fibrillat- 
ing  auricle. 

Bradycardia. — This  term  is  generally  applied  to  a  pulse  rate  of,  or  of 
less  than,  60  per  minute.  It  may  occur  in  convalescence,  after  vomiting, 
in  basilar  meningitis  or  increased  intracranial  pressure  (vagus  irritability 
or  stimulation)  and  also  in  jaundice  (toxic  effect).  It  occurs  character- 
istically in  heart  block,  in  which  condition  it  may  fall  to  twelve  beats 
per  minute. 

The  Pulse  Rhythm. — The  pulse  may  be  irregular  either  in  regard  to 
(1)  time  or  (2)  force.  Not  infrequently  both  factors  are  combined,  as  in 
auricular  fibrillation  (see  Cardiac  Arrhythmia). 

The  Pulse  Volume. — The  volume  of  the  pulse  is  gauged  by  estimating 
the  degree  of  pulsatile  oscillation — the  amount  of  systolic  filling  and  the 
completeness  of  diastohc  collapse.  It  depends  upon,  and  is  in  part  a 
measure  of  the  systolic  output.  The  pulse  pressure — the  difference  be- 
tween the  systolic  and  the  diastohc  pressures — may  be  taken  as  a  rough 
index  of  pulse  volume.  As  a  general  rule  the  more  rapid  the  rate,  the 
smaller  the  volume  of  the  pulse. 

The  Pulse  Tension. — This  is  estimated  by  gauging  the  amount  of 
pressure  which  must  be  exerted  upon  the  artery  before  the  flow  of  blood 
is  stopped.  In  other  words  it  depends  upon  the  blood-pressure  which  is 
due  chiefly  to  vascular  tonus,  cardiac  force  and  valvular  sufficiency.  The 
pulse  is  sometimes  described  as  hard  or  soft,  depending  upon  whether 
arterial  tension  is  high  or  low.  These  terms  are  obsolete,  the  degree  of 
tension  should  be  measured  with  a  sphygmomanometer  and  the  height 
of  the  sj'stolic  and  the  diastolic  pressures  recorded  in  millimeters  of 
mercury  (see  Blood-pressure  Instruments,  p.  163).  The  celerity  of  the 
pulse  wave  depends  upon  the  suddenness  of  its  collapse.  A  "quick" 
pulse  is  not  a  rapid  pulse,  but  one  which  disappears  quickly.  It  occurs 
characteristically  in  aortic  insufficiency  and  is  known  as  the  water-ham- 


meror  Corrigan  pulse,  but  it  also  occurs  in  a  minor  degree  in  severe  anemia 
and  in  vasomotor  paresis. 

The  opposite  condition — pulsus  tardus — ^appears  and  disappears 
slowly.  The  systolic  ascent  of  the  sphygmogram  is  gradual,  the  plateau 
long  and  the  descent  prolonged.  This  type  of  pulse  is  observed  es- 
pecially in  aortic,  and  in  a  minor  degree  mitral,  obstruction.  It  is  a 
valuable  diagnostic  sign  of  the  former. 

The  Equality  of  the  Pulse. — By  this  we  mean  equality  in  (1)  volume, 
(2)  time  and  (3)  force,  in  symmetrical  arteries  of  the  body.  Inequality 
of  the  radial  arteries  maj^  result  from:  (1)  surgical  injuries  of  the  upper 
extremities,  (2)  axillary  growths,  (3)  aneurism  of  the  aorta,  innominate, 
subclavian,  brachial  or  radial  arteries,  (4)  emboh  or  thrombi  or  syphilitic 
disease  in  these  arteries,  (5)  massive  pleural,  effusions,  (6)  local  inflam- 
matory conditions,  (7)  extreme  auricular  dilatation.  Slight  degrees  of 
inequality  occur  very  commonly.  This  sign  is  of  little  importance  unless 
it  is  well  marked.^ 


The  normal  arterial  pulse  which  is  felt  as  a  single  "beat"  consists 
when  analj^zed  of  the  following  waves: 

Fig.  129.— The  cardiogram_( tracing  from  Fig.   130. — The   normal   radial    curves: 

the    precordium) :    a,    auricular   wave;    c.d.-  a-5,  the  tidal  wave;  6-e,  the  aortic  notch;  gr, 

e.f.,  ventricular  systole) ;  d,  marks  the  open-  the  dicrotic  wave;  h,  the  post-dicrotic  wave, 
ing  and  /,  the  closure  of  the  semilunar  valves, 
(beginning  of  diastole) ;  k,  sudden  ventricular 

The  arterial  pulse,  by  which  term  we  designate  the  expansion  and 
contraction  of  an  artery  which  occurs  during  the  systole  and  diastole  of 
the  heart,  has  long  been  used  as  a  diagnostic  criterion.  When  the  sphyg- 
mograph  was  first  introduced  in  medicine  it  was  hoped  that  a  detailed 
study  of  the  length,  height  and  time  relations  of  the  various  phases  of 
the  pulse  tracing  would  lead  us  far  toward  perfection  in  diagnosis.  As  a 
result  of  such  studies  many  different  types  of  the  arterial  pulse  were 
classified,  named  and  studied,  though  with  but  little  practical  result. 
Such  studies  do,  of  course,  enable  us  to  visualize  our  palpatory  sensations, 
but  the  value  of  the  sphygmogram  to-day  lies  almost  wholly  in  the  time 
relationship  between  the  arterial  and  the  venous  pulse  waves.  There 
are,  however,  certain  types  of  the  arterial  pulse  which  are  more  or  less 
characteristic  of  certain  conditions  which  find  a  place  in  clinical  nomen- 

^  In  a  study  of  500  cases  (well  and  ill)  the  two  radial  pulses  were  alike  in  only  56 
per  cent.  There  was  marked  difference  in  2.5  per  cent.  The  left  pulse  was  stronger  in 
14  per-cent.  of  455  right-handed  people,  and  in  43  per  cent,  of  the  21  ambidextrous. 
In  advanced  life  inequalitj^  is  generally  due  to  arteriosclerosis  (Koennicke:  Therap. 
d.  Gegenw.,  September,  1911). 


clature  and  are  recognizable  by  the  sense  of  touch.  Among  these  the 
following  may  be  mentioned : 

The  Dicrotic  Pulse. — A  dicrotic  pulse  is  one  of  low  tension  in  which 
the  normal  secondary  wave  becomes  exaggerated,  so  that  it  may  be  both 
felt  and  instrumentallj^  demonstrated  to  consist  of  a  more  or  less  separate 
wave.  It  appears  therefore  as  a  repetition  or  echo  of  the  primary  wave. 
If  the  pulse  rate  is  rapid,  the  line  of  descent  of  the  dicrotic  wave  is 
interrupted  by  the  next  primary  wave,  which  condition  is  known  as  anac- 
rotism.  In  the  majority  of  the  febrile  cases  at  least,  it  is  brought  about 
by  relaxation  of  the  arteries  and  constriction  of  the  arterioles,  which 
condition  causes  an  actual  backward  flow  of  blood  in  the  primary  pulse 
wave,  a  phenomenon  which  is  repeated  in  the  case  of  the  dicrotic  wave. 
Other  causes  such  as  a  brief  sj'stolic  output  from  the  heart,  or  dilatation 
of  certain  vascular  areas,  especially  the  splanchnics,  have  been  suggested 

The  Pulsus  Bisferiens. — This  term  should  be  applied  only  to  those 
cases  in  which  the  apices  of  the  two  waves  are  separated  by  a  time  interval 
of  not  less  than  ^-{o  second,  thus  eliminating  cases  of  mere  dicrotism. 
It  is  usually  associated  with  reduplication  of  the  first  sound,  and  an 
analogous  cardiogram,  being  therefore  central  in  origin.  It  is  uncertain 
whether  the  second  wave  arises  in  the  ventricle  or  in  the  aorta.  It  is 
generally  met  with  in  cases  of  left  ventricular  hypertrophy  in  association 
with  disease  of  the  aortic  valves  of  the  large  arteries.^ 

The  Pulsus  Bigeminus. — By  this  term  we  understand  a  tj^pe  of  regular 
irregularity  in  which  the  pulse  waves  instead  of  being  equally  spaced 
occur  in  groups  of  two,  to  be  followed  by  a  more  or  less  prolonged  pause 
(see  Extrasystoles). 

"Ventricular  bigeminy  which  occurs  in  clinical  instances  of  auricular 
fibrillation  either  spontaneously  or  in  the  wake  of  digitalis  administra- 
tion, is  due  to  a  disturbance  of  the  irregular  series  of  responses  to  the 
auricle  by  ectopic  beats  arising  in  the  ventricular  musculature"  (Lewis). 
It  includes  practically  all  instances  of  accurate  coupling.  The  two  beats 
should  bear  a  constant  time  relationship  to  each  other  (Wenckebach). 
If  the  pulse  waves  occur  in  groups  of  three  or  four,  we  describe  it  as  a 
pulsus  tri-  or  quadrigeminus,  respectively. 

The  Water-hammer  Pulse. — The  Corrigan  or  water-hammer  pulse 
occurs  chiefl}''  and  most  characteristically  in  aortic  insufficiency.  It  is 
quick,  collapsing  and  large  in  volume.  The  diastolic  pressure  is  always 
low  (60  to  40  mm.  Hg.),  and  the  systolic  pressure  generally  high  (180  to 
140  mm.  Hg.).  Diastole  is  shortened  and  the  height  of  the  secondary 
wave  is  in  direct  proportion  to  the  amount  of  arterio-sclerosis  present, 
and  not  to  that  of  the  blood-pressure  (Lewis). 

The  Pulsus  Paradoxus. — This  term  is  applied  to  the  disappearance  or 
enfeeblement  of  the  pulse  during  inspiration. 

It  may  occur  normally: 

(1)  During  deep  inspiration  with  glottis  closed — negative  intrathoracic  pressure 
(Mueller's  experiment).  (2)  During  forced  expiration  with  closed  glottis — high 
intrathoracic  pressure  (Valsalva's  experiment).  (3)  If  the  breath  is  held  after  a 
forced  inspiration — pressure  on  the  subclavian  artery — glottis  open.  (The  muscles 
of  shoulder  girdle  compress  the  subclavian  arterv  between  the  clavicle  and  the  first 

1  Lewis,  T.:  Brit.  Med.  Jour.,  April  20,  1907. 



The  bigeminal  pulse  (digitalis  effect  in  auricular  fibrillation 


The  water-hammer  pulse  (aortic  insufficiency) 

Slow  hiah  tension  pulse   (arteriosclerosis') 

Pulsus  irregularis  perpetuus  (auricular  fibrillation).     Irregular  both  as  to  time  and  volume. 

Fig.  131. 



It  may  occur  pathologically: 

(1)  At  the  extremes  of  life  during  inspiration.  (2)  During  inspiratory  dyspnea — 
croup — slow  inspiration,  high  negative  intrathoracic  pressure.  (3)  In  cases  of  ad- 
hesive (mediastino)  pericarditis.  Respiratory  traction  resulting  from  mediastinal 
adhesions,  is  brought  to  bear  on  some  of  the  large  vessels.  (It  may  be  a  unilateral 
phenomenon.)  If  enfeeblement  or  disappearance  occurs  during  expiration  it  is 
called  Riegel's  pulse.  The  paradoxical  pulse  has  little  if  any  pathologic  significance. 
The  pathological  paradoxic  pulse  is  generally  assumed  to  be  due  to  constriction  of 
some  of  the  large  vessels  by  mediastinal  adhesions.  The  paradoxic  venous  pulse — • 
filling  of  the  veins  during  inspiration — has  a  similar  genesis. 



Pulse  tension  or  blood-pressure  is  best  estimated  by  means  of  a 
mercurial  sphygmomanometer  equipped  with  a  cuff,  not  less  than  12  cm. 
in  width.     For  children  smaller  sizes  may  be  employed. 


The  Systolic  Pressure. — The  cuff  is  applied  snugly  to  the  upper  arm 
and  secured  by  means  of  straps  or  a  bandage.  The  cuff  is  then  connected 
with  the  manometer  and  quickly  inflated  to  a  point  well  above  the  sys- 

FiG.   132. — The  Uskoff  sphygmotonograph. 

folic  pressure,  after  which  the  stop-cock  is  turned,  so  as  to  exclude  the 
pump  from  communication  with  the  cuff.  A  stethoscope  is  now  placed 
over  the  brachial  artery  below  but  not  in  contact  with  the  cuff,  and  auscul- 
tation is  practised  while  the  pressure  is  gradually  allowed  to  fall.  The 
first  clear  thumping  or  pounding  noise  indicates  the  fact  that  pressure  in 
the  artery  is  now  sufficiently  high  to  force  the  blood  under  the  constricting 
cuff,  and  to  distend  the  artery  below.     The  height  of  the  mercurial 



column  at  which  this  acoustic  phenomenon  occurs  indicates  the  systolic 
pressure  in  the  brachial  artery. 

The  Diastolic  Pressure. — The  examiner  should  continue  to  listen 
while  the  mercury  falls,  and  in  doing  so  will  notice  after  a  time,  that  the 
thumping  sound  is  followed  by  a  "hiss"  or  murmur  which  in  turn  dis- 
appears and  is  replaced  by  a  clear-cut  sound  similar  to  that  first  heard. 
As  the  mercury  falls  still  lower  this  clear-cut  sound  suddenly  becomes 
muffled  and  distant.  This,  the  beginning  of  the  fourth  auscultatory  phase, 
indicates  the  diastolic  pressure. 

Occasionally  it  happens  that  the  fourth  phase  cannot  be  accurately 
identified.  In  such  cases  the  fifth  phase  (the  disappearance  of  all  sound) 
is  chosen  as  the  diastolic  criterion.  The  difference  between  these  two 
phases  rarely  exceeds  a  few  millimeters  of  mercury,  but  at  times  they 
may  be  separated  by  15  mm.  or  more.  The  fifth  phase  is  sometimes 
persistent  clown  to  0  mm.  Hg.  in  aortic  insufficiency.  In  these  cases  the 
diastolic  pressure  must  be  estimated  b^^  the  fourth  phase  or  not  by 
auscultation  at  all. 

For  purposes  of  comparison,  blood-pressure  readings  should  be  made 
(1)  in  the  same  posture;  (2)  on  the  same  arm;  (3)  in  about  the  same 
relation  to  meals.  It  should  be  remembered  that  pain,  fear,  anxiety, 
excitement,  exercise,  etc.,  may  cause  marked  increase  in  pressure  although 
in  such  instances  it  is  the  systolic  pressure  which  is  chiefly  affected.  The 
readings  should  be  made  as  quickly  as  is  consistent  with  accuracy.  After 
estimating  the  pressure  the  air  should  be  allowed  to  escape  from  the  cuff 
and  after  the  lapse  of  a  few  minutes  a  control  observation  should  be  made. 
This  will  often  be  found  to  be  lower  than  the  first  reading,  especially 
in  patients  unaccustomed  to  the  procedure,  the  initial  high  reading  being 
due  to  psychic  influences.  If  the  cuff  remains  inflated  for  too  long  a 
time,  the  resultant  venous  stasis  will  per  se  increase  the  pressure. 


In  healthy  adults  the  normal  systolic  pressure  is  about  130,  the 
diastolic  pressure  about  80  mm.  Hg.  During  the  first  month  of  life  the 
sj'stolic  pressure  ranges  between  60  and  90  mm.  Hg.  and  gradually  in- 
creases. This  increase  bears  a  more  constant  relation  to  height  and 
weight  than  to  age  or  sex.  The  diastolic  pressure  in  infants  is  ver}^ 
difficult  to  estimate  owing  to  the  small  size  and  relatively  deep  situa- 
tion of  the  artery. 

As  age  increases  pressure  gradually  tends  to  rise,  generally  at  the 
ratio  of  about  1  mm.  Hg.  for  every  two  years  of  life,  assuming  that  a 
youth  of  twenty  years  has  a  pressure  of  120  mm.  Hg.  Pressure  readings 
above  160  mm.  {systolic)  or  100  mm.  (diastolic)  if  constantly  present  must 
be  considered  pathologic  at  any  age. 


Increased  blood-pressure  is  clinically  more  common  and  diagnostically 
far  more  significant  than  decreased  blood-pressure. 

Hypotension. — Occurs  chiefly  in  early  life  (constitutional  or  essential 
hypotension)  and  is  often  associated  with  visceroptosis  and  sometimes 
with  tuberculous  disease.  It  is  also  met  with  after  exhausting  fevers, 
in  cachexia,  as  a  terminal  phase  of  hypertension,  and  in  shock. 


Fig.  133. — The  Jacquet  cardiosphygmograph.      The  jugular  vein  on  the  right,  and  the  caro- 
tid artery  on  the  left  as  well  as  the  radial  pulse  are  being  simultaneously  recorded. 

Fig.  134.1 — '^^^  Jacquet  cardiosphygmograph.  A  detailed  view  of  the  instrument, 
showing  special^ apparatus  for  steadying  the  hand  and  throwing  the  radial  artery  into  more 
close  contact  with  the  receiver. 


Hypertension. — Occurs  chiefly  after  middle  life  and  suggests  the  clini- 
cal symptom  complex  known  as  Bright's  disease — arteriolar  disease  with 
cardiac  hypertrophy  and  more  or  less  destruction  of  renal  tissue,  ter- 
minating in  cardio-vascular  failure,  uremia,  apoplexy  or  angina  pectoris. 
Hypertension  may  also  occur  in  plumbism,  polycythemia,  etc.,  or  it 
may  be  temporarily  present  as  the  result  of  anger,  fright,  excitement  or 
physical  exercise.  It  maj^  occur  locally  as  a  result  of  vascular  spasm 
{vascular  crises)  and  cause  intermittent  claudication,  blindness,  aphasia, 
angina  pectoris,  etc. 


The  clinical  estimation  of  venous  blood-pressure  is  attended  with  much 
more  difficulty  and  much  less  accuracy  than  in  the  case  of  arterial  ten- 
sion. A  rough  clinical  test  may  be  made  by  noting  the  level  at  which 
the  veins  of  the  hand  collapse  while  the  arm  is  being  gradually  raised 
from  the  level  of  the  hip  to  above  that  of  the  shoulder.  Collapse  normally 
should  occur  at  xipho-sternal  articulation  (Gaertner's  test).  Venous 
pressure  is  estimated  in  centimeters  of  HoO.  The  normal  pressure  at 
the  level  of  the  auricles  (Louis'  angle)  ranges  between  5  and  10  cm.  H2O, 
It  is  increased  by  exercise,  weakness  of  the  right  heart,  etc.,  and  may 
reach  as  high  a  figure  as  30+  cm.^  An  increase  in  venous  pressure 
generally  occurs  with  a  fall  of  arterial  pressure  when  cardiac  compensation 


Relatively  little  knowledge  can  be  derived  from  a  sphygmographic 
tracing  of  the  arterial  pulse  alone,  but  combined,  simultaneous  records 
taken  from  the  jugular  vein  and  from  the  radial  or  brachial  artery  are 
often  of  extreme  importance  and  are,  indeed,  the  chief  method  by  which 
the  different  forms  of  cardiac  arrhythmia  are  clinically  studied.  The 
phlebogram  from  the  jugular  vein  depicts  the  activity  of  the  right  auricle, 

Fig.   135. — Normal  phlebogram. 

the  sphygmogram  of  the  brachial  arteiy  that  of  the  left  ventricle.  The 
cardiogram — -the  tracing  taken  from  the  apex  impulse — is  often  un- 
satisfactory and  clinically  of  minor  importance. 

The  normal  venous  pulse  consists  of  three,  sometimes  of  four  curves. 

The  "a"  wave  is  a  stasis  wave  due  to  the  contraction  of  the  right 
auricle.  It  is  presystolic  in  time.  The  "c"  wave  is  a  true  venous  wave 
due  to  contraction  of  the  right  ventricle,  but  in  clinical  tracings  made 
over  the  jugular  vein  this  wave  is  in  part  due  to  the  impulse  transmitted 
from  the  neighboring  carotid  artery.  The  interval  which  elapses  be- 
tween the  beginning  of  the  "a"  and  the  ''c"  waves  is  known  as  the  con- 
duction time.     It  represents  the  length  of  time  required  for  the  stimulus 

1  For  more  detailed  information  see  Norris.  G.  W.:  "Blood-pressure,  Its  Clinical 
Application,"  Philadelphia,  1917. 


which  causes  the  heart  to  contract,  to  pass  from  the  auricles  through  the 
auriculo-ventricular  bundle  to  the  ventricles  and  to  produce  contrac- 
tions in  these  chambers.  The  time  normally  reciuired  is  0.2  second 
with  a  pulse  rate  of  80  per  minute.  An  increase  of  the  "a-c"  time 
often  indicates  a  lesion  in  the  bundle  of  His. 

The  "v"  wave  is  a  stasis  wave  which  occurs  while  the  ventricle  is 
filhng  with  blood,  and  which  disappears  suddenly  when  the  auriculo- 
ventricular  valves  open.  The  "v"  wave  occurs  early,  is  large  and  pro- 
longed when  the  right  ventricle  is  overloaded.  In  cases  of  tricuspid 
insufficiency  the  "c"  wave  disappears  and  is  supplanted  by  a  large  "v" 
wave.  The  venous  pulse  under  these  circumstances  is  spoken  of  as  a 
"positive  venous  pulse." 

The  "h"  wave  is  not  normally  present.  It  is  due  to  a  flapping  to-" 
gether  (upward;  of  the  tricuspid  and  mitral  leaflets,  and  is  protodiastolic 
in  time.  It  is  synchronous  with  the  third  heart  sound  and  Taay  occur 
(1)  in  slowly  beating  hearts  (because  of  relatively  early  diastolic  ven- 
tricular distention);  (2)  in  aortic  insufficiency  (because  of  high  intra- 
ventricular pressure);  (3)  in  the  early  stages  of  mitral  stenosis  (rapid 
ventricular  filling  due  to  a  distended  auricle). 


Numerous  instruments  have  been  devised  for  the  recording  of  arterial 
and  venous  pulse  waves.  The  author  personally  prefers  the  Uskoff 
sphygmotonograph,  which  may  be  obtained  either  with  or  without  a 
manometer  for  estimating  blood-pressure.  The  driving  mechanism 
which  propels  the  smoked  paper  is  equipped  with  two  speeds  and  very 
excellent  records  from  the  brachial  artery  and  the  jugular  vein  can  be 
made  in  a  xevy  few  minutes. 

The  Jacquet  cardio-sphygmograph  has  the  advantage  of  permitting 
one  to  make  three  simultaneous  records,  but  as  already  stated  the  car- 
diogram is  of  little  value  in  the  average  case.  The  respiratory  movements 
can,  however,  be  traced  instead  of  the  cardiac  impulse.  Like  all  instru- 
ments which  are  attached  to  the  wrist,  the  adjustment  is  more  trouble- 
some and  more  time  is  required  to  make  a  tracing. 

The  Mackenzie  polygraph  is  much  used,  but  in  our  experience  the 
jugular  tracing  is  not  as  satisfactory  as  with  the  above-mentioned  in- 
struments, and  a  good  deal  of  time  is  sometimes  required  for  adjustment. 
The  tracings  are  made  with  ink  pens  upon  white  paper  which  runs  off  a 
spool,  so  that  very  long  tracings  can  be  made.  This  is  a  feature  of  un- 
doubted utility  in  some  cases. 

General  Technique. — For  the  purpose  of  making  jugidar  tracings  the 
patient  must  be  in  the  recumbent  position,  with  the  head  as  low  as 
possible.  A  small  piUow  under  the  head,  however,  is  sometimes  neces- 
sary, in  order  to  relax  the  sternomastoid  muscle  at  the  origin  of  which 
the  receiver  is  placed.  When  respiratory  excursions  are  deep,  it  is  often 
necessary  for  the  patient  to  hold  his  breath  while  the  phlebogram  is  being 
made,  since  the  oscillation  of  the  supraclavicular  structures  may  confuse 
the  venous  waves.  The  L'skoff  cuff  requires  no  adjustment  other  than 
inflation  to  about  the  level  of  the  diastolic  pressure.  With  the  Jacquet 
instrument,  however,  the  receiver  must  be  placed  exactly  OA'er  the  radial 
artery.     If  the  course  of  the  arterj-  is  outlined  upon  the  skin  by  means  of 



a  blue  pencil,  this  procedure  is  much  facilitated.     The  patient  must  be 
cautioned  not  to  move  the  hand  once  the  instrument  has  been  adjusted. 

The  cardiogram  should  be  taken  over  the  outermost  portion  of  the 
apex  impulse.  In  many  cases  no  impulse  may  be  perceptible  unless  the 
patient  rolls  more  or  less  upon  his  left  side.     The  cardiogram  of  the 

Right  int.  jugular  vein. 

Superior       ■^M^ti^i&^j 
vena  pn  va  ^™  *■*  tmii^i 


Fig.  136. — The  right  internal  jugular  vein  emptie.s  through  the  right  innominate  vein 
into  the  superior  vena  cava.  The  distance  between  the  jugular  bulb  over  which  phlebo- 
grams  are  taken  is  not  far  from  the  right  auricle  and  since  no  venous  valves  are  interposed, 
auricular  pressure  changes  promptly  produce  relatively  similar  changes  in  the  jugular  vein. 

right  ventricle  may  often  be  obtained  in  or  near  the  epigastrium.  In 
contradistinction  to  that  of  the  left  ventricle  it  consists  of  a  systolic 
retraction,  not  an  elevation. 

The  respirations  may  be  charted   by  placing  a  cup  receiver  in  the 
episternal  notch  or  by  placing  the  cardiograph  attachment  in  the  epigas- 


trium  and  maintaining  it  in  position  by  means  of  an  elastic  strap.  The 
registration  of  the  respiratory  curve  is  chiefly  important  in  relation  to 
sinus  arrhythmia.  In  most  of  the  instruments  in  clinical  use  the  time  is 
recorded  in  fifths  of  a  second. 

It  is  necessary  that  either  (1)  the  recording  needles  be  directly  in  line 
where  the  tracing  is  made,  or  (2)  that  any  discrepancy  which  may  exist 
between  their  position  be  shown  upon  the  tracing  so  that  allowance  may 
be  made  for  it  in  identifying  the  venous  waves.  This  is  shown  in  Fig. 
137  in  which  the  driving  mechanism  has  been  stopped  near  the  middle 
of  the  tracing  and  the  relative  position  of  the  recording  needles  is  shown 
by  the  vertical  strokes  of  the  lever. 


First. — The  first  point  requiring  attention  is  the  identification  of  the 
"c"  wave  in  the  jugular  tracing.  This  is  accomplished  by  selecting  the 
wave  which  very  slightly  precedes  the  systolic  wave  in  the  brachial 
tracing.  In  doubtful  cases  the  receiver  may  be  moved  up  higher  along 
the  edge  of  the  sternomastoid  muscle  where  a  pure  carotid  tracing  can  be 

Second. — The  "a"  wave  is  identified  by  the  fact  that  it  immediately 
precedes  the  "c"  wave.  It  appears  from  0.15  to  0.2  second  before  the 
latter  and  almost  synchronously  with  the  "a"  wave  of  the  cardiogram 
since  there  are  no  venous  valves  interposed  between  the  right  auricle 
and  the  jugular  bulb  (see  Fig.  137). 

Third. — The  "v"  wave  follows  the  "c"  wave  after  a  variable  interval. 
It  is  often  separated  from  the  former  by  a  sharp  negative  depression 
"x"  which  is  chiefly  due  to  negative  auricular  pressure  due  to  displace- 
ment of  the  auriculo-ventricular  tissues  during  ventricular  systole. 

The  ''v"  wave  is  sometimes  split,  the  first  portion  "v"  being  due  to 
ventricular  systole  and  occurring  during  the  latter  part  of  the  systolic 
plateau  in  the  cardiogram.  The  second  portion  "v^"  occurs  at  the  end 
of  this  time  and  is  due  to  the  downward  rebound  of  the  auriculo- 
ventricular  tissues  to  their  normal  position. 

The  second  negative  depression  "y"  is  due  to  the  opening  of  the 
auriculo-ventricular  valves. 



Recent  additions  to  our  knowledge  of  cardiac  anatomy  and  physi- 
ology have  thrown  much  valuable  light  upon  our  conception  of  heart 
disease,  and  have  placed  cardiac  diagnosis  and  therapy  upon  a  much 
more  accurate  scientific  basis.  As  a  result  of  these  advances  the  study 
of  cardiac  irregularities  has  been  greatly  simplified,  and  the  classifica- 
tion of  these  conditions  has  changed  from  the  hopeless  jumble  which 
existed  a  few  years  ago,  to  a  small  and  relatively  simple  grouping. 


The  stimulus  which  causes  the  heart  to  contract  arises  in  the  sino- 
auricular  node,  a  small  collection  of  specialized  right  auricular  tissue 
which  lies  "in  the  sulcus  terminalis  just  below  the  fork  formed  between 
the  superior  surface  of  the  auricular  appendix  and  the  superior  vena 

Fig.  137. — Xormal  phlebogram.  Blood-pressure  .S.  130,  D.  78  mm.  Hg.  Note  the  regu- 
lar sequence  of  the  "a,"  "c,"  "v"  waves  bearing  a  definite  time  relationship  to  the  brachial 
arterial  waves.     The  conduction  time  ("  a-c  "  interval)  is  normal. 

The  impulse  is  conducted  from  the  auricles  to  the  ventricles  by  means 
of  the  auriculo-ventricular  bundle  (His'  bundle),  a  network  of  specialized 
tissue  which  begins  in  the  right  posterior  margin  of  the  base  of  the 
interauricular  septum  (the  auriculo-ventricular  or  Tawara's  node)  and 
narrowing  to  form  a  bundle  of  fibers,  leads  through  the  interventricular 
septum  to  the  ventricles.  Before  entering  these  structures  it  divides 
into  two  branches  (a  right  and  a  left)  and  again  spreads  out  into  a  net- 
work which  is  distributed  to  the  papillary  muscles  and  to  the  ventricular 
walls,  and  causes  a  contraction  of  these  structures. 

Normal  cardiac  contraction  is  due  to  the  fact  that  this  organ  possesses 
the  functions  of  (1)  stimulus  production,  (2)  excitability,  (3)  conductivity , 
(4)  contractility,  and  perhaps  (5)  tonicity.     Further,  that  these  functions 



are  definitely  coordinated.  The  cardiac  nerves  have  apparently  both  a 
direct  and  an  indirect  modifying  and  controlling  function. 

If  any  portion  of  the  foregoing  mechanism  fails  in  its  proper,  coordi- 
nated function  either  from  the  standpoint  of  time,  place,  or  intensity, 
arrhythmia  will  result.  Thus,  for  instance,  the  stimulus  may  be  generated 
too  rapidly,  or  from  abnormal  regions  (heterogenetic  stimuli),  as  in 
auricular  fibrillation,  so  that  the  ventricles  cannot  keep  pace.  Or  it 
may  be  that  the  auriculo-ventricular  bundle  is  diseased  and  fails  to  con- 
duct impulses  normally  from  the  sinus  node  to  the  ventricles,  and  heart 
block  results.  Again,  the  excitability  of  the  ventricles  may  be  increased 
so  that  they  respond  to  abnormal  stimuli  and  contract  before  the  proper 
time,  producing  ventricular  extrasystoles;  or  the  ventricular  muscle  may 
be  deficient  in  contractile  power  and  contract  with  irregular  force  (pulsus 
alternans) . 

The  term  allorhythmia  (altered  rhythm)  is  applied  to  cases  which 
show  a  regular  irregularity  {e.g.,  2  to  1  heart  block)  and  pararhythmia  to 
those  in  which  two  separate  rhythms  are  simultaneously  seen  in  the 
same  or  different  heart  chambers.  Several  different  types  of  irregularity 
may  coincidently  be  present  in  a  given  case.  Thus  extrasystole  not 
infrequently  complicates  the  other  forms.  Among  the  pathologic  types 
of  arrhythmia,  extrasystole  and  auricular  fibrillation  are  the  most  com- 
mon. Auricular  fibrillation  is  next  in  order  of  frequency,  the  third  place 
being  filled  by  pulsus  alternans,  and  the  rarest  being  heart  block. 

The  vast  majority  of  cases  of  cardiac  irregularity  will  upon  analysis 
be  found  to  conform  to  one  of  the  following  types.  The  modern  classifi- 
cation of  heart  irregularities,  based  as  it  is  upon  variations  of  definite 
physiologic  functions  of  the  heart  mechanism,  has  greatly  simplified  the 
whole  question. 

Irregularity  of  the  pulse  occurring  within  the  first  ten  years  of  Hfe 
is  usually  due  to  sinus  arrhythmia.  The  relative  frequency  of  different 
arrhythmias  from  adolescence  to  old  age  as  seen  in  general  hospital  prac- 
tice is  auricular  fibrillation  40  per  cent.,  extrasystole  35  per  cent.,  pulsus 
alternans  15  per  cent.,  paroxysmal  tachycardia,  sinus  arrhythmia,  heart 
block  or  flutter,  10  per  cent.  A  persistent  pulse  rate  of  35  suggests 
complete  heart  block;  of  40-50,  partial  heart  block.  On  the  other  hand 
a  continual  rate  of  130  leads  one  to  expect  either  auricular  flutter  or  a 
prolonged  paroxysm  of  tachycardia.  An  irregular  pulse  of  120  or  more 
usually  means  auricular  fibrillation.  Extra-systoles  are  unusual  with 
a  pulse  of  or  over  120.  The  more  persistent  the  irregularity  and  the 
higher  the  pulse  rate,  the  greater  is  the  likelihood  that  we  are  confronted 
with  fibrillation  (Lewis). 


Pulse  Intermission. — If  a  pulse  of  regular  rhythm  is  interrupted 
from  time  to  time  by  a  pause,  we  are  dealing  either  with  (a)  extra- 
systoles — common;  the  intermission  corresponds  with  a  heart  impulse 
and  sound  at  the  precordium;  or  (b)  heart  block — rare;  no  impulse ^or 
sound  at  the  precordium. 

"If  the  patient  is  up  and  about  and  has  not  symptoms  of  cardiac 
insufliciency  we  are  almost  surely  dealing  with  extrasystoles.  If  marked 
evidences  of  decompensation  exist  the  probabilities  are  in  favor  of 


"  Coupled^ Beats. — If  the  ventricular  beats  are  coupled  and  the  couples 
are  evenly  spaced  they  are  the  result  of  'one  of  two  mechanisms :  1 .  for 
either  the  alternate  beats  of  the  normal  rhythm  have  been  replaced  by 
premature  contractions — ^in  which  case  the  second  beat  of  the  couple  is 
weak  and  may  not  reach  the  wrist — or  2.  each  third  ventricular  con- 
traction has  been  lost  and  heart  block  is  present.  If  the  -pulse  beats  are 
coupled  {pulsus  higeminus)  a  third  possibiHty  remains;  the  pulse  pairing 
may  be  due  to  the  occurrence  of  premature  heart  beats  which  replace 
each  third  rhj'thmic  beat.  If  such  is  the  case  the  premature  beat  will 
be  appreciable  at  the  apex,  though  it  does  not  reach  the  wrist." 

"  Triple  Beating. — The  recognition  of  the  cause  proceeds  along  similar 
lines.  Tripling  at  the  apex  is  due  to  premature  contractions  which 
replace  each  third  rhythmic  beat,  or  to  heart-block  in  wliich  each  fourth 
ventricular  contraction  has  been  lost.  Tripling  of  the  puhe  {pulsus 
trigeminus)  may  be  due  to  a  third  cause,  namely,  premature  beats  re- 
placing each  fourth  rhythmic  beat,  the  earl}-  beat  failing  to  reach  the 

"Halved  Pulse  Rate. — When  the  ventricle  beats  at  twice  the  pulse 
rate,  the  disorder  is  due  to  premature  contractions  in  all  but  the  rarest 
instances.  Alternation  has  been  known  to  occasion  halving,  the  weak 
alternate  beats  failing  to  reach  the  wrist ;  but  this  condition  is  of  great 
rarity  and,  when  it  occurs,  is  ver}-  transient.  The  two  are  readily 
differentiated,  for  in  the  first  instance  the  ventricular  beats  are  coupled 
while  in  the  last  they  appear  regularly." 

"  When  sudden  and  exact  halving  of  pulse  rate  is  noted  and  the  ven- 
tricular rate  is  halved  simultaneously,  the  disorder  is  the  result  of  heart- 

"A  grossly  irregular  pulse  in  which  there  is  hopeless  jumbling  of 
stronger  pulsations,  with  quick  runs  of  almost  imperceptible  beats,  and  in 
which  the  lengths  of  intervening  pauses  are  constantly  varjdng,  is  due 
to  auricular  fibrillation." 

"A  mild  grade  of  irregularity  which  persists,  which  is  not  related  to 
respiration  even  when  the  breathing  is  deepened  and  in  which  no  definite 
sequence  of  events  can  be  determined,  is  also  due  to  aui'icular  fibrillation 
in  most  cases.  A  similar  irregularity,  which  shows  relations  to  respira- 
tion, is  a  sinus  arrhythmia"  (Lewis). ^ 


Under  normal  conditions  a  deep  inspiration  tends  to  accelerate,  a 
deep  expiration,  to  retard  the  pulse.  If  this  condition  becomes  exagger- 
ated so  that  ordinary  breathing  produces  a  distinct  pulse  irregularity'',  we 
speak  of  it  as  sinus  arrhythmia.  The  name  juvenile  arrhythmia  has  also 
been  used  on  account  of  the  frequency  with  which  it  occurs  in  children. 
It  is  essentially  a  vagus  phenomenon,  being  due  to  overactivity  of  the 
tenth  nerve.  Sinus  arrhythmia  may  also  occur  independently  of  the 
respiratory  act.  It  occurs  characteristically  during  convalescence  from 
infections,  can  be  abated  by  full  doses  of  atropin  and  possesses  no  patho- 
logic significance.  Its  recognition  becomes  important  mainly  for  the 
purpose  of  excluding  serious  forms  of  arrhythmia  during  convalescence  in 
diphtheria,  etc.,  or  when  myocardial  disease  is  suspected.     The  heart 

1  Lewis,  Thos. :  "Clinical  Disorders  of  the  Heart  Beat."  X.  Y.,  1916.  (An 
excellent,  brief  and  practical  handbook.) 



sounds  remain  unaltered  during  sinus  arrhythmia,  only  diastole  being 


This  form  of  arrhythmia  is  characterized  by  bradycardia  (pulse  rate 
35  to  10  per  minute)  and  by  the  fact  that  venous  pulsations  in  the  jugular 
veins  are  visible  more  frequently  than  ventricular  contractions  over  the 
precordium.     When  the  bradycardia  is  associated  with  periods  of  asystole, 

y5/i>CC4>vv'i>S,  ,                                                                              ^ 





cuff  h 

*o  i( 

tl        11         /; 

ft  .    /.if      la  ,  iz    OS  '  I 

O         1-2           l.£l       O.cj 

Fig.    138a. — Sinus  arrhythmia,  showing  pulse  acceleration  during  inspiration. 

0^     09     0-9    0-9    0 8     c-S    O'*^   °^ 

^0  20 


Fig.   1386. — Auriculo-ventricular  heart  block,  with  the  auricles  beating  twice  as  fast  as  the 
ventricles,  the  rate  of  the  latter  being  30  per  minute. 

syncopal  attacks  or  convulsions,  the  condition  is  known  as  the  Adams- 
Stokes  syndrome.  The  phlebogram  shows  from  two  to  four  "a"  waves 
for  each  "c"  wave.  The  lesion  generally  lies  in  the  auriculo-ventricular 
bundle  and  is  frequently  syphilitic  in  origin.  More  or  less  destruction 
of  the  bundle  "blocks"  the  stimuli  between  the  sinus  node  and  the  ven- 
tricle.    When  the  block  is  complete  the  ventricle  initiates  its  own  rhythm 



(about  30  per  minute).  If  the  block  is  incomplete  every  second,  third, 
or  fourth  sinus  impulse  produces  a  ventricular  contraction  and  the  condi- 
tion is  spoken  of  as  a  2  to  1,  3  to  1,  or  4  to  1,  block.  Incomplete  block 
often  shows  a  prolongation  of  the  "a-c"  interval.  The  conductivity 
time  is  also  frequently  increased  in  rheumatic  valvular  lesions.  The 
abortive  auricular  systoles  can  sometimes  be  heard  over  the  precordium 
as  ill-defined  muffled  heart  sounds.  Heart  block  is  always  serious  and 
frequently  a  fatal  condition.  Some  seven  cases  of  the  Adams-Stokes  syn- 
drome have,  however,  been  known  to  recover.  Temporary  block  (espe- 
cially in  the  milder  forms  of  prolongation  of  the  "a-c"  interval,  or  an 
occasional  dropped  beat)  may  be  caused  by  full  doses  of  digitalis  and 
similar  remedies.  It  also  may  occur  in  several  of  the  acute  infections, 
especially  rheumatic  fever,  under  which  circumstances  it  is  due  to  acute 
myocardial  inflammation  involving  the  conductive  system. 

Fig.    139.- 

-Auriculo-ventricular    bundle    in    a    human    heart,    injected    with    India    ink. 
(Courtesy  of  Dr.  F.  T.  Fulton.) 


Under  normal  conditions  ventricular  contractions  are  due  to  stimuli 
originating  in  the  sinus  node  and  transmitted  through  the  auricle  and  the 
bundle  of  His  to  the  ventricle.  The  contractions  occur  at  regularly 
spaced  intervals.  Under  abnormal  conditions  additional  effective  stim- 
uli may  arise  at  other  portions  of  the  heart  (auricle,  ventricle,  bundle). 
Such  stimuli  interfere  with  the  regular  rhythm  by  producing  premature 
contractions — extrasystoles.  Such  abnormal  stimuli  are  most  apt  to 
occur  when  the  cardiac  rate  is  slow.     The  muscle  becomes  impatient  in 



waiting  for  its  signal  and  contracts  without  orders.  The  sound  produced 
by  an  extrasystole  is  less  intense  than  the  normal  sound,  and  may  even 
be  inaudible. 

Ventricular  extrasystoles  are  characterized  by  the  fact  that  they  are 
followed  by  compensatory  pauses,  so  that  the  time  occupied  by  the  sys- 

t  W\v*^ 

.UA-r^ct  a^^nX^^ 



Fig.   140. — Extrasystoles,  ventricular  in  origin,  followed  by  compensatory  pauses. 

tole  and  the  extrasystole  is  equal  to  that  of  two  normal  contractions. 
Also  by  the  fact  that  the  extrasystole  occurs  early  in  diastole  and  pro- 
duces either  a  weak  or  a  missed  beat  at  the  wrist  while  the  succeeding  one 
is  forcible,  so  that  the  patient  is  often  conscious  of  it.  The  compensatory 
pause  is  due  to  the  fact  that  the  next  normal  stimulus  reaches  the  ven- 



Radial  pulse 

Fig.  141. — Coupled  heats.  The  coupling  is  visible  in  the  jugular  and  apex  tracings, 
only  occasionally  in  the  radial.  The  case  was  one  of  auricular  fibrillation  under  full  digi- 
talization.  The  radial  pulse  rate  is  about  one-half  of  that  of  the  heart.  An  extrasystole 
occurred  at  "x." 

tricle  so  soon  after  the  premature  contraction  that  the  latter  is  still  in  the 
refractory  phase.  Ventricular  extrasystoles  may  occur  without  interfer- 
ing with  any  of  the  normal  stimuli,  in  which  case  the  pause  after  the  pre- 
mature contraction  is  shorter  than  normal,  and  an  "interpolated"  extra- 


systole  occurs.  Inspection  of  the  phlebogram  shows  the  absence  of  an 
"a"  wave  to  correspond  with  the  extra  "c"  wave;  and  auscultation  of 
the  precordium  often  demonstrates  the  absence  of  a  second  sound  to  cor- 
respond with  the  ventricular  contraction. 

Auricular  extrasystoles  are  clue  to  stimuli  arising  at  some  point  of 
the  auricle  other  than  at  the  sinus  node.  The  phlebogram  shows  an  "a" 
wave  preceding  each  extrasystole  of  the  ventricle.  The  compensatory 
pause  is  generally  absent,  but  may  be  almost  or  even  wholly  complete. 
Auricular  extrasystoles  may  be  induced  or  abated  by  digitalis. 

The  significance  of  extrasystoles  is  very  variable.  They  may  be  due 
to  many  direct  or  reflex  causes.  Thus  the  excessive  use  of  tobacco  may 
produce  them,  as  may  increased  blood-pressure,  especially  with  a  weak- 
ened myocardium. 


This  term  is  applied  to  a  distinct  pathologic  entity  due  to  a  disturb- 
ance of  the  intrinsic  cardiac  mechanism.  It  should  not  be  applied  to 
simple  tachycardia  due  to  extrinsic  causes  such  as  exophthalmic  goitre. 

Clinically  this  condition  is  characterized  by  sudden  attacks  of  rapid 
heart  action  in  which  the  previous  cardiac  rate  is  approximately  doubled, 
trebled  or  quadrupled.  Ordinary  tachycardia  rarely  produces  a  pulse 
rate  over  140  per  minute,  in  paroxysmal  tachycardia  the  rate  ranges 
between  1-40  and  280  per  minute.  These  attacks  may  be  precipitated  by 
diverse  causes  such  as  excitement,  change  of  posture,  flatulence,  exercise, 
etc.;  and  end  after  a  variable  duration  as  abruptly  as  they  began.  Thej^ 
are  frequently  associated  with  subjective  sensations  of  palpitation,  op- 
pression, fullness  of  the  neck,  dyspnea,  vertigo,  etc.,  the  intensity  of 
which  often  depends  upon  the  integrity  of  the  heart  muscle. 

\>nous  and  electrocardiographic  studies  taken  at  the  beginning  and 
end  of  the  paroxysms  have  shown  that  the  cardiac  rhythm  may  be  vari- 
able.    Two  types  of  this  phenomenon  have  been  described: 

1.  The  type  in  which  the  auricular  type  of  venous  pulse  persists,  in 
which  the  end  of  the  attack  may  terminate  with  normal  coordination 
or  with  a  temporary  auriculo-ventricular  block. 

2.  A  second  rarer  ventricular  type  has  also  been  observed  in  which 
the  paroxysms  are  characterized  by  the  entire  absence  of  auricular  waves, 
which  do,  however,  reappear  at  the  end  of  the  attack,  without  any  evi- 
dences of  auriculo-ventricular  block. 

The  etiology  of  paroxysmal  tachycardia  is  obscure.  Numerous  ex- 
planations such  as  the  interpolation  of  extrasystoles,  abnormal  stimulus 
production  in  the  Purkinje  cells  of  the  auriculo-ventricular  bundle,  etc., 
have  been  suggested.  Practically  the  condition  may  be  regarded  as  due 
to  an  increased  irritability  of  the  myocardium  in  which  diverse  reflex 
stimuli  may  precipitate  a  paroxysm. 

The  effects  upon  the  circulation  are  those  of  a  shortened  diastole  with 
insufficient  ventricular  filling,  as  the  result  of  which  arterial  pressure  falls, 
venous  pressure  rises  and  variable  degrees  of  local  or  general  circulatory 
stasis  may  occur. 


Auricular  flutter  is  a  not  uncommon  form  of  arrhythmia  which  occurs 
chiefly  in  elderly  subjects.     It  is  characterized  by  an  extremely  rapid 


auricular  action,  the  rate  being  from  200  to  400  per  minute  (usually 
above  300).  When  established  it  generally  lasts  for  months  or  years, 
but  paroxysms  may  be  shorter.  It  is  due  to  pathologic  or  heterogenetic 
impulses  which  probabl}^  have  an  ectopic  auricular  origin.  It  is  not 
under  nerve  control.  The  rate  is  wonderfully  constant  as  a  rule,  and  is 
uninfluenced  by  position,  exercise  or  stimulation.  The  ventricular  rate  is 
generall}^  one-half  the  auricular  rate,  but  any  degree  of  block  may  be 
present.  The  ventricle  may  beat  regularly  if  the  degree  of  partial  block 
is  constant,  or  irregularly,  if  the  degree  of  block  varies  (e.g.,  3  to  2,  2  to 
1,  etc.).  Auricular  flutter  is  closely  related  to  paroxysmal  tachycardia. 
It  is  much  influenced  by  digitalis  and  vagal  compression.  Digitalis  may 
change  auricular  flutter  to  fibrillation  and  the  latter  to  a  normal  rhj^thm 
or  it  may  have  no  demonstrable  effect.  The  arterial  tracings  may  be 
regular  or  irregular,  fast  or  slow,  and  may  suggest  fibrillation  or  extra- 
systoles.  The  venous  curves  are  generally  obscure  on  account  of 
auricular  weakness,  but  when  pauses  are  long  "a"  waves  may  be  distinct 
(T.  Lewis).! 


This  common  form  of  arrhythmia  occurs  in  serious  oiganic  lesions  of 
the  heart  muscle.  It  can  be  produced  experimentally  by  electric  over- 
stimulation of  the  auricle  and  may  be  regarded  as  manifestation  of 
auricular  exhaustion.  It  occurs  mainly  in  rheumatic  endocardial  lesions, 
especially  in  long  standing  mitral  stenosis  with  right  auricular  dilatation, 
but  is  also  seen  in  arterio-sclerotic  lesions.  It  is  identical  with  what  was 
formerly  described  as  "pulsus  irregularis  'perpetuus,'^  "nodal  rhythm" 
and  "delirium  cordis."  It  is  characterized  by  an  absolutely  irregular 
arterial  pulse.  The  pulse  waves  are  irregular  both  as  to  force  and  time, 
and  many  ventricular  contractions  fail  to  produce  a  peripheral  pulse, 
hence  we  find  a  pulse  deficit  in  the  radial  and  other  peripheral  arteries. 
The  phlebogram  shows  the  absence  of  "a"  waves  and  the  presence  of  a 
large  "v"  wave,  which  can  also  often  be  seen  as  a  systolic  venous  pulsa- 
tion in  the  jugular  veins.  The  foregoing  characteristics  are  due  to  the 
fact  that  the  ventricle  instead  of  receiving  the  normal  stimuli  from  the 
sinus  node  transmitted  through  the  auriculo-ventricular  bundle  at  regular 
intervals,  and  with  definite  intermissions,  is  overwhelmed  by  stimuli 
received  so  frequently  that  diastolic  filling  and  rest  are  impossible. 
Digitalis  in  sufficient  dosage  produces  a  specific  reaction  which  is  attended 
by  excellent  clinical  results.  This  is  accomplished  by  lowering  the  con- 
ductivity of  the  auricular-ventricular  bundle,  so  that  fewer  stimuli  reach 
the  ventricle.  Excessive  digiialization  often  results  in  the  production 
of  a  higeminal  pulse  (p.  161).  A  rare  form  of  auricular  fibrillation  exists 
in  which  attacks  occur  in  paroxysms  lasting  a  few  hours,  days  or  weeks. 
They  may  be  brought  on  by  emotion  or  physical  strain,  and  maj^  cause 
severe  symptoms  of  cardiac  distress  and  palpitation.  By  palpitation 
we  understand  rapid  or  tumultuous  heart  action  of  which  the  patient 
is  subjectively  conscious.  Auricular  fibrillation  is  a  serious  form  of 
arrhythmia  which  once  it  has  set  in  generally  persists,  although  life 
under  restricted  conditions  may  last  several  years. 

Blood-pressure  in  auricular  fibrillation  often  cannot  be  estimated  by 
the  usual  methods,  owing  to  the  variable  size  and  force  of  succeecUng 

1  Lewis:  "Heart,"  IV,  1912,  171. 



pulse  waves.     This  difficulty  may  be  overcome  by  the  method  suggested 
by  James  and  Hart : 

"The  apex  and  radial  impulses  are  counted  for  one  minute,  then  a 
blood-pressure  cuff  is  applied  to  the  arm,  and  the  pressure  raised  until 
the  radial  pulse  is  completeh'  obliterated;  the  pressure  is  then  lowered 
10  mm.  and  held  at  this  point  for  one  minute  while  the  radial  pulse  is 
counted;  the  pressure  is  again  lowered  10  mm.  and  a  second  radial  count 
is  made;  this  count  is  repeated  at  intervals  of  10  mm.  lowered  pressure 
until  the  cuff  pressure  is  insufficient  to  cut  off  any  of  the  radial  waves 
(between  each  estimation  the  pressure  on  the  arm  should  be  lowered  to  0). 
From  the  figures  thus  obtained  the  average  sj'stolic  blood-pressure  is 
calculated  by  multiplying  the  number  of  radial  beats  by  the  pressures 
under  which  they  came  through,  adding  together  these  products  and 
dividing  their  sum  by  the  number  of  apex  beats  per  minute.  The  result- 
ing.figure  is  what  we  have  called  the  'average  systolic  blood-pressure.'" 


Fig.  142. — Auricular  fihr illation  showing  absolute  irregularity  of  the  brachial  pulse  %rith 
a  deficit,  as  contrasted  with  the  phlebogram.  The  latter  shows  an  absence  of  "a"gwave3 
and  is  of  the  positive  or  ventricular  type.  From  a  case  of  broken  compensation  occurring 
in  rheumatic  mitral  and  tricuspid  disease. 

The  following  observation  made  on  a  patient  will  indicate  the  method  of 
computation : 

B.  S.,  AprU  29,  1910.     Apex,  131;  radial,  101;  deficit,  30. 

Brachial  pressure  Rartial  count 

100  mm 0 

90  mm 13                  13  X  90  =  1,170 

80  mm 47  -  13  =  34  X  80  =  2,720 

70  mm 75  -  47  =  28  X  70  =  1,960 

60  mm 82  -  75  =     7  X  60  =      420 

50  mm 101  -  82  =  19  X  50  =      950 

Apex  =  131)  7,220 

Average  systolic  blood-pressure 55  4- 


Pulsus  alternans.  the  third  in  order  of  frequency  and  prognostically 
one  of  the  most  grave  forms  of  cardiac  arrhythmia,  is  characterized  by  the 
alternate  appearance  of  large  and  small  arterial  pulse  waves.  The  time 
interval  separating  the  large  from  the  small  beats  is  generally  greater 


than  that  which  separates  the  small  waves  from  the  large  ones._  This 
form  of  arrhythmia,  which  can  be  produced  experimentally  after  ligation 
of  a  coronary  artery  if  the  heart  rate  is  much  increased,  is  due  to  failure 
of  ventricular  contractility  and  may  occur  (1)  in  a  normal  heart  beating 
at  an  excessive  rate,  or  (2)  in  a  degenerated  myocardium  contracting  at 
a  normal  rate.  The  rate  being  too  rapid  for  the  myocardium,  only  a 
partial  systole  occurs,  since  the  ventricle  is  insuflSciently  rested,  but  in 
the  weaker  systole  less  energy  is  consumed  and  hence  the  next  contrac- 
tion will  be  normal  in  force.  According  to  another  explanation,  a  part 
of  the  ventricle  altogether  fails  to  contract,  remaining  in  a  refractory  state 
and  thus  causing  a  weak  contraction.  Whether  this  is  due  to  a  disturb- 
ance of  irritability,  conductivity,  or  contractility  is  still  an  open  question . 
The  last-mentioned  function  seems  to  be  most  commonly  at  fault. 
Gravier,  who  has  pubhshed  an  elaborate  monograph  on  the  subject, 
speaks  of  pulsus  alternans  as  "a  disorder  of  the  refractory  phase. -'^ 

The  alternation  of  force  so  apparent  at  the  wrist  is  rarely  demon- 
strable at  the  cardiac  apex  and  the  relationship  has  actually  been  found 
reversed — a  strong  systole  being  associated  with  a  small  radial  pulse 
and  vice  versa.  The  explanation  of  this  phenomenon  perhaps  lies  in  the 
fact  stated  by  Hering  that  that  part  of  the  cardiac  musculature  which 
forms  the  cardiac  apex  is  not  the  part  which  propels  the  ventricular  blood 
into  the  aorta. 

Lewis  has  noted  a  similar  divergence  in  force  between  the  ventricle 
and  the  carotid,  which  he  attributes  to  alternating  auricular  force.  This 
corresponds  with  Volhard's  tracings  which  showed  an  alternation  of  the 
"a"  waves  in  the  phlebogram,  the  large  jugular  wave  being  followed  by 
the  small  radial  pulse. 

''Temporary  exhaustion  of  contractility  often  occurs  with  the  pro- 
duction of  a  typical  pulsus  alternans  from  an  overtaxation  of  the  cardiac 
musculature,  the  result  of  a  too  rapid  rate,  such  as  may  occur  in  paroxj^s- 
mal  tachycardia,  auricular  flutter,  auricular  fibrillation,  or  the  long- 
continued  tachycardia  which  accompanies  Graves'  disease.  Experi- 
mentally it  may  be  produced  in  healthy  hearts  by  electrical  stimulation, 
the  injection  into  the  blood  stream  of  digitalis,  antiarin,  aconitin,  and 
hemolytic  serum.  It  is  most  frequently  encountered,  however,  when  the 
heart  is  beating  within  its  normal  rate,  and  when  it  denotes  a  grave 
pathological  condition  of  the  myocardium,  with  failing  contractility" 

Pulsus  alternans  is  met  with  in  cases  of  nephritis  and  myocarditis, 
generally  during  failing  compensation.  It  may  be  complicated  by 

Pulsus  alternans  must  be  differentiated  from  regular  bigeminus  due 
to  extrasystoles.  The  latter  are  to  be  distinguished  from  true  alter- 
nans by  the  long  diastolic  time  interval,  or  by  the  long  compensatory 
pause  following  the  small  extrasystolic  beats,  whereas  in  true  pulsus 
alternans  the  longer  period  follows  the  large  beat,  or  else  the  contractions 
are  equally  spaced  (Gordinier). 

The  phlebogram  in  pulsus  alternans  shows  no  abnormal  waves,  but 
the  "a-c"  interval  may  be  prolonged.  Alternation  in  the  intensity, 
quality  or  pitch  of  the  heart  sounds  is  rarely  demonstrable.  A  markedly 
dicrotic  pulse  may  on  superficial  inspection  simulate  alternation,  but  this 

^Gravier,  L.:  "L'Alternance  du  Coeur,"  Paris,  1914. 



source  of  error  may  readily  be  excluded  by  counting  the  pulse  over  the 
precordium.  Alternation  is  frequently  overlooked  if  sphygmographic 
tracings  are  not  made.  The  sphygmograph  is  also  useful  in  demonstrat- 
ing late72i  case";  of  alternation.  It  also  enhances  one's  tactile  perception 
of  this  arrhythmia.  "The  cuff  is  inflated  to  the  point  at  which  the  pulse 
rate  becomes  halved.  If  the  cuff  pressure  is  allowed  to  fall  somewhat 
lower  all  the  beats  will  come  through,  but  the  alternation  in  their  size  be- 
comes more  noticeable  than  when  the  arterial  lumen  is  uncompromised."^ 



®  vacVvi  oX- 

Fig.  14.3. — Pulsus  Alicrnans  from  a  case  of  cardio-vascular  sclerosis  with  angina  pec- 
toris. This  arrhythmia  was  apparently  precipitated  by  digitalis.  It  was  most  marked 
when  blood-pressure  was  at  its  highest  (S.  190,  D.  140  mm.  Hg.).  Death  three  months 
later.     Note  the  alternate  large  and  small  brachial  waves  occurring  at  regular  intervals. 


("Disordered  Action  of  the  Heart;"  "D.  A.  H.;"  Neurocirculatory 

Asthenia;  Soldier's  Heart;  The  Irritable  Heart  of  Soldiers) 

The  syndrome  upon  which  these  various  names  have  been  bestowed, 
was  first  described  by  Hartshorne  and  by  DaCosta  during  our  Civil 
War.  It  has  been  much  in  evidence  in  the  "  Great  War"  just  terminated 
in  which  it  played  a  conspicuous  part,  as  a  cause  of  physical  disability. 
Much  has  been  written  on  the  subject  which  has  been  carefully  inves- 
tigated by  many  able  men,  notabh'  Thomas  Lewis,-  although  as  yet 
its  exact  etiology  and  pathology  still  remains  unsolved. 

Symptoms. — The  "effort  syndrome"  is  characterized  by  dyspnea 
on  exertion,  precordial  pain,  undue  exhaustion,  vertigo  and  syncope, 
palpitation,  headache,  lassitude,  vasomotor  disturbance  such  as  coldness, 
cyanosis,  sweating  of  the  extremities,  irritabiUt}-  of  temper,  flushing  of  the 
skin,  tremor,  inabihty  to  concentrate  mentally.  Cutaneous  hyperalgesia 
is-frequently  present. 

1  NoRRis,  G.  W. :  "Blood-pressure,  Its  Clinical  Applications,"  Philadelphia,  1917, 
p.  250. 

-  Report  upon  soldiers  returned  as  cases  of  "Disordered  Action  of  the  Heart" 
(D.  A.  H.)  or  "Valvular  Diseases  of  the  Heart"  (V.  D.  H.).  Med.  Research  Comm., 
London,  1914. 


The  respirations  which  are  rapid  (20-60  per  min.)  and  shallow  (250- 
350  cc.)  increase  greatly  on  exertion  as  regards  rate,  but  not  in  regard 
to  depth.  This  as  has  been  noted  is  characteristic  of  anoxemia  as 
contrasted  with  an  increased  carbon  dioxide  tension  of  the  blood,  and 
these  patients  while  breathing  oxygen  are  able  to  carry  on  physical 
exertion,  which,  while  breathing  atmospheric  air  are  quite  beyond  their 
powers.  Oxygen  relieves  their  subjective  symptoms.  It  is  not  yet 
known,  however,  whether  the  anoxemia  results  fron  an  impaired  circula- 
tion or  from  other  factors  which  prevent  adequate  pulmonary  ventilation.^ 

Physical  Signs. — Increased  pulse  rate  is  very  common,  but  lability 
of  the  pulse  especially  in  response  of  emotion  or  exercise  is  most  character- 
istic. The  systolic  blood  pressure  shows  an  equally  exaggerated  re- 
sponse of  mental  or  physical  effort.  The  apex  beat  is  diffuse,  forcible 
and  jerky,  is  often  accompanied  by  a  systolic  thrill  and  accentuation 
of  the  heart  sounds.  The  heart  rhythm  is  often  irregular — intermittent 
or  unduly  affected  by  respiration.  Tremor  of  the  hands,  vasomotor 
ataxia — excessive  coldness,  blueness,  wetness  of  the  palms  and  soles, 
increased  axillary  sudation,  slight  degrees  of  fever  and  tachycardia 
especially  after  exertion  are  commonly  noted,  as  is  also  capillary 

It  is  needless  to  say  not  every  one  of  the  symptoms  and  signs  just 
enumerated  will  be  present  in  every  case.  Dyspnea,  pain,  undue  ex- 
haustion and  giddiness  are  however  practically  constant  features.  It 
will  be  noted  that  virtually  all  the  features  above  referred  to  are  identical 
with  those  which  might  be  encountered  in  a  normal  individual  if  the 
human  machine  had  been  driven  to  the  point  of  exhaustion.  In  the  effort 
syndrome  they  occur  after  the  most  trivial  physical  exercise  or  mental 
emotion.  Practically  speaking  the  Effort  Syndrome  may  be  regarded  as 
the  response  of  an  individual  who  is  unfit — from  a  physical,  psychic  or 
nervous  standpoint  to  withstand  unwonted  calls  for  the  expenditure  of 
energy.  It  is  encountered  not  only  in  the  trenches  but  also  in  the  train- 
ing camps  hundreds,  and  even  thousands  of  miles  from  the  firing  line. 

Diagnosis. — The  Effort  Syndrome  may  be  closely  simulated  by  (1) 
hyperthyroidism;  (2)  mitral  obstruction,  and  (3)  gas  poisoning.  In 
the  early  stages  a  differential  diagnosis  may  indeed  be  difficult,  and 
thus  far  neither  the  history,  the  employment  of  the  sphygmomanometer, 
the  electrocardiograph  or  other  instruments  of  precision  have  added 
much  to  our  diagnostic  ability. 

In  early  mitral  stenosis  exercise  sometimes  tends  to  increase  the  thrill, 
the  murmur  and  the  accentuation  of  the  second  sound.  In  case  of  the 
Effort  Syndrome  the  reverse  is  usually  the  case.  In  hyperthyroidism 
the  tremor  is  fine,  diarrhea  is  common,  and  constant  tachycardia  the 
rule.  In  the  Effort  Syndrome  the  tremor  is  coarse,  while  the  rapid  pulse 
and  dyspnea  disappear  during  sleep  and  rest. 

Cases  of  gas  poisoning  are  to  be  differentiated  by  the  absence  of 
"neurotic"  features,  for  it  is  to  be  remembered  that  the  Effort  Syndrome 
presents  many  parallels  with  an  anxiety  neurosis.  It  must  not  be 
forgotten,  however,  that  a  man  who  has  been  gassed  may  develop  the 
Effort  Syndrome.     As   Cohn^  has  pointed  out  surgical   cases  do  not 

^Haldane,  Meakins  and  Priestley:  "  The  Effects  of  Shallow  Breathing."  J. 
Physiol.,  In,  1919,  433. 

2  CoHN,  A.  E.:  "The  Effort  Syndrome,"  War  Medicine  ii,  Dec,  1918,  757. 


develop  the  Effort  Syndrome  with  anything  hke  the  frequency  that 
medical  cases  do,  especially  during  convalescence.  The  leisure  to  reflect 
upon  the  invisible,  intangible  and  to  many,  mysterious  factor,  in  gas 
poison'ng  perhaps  plays  an  important  role.  No  one  who  has  seen 
large  numbers  of  Effort  Syndrome  cases  can  fail  to  be  impressed  with 
the  importance  from  an  etiologic  standpoint  of  the  subconscious  mind. 


Many  tests  based  upon  sphygmographic  or  sphygmanometric  ob- 
servations for  the  determination  of  carcho-vascular  efficiency  have  been 
devised.  Thus  far  no  one  is  free  from  criticism,  or  entirely  satisfactory, 
but  the  following  test  which  is  simple  and  can  be  briefly  completed,  often 
sheds  a  useful  light  upon  doubtful  cases.  It  must  be  remembered,  how- 
ever, that  it  simply  aims  to  show  functional  efficiency,  not  structural 

Crampton's  Test  of  Vasomotor  Efficiency. — In  rising  from  the  re- 
cumbent to  the  erect  posture  blood-pressure  tends  to  fall  as  a  result  of 
gravity.  Unless  this  tendency  were  automatically  regulated,  syncope 
would  occur  as  a  result  of  cerebral  anemia.  In  a  normal  vigorous  man, 
however,  such  a  change  of  position  causes  a  rise  of  blood-pressure  amount- 
ing to  8  or  10  mm.  Hg.  This  increase  may  result  from  increased  vaso- 
motor tone  or  from  increased  cardiac  work,  or  as  a  result  of  both  factors. 
Bearing  these  facts  in  mind  Crampton^  has  devised  the  following  table 
to  test  vasomotor  efficiency  through  the  observation  of  pulse  rate  and 
blood-pressure  responses  to  postural  change.  The  tables  while  setting 
what  is  perhaps  a  high  normal  have  shown  that  vasomotor  tone  in  the 
same  individual  varies  greatly  as  a  result  of  mental  or  physical  fatigue, 
infectious  processes,  etc.  It  may  be  used  with  especial  edification  in 
the  study  of  essential  hypotension  cases. 

The  Technique. — The  cuff  of  the  sphygmomanometer  is  adjusted  over 
the  brachial  artery  and  the  patient  is  placed  on  a  comfortable  couch  with  a 
low  pillow.  The  heart  rate  is  counted  by  quarter-minutes  and  a  gradually 
decreasing  rate  is  usually  observed.  Counting  should  continue  until 
two  successive  quarter-minutes  are  the  same,  this  is  multiplied  by  4  and 
recorded.  The  systolic  pressure  is  then  taken  preferably  by  ausculta- 
tion. The  patient  stands,  the  heart  rate  is  counted  as  before  until  it 
reaches  the  "standing  normal,"  when  it  is  recorded,  and  the  blood- 
pressure  is  then  taken.  The  differences  are  calculated  and  reference  is 
made  to  the  scale. 

"This  scale  provides  a  convenient  and  intelligible  method  of  record- 
ing and  reporting  cases  and  permits  a  numerical  statement  of  the  func- 
tion in  question.  Its  100  mark  indicates  a  perfectly  efficient  working 
of  the  vasomotor  system  under  test,  the  zero  is  approximately  the  point 
where  the  average  person  is  unable  to  maintain  the  erect  posture." 

1  Crampton,  C.  W.  :  "The  Blood  Ptosis  Test  and  Its  Use  in  Experimental  Work  in 
Hygiene,"     Proceed.  Soc.  Exp.  Biol.  &  Med.,  1915,  xii,  119. 



Vasomotor  Toste 








+  10 

+  8 

+  6 

+  4 

+  2     1 



-  4 

-  6 

-  8 

-  10 

0  to  4 












5  to  8 












9  to  12 












13  to  16 












17  to  20 












21  to  24 












25  to  28 












29  to  32 












33  to  36 












37  to  40 












41  to  44 












Note. — In  case  of  increase  in  pressure  higher  than  -HIO  add  3  per  cent,  to  the 
+  10  column  for  each  2  mm.  in  excess  of  10. 



By  Edward  B.  Krumbhaar,  Ph.  D.,  M.  D. 

Among  the  instruments  of  precision  recently  become  available  for 
clinical  purposes  is  the  electrocardiograph,  adapted  from  Einthoven's 
string  galvanometer.  In  the  short  space  of  time  elapsed  since  its  inven- 
tion in  1903,  it  has  not  only  already  proved  its  clinical  value  as  the  most 
accurate  analyzer  of  cardiac  arrhythmias,  but  bids  fair  to  give  further 
information  about  the  cardiac  muscle  that  is  obtainable  in  no  other  way. 
In  the  hands  of  Lewis,  Rothberger  and  Winterberg,  Einthoven  and  others, 
it  has  materially  aided  in  increasing  our  knowledge  of  the  mechanism 
of  the  heart  beat,  both  in  health  and  disease. 

Fig.  144. — An  electrocardiograph  station.  A,  string  galvanometer;  B,  registering  ap- 
paratus (camera);  C,  electric  light;  D,  rheostat;  E,  leads  from  which  current  is  taken. 
(After  Hoffman.) 

The  Princ'ple. — The  string  galvanometer  depends  on  the  principle 
that  a  conducting  string  or  wire  lying  in  a  strong  magnetic  field,  if  suffi- 
ciently sensitive,  will  move  vertically  to  the  lines  of  force  when  an  electric 
current  passes  through  it.  As  every  contracting  muscle  initiates  such  a 
current  (the  part  at  which  the  contraction  starts  becoming  electrically 
negative  to  the  rest  of  the  muscle) ,  the  contractions  of  the  various  cham- 
bers of  the  heart  cause  a  series  of  such  deflections.     These  minute  currents 



radiating  through  the  body,  if  the  extremities  of  the  patient  are  connected 
with  the  galvanometer  by  suitable  non-polarizable  electrodes,  may  be  per- 
petuated as  a  graphic  record  by  photographing  the  shadow  cast  by  the 
vibrating  string  on  a  moving  sensitive  film  or  plate.  The  galvanometer 
and  registering  apparatus  are  so  arranged  that  a  contraction  starting  nearer 
the  base  of  the  heart  and  proceeding  toward  the  apex  will  cause  a  deflec- 
tion of  the  vertical  string  to  the  left,  or  upward  on  standardized  records. 
The  field  of  the  electrocardiograph  and  its  limitations  will  be  best  compre- 
hended, if  it  is  remembered  that  it  merely  registers  all  changes  of  electrical 
potential  occurring  between  the  two  electrodes  in  use.  Voluntary  muscle 
tremors  or  contractions,  when  present,  are  consequently  recorded  as  well 
as  the  heart  beat. 

The  three  leads  (places  for  attachment  of  electrodes),  adopted  by 
Einthoven  as  best  exhibiting  the  electrical  changes  caused  by  the  heart 
beat,  are  as  follows:  lead  I,  right  arm  to  left  arm  (horizontal);  lead  II, 
right  arm  to  left  leg  (long  axis  of  the  heart) ;  and  lead  III,  left  arm  to  left 
leg  (vertical).  These  leads  have  now  come  into  general  use,  and  should 
always  be  taken  in  routine  examinations.  Leads  may  be  taken  in  special 
cases,  however,  from  any  part  of  the  body.  A  time  marker,  registering 
fifths  or  twenty-fifths  of  seconds,  allows  an  accurate  computation  of  the 
various  time  intervals. 

The  Normal  Electrocardiogram.- — The  normal  mammalian  electro- 
cardiogram consists  of  a  single  summit  or  peak  ('"P"  wave),  due  to 
contraction  of  the  auricles,  and  two  to  four  deviations  ("Q, "  "R," 
"S,"  "T"),  due  to  contraction  of  the  ventricles.  Of  these  four,  "R"' 
and  "  T  "  are  the  most  constant,  and  "  Q  "  and  "  S  "  are  of  little  importance 
in  the  normal  record.  Though  no  two  normal  hearts  give  exactly  similar 
records,  the  individual  peculiarities  are  retained  with  remarkable  con- 
stancy as  long  as  the  heart  stays  normal.  Although  the  factors  that 
cause  the  individual  deviations  are  not  yet  clearly  understood,  certain 
explanations  are  generally  accepted.  Thus  the  monophasic  "P"  sum- 
mit is  unquestionably  due  to  the  impulse  starting  at  the  sinus  node  and 
spreading  through  both  auricles  toward  the  ventricle.  This  is  followed 
by  an  inactive  period,  normally  of  0.12  to  0.17  seconds,  called  the  ''P-R" 
interval,  which  corresponds  to  the  "A-C"  interval  of  polygraphic  trac- 
ings. Most  of  this  delay  is  caused  by  the  passage  of  the  impulse  through 
Tawara's  node  and  the  bundle  of  His.  The  path  followed  by  the  con- 
traction stimulus  on  entering  the  ventricle  is  a  very  complex  one,  not 
lending  itself  to  simple  representation  by  such  deviations.  The  "R" 
deflection  was  formerly  considered  as  the  evidence  of  the  basifugal  stim- 
ulus conduction  in  the  ventricle.  In  those  cases  where  it  was  preceded 
by  "Q,"  it  was  assumed  that  the  impulse  has  first  been  distributed  to 
tissues  near  the  apex  and  that  the  predominating  influence  for  a  short 
period  was  basipetal  (Einthoven).  Later  experimental  and  clinical  investi- 
gations by  Thomas  Lewis,  Buchanan,  and  de  Boer  indicate  that  the  form 
of  the  "Q,"  "R,"  "S"  group  of  the  ventricular  complex  is  the  result  of 
the  algebraic  summation  of  the  opposing  influences  of  the  right  and  left 
ventricle,  in  other  words,  a  bigram  due  to  the  superposition  of  dextrogram 
on  levogram.  From  this  point  of  view  "Q"  in  lead  I  C'Qi")  of  the  human 
electrocardiogram  is  a  left  ventricular  effect,  in  lead  II  and  III  C'Q2"  and 
"Q3")  a  right  ventricular  effect.  Clinical  confirmation  of  this  conception 
is  found  in  the  prominent  "Q?."  and  "Q3"  of  infants'  electrocardiograms 



(Krumbhaar  and  Jenks).  "R2",  "R3"  and  "Si"  are  due  to  spread  of 
activit}^  in  the  left  ventricle;  "Ri",  "S2"  and  "S3"  to  spread  of  activity 
in  the  right  ventricle.  The  normal  hmits  of  the  QRS  deflection  time  are 
between  0.06  and  0.10  seconds.  In  the  isoelectric  period  preceding  "T," 
a  balance  is  maintained  by  the  whole  mass  of  the  heart  being  in  a  state 

zj-  i«£z:::izzzrzz=-r  Tzn:  -zzi 

Fig.  145. — Normal  electrocardiogram.  Taken  from  the  three  customary  leads.  Lead 
T,  risht  arm  to  left  arm;  lead  II,  right  arm  to  left  foot;  lead  III,  left  arm  to  left  foot.  Note 
that  R2  is  the  largest,  and  that  T3  is  small  and  slightly  diphapic.  In  this,  as  in  all  illustra- 
tions. 1  cm.,  deflection  of  string  (i.e.,  five  of  the  small  ruled  lines)  represents  a  change  in 
potential  of  one  millivolt.     Time  record,  H  second. 

of  contraction.  The  final  upward  deflection,  "T,"  is  still  taken  by  some 
authorities  to  be  an  indication  of  the  driving  force  of  the  heart,  repre- 
sented by  the  circular  muscle  bands  at  the  roots  of  the  great  arteries; 
to  others  however,  the  upward  T  indicates  that  the  impulse  to  the  right 
ventricle  has  persisted  longer  than  that  to  the  left.  The  "U"  w^ave, 
which  is  occasionally  seen  in  both  normal  and  pathological  records,  is 
unimportant  and  but  little  understood.     It  is  taken  b}^  Hering  to  be 


due  to  changes  in  electrical  potential  in  the  great  vessels,  i.e.,  an  angio- 
gram. It  should  be  remembered  that  neither  the  amplitude  nor  the 
duration  of  the  electrical  variations  are  criteria  of  the  force  or  duration 
of  the  contraction  of  the  various  heart  chambers. 

Abnormal  Forms  of  Complexes. — Many  variations  from  what  is  ac- 
cepted as  the  standard  form  of  the  electrocardiogram  may  result  from  a 
normal  action  of  the  heart,  or  may  have  a  significance  that  is  as  yet  but 
little  or  not  at  ail  understood.  If,  however,  repeated  records  from  a  dis- 
eased heart  show  a  constant  approach  to  or  recession  from  the  standard 
form,  it  is  very  probable  that  that  heart  is  either  improving  or  getting 
worse  as  the  case  may  be.  Thus  I  have  seen  a  notch  in  an  R  wave,  so  deep 
that  it  resembled  a  thin  letter  M,  gradually  diminish  as  the  condition  of 
the  heart  improved,  until  after  recovery  a  normal  R  wave  was  found. 
Notches  may  occur  on  either  the  up  or  down  stroke  of  the  R  or  S  wave, 
and  in  single  records  little  significance  can  be  attached  to  them._  If 
permanent,  they  maj^  indicate  pathologic  changes  in  the  myocardium; 
if  temporary,  a  transient  or  potential  defect  in  the  intraventricular  con- 
ducting system.  Prolonged  deflection  time  of  the  QRS  group  wiU  be 
considered  later  under  the  head  of  Intraventricular  block. 

The  P  wave  may  be  changed  in  various  ways  in  any  of  the  leads  but 
most  frequently  in  Lead  III.  It  may  be  either  notched,  broadened, 
diphasic  or  inverted  in  one  or  more  leads,  and  either  under  or  independ- 
ent of  vagus  control.  In  the  former  case,  it  is  probably  due  to  a 
migration  of  the  pacemaker  from  the  sinus  node  (Wilson),  and  in  the 
latter  possibly  to  anomalous  position  of  the  sinus  node,  extra-sinus 
location  of  the  pacemaker,  a  change  of  the  heart's  position  or  alterations 
in  muscle  balance. 

The  T  wave  is  frequently  diphasic  or  inverted,  and  especially  in  Lead 
III,  where  such  variations  have  little  significance.  In  the  other  leads  they 
are  taken  by  some  authors  to  indicate  a  bad  prognosis;  but  Cohn  has 
shown  that  inversion  of  the  T  wave  can  constantly  be  produced  if  sufla- 
ciently  large  doses  of  digitalis  are  administered.  In  my  own  series  of 
cases,  negative  T  waves  in  Leads  I  and  II  in  the  absence  of  digitalis 
medication  have  usually  occurred  in  A^ery  grave  cases,  and  the  develop- 
ment of  negative  T  waves  in  these  leads  has  coincided  with  an  aggrava- 
tion of  the  patient's  condition.  The  direction  of  the  T  wave  is  thought 
by  some  to  depend  on  the  relative  duration  of  stimulus  activity  in  the 
two  ventricles  (inverted  T  due  to  unusually  long  duration  in  the  left 
ventricle).  A  diphasic  T  is  hard  to  explain  under  this  conception,  unless 
one  assumes  a  transient  preponderating  influence  of  that  ventricle  which 
is  the  first  to  finish.  In  some  clinical  cases,  and  more  often  under  ex- 
perimental conditions,  the  iso-electric  hne  preceding  the  T  wave,  instead 
of  being  on  the  usual  level,  is  slightly  lower.  According  to  the  above 
conception,  this  would  indicate  a  preponderance  of  left  ventricular  ac- 
tivity continued  during  most  of  systole.  Its  significance  is  not  yet 

Preponderating  Ventricular  Hypertrophy.^ — In  hypertrophy  of  the 
heart,  the  actual  size  of  "S"  and  its  size  relative  to  ''R"  assume  great 
importance.  Thus,  when  the  mass  of  the  right  ventricle  has  become  rel- 
atively larger  than  that  of  the  left,  "S"  is  extremely  prominent  in  lead  I, 
whereas  the  ''R"  of  lead  III  becomes  larger  than  that  of  lead  II  (normally 
the  largest).     Conversely,  when  the  mass  of  the  left  ventricle  has  become 



relatively  larger  than  the  right,  as  in  some  cases  of  aortic,  arterial  or  cardio- 
renal  disease,  "S"  is  extremely  prominent  in  lead  III,  whereas  the  "R" 
of  lead  I  has  become  larger  than  the  "R"  of  lead  II.     These  phenomena, 


X         A' 

T            1 

r    r    T    ^r 

s               s                 I                  ^ 


L/ — ^'\    ^ 

FiQ.  146. — Preponderance  of  right  ventricle.  Curves  from  the  three  leads  in  a  case  of 
mitral  stenosis,  associated  with  auricular  and  right  ventricular  hypertrophy.  In  the  ven- 
tricular complexes  Ri  is  almost  absent  and  Si  is  very  large,  whereas  Rz  is  considerably  larger 
than  ^2.  Note  the  unusually  large  P  of  auricular  hypertrophy.  The  black  background 
and  white  string  ol  this  illustration  are  due  to  the  fact  that  the  record  is  taken  directly  on 
sensitive  paper.  In  this,  as  in  a  few  others  of  the  illustrations,  some  lines  have  beenjrein- 
forced  for  purposes  of  reproduction.  The  magnification  of  the  string  shadow  is  less  than  in 
Fig.  145. 

the  meaning  of  which  has  been  put  on  a  logical  basis  by  the  investigators 
previously  referred  to,  have  been  confirmed  by  experimental  and  post- 
mortem evidence,  and  are  considered  by  Lewis  as  the  most  reliable  means 



of  estimating  the  relative  size  of  the  two  ventricles.  Clinical  evidence 
that  has  been  brought  forward  now  and  then  to  contradict  this  view  has 
not  been  sustained,  but  it  is  certain  at  least  that  the  form  of  the  electro- 
cardiogram is  slightly  influenced  by  the  position  of  the  heart  in  the  body. 
(Compare  the  changes  in  form  of  the  ventricular  complex  in  deep  respi- 
ration and  after  removal  of  large  pleural  effusions.)  Electrocardio- 
grams repeated  on  such  cases  over  a  period  of  several  years  will  give 
valuable  information  as  to  the  progress  or  stationary  condition  of  the 
muscle  changes  in  one  or  other  ventricle. 



Fig.  147. — Preponderance  of  the  left  ventricle.  Note  that/?i  is  here  higher  than  Rt, 
and  that  ^3  is  the  deepest  of  all.  This  case  also  shows  interesting  abnormal  complexes,  re- 
curring in  groups  of  four.  It  will  be  noticed  that  although  the  first  three  complexes  of  each 
group  are  rhythmical,  yet  the  corresponding  P  and  T  waves  of  each  group  show  con- 
stantly recurring  small  differences.  The  fourth  complex  is  always  premature,  most  prob- 
ably a  nodal  extrasystole,  and  the  whole  represents  a  recurring  "dislocation  of  the  pace- 
maker," the  origin  of  each  of  the  4  stimuli  being  different. 

Congenital  Heart  Lesions.- — In  most  cases  of  congenital  heart  disease, 
the  electrocardiogram  will  merely  show  the  result  that  the  lesion  has 
produced  in  the  muscle  balance  [i.e.,  there  is  usually  a  right  ventricular 
preponderance)  with  exaggerated  amphtude  of  all  deflections.  In 
dextrocardia,  however,  there  is  so  great  a  change  in  the  position  of  the 
heart  in  relation  to  the  3  customary  leads  that  the  form  of  the  electro- 



cardiogram  is  greath'  changed.  In  Lead  I,  all  deflections  are  completely 
inverted,  and  if  the  heart  hes  horizontally,  Lead  II  will  also  be  inverted. 
Lead  III  is  usually  normal.  (With  such  records,  especial  caution  must  be 
observed  that  the  electrodes  are  properly  apphed.  It  will  readily  be  seen 
that  accidental  transposition  of  the  electrodes  to  the  two  arms  or  leg 
might  produce  records  that  would  be  confused  with  that  of  dextrocardia.) 


As  the  different  tj'pes  of  cardiac  arrhythmias  have  been  set  forth  in 
the  previous  chapter,  it  will  be  necessary  here  only  to  indicate  how  thej' 
are  manifested  in  the  electrocardiogram. 

Sinus  Arrhythmia. — In  sinus  arrhj^thmia,  the  auricular  summit  and 
the  ventricular  complexes  are  of  the  normal  supraventricular  form;  in 
other  words,  the  impulse  arises  at  the  normal  site  and  traverses  the  normal 
channels.  That  it  is  given  out  from  the  sinus,  however,  at  irregular 
intervals,  can  readily  be  determined  by  measuring  the  varying  intervals 
between  the  "P''  summits. 

Extrasystole. — Extrasystoles  or  premature  contractions  appear  in  the 
electrocardiogram  in  very  striking  guise.  The  ectopic  origin  of  the 
stimulus  is  shown  by  marked  changes  in  the  shape  of  the  deviations. 

-: — *- 






(   %jucjrr<^etr 

._  ^^  vm;  ,j .  _  V  ■_,  r^>  _-.    .    ,     ^  \,    .   -.  _»-^ 

Fig.  148. — Sinus  arrhythmia.  Xote  that  although  all  complexes  are  of  normal  shape, 
and  the  P-R  interval  is  normal  and  constant,  yet  theP  waves  occur  at  irregular  intervals, 
owing  to  arrhythmic  stimulus  production  in  the  sinus. 

Thus  in  auricular  extrasystole,  the  normal  "P"  either  becomes  flattened 
out,  diphasic  or  inverted.  It  is  usually  followed  by  a  normal  ventricular 
complex,  and  the  pause  before  the  next  P  wave  is  very  rarely  compen- 
satoiy.  Occasionally  an  auricular  extrasj'stole  may  affect  the  succeed- 
ing ventricular  complex,  causing  a  so-called  ''aberrant"  type.  This 
may  vaij'  considerably  or  only  slightly  from  the  normal  complex. 

Extrasystoles  arising  in  the  ventricle  have  been  grouped  into  three 
main  types,  according  to  the  site  of  origin.  All  are  easily  recogniz- 
able in  the  electrocardiogram  and  are  characterized  by  the  slowness  and 
great  amplitude  of  the  deflections.  Those  arising  near  the  apex  of  the 
left  ventricle  cause  in  lead  I  an  extremeh'  large  deflection  corresponding 
to  "R"  usually  with  an  inverted  "T";  in  lead  III,  the  deflection  corre- 
sponding to  "S"  is  unusualh'  deep  with  an  extra  large  ''T."  Extras3's- 
toles  arising  near  the  basal  portions  of  the  right  ventricle  cause  the  reverse 




___  S- 



t^Tliiii mmJmmm^mJ^mmi^iaimi 

Fig.  149. — Auricular  extrasystole.  The  normal  rhythm  is  disturbed  by  the  premature 
appearance  of  a  P  wave.  In  such  cases  it  is  frequently  found  to  be  of  different  outline  than 
the  normal  or  inverted.  An  auricular  extrasystole  is  usually  followed  by  a  ventricular  com- 
plex of  normal  outline,  but  may  give  rise  to  an  "aberrant"  ventricular  complex,  as  in  the 
present  instance.  Note  the  larger  R  and  relatively  small  S  of  the  ventricular  complex.  The 
post-extrasystolic  pause  is  not  compensatory,  i.e.  the  distance  from  the  first  to  the  third 
S  is  less  then  that  from  the  third  to  the  fifth  (not  lettered). 

L^  X^  _4_  4^  __,|j_^!^,g^\j|_Jj,_^ 

^iG- 150.— Ventricular  extrasystole  arising  near  apex  of  left  ventricle.  The  deep  down- 
ward.deflection  and  large  T  wave  indicate  that  this  extrasystole  arose  near  the  apexjof  the 
left  ventricle.  In  lead  III  it  would  probably  have  had  much  the  same  form,  and  in  lead  I, 
resembled  those  pf  Fig.  154;  although  in  some  cases  the  form  remains  the  same  in|allileads. 
JNote  that  there  is  no  compensatory  pause  in  this  instance;  such  an  extrasvstole  is  said  to  be 



Fig.  151. — Ventricular  extrasystole  arising  near  base  of  right  ventricle.  Note  the  ex- 
treme height  of  the  initial  deflection,  with  the  exaggerated  inverted  T.  The  deflection  time 
of  the  extrasystole  is  considerably  longer  than  the  normal.  The  extrasystolic  complex  in 
lead  III  was  identical  with  this,  whereas  in  lead  I  it  resembled  that  of  Fig.  153.  The^re- 
currence  of  an  extrasj^stole  after  each  normal  beat  in  this  case  causes  a  true  bigeminy. 



of  this  picture  (i.e.,  deep  "S"  and  large  "T"  in  lead  I,  and  large  "R"  and 
inverted  "T"  in  lead  III).  The  site  of  origin  of  such  extrasystoles  has 
been  proved  bj'^  stimulation  of  these  areas  in  animals  with  the  production 
of  similar  electrocardiograms.  Extrasystoles  arising  in  the  septum  or 
intermediate  positions  give  rise  to  a  variety  of  anomalous  complexes. 

Extrasystoles  arising  in  the  junctional  tissues  (Tawara's  Node  and 
His'  Bundle)  are  rare.     In  such  a  premature  contraction,  evidence  of 


t"   .  — '.- 

-,   ,     ,    ,    ,r^  ,-,   ,             "           1 


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_     ^                -R. 

if%l    yLjJ 




1             -.          A.      i  \             ,   ,„     >,      >   \ ^ 

■   ' '  "    ' 









J.(  ivc-. 


___  __ 

— — ■— 


____ . 


Fig.  152. — Ventricular  extrasystole  (intermediate).  Extrasystoles  arising  near  the 
ventricular  septum  appear  in  various  intermediate  forms,  such  as  seen  in  the  third  complex 
of  this  illustration.  The  form  of  the  second  half  of  this  extrasystole  is  undoubtedly  in- 
fluencced  by  the  superposed  P  wave.  Note  that  the  fundamental  auricular  rhythm  is 
undisturbed.  The  post-extrasystolic  pause  would  be  quite  compensatory,  were  it  not  for 
the  fact  that   the  next  succeeding  P-R  interval  is  shortened. 

auricular  activity  occurs  either  very  close  to  the  ventricular  complex 
(shortened  "P-R"  interval)  or  synchronously  with  the  ventricular  complex, 
which  is  of  the  normal  or  supraventricular  shape.  The  "P"  wave  is 
usually  diphasic  or  inverted  on  account  of  the  changed  direction  of  travel 
of  the  auricular  impulse. 

The  site  of  the  impulse  formation  of  the  premature  contraction  usu- 
ally remains  the  same  for  long  periods.     In  some  cases,  however,  the 

Leap  3.         h  ^n    _       ,       -^  b 

FiQ.  153. — Auricular  fibrillation.  From  a  case  of  rheumatic  mitral  disease  of  long 
duration.  Note  the  absence  of  P  waves  and  the  ventricular  arrhythmia.  The  irregular 
waves  of  fibrillation  occur  over  300  to  the  minute,  and  obscure  the  T  waves  of  the  ventricu- 
lar complex. 

anomalous  impulse  may  arise  in  several  locations  ("dislocation  of  the 
pacemaker  ") .  (See  Fig.  147,  where  there  are  recurring  cycles  of  four  beats 
each.  The  stimulus  for  each  beat  of  the  four  arises  in  a  different  spot, 
the  last  of  the  four  being  a  nodal  extrasystole.)  If  for  any  reason,  the 
ventricular  rate  is  very  slow  (as  in  partial  block),  the  ventricle  may 
occasionally  "escape"  and  insert  a  beat  either  of  supra-  or  intraventricu- 
lar origin  into  the  otherwise  regular  rhythm. 



Auricular  Fibrillation. — Fibrillation  of  the  auricle  is  indicated  in  the 
electrocardiogram  by  three  phenomena;  first,  the  absence  of  "P, "  the 
sign  of  coordinate  auricular  contraction;  second,  the  presence  of  low, 
rapid  waves  of  fibrillation;  and  third,  the  irregular  response  of  the  ven- 
tricle. The  fibrillation  waves  are  best  detected  in  lead  III,  or  by  a  special 
lead  from  sternum  to  vertebrae.  They  maj'  be  barely  discernible,  fine  or 
coarse.  The  ventricular  complex  is  of  supraventricular  type,  but  may 
show  such  changes  as  those  found  in  ventricular  hypertrophy,  deficient 
conductivity  and  so  forth.  While  this  condition  is  usually  permanent, 
undoubted  cases  of  paroxysmal  or  temporary  fibrillation  have  been 

Heart  Block.  Auriculo-ventricular. — The  various  stages  of  auriculo- 
ventricular  heart  block  are  easily  recognizable  in  the  electrocardiogram. 
In  the  earliest  stage  (delayed  conductivity),  the  time  interval  between 
"P"  and  "R"  is  found  to  exceed  the  normal  limit  of  0.2  seconds.     In  the 

1<-  '^•r 

^jg&LOfi&ip    P-K     iNTgRVAL 

Fig.  154. — Auriculo-ventricular  heart  block.  Prolonged  P-i2  inten^al.  From  a  case 
of  paroxysmal  tachycardia  taken  between  paroxysms,  the  P—R  interval  is  prolonged  to 
0.35  second.     At  other  times,  the  P—R  interval  in  this  case  was  normal. 

Fig.  155. — Auriculo-ventricular  heart  block.  "Dropped  beat."  From  a  case  of 
mitral  stenosis,  taken  during  a  recurrence  of  acute  articular  rheumatism.  The  temporary 
occurrence  of  partial  heart  block  in  this  case  indicates  an  acute  rheumatic  myocarditis  of 
the  junctional  tissues.  With  subsidence  of  rheumatic  symptoms,  the  rhythm  returned  to 
normal,  the  P-R  interval  remaining  prolonged  for  several  days  after  the  dropped  beats  had 
disappeared.  Note  here  the  regular  recurrence  of  P,  the  gradual  increase  of  the  P-R  inter- 
val, until  R  fails  to  respond  and  the  re.sulting  ventricular  arrhythmia.  In  spite  of  the 
occasional  superposition  of  P  and  T,  each  wave  can  usually  be  identified  by  measurement, 
complete  or  partial. 

next  stage,  "dropped  beat,"'  the  '•'P-R"  interval  gradually  gets  longer 
until  after  several  beats,  a  second  "P"  follows  before  the  ventricle  has 
responded  to  the  first  auricular  impulgft*  On  account  of  the  varying 
''P-R"  inteiwal,  accurate  measurement  shows  a  ventricular  arrhythmia. 
Dropped  beats  may  occur,  however,  without  this  gradual  increase  of  the 
"P-R"  interval.  In  partial  block,  every  second,  third  or  fourth  "P"  (2 
to  1,  3  to  1,  or  4  to  1  block)  is  followed  by  the  ventricular  response.      In  3 




to  2  rhythm,  only  one  "  P"  in  three  is  not  followed  by  ventricular  contrac- 
tion. The  grades  of  block  may  change  from  moment  to  moment,  even 
while  a  record  is  being  made.  In  complete  block,  ''P"  recurs  at  regular 
intervals,  but  bears  no  relation  to  the  much  slower,  but  also  regular  ven- 
tricular complex.  The  interpretation  of  these  records  is  sometimes  com- 
plicated by  the  coincidence  of  auricular  and  ventricular  contraction. 
Careful  analysis,  however,  of  the  summation  of  the  electrical  effects  thus 
produced  will  show  evidence  of  each  of  the  individual  peaks. 


%  GoMPLSTE  Block 

Fig.  156. — Auriculo-ventricular  heart  block.  Complete  block.  Note  that  the  P  wave 
now  occurs  quite  independently  of  the  ventricular  complexes,  i.e.,  there  is  no  simple  ratio 
between  auricular  and  ventricular  rate. 

Intraventricular.  A.  Bundle  Branch  Block. — A  fairly  common  type 
of  heart  block,  that  is  only  detectable  by  the  electrocardiograph,  is  that 
occurring  in  one  of  the  branches  of  His'  Bundle.  If  one  or  other  is  de- 
ficient in  conductivity,  an  anomalous  complex  results,  which  resembles 
that  of  right  or  left  ventricular  hypertrophy  {q.v.),  except  that  the  QRS 
deflection  time  is  considerably  lengthened  (more  than  0.1  seconds), 
the  initial  deflections  aie  of  high  amplitude,  bizarre  shape  and  notched. 

BiaJeK  \U    "HjChT   BsAfVCH  af  H|V  ^^H\ 

Fig.  157. — Intraventiicular  heart  block.  Right  branch  of  His's  bundle.  From  a 
case  of  decompensated  myocarditis,  which  has  been  for  two  weeks  on  large  doses  of 
digitalis.  Note  the  notching  of  <S  and  the  prolonged  deflection  time  of  the  R-S  group 
(more  than  0.1  second).  The  P-R  interval  is  prolonged  to  0.24  second.  As  both  these 
signs  continued  after  the  cessation  of  digitalis,  they  were  presumably  due  to  deficient  con- 
ductivity caused  by  organic  changes.  Note  also  the  small  U  wave  that  is  occasionally  seen 
in  normal  records. 

There  is  usually  a  high  T  wave,  in  the  opposite  direction  to  the  larger 
of  the  initial  deflections.  If  the  right  branch  is  deficient  and  .the  im- 
pulse reaches  the  ventricle  through  the  left  branch,  the  picture  resembles 
that  of  left  ventricular  hypertophy;  and  vice  versa  if  the  left  branch  is 
deficient.  This  condition  may  be  a  permanent  result  of  organic  disease 
or  a  temporary  result  of  digitalis. 





B.  Arborization  Block. — Oppenheinier  and  Rothschild  have  described 
abnormal  electrocardiograms,  which  they  consider  to  be  due  to  inter- 
ference with  stimulus  conduction  bej'ond  the  two  chief  branches  of  the 
bundle  of  His,  i.e.,  in  the  arborization  of  the  Purkinje fibers.  Like  bundle 
branch  block,  this  condition  shows  the  notching  and  prolonged  duration 
of  the  initial  deflections;  but  differs  in  the  low  amplitude  of  the  initial 
deflections  in  all  leads  and  in  the  absence  of  "typical  diphasic  curves" 
with  huge  T  waves.  This  form  of  electrocardiogram  is  probably  more 
frequent  than  that  due  to  block  of  the  main  branch,  and  is  important  on 
account  of  its  serious  prognosis  (Willius),  and  frequent  association  with 
coronary  thrombosis. 

Sino-auriadar. — In  the  rare  condition  of  sino-auricular  block,  oc- 
casional cycles  are  entirely  absent  {i.e.,  there  is  no  evidence  of  either 
auricular  or  ventricular  activity).  It  is  assumed  in  these  cases  that  the 
sinus  impulse  has  been  blocked  before  reaching  the  auricle. 

Auricular  Flutter. — This  relatively  common  form  of  arrhythmia  was 
discovered  by  means  of  the  electrocardiograph,  and  it  is  still  impossible 

T^bctdbuu-  AxA*^  ^A/j7^<xi>Ti .  '^-^^t. 

Fig.  159. — Alternation  of  initial  deflections.  Taken  during  an  attack  of  paroxysmal 
tachycardia.  Note  the  alternating  height  of  i?  (this  is  further  modified  by  changes  due  to 
respiration).  Note  also  in  each  cycle  that  the  bigger  R  is  associated  with  a  smaller  Q  and 
a  bigger  .S.  After  the  paroxysm  alternation  was  no  longer  found.  (N.B. — Alternation  may 
also  cause  a  similar  difference  in  height  of  the  T  waves.) 

definitely  to  diagnose  the  condition  without  its  aid.  The  ectopic  origin 
in  the  auricle  of  the  rapid  stimulus  production  is  usually  shown  by  the 
inversion  of  "P"  in  one  or  other  lead.  If  due  allowance  is  made  for  the 
breaks  caused  by  "R"  and  "T, "  a  regular  rapid  succession  of  "P"  sum- 
mits can  be  traced  through  the  record.  As  the  ventricle  cannot  respond 
to  all  the  impulses  from  the  auricle,  a  state  of  partial  block  is  present. 
If  2  or  3  to  1,  the  ventricular  rhythm  will  be  regular;  if  a  3  to  2  rhythm 
exists,  the  ventricular  response  will  of  course  be  irregular.  This  ar- 
rhythmia with  the  distortion  of  the  succession  of  "P"  summits  by  the 
superposition  of  occasional  "T"  summits,  occasionally  makes  it 
difficult  to  diagnose  true  flutter  from  the  coarse  type  of  fibrillation. 

Pulsus  Alternans. — Many  cases  that  show  well-marked  alternation  in 
the  arteriogram  fail  to  show  any  abnormality  in  the  electrocardiogram; 
evidence  that  the  "R"  peak  is  not  a  measure  of  contractilit3^  Alterna- 
tion of  "R"  may  be  present,  however,  in  cases  that  may  or  may  not  show 
alternation  in  the  arteriogram.  This  might  be  taken  to  show  that  alterna- 
tion may  result  from  deficiency  in  irritability  or  stimulus  production  as 
well  as  in  contractility,  but  the  question  is  still  quite  undecided.  Con- 
siderable variation  may  occur  in  the  height  of  successive  "R"  waves, 



without  true  alternation  (e.g.,  the  changes  in  "R"  due  to  forced  respira- 
tion). If  the  respirator}^  factor  can,  however,  be  excluded,  this  never 
occurs  in  the  normal  heart,  and  though  its  presence  is  not  necessarily  of 
grave  import,  it  must  be  taken  as  a  sign  of  myocardial  trouble.  Alterna- 
tion of  T  also  occurs. 

Paroxysmal  Tachycardia. — Electrocardiographic  records  taken  dur- 
ing a  paroxysm  of  paroxj^smal  tachycardia,  frequently  show  only  two 


FiG.  160. — Paroxysmal  tachycardia  (auricular).  Three  beats  of  the  paroxysm  are 
reproduced  to  the  left.  The  P-R  interval  is  prolonged  and  P  and  T  are  superimposed. 
The  rate  is  about  120;  the  rhythm  suddenly  drops  to  about  70,  the  P-R  interval  remaining 
prolonged.  When  the  P  waves  of  the  paroxysm  are  visible,  they  are  usually  found  to  be  of 
abnormal  shape  or  inverted. 

main  deflections,  "QRS"  and  a  combination  of  "T"  and  the  succeeding 
"P"  (see  Figs.  159  and  160).  If  these  are  separated,  however,  some 
abnormaht}^  in  "P"  usually  betraj^s  its  ectopic  origin  (inverted,  diphasic, 
or  prolonged),  if  the  paroxj^sm  is  of  aiuicular  origin.  In  some  paroxysms, 
however,  if  the  new  site  of  stimulus  production  is  near  the  sinus  node, 



'/f  SKi. 

Fig.  161. — Blocked  auricular  extrasystole.  The  normal  rhythm  is  interrupted  by  a 
long  pause,  and  it  will  be  noted  that  the  T  wave  of  the  preceding  systole  is  altered  by  the 
superposition  of  the  auricular  extrasystole  (P').  That  this  (and  not  sino-auricular  block) 
is  the  correct  interpretation,  is  confirmed  by  the  fact  that  the  alteration  of  the  T  wave  is 
constant,  and  that  after  the  administration  of  atropin,  the  auricular  premature  contraction 
is  invariably  followed  by  a  ventricular  contraction  which  partially  obliterates  the  pause. 

''  P"  almost  or  entirely  retains  its  normal  shape.  The  end  of  a  paroxysm 
is  shown  by  the  sudden  slowing  of  the  cardiac  rate,  with  the  appearance 
of  a  normal  "P"  followed  by  a  normal  ventricular  complex.  Occasion- 
ally isolated  auricular  extrasystoles  may  disturb  the  normal  rhythm 
for  a  short  period  after  the  end  of  the  paroxysm,  or  the  paroxj^sm  may 
end  in  a  short  transition  period  of  auricular  or  ventricular  fibrillation. 


Paroxysms  due  to  heterogenetic  impulses  arising  in  the  ventricular 
or  junctional  tissues  are  rare.  The  former  are  characterized  by  the  ano- 
malous form  of  the  ventricular  complex;  the  latter  by  the  very  short  or 
absent  "P-R"  interval. 

Combined  Arrhythmias. — A  combination  of  two  or  more  of  these 
arrhythmias  may  occur  in  a  single  record.  Thus  in  cases  of  auricular 
fibrillation  the  dominant  complex  of  "supraventricular"  origin,  may 
occasionally  be  replaced  by  a  beat  of  "intraventricular"  origin,  indistin- 
guishable in  form  from  a  ventricular  extrasj'stole  or  premature  contrac- 
tion. In  the  coupled  beat  of  digitalis,  the  second  beat  of  each  pair  is  of 
this  character.  Just  as  the  ventricle  may  "escape"  if  its  irritability 
reaches  too  high  a  level,  so  the  impulse  from  an  auricular  extrasystole 
may  be  blocked  if  it  reaches  the  ventricle  when  its  irritability  is  still 
lowered  by  the  preceding  beat  (refractory  period).  An  example  of  this 
is  given  in  the  accompanjdng  figure,  which  duplicates  the  picture  of 
sino-auricular  block,  except  for  the  fact  that  the  T  wave  preceding  the 
pause  is  altered  bj'  the  superposed  auriclar  extrasystole. 

Effort  Syndrome.— Inasmuch  as  the  Effort  Syndrome  is  not  primarily 
a  heart  condition,  but  rather  the  general  response  of  an  exhausted  nervous 
system,  it  is  not  surprising  that  the  electrocardiograph  furnishes  only 
what  evidence  might  be  expected  from  consideration  of  the  preceding 
paragraphs.  Arrhythmia  is  uncommon  and  when  present  is  nearly  al- 
ways either  of  the  sinus  or  extrasystolic  type,  and  is  apt  to  disappear  with 
the  recoveiy  of  the  patient.  The  signs  of  preponderance  of  one  or  other 
ventricle  (usuall}'  the  right)  are  occasionally  found,  and  some  cases  of 
dilated  hearts  show  the  small  deflections  of  "R"  and  "S,"  such  as  are 
often  associated  with  myocardial  weakness  (see  p.  180). 


From  the  above  considerations,  it  will  readily  be  seen  that  much  of 
the  information  given  by  the  electrocardiograph  has  not  3^et  been  prop- 
erly appraised.  In  the  anah'sis  of  cardiac  arrhythmias,  to  be  sure, 
most  moot  points  have  alread}^  been  settled;  but  as  an  indicator  of  the 
condition  of  the  heart  muscle — the  most  important  item  in  the  prognosis 
and  treatment  of  cardiac  disease — the  limitations  and  possibilities  of  the 
electrocardiograph  have  not  yet  been  realized.  It  furnishes  valuable 
evidence  about  the  relative  size  of  the  two  ventricles,  locates  the  site  of 
origin  of  abnormal  stimuli  and  accurately  determines  the  various  time 
relations  of  the  cardiac  cycle.  Repeated  records  give  information  in 
several  ways  about  the  progress  of  the  disease  and  the  response  of  the 
heart  to  digitalis.  Like  all  other  clinical  instruments  of  precision,  how- 
ever, it  is  at  the  best  but  one  of  several  aids  to  the  discriminating 



This  term  is  applied  to  the  impulse  of  the  heart  against  the  chest  wall. 
The  study  of  this  phenomenon  may  be  carried  on  by  simple  inspection, 
by  palpation  or  by  graphic  records. 

The  occurrence  of  the  cardiac  impulse  marks  the  time  of:  (1) 
ventricular  contraction;  (2)  the  beginning  of  the  first  sound;  (3)  arterial 
filling.  It  is  felt  as  a  slight  movement  under  the  chest  wall,  somewhat 
gliding  and  slightly  lifting  in  character,  of  definite  rhythm  but  uncer- 
tain beginning,  whose  intensity  depends  on  (a)  the  rapidity  and  force  of 
the  ventricular  contraction,  but  even  more  largely  on  (5)  the  shape  of  the 

Fig.   162. — The  normal  cardiogram. 

chest — the  extent  to  which  the  lungs  overlap  the  heart;  and  finally  upon 
(c)  the  amount  and  character  of  overlying  soft  tissue.  Thus  in  deep- 
chested,  or  corpulent  individuals  and  in  recumbency,  the  impulse  may  be 
normally  imperceptible;  while  in  long-chested  persons,  especially  in 
emaciated  subjects,  in  children,  during  forced  expiration,  under  excite- 
ment, or  exertion,  it  is  disproportionately  strong.  The  point  of  percep- 
tion is  found  lower  by  palpation  than  by  inspection.  The  duration  of 
the  impulse  is  normally  about  one-third  of  a  second. 

During  ventricular  systole  the  heart  (1)  becomes  smaller,  especially 
in  its  transverse  diameter;  (2)  twists  about  its  longitudinal  axis  from  left 
to  right  and  forward  (Hirschf elder). 

It  has  been  graphically  shown  that  what  we  see  as  the  "apex  beat" 
consists  of  variable  and  often  complex  elevations  and  depressions  of  the 
precordium.     The  movements  may  be  grouped  as: 

1.  A  normal  type:  a  considerable  protrusion  of  the  precordium,  occur- 
ring with  and  during  ventricular  systole.  Graphic  tracings  in  such  a 
case  show  three  waves:  (a)  auricular  systole;  (6)  ventricular  systole;  (c) 
rebound  due  to  ventricular  diastole  (see  Fig.  129). 

2.  Elevation  of  the  whole  precordium  due  to  pivotal  action  of  the 




heart  against  the  vertebral  column.  Seen  chiefly  in  hypertrophied 
hearts,  especially  in  flat-chested  people. 

3.  Systolic  retraction. 

During  systole,  the  right  side  of  the  right  ventricle  tends  to  recede 
from   the  chest  wall.     When  this  chamber  is  hypertrophied  or  acting 





Fig.  1G3. — The  cardiac  impulse  ("apex  beat")  does  not  correspond  to  the  anatomic 
apex  of  the  heart  but  is  due  to  a  sudden  hardening  and  increase  in  tension  of  the  anterior 
surface  of  the  right  ventricle,  about  1  inch  (2.5  cm.)  to  the  right  of  the  anatomic  apex. 

Practically  the  whole  anterior  surface  of  the  heart,  is  the  right  heart.  The  left  ventricle 
normally  forms  only  the  extreme  left  border  of  the  anterior  surface  and  comes  in  contact 
with  the  chest  wall  mainly  when  this  chamber  is  enlarged,  as  is  the  case  in  the  accompany- 
ing photograph,  in  which  the  whole  heart,  but  especially  the  left  ventricle,  is  greatly  hyper- 

forcibly,  sufficient  negative  intrathoracic  pressure  is  produced  to  cause 
a  sinking  in  of  more  or  less  of  the  precordium.  This  normal  retraction 
is  sometimes  mistakenh^  attributed  to  pericardial  adhesions.  When  both 
elevation  and  retraction  are  coincidentallj"  present  over  different  areas, 
we  get  an  impression  of  a  wavj'  or  peristaltic  impulse.  Retraction,  else- 
where, may  be  caused  by  pericardial  adhesions  and  when  noted  posteriorly 


at  the  level  of  the  eleventh  and  twelfth  ribs  is  known  as  BroadbenV s  sign 
of  adhesive  pericarditis. 

The  examination  of  the  cardiac  impulse  is  of  diagnostic  importamce 
since  it  enables  us  to  estimate  the  degree  of  enlargement  or  displacement 
of  the  heart,  especially  to  the  left  and  downward,  and  often  to  determine 
whether  enlargement  is  due  to  hypertrophy  or  dilatation.  It  is  impor- 
tant, therefore,  to  know  not  so  much  the  point  of  maximum  intensity, 
but  the  lowermost,  outermost  point  of  impulse.  It  also  enables  us  to 
accurately  count  the  pulse  in  auricular  fibrillation,  etc.,  when  the  radial 
count  is  no  longer  a  criterion  of  the  pulse  rate.  It  also  renders  possible 
the  timing  of  heart  sounds,  murmurs,  thrills,  etc. 

Fig.  164. — Palpation  of  the  precordium.  The  hand  should  rest  lightly  upon  the 
chest  wall  in  order  to  determine  the  position  and  character  of  the  cardiac  impulse,  or  the 
existence  of  thrills. 

Palpation  of  the  cardiac  impulse  is  generally  more  satisfactoiy  than 
mere  inspection.  By  placing  a  finger  tip  in  an  intercostal  space,  or  by 
laying  the  whole  palmar  surface  of  the  fingers  Hghth'  upon  the  pre- 
cordium we  not  only  confirm  the  data  obtained  by  inspection  but  we  may 
determine  other  important  phenomena.  In  left  ventricular  hypertrophy 
a  forcible,  deliberate,  prolonged  heaving  impulse  is  felt,  while  that  of 
dilatation  often  has  an  abrupt,  slapping  quahty.  A  heaving  impulse, 
however,  may  be  noted  even  in  dilatation  when  compensation  is  far  from 
good.  The  force  of  the  impulse  is  decreased  in  obesity,  emphj-sema,  edema 
of  the  precordium,  thickening  of  the  lung  or  pleura,  feeble  heart  action, 
cardiac  dilatation,  pericardial  or  pleural  effusion. 

Pulsation  of  the  aorta  may  sometimes  be  noted  in  the  second  left 


intercostal  space,  but  when  marked  should  alwaj'S  suggest  the  possibility 
of  aneurism  (Fig.  432).  The  pulsation  most  commonh^  encountered  at 
the  base  of  the  heart  is  that  of  the  pulmonary  artery.  Epigastric  pulsation 
generally  indicates  active  right  ventricular  contraction  or  a  low  diaphragm. 
It  is,  therefore,  most  marked  when  this  chamber  is  hypertrophied,  or 
when  general  visceroptosis  is  marked.  Pulsation  in  this  region  may  result 
from  abdominal  aneurism,  tumor,  a  relaxed  aorta,  or  from  a  pulsating 
liver  (tricuspid  insufficiency').  A  diastolic  "shock"  over  the  base  of  the 
heart  indicates  a  sudden,  forcible  closure  of  the  semilunar  valves.  It 
may  be  felt  when  congestion  of  the  lungs  is  associated  with  a  vigorous 
right  heart,  and  in  aortic  aneurism. 

In  referring  to  the  apex  impulse  it  is  to  be  definiteh'  understood  we 
mean  the  outermGst,  lotvermost  point  at  which  it  is  either-  visible  or  palpable, 
and  not  the  point  of  maximum  intensity.  It  is  generally  felt  as  a  diffuse 
throb  3^  inch  inside  the  left  border  of  percussion  dulness ;  and  almost  always 
one  interspace  higher  than  the  silhouette  obtained  by  the  orthodiagraph : 
firstly,  because  it  is  felt  and  seen  in  systole,  while  the  X-raj'  shows  the 
heart  in  diastole  (Dietlen) ;  and  secondly,  because  what  is  generally  felt  as 
the  apex  beat  is  not  due  to  a  slapping  of  the  anatomic  apex  against  the 
thoracic  parietes,  but  to  a  sudden  marked  increase  in  tension  of  the  lower, 
anterior  surface  of  the  right  ventricle. 

The  left  ventricle  is  a  direct  factor  in  its  production  onlj^  in  case  of 
hypertrophy'  of  that  chamber,  or  of  cardiac  displacement.  "The  ana- 
tomic apex,  formed  by  the  tip  of  the  left  ventricle,  comes  into  direct  con- 
tact with  the  thoracic  wall  only  when  the  apex  is  situated  far  enough  to 
the  left  to  strike  the  lateral  wall  of  the  chest"  (Dayton).^ 

Normal  Position  of  the  Cardiac  Impulse. — The  cardiac  impulse  is 
normally  observed  (in  adults)  in  the  fifth  interspace  from  9  to  10.5  cm. 
from  the  mid-sternal  line  as  an  ill-defined  and  sometimes  distincth'  wavy 
elevation  and  retraction  of  the  intercostal  space.  From  what  has  been 
stated  it  is  evident  that  the  position  and  character  of  the  cardiac  impulse 
will  vary  greatly  in  different  individuals.  Such  variations  may  result 
from  a  change  of  posture:  the  impulse  is  generally  less  marked  in  recum- 
bency, and  can  often  only  be  felt  when  the  individual  is  erect  and  leans  for- 
ward; sometimes  in  normal  cases  not  even  then.  The  assumption  of  the 
left  lateral  decubitus  causes  it  to  move  l}-2  to  2  inches  to  the  left;  lying  on 
the  right  side  causes  less  displacement.  The  failure  of  the  impulse  to 
move  with  a  change  of   posture  maj^  be  due  to   pericardial  adhesions 

^  Numerous  physiologists  teach  that  the  apex  impulse  is  due  to  the  thrust  of  the 
left  apex  against  the  chest  wall,  the  heart  being  rotated  on  its  axis  in  the  process  of 
contraction,  so  as  to  bring  the  left  ventricle  into  an  anterior  position.  In  defence  of 
the  statement  made  by  us  the  following  facts  may  be  mentioned:  (1)  The  left  ven- 
tricle in  the  normal  heart  is  a  posterior  structure,  only  a  narrow  margin  of  which  is 
visible  from  in  front.  (2)  The  cardiac  dulness  always  extends  at  least  ^2  inch  to  the 
left  of  the  outermost  portion  of  the  apex  impulse,  showing  that  the  impulse  is  not  pro- 
duced b}^  the  anatomic  apex  of  the  heart.  (3)  The  fact  that  the  exposed  heart  can  be 
seen  to  twist  upon  its  axis  during  systole  is  not  proof  that  the  normally  surrounded 
heart  performs  the  same  movement.  "The  heart  is  not  tilted  forward  to  the  right 
during  sj^stole;  this  occurs  only  when  the  heart  has  been  displaced  on  opening  the 
chest."  (4)  "'As  the  heart  expands  during  diastole  it  becomes  at  the  same  time  so 
flaccid  as  to  flatten  by  its  own  weight ;  it  therefore  becomes  distorted  by  the  ever- 
changing  walls  of  the  cavity  in  which  it  rests  (chest  walls  and  lungs)  and  during 
systole  its  first  act  is  to  recover  itself,  'asserting  itself,  against  the  tissues  which  sur- 
round it.'  This  causes  the  apex  beat"  (H.wcroft,  J.  B.:  "The  Movements  of  the 
Heart  within  the  Chest  Cavity  and  the  Cardiogram,"  Jour.  Physiol.,  1891,  438). 



(Figs.  218,  380,  381).  Excessive  motion  "cor  mobile"  (3  to  5  inches)  oc- 
curs in  cardioptosis,  and  is  associated  with  a  low  diaphragm,  and  often 
with  visceroptosis  and  arterial  hypotension.  The  cardiac  impulse  is  higher 
in  children,  and  lower  in  old  age,  than  in  adult  life.  A  feeble  impulse,  like 
a  faint  heart  sound,  by  no  means  indicates  a  weak  heart  action.  It  points 
rather  to  large  lungs,  a  deep  chest  or  thickness  of  the  superficial  tissues. 


Right  bronchus 

Branch,  left  pul- 
monary artery' 

Left  superior'pu  1- 
monary  vein 

Left  inferior  pul- 
monary vein 

Left  auricle 

Thoracic  aotra 

Right  kidney 



Left  kidney 

Spinal  cord 

Fig.  165. — The  posteriok  part  of  the  middle  mediastinum.  Showing  the  anatomic 
relations  immediately  behind  the  heart  viewed  from  in  front.  Compare  Figs.  91  and  92, 
showing  the  rear  view. 

Displacement  of  the  Cardiac  Impulse. — The  cardiac  impulse  may  be 
displaced  downward  if  the  diaphragm  occupies  a  low  position  (cardi- 
optosis, visceroptosis)  and  in  left  ventricular  hypertrophy.  It  may  be 
found  to  the  right  of  its  normal  position  in  pericardial  effusions,  left-. 


sided  pleural  effusions  or  pneumothoraces,  or  as  a  result  of  right-sided 
pulmonary  adhesions  or  fibrosis,  as  well  as  in  situs  inversus  viscerum 
(Figs.  215,  216,  217). 

"The  character  and  degree  of  cardiac  displacement  in  cases  of  peri- 
cardial effusion  depends  mainly  upon  the  degree  of  compensation — the 
degree  of  increased  venous  pressure — in  other  words  upon  the  specific 
gravity  of  the  heart.  If  venous  pressure  is  considerably  higher  than 
intrapericardial  pressure,  the  heart  will  contain  a  normal  amount  of 
blood  and  remain  in  its  normal  position;  if  venous  pressure  is  low,  the 
heart  will  contain  but  little  blood  and  hence  will  be  pushed  upward  and 
backward,  the  apex  deviating  to  the  right "^  (see  Figs.  377,  378,  379). 

The  impulse  may  be  displaced  to  the  left  in  hypertrophy  or  dilatation 
of  the  ventricles,  especially  the  left;  or  by  a  right-sided  pleural  effusion 
or  pneumothorax  and  as  a  result  of  left-sided  pulmonary  fibrosis. 

Dislocation  in  an  upward  direction  may  be  caused  by  a  high  dia- 
phragmatic position — meteorism,  ascites,  pregnancy,  massive  abdominal 
tumors — or  by  fibrosis  of  the  upper  pulmonary  lobes. 


A  thrill  is  the  tactile  perception  of  vibrations  produced  by  flowing 
liquid.  It  generally  consists  of  intermittent  vibrations  of  the  chest  wall, 
not  unhke  the  sensation  imparted  by  a  purring  cat;  but  the  vibrations  of 
a  thrill  are  much  finer  and  more  rapid.  Experimentally  thrills  may  be 
produced  by  constricting  a  rubber  tube  or  a  blood-vessel  through  which 
fluid  is  flowing.  They  are  due  to  vibrations  of  tissues,  the  mechanism 
being  similar  to  that  which  produces  murmurs  (see  p.  227).  They  may 
disappear  if  blood  flow  is  insufficiently  rapid  to  throw  the  tissues  into 
vibration — low  pressure,  weak  heart.  Like  murmurs,  they  maj^  be  con- 
ducted by  the  blood  stream  or  the  vessel  walls.  The  hand  must  be  placed 
very  lightly  upon  the  chest  wall,  since  firm  pressure  may  abolish  the 
vibrations,  which  are  generally  produced  by  the  eddies  in  the  blood  stream, 
caused  by  localized  constrictions  or  dilatations  of  the  heart  chambers  or 
vessel  walls,  e.g.,  mitral  obstruction,  aortic  aneurism. 

In  studying  a  thrill  it  is  essential  to  determine:  (1)  the  exact  time  of 
the  cardiac  cycle  at  which  it  occurs.  This  is  accomphshed  by  noting  the 
relation  of  the  latter  to  the  apex  impulse,  (2)  the  location,  and  (3)  the 
extent  of  the  thrill. 

Normal  Thrills. — -These  occur  when  heart  action  is  vigorous  and  the 
chest  wall  is  thin — ^children,  emaciated  subjects,  retracted  lungs.  In 
these  cases  the  first  heart  sound  is  often  loud  and  somewhat  rasping,  and 
in  children  the  pulmonic  second  sound,  loud.  These  signs  may  lead  to 
an  erroneous  diagnosis  of  mitral  obstruction,  especially  since  with  a 
rapid  heart  action  a  normal  systolic  thrill  may  be  interpreted  as  being 
presystolic,  and  inasmuch  as  a  normal  presystolic  sound  is  sometimes 
audible  (see  p.  221). 

Such  cases  may  be  differentiated  from  mitral  obstruction  by  the  fact 
that  in  the  latter  condition  the  heart  is  enlarged,  the  pulse  volume  small, 
the  rate  not  infrequently  irregular,  while  the  pulmonic  second  sound  is 
unduly  accentuated.  In  addition  to  these  signs  the  patient  with  a 
stenotic  lesion  is  apt  to  suffer  from  dyspnea,  cyanosis,  or  cough  on  severe 

iNoRRis,  G.  W.:  "Studies  in  Cardiac  Pathology,"  1911,  123. 



Pathologic  Thrills. — Thrills  of  pathologic  origin  are  encountered  in 
valvular  heart  disease  and  in  aneurism.  Thrills  may  also  be  felt  in 
the  large  arteries  and  veins,  as  well  as  over  the  thyroid  gland  in  exoph- 





Fig.  166. — Sectiox  through  the  middle  of  the  sterxum  axd  vertebral  coLtriiN 
(adultj.  Sho-wing  the  anatomic  relations  of  various  cardiac  structures.  At  tMs  point  the 
heart  occupies  practically  the  entire  mediastinal  space.  The  esophagus  lies  closely  behind 
the  left  auricle.  Venous  tracing  depicting  the  functional  activity  may  be  made  by  intro- 
ducing a  rubber  capsule  into  the  esophagus.  T.,  trachea;  L.I.V.,  left  innominate  vein; 
R. A. A.,  right  auricular  appendage;  R.V.,  right  ventricle;  A.,  aorta;  iS.P..-!.,  right  pulmo- 
nary arterj^;  L.B.,  left  bronchus;  L.A.,  left  auricle;  R.A.,  right  auricle;  A,  abdominal  aorta; 
V.C,  inferior  vena  cava. 

thalmic  goitre.  The  most  intense  systolic  thrills  are  generally  met  with 
in  aortic  obstruction,  and  pulmonary  stenosis.  Very  marked  diastolic 
thrUls  are  frecpentlj"  encountered  in  aortic  insufficiency  and  mitral 


The  heart  is  outlined  by  percussion  in  order  to  determine:  (1)  the  size 
of  the  organ  as  a  whole  or  the  relative  size  of  its  different  chambers; 
(2)  its  position;  (3)  the  size  of  the  great  vessels  at  its  base. 

Method. — (1)  Begin  percussing  below  the  left  clavicle  and  continue 
downward  until  the  upper  border  of  cardiac  dulness  is  reached.     This 

Fig.  167. — ^The  anterior  chest  wall  viewed  from  behind.  This,  the  first  of  a  series  of 
sections,  shows  the  anterior  wall  of  the  heart  viewed  from  within,  surrounded  by  the  lungs- 
R.V.,  anterior  wall  of  right  ventricle;  S,  stomach;  D,  diaphragm. 

point  is  indicated  by  a  diminution  of  pulmonary  resonance  and  will 
generally  correspond  to  the  upper  border  of  the  third  rib.  (2)  Percuss 
from  the  left  mid-axillary  line  toward  the  heart  and  note  the  point  at 
which,  over  different  ribs  or  interspaces  the  percussion  sound  becomes 




Fig.  168. — OETHOPEECussIO^^  The  tendency  is  for  the  examiner  to  underestimate  the- 
right,  and  overestimate  the  left,  border  of  the  heart.  This  error  may  be  minimized  by- 
using  ortho-percussion  with  a  very  light  stroke. 

•Fig.  169.; — Horizontal  section  through  the  chest.  Showing  the  unavoidable  margin  of 
error  in  outlining  the  left  cardiac  border  by  percussion.  The  solid  line  indicates  the  ver- 
tical penetration  of  the  orthodiagraph.  The  dotted  line  illustrates  the  oblique  penetration 
of  percussion  vibrations.  A-B,  orthodiagram  shadow.  A-C,  percussion  dulness.  Light 
vertical  percussion  (orthopercussion)  minimizes  lateral  radiation  and  gives  the  most  ac- 
curate results  attainable  by  percussion.  The  tendency  is  generally  to  overestimate  the 
left  and  to  underestimate  the  right  cardiac  border.  The  margin  of  error  is  increased  in 
cases  of  left  ventricular  enlargement  and  in  patients  with  deep  thoraces.  The  drawing 
further  shows  the  deep  situation  of  the  mitral,  and  the  relatively  superficial  position  of 
the  tricuspid  valves.      (After  Braiine.) 



slightly  dull.     (3)  Percuss  from  the  right  mid-clavicular  line  and  outline 
the  right  border  in  a  similar  manner. 

The  points  at  which  the  clear  pulmonary  resonance  becomes  impaired 
should  be  marked  by  means  of  a  series  of  dots  with  a  skin  pencil  or 
ink.     Connecting  lines  between  these  dots  should  not  be  drawn  until 

Left  vagus 


:  ventricle 

Fig.  170. — \'erliciil  autero-posturiui-  suciiuu  thiuuyli  ihu  liourt  showing  this  organ  from 
a  lateral  aspect.  In  following  the  curv^e  of  the  ribs  during  percussion  from  the  sternum  to 
the  axilla,  if  forcible  percussion  is  used  the  cardiac  dulness  obtained  will  be  equivalent  not 
only  to  the  lateral  boundary  of  the  organ  (which  we  wish  to  determine)  but  also  to  the 
depth  or  antero-posterior  diameter  (which  vitiates  the  results).  The  only  part  of  the  left 
auricle  which  approaches  the  anterior  chest  wall  is  its  appendage,  which  juts  around  the 
pulmonary  artery  and  if  greatly  enlarged  may  cause  an  increase  in  dulness  upward  and  to 
the  left.     (Compare  Fig.  163.) 

after  the  examination  is  complete,  lest  expectancy  warp  one's  judgment. 
The  light  border  requires  the  heavier  percussion;  the  heart  at  this  point 
recedes  from  the  chest  wall  and  its  location  is  often  determined  with 
difficulty.     Dulness  normally  extends  slightly  beyond  the  right  sternal 



border,  but  the  position  of  the  right-sided  dulness  varies  greatly  in  health. 
Very  light  percussion  should  be  used  for  the  left  border  and  especial  care 
should  be  exercised  to  deliver  the  percussion  blow  in  a  vertical  direction 
(see  Fig.  80). 

Unless  the  percussion  is  performed  with  great  care,  the  left  border  of 
the  heart  will  be  over-,  the  right  border,  under-estimated.  In  the  majority 
of  cases  percussion  of  the  cardiac  outline  by  a  skilful  examiner  yields 

Fig.  171. — The  deep  cardiac  dulness  corresponds  to  the  actual  size  of  the  heart.  In 
percussing,  we  generally  overestimate  the  extension  of  the  left  border  since  the  slope  of  the 
ribs  causes  the  percussion  stroke  to  fall  upon  the  side  of  the  heart  instead  of  solely  upon  its 
anterior  surface.  The  extension  of  the  right  border,  on  the  other  hand,  is  generally  under- 
estimated since  it  slopes  sharply  away  from  the  chest  wall  and  is  overlain  by  a  thick  section 
of  lung  tissue.  The  superficial  (absolute)  cardiac  dulness  represents  the  portion  of  the 
heart  which  is  uncovered  by  lung  tissue.  This  photograph  depicts  an  unusually  large 
superficial  dulness. 

results  which  are_  sufficiently  accurate  for  most  clinical  purposes.  Such 
accuracy  consists,  however,  of  variations  in  centimeters,  not  millimeters. 
In  some  instances,  however,  other  methods  of  examination  such  as  ortho- 
diagraphy and  teleoroentgenography  must  be  employed  and  in  all  in- 
stances percussion  should  be  controlled  by  palpation,  it  being  borne  in 


mind  that  the  left  border  usually  extends  1.5  cm.  beyond  the  lowermost 
and  outermost  point  at  which  the  heart  impulse  can  be  felt. 

The  portion  of  the  heart  which  is  uncovered  by  lung  jdelds  a  flat 
percussion  note.  This  area  is  known  as  the  superficial  cardiac  dulness. 
It  is  of  minor  importance  since  it  tells  us  more  concerning  the  state  of  the 
lungs  than  that  of  the  heart.  The  deep  cardiac  didness,  on  the  other  hand, 
corresponds  to  the  size  of  the  heart.  It  may  be  determined  bj'  light  or 
moderately  heavj""  percussion,  by  noting  the  points  at  which  clear  pul- 
monary resonance  ceases  and  slight  dulness  begins.  A  distinct  increase 
of  resistance  will  be  noted  at  similar  points.  Light  percussion  is  generally 
preferable  since  there  is  less  radiation  of  the  vibrations  and  a  keener 
perception  of  them  both  by  hearing  and  touch. ^  The  superficial  area 
of  dulness  is  absent  in  animals  and  in  some  people  with  long  thoraces  and 
freeh'  movable  hearts,  also  in  barrel-shaped  chests  with  large  lungs — 
emphysema.  It  is  enlarged  in  flat-chested  individuals,  in  tuberculosis — 
retracted  lungs — in  some  rachitic  deformities  and  in  pericardial  effusions. 
The  cardio-hepatic  angle  is  normalh'  acute,  with  its  concavity  toward  the 
right.  It  becomes  obtuse,  with  a  convexity  toward  the  right  in  pericar- 
dial effusions  and  in  right  ventricular  dilatation.  In  the  latter  condition 
an  interrupted  hne — staircase  form — has  been  described. 

The  lower  cardiac  border  cannot  be  outlined  by  percussion  because  the 
heart  and  the  Kver  overlap,  and  being  structures  of  relatively  equal 
densities  both  jdeld  a  similar  note.  Furthermore,  the  proximity-  of 
Traube's  space  (Fig.  89)  adds  a  t3'mpanitic  element  to  the  sound  and  as 
we  have  already  learned,  vibrations  cannot  be  localized  in  t3'mpany 
producing  organs.  Orthodiagraphic  as  well  as  post-mortem  studies  have 
shown  that  the  heart  can  be  very  accm-ately  outlined  by  careful,  skilful 
percussion;  the  margin  of  error  should  in  the  average  case  not  exceed 
1  cm. 


The  different  diameters  of  the  heart  bear  a  definite  relation  to  the 
age,  sex  and  height  of  the  individual.  Disproportionate  enlargement  of 
certain  diameters  is  quite  characteristic  of  certain  cardiac  lesions.  A 
satisfactory  method  of  recording  the  cardiac  dimensions  is  shown  in  Fig. 
173.  The  area  of  heart  dulness  is  normally  from  10  to  30  per  cent,  larger 
in  the  horizontal  than  in  the  erect  posture.  This  is  due  to  flattening  of  the 
chest  and  decreased  backward  convexity  of  the  dorsal  spine  in  the  former 
position.  In  the  erect  posture  the  heart  tends  to  fall  away  from  the  chest 
wall.  Furthermore,  the  heart  contains  more  blood  in  recumbency,  owing 
to  a  higher  venous  pressure;  its  sj'stoUc  output  is  larger.  The  left 
border  of  the  heart  is  in  adults;  usually  situated  from  9  to  10.5  cm.  to 
the  left  of  the  mid-sternal  line. 

^  Moritz  found  that  with  light  percussion  for  the  right  and  threshold  percussion 
for  the  left,  cardiac  border,  the  former  corresponded  with  the  orthodiagraphic  findings 
in  86,  the  latter  in  70,  per  cent,  of  his  cases. 

Fig.  172. — Heabt  DtrLNESs  as  modified  by  disease.  These  figures  illustrate  the  more 
or  less  characteristic  shape  and  size  of  the  heart  as  a  result  of  different  cardiac  lesions. 
They  are  drawn  after  radiograms  and  correspond  to  the  areas  of  dulness  which  would 
be  obtained  by  skilful  percussion.     (After  F.  M.  Groedel.) 



Aortic  insufficiency. 

Aortic  obstruction. 

Mitral  obstruction. 

Mitral  insufficiency. 

Mitral  obstruction  and 

Aortic  obstruction  and 
mitral  insufficiency. 

Chronic  myocarditis. 
Fig.  172. 



Enlargement  toward  the  left  indicates  left,  sometimes  right,  ven- 
tricular enlargement.  An  increase  of  dulness  to  the  right  of  the  sternum 
may  be  due  to  right  auricular  dilatation  or  to  pericardial  effusion.  An 
enlarged  area  of  dulness  at  the  base  is  often  the  result  of  aortic  dilation  or 
aneurism.  The  left  auricle  being  a  posterior  chamber  cannot  be  outlined 
by  percussion.     Marked  enlargement  of  the  left  upper  cardiac  dulness 

Fig.   173. — Method  for  recording  cardiac  dulness. 

Fig.  174. — The  influence  of  respiration  upon  the  position  of  the  heart.  (Groedel.) 
Heavy  line:  normal  breathing.  Interrupted  line:  deep  expiration.  Dotted  line:  deep 

may  result  from  dilatation  of  the  left  auricular  appendix  which  lies  just 
to  the  left  of  the  pulmonary  artery  (see  Fig.  163).  X-ray  studies  have 
shown  that  simple  mitral  insufficiency  never  causes  dilatation  of  the  left 
auricular  appendix,  but  in  mitral  stenosis  with  insufficiency  and  in  mitral 
insufficiency  during  broken  compensation  (tricuspid  insufficiency)  both 
dilatation  and  pulsation  are  demonstrable.^ 

1  Pesci,  G.  :  "L'augmento  di  volume  della  brecchietta  sinistra  del  cuore  nel  quadro 
radiologico."     Radiologia  med.,  I,  1914,  106. 








Increased  dulness  at  the  base  is  generally  due  to  dilatation  or  aneur- 
ism of  the  aorta  (Figs.  409,  412) ;  it  may  in  rare  instances  be  due  to  a 
patulous  ductus  arteriosus.  This  lesion  produces  a  quadrilateral  area  of 
dulness  to  the  left  in  the  second  (and  first)  interspace.  Accurate  outlining 
by  percussion  of  the  normal  aorta  and  pulmonary  artery  is  difficult  and 
erroneous  results  are  frequent,  owing  to  the  overlying  sternum. 

Method  of  Recording  the  Size  of  the  Heart. — After  outhning  the  heart 
by  percussion  and  drawing  hues  upon  the  skin  to  correspond  with  the 
area  of  dulness,  the  following  dimensions  should  be  measured  and  recorded. 

A  Hne  is  drawn  from  the  cardio-hepatic  angle  to  the  lowermost  portion 
of  the  left  border.     A  second  line  is  drawn  from  the  upper  border  of 

Fig.   175. — Moritz's  conjugates. 

cardiac  dulness  down  the  middle  of  the  sternum  to  connect  with  the  first 
line.  The  extremes  of  these  lines  are  connected  and  the  following  dimen- 
sions recorded  in  centimeters. 

Height  (S.  H.) ;  Left  obhque  (L.  S.) ;  Right  obhque  (R.  S.) ;  Right 
base  (R.  H.);  Left  base  (L.  H.)  (see  Fig.  173). 

These  dimensions  undergo  characteristic  variations  in  different  valvu- 
lar lesions,  owing  to  a  disproportionate  increase  in  the  size  of  different 
chambers.  Thus  the  left  base  is  increased  in  left  ventricular  hypertrophy 
and  in  mitral  insufficiency.  The  right  base  is  increased  in  tricuspid  lesions 
and  dilatation  of  the  right  auricle.  The  height  is  increased  in  aortic 
disease,  etc.  (Fig.  172). 

Moritz  has  suggested  a  somewhat  different  method  of  recording  the 
cardiac  area  which  has  found  considerable  favor,  the  dimensions  thus  ob- 
tained being  known  as  Moritz's  conjugates  (Fig.  175). | 



It  has  been  shown  by  a  large  number  of  orthodiagraphic  studies^that 
the  normal  heart  bears  a  fairly  constant  relation  to  the  height  of  the  indi- 
vidual.    The  normal  averages  are  shown  in  the  following  table. 

Height  of  individual 




r"-.             Feet  and 
^™-              inches 





Cardiac!     %r7} 
area,       ^^ 
Q  Cm.      ^™- 

ML    \      L             Q 
Cm.    J    Cm.        Cm. 

Q  Cm. 

145-154     4.7.-5 
155-164      5.1-5.5 
165-174      5.5-5.9 
175-187      5.9-6.2 











95        3.5 
109  1    3.5 
116  1    3.8 





■  ioi 


FiQ.  176. — Pkricardial  EFFUSION.  Viewed  from  behind,  causing  enlargement  of  cardiac 
dulness  to  the  left  and  compression  of  the  left  lower  pulmonary  lobe.  The  left  ventricle  is 
hypertrophied,  the  mitral  valve  sclerotic.  The  liver  is  enlarged  and  upward  pressure  from 
ascitic  fluid  has  caused  compression  of  the  right  lower  lobe.  A,  aorta;  T,  trachea;  E, 
esophagus;  P. A.,  right  pulmonary  artery;  L.P.A.,  left  pulmonary  artery;  S.C,  superior 
vena  cava;L..4.,  left  auricular  appendage;  I.C.,  inferior  vena  cava.     (Compare  Fig.  216.) 

The  Orthodiagraph. — The  ordinary  X-ray  plate  is  inaccurate  for  the 
purpose  of  determining  the  size  of  the  heart.  The  reason  for  this  is 
the  fact  that  the  heart  lies  from  7  to  10  cm.  from  the  anterior  chest  wall. 



It  is,  therefore,  further  from  the  source  of  Hght  than  are  the  anterior  ribs 
and  since  the  X-rays  are  divergent  the  heart  shadow  varies  inconstantly 
and  disproportionately  in  relation  to  the  ribs. 

The  orthodiagraph  overcomes  this  difficulty  by  allowing  only  per- 
pendicular rays  to  fall  upon  a  fluorescent  screen  and  hence  a  parallel  pro- 

FiG.   177. — The  orthodiagraph.     {Hoffman.) 

jection  is  obtained.  The  patient  is  placed  between  the  source  of  hght 
and  the  screen,  and  the  outline  cast  by  the  shadow  of  the  heart  in  its 
different  dimensions  is  plotted  upon  the  screen  from  which  it  can  be  ac- 
curately reproduced  and  measured. 

Almost  equally  accurate  results  may  be  obtained  by  teleoroentgen- 
ography,  i.e.,  photographing  the  heart  by  placing  the  plate  over  the  pre- 
cordium  the  tube  being  behind  and  at  a  distance  of  two  meters  from  the 
patient,  thus  practically  eliminating  distortion. 


In  ausculting  the  heart,  the  stethoscope  is  far  preferable  to  the  unaided 
ear  since  we  are  better  able  to  localize  sounds.  The  bell  of  the  stethoscope 
is  placed  especially  over  certain  areas  of  the  chest  wall  at  which  the  sounds 
produced  at  different  valvular  areas  are  best  heard.  These  areas  are 
named  after  the  valves  in  question.  It  is  to  be  remembered  that  these 
valvular  areas  do  not  correspond  to  the  anatomic  location  of  the  valves. 
Anatomically  the  valves  lie  very  close  together  (see  Fig.  125). 

The  heart  is  ausculted  to  determine  the  character  of  normal  sounds, 
the  presence  of  abnormal  sounds,  and  the  regularit}'  of  cardiac  rhythm. 
When  the  heart  sounds  are  feeble  or  when  the  respiratory  sounds  are  un- 
duly loud,  it  may  be  necessary  to  have  the  patient  hold  his  breath  for 
brief  intervals  while  we  auscult.  The  procedure,  however,  if  long  con- 
tinued brings  about  abnormal  conditions  which  affect  the  heart,  and  in 
patients  suffering  from  marked  dj^spnea,  may  be  impossible.  In  deep- 
chested  individuals  it  is  often  advantageous  to  have  the  patient  lean 
forward  while  the  heart  is  being  ausculted,  a  procedure  which  brings  the 
heart  nearer  to  the  anterior  chest  wall. 

With  the  exception  of  the  pulmonary  valve,  the  sound  produced  at  a 
given  orifice  is  heard  best,  not  immediately  over  the  area  beneath  which 
the  valve  is  situated,  but  a  distance  from  it.  This  is  because  although 
the  sound  in  question  is  still  heard  over  its  specific  area,  the  other  sounds 
are  at  that  point  heard  less  distinctly.  Heart  sourids  and  murmurs 
are  not  infrequently  audible  over  the  back.  This  is  almost  invariably 
the  case  in  childhood. 


The  functional  activity  of  the  heart  produces  certain  sounds  which 
can  be  best  heard  over  the  precordium.  If  the  bell  of  the  stethoscope  is 
placed  over  the  left  lower  portion  of  the  precordium  (mitral  area)  two, 
occasionally  three,  distinct  sounds  will  be  heard.  The  sounds  are  in 
normal  cases  easily  differentiable  by  their  acoustic  qualities.  Under 
certain  abnormal  conditions  they  can  be  distinguished  only  by  timing 
their  occurrence  with  the  cardiac  impulse  or  if  this  is  invisible  and  impal- 
pable, by  palpating  the  carotid  pulse  which  occurs  0.1  second  after  ven- 
tricular systole.  The  two  sounds  mentioned  may  be  imitated  by  the 
syllables,  lubb-dupp. 

The  First  Sound. — The  fh'st  sound  is  systolic  in  time  and  synchronous 
with  ventricular  contraction.  It  is  long,  more  or  less  loud,  low-pitched 
and  terminates  abruptly.  It  is  due  to:  (a)  muscular  contraction  of  the 
ventricles;  (6)  systolic  tension  of  the  auriculo-ventricular  valves;  (c) 
distention  of  the  aorta  and  pulmonary  artery.  It  is  loudest  over  the 
body  of  the  heart  but  also  heard  over  the  base.  It  is  normally  louder  as 
well  as  longer  (0.8  second)  than  the  second  sound  (0.05  second)  from 




which  it  is  separated  hj  the  short  pause.  Systole  is  shorter  than  dias- 
tole, therefore  the  first  sound  is  preceded  by  the  long  pause. 

The  Second  Sound. — -The  second  sound  marks  the  beginning  of  dias- 
tole, it  is  shorter,  less  loud,  higher-pitched  and  less  voluminous  than  the 
first  sound.  It  is  due  to  the  sudden  increase  in  tension  of  the  semilunar 
valves.  It  is  preceded  by  the  short  and  followed  by,  the  long  pause.  It 
terminates  even  more  abruptly  than  the  first  sound. 

The  Third  Sound. — ^This  can  occasionally  be  heard  especially  in 
children,  in  the  left  lateral  decubitus,  and  if  the  heart  action  is  slow;  as 
a  faint  echo  of  the  second  sound.     It  occurs  early  in  diastole,  about  0.1 

Fig.  178. — Showing  the  areas  of  the  chest  over  which  sounds  produced  at  the  various 
valvular  orifices  are  generally  most  distinctly  heard.  A,  aortic  area;  P,  pulmonic  area; 
M,  mitral  area;  T,  tricuspid  area. 

The  unmarked  area  at  the  third  left  costo-sternal  articulation  is  one  at  which  aortic 
regurgitant  murmur  is  often  most  loudly  heard.  The  arrows  indicate  the  direction  of 
transmission  of  murmurs — the  obstructive  aortic,  into  the  carotids,  the  regurgitant  aortic, 
down  the  sternum  and  toward  the  apex;  the  regurgitant  mitral,  toward  the  axilla.  (Comp. 
Figs.  124  and  125.) 

second  after  the  second  sound,  and  when  sufiiciently  marked,  causes  the 
protodiastohc  gallop  rhythm.  It  is  synchronous  with  the  early  normal 
diastohc  elevation  of  the  apex  cardiogram,  and  with  the  descending  Hmb 
of  the  "v"  wave  of  the  jugular  pulse.  When,  however,  allowance  is 
made  for  the  transmission,  the  impulse  of  the  protodiastolic  elevation  is 
found  to  be  synchronous  with  the  "h"  wave.  Thayer^  believes  the  third 
sound  to  be  due  to  the  sudden  tension  of  the  mitral  valve  which  occurs 
with  the  first  inrush  of  blood  at  the  beginning  of  diastole. 

The  rhythm  and  accentuation  of  each  sound  varies  with  the  location 

^Thayer:  "Further  Observation  on  the  Third  Heart  Sound." 
Amer.  Physicians,  May,  1909. 

Trans.  Assoc, 



at  which  it  is  heard.  At  the  mitral  area  the  first  sound  seems  louder — 
appears  to  bear  the  greater  stress.  Over  the  semilunar  valves  the  accent 
falls  upon  the  second  sound.  This  is  due  to  the  variation  in  distance 
between  the  point  of  origin  of  the  sound  and  the  location  of  the  stetho- 
scopic  bell. 

Approximate'  Musical  Eq^u-ivaUrct 



Fig. 1179. — Diagrammatic  representation  of  the  heart  sounds,  and  the  pressure  curvea 
in  the  auricle,  ventricle  and  aorta.  D,  presphygmic  period;  E,  sphygmic  period;  F,  post- 
sphygmic  period. 

The  first  heart  sound  corresponds  to  a  vibratory  rate  of  about  55  per  second,  the  second 
sound,  to  a  rate  of  about  62.  The  latter  is,  therefore,  from  1  to  5  musical  notes  higher 
than  the  former.  Both  sounds  are  subject  to  considerable  individual  variation  both  as  to 
duration  and  pitch,  especially  the  second  heart  sound.  The  first  sound  begins  from  0.01 
to  0.02  seconds  after  the  upstroke  of  the  apical  cardiogram,  and  ends  during  the  fall  of 
the  level  of  the  systolic  plateau,  generally  during  the  systolic  elevation  of  the  carotid 
pulse.      {Gerhartz.) 


We  speak  of  an  heart  or  an  arterial  "tone"  or  sound  as  opposed  to  a 
murmur — a  distinction  made  by  Rouanet,  and  now  ineradically  custom 
sanctioned.  But  in  a  purely  physical  sense  such  a  differentiation  is 
entirely  unjustified  since  both  are  the  result  of  irregular  sonorous  vibra- 
tions. Indeed,  of  the  two,  the  vibrations  which  produce  a  "murmur  "  are 
more  rhythmic  than  those  which  produce  a  "sound." 


Heart  sounds  are  produced  by  vibrations  of  the  muscular  or  mem- 
branous structures;  not  by  their  fluid  contents.  Sudden  increase  in 
valvular  or  arterial  tension  alone  may  produce  longitudinal  but  not  hori- 
zontal \'ibrations,  and  only  the  latter  are  capable  of  sound  production. 
If  an  elastic  band  which  has  been  stretched  is  plucked,  horizontal  ^dbra- 
tions  are  set  up  and  a  sound  is  produced.  If  the  band  is  merely  suddenly 
stretched  by  pulling  upon  either  end.  longitudinal  vibrations  are  set  up 
but  unless  accidental  horizontal  vibrations  result  from  the  irregularity 
of  the  jerk  no  sound  results. 

A  membranous  sac  suddenly  distended  by  fluid  not  only  expands 
sufficiently  to  accommodate  the  increased  contents,  but  OT\^ng  to  its 
"inertia"  at  first  overexpands  and  in  turn,  O'^ing  to  its  elasticity,  con- 
tracts. In  this  manner  a  series  of  transverse,  tone-producing  "vibrations 
are  set  up.  Thus  arterial  sounds  are  produced  in  all  arteries  in  which 
the  disturbance  of  equihbrium  is  sufficiently  rapid.  Sclerotic  vessels 
are  less  distensible,  hence  the  arterial  sounds  OA^er  such  arteries  often 
have  a  metaUic  quality  owing  to  the  very  unrhAi;hmic  \abrations  en- 
gendered b}'  the  stiffened  tissues.  Heart  sounds  arise  in  a  similar  man- 
ner. If,  owing  to  vahoilar  leakage  or  low  arterial  blood-pressure,  out- 
flow begins  before  a  rise  in  tension  suffxcient  for  sonorous  vibration  occurs, 
the  sounds  are  weak  or  inauchble.  The  first  heart  "sound"  is  only  pos- 
sible, therefore,  if  a  presphygmic  period  of  increased  tension  precedes  the 
outflow  of  blood.  The  slower  the  pulse  rate,  and  the  lower  the  diastolic 
pressure,  the  easier  the  outflow  and  the  weaker  the  flrst  sound. 

The  First  Heart  Sound. — The  first  heart  sound  is  mainly  due  to  "vibra- 
tions of  heart  walls  and  of  the  valves.  The  latter  elements  contribute  in 
no  small  measure  to  the  total  sound.  (The  intra-auricular  pressure  is  so 
low  compared  to  that  of  the  ventricles,  that  the  cuspid  valves  close  quickly, 
and  owing  to  their  anatomical  configuration  have  a  large  A-ibratory 
excursion,  j 

Following  the  muscular  and  valvular  elements  of  the  first  sound  b\' 
0.06  to  0.07  second  (presphygmic  periodj  the  vascular  element  due  to 
the  sudden  cUstention  of  the  aorta  and  the  pulmonary  artery  occurs. 
Ordinarily  these  three  elements  are  fused  into  a  single  sound,  but  if  the 
presphygmic  period  is  delayed  the  different  sound  elements  become 
asynchronous  and  a  recognizable  splitting  of  the  first  sound  occurs. 

The  Second  Heart  Sound. — The  second  heart  sound  is  due  to  sudden 
increase  of  tension  and  subsequent  vibration  of  the  aortic  and  pulmonary 
valve  during  closure.  The  difference  in  intra-ventricular  and  intra-arterial 
pressure  at  the  end  of  systole  being  great,  especially  in  the  former  case, 
the  valves  snap  back,  and  -vibrate  until  eciuilibrium  is  reestablished.  The 
sounds  produced  by  aortic  and  pulmonic  closure  while  not  quite  s^mchro- 
nous,  are  separatee!  normally  by  too  short  a  time  interval  to  be  auditorily 
appreciable  as  separate  sounds.  When  pathologicalh'  the  normal  pres- 
sure differences  are  exaggerated,  a  split,  second  sound  is  noted,  a  condition 
which  is  more  readily  appreciable  if  the  first  element  is  the  weaker  of  the 

Inasmuch  as  our  auditory  impressions  of  the  two  elements  of  the 
second  sound  are  always  to  some  extent  fused,  it  is  probable  that  we  can 
recognize  one  as  increased  over  the  other  only  when  at  least  a  2  to  1 
difference  in  intensity  prevails.  "When  a  "marked  increase"  both  of 
pitch  and  intensity  of  the  pulmonic  second  sound  is  noted,  the  actual 



relative  iiiten^^ity  is  several  times  greater.  In  attempting  to  estimate 
relative  differences  in  intensity-  auscultation  should  be  practised  close 
to  the  sternal  margin  and  not  at  a  distance  from  it,  since  the  relative 
difference  tends  to  become  less  marked  in  the  process  of  conduction 

Fig.  ISO. — Section  of  the  thor.vx  viewed  from  ix  froxt.  Systolic  (obstructive) 
aortic  murmurs  are  transmitted  in  the  direction  of  blood  flow,  upward  into  the  carotid 
arteries.  Systolic  (regurgitant)  mitral  murmurs  are  transmitted  in  the  opposite  direction 
to  the  blood  current,  toward  the  left  axilla,  being  conducted  thence  by  the  chordae  tendineae 
and  the  papillary  muscles.  A  =  aorta;  P  =  pulmonary  artery;  C  =  carotid  arteries;  P.M. 
=  papillary  muscle;  R  =  right  auricle;  5  =  superior  vena  cava. 


There  is  no  absolutely  normal  standard  of  the  heart  sounds  and  a 
certain  allowance  must  be  made  for  individual  peculiarities.  As  a  gen- 
eral rule  such  variations  can  be  explained  either  upon  anatomic  grounds  — 
the  size  of  the  lungs,  the  depth  of  the  chest,  etc.,  or  upon  the  basis  of  age 
and  sex. 


Substernal  Sounds. — In  a  considerable  number  of  perfectly  healthy 
individuals  the  heart  sounds  heard  just  over  the  ensiform  cartilage,  and 
in  its  immediate  vicinity,  have  a  peculiar  harsh,  scratching,  scraping  or 
crunching  quality  closely  resembling  a  pericardial  friction  sound.  This 
sound  which  has  been  described  as  the  xypho-sternal  crunch,  seems  super- 
ficial, is  increased  and  sometimes  audible  only  when  the  patient  leans 
forward  or  to  the  left.  It  is  short  and  heard  with  variable  intensity 
during  both  systole  and  diastole.  Its  etiology  is  uncertain.  Blumer 
has  suggested  that  it  is  due  to  changes  in  tension  of  the  loose  areolar 
tissue  in  the  sterno-pericardial  ligament.  This  sound  is  frequently  met 
in  cases  of  cardioptosis.  It  is  a  relatively  frequent  normal  phenomenon, 
the  importance  of  which  lies  in  the  fact  that  it  may  readily  be  mistaken 
for  a  pericardial  friction,  or  an  obstructive  mitral  murmur. 

The  Presystolic  Sound. — The  recent  electrophonographic  studies  of 
Bridgman  have  corroborated  by  means  of  graphic  records,  the  existence 
of  a  normal  presystolic  sound.  The  sound  in  question,  while  clinically 
unusual,  has  long  been  recognized  as  a  diagnostic  stumbling  block,  since 
it  may  closely  simulate  the  faint  presystolic  murmur  of  a  slight  degree 
of  mitral  stenosis. 

This  sound  is  perhaps  due  to  the  tension  of  the  ventricular  walls,  and 
the  fact  that  it  is  not  more  frequently  heard  appears  to  be  owing  to  the 
fact  that  the  sound  waves  are  normally  below  the  limits  of  human 


The  relative  intensity  of  normal  heart  sounds  as  determined  with  the 
Oertel  stethoscope  by  Bock  are:  mitral  sound,  40;  pulmonic  sound,  18; 
aortic  sound,  20.  The  sound  heard  over  the  mitral  area  is  normally 
twice  as  loud  as  the  aortic. 

Accentuation  of  the  first  sound  is  due  to  increased  contractile  force  of 
the  papillary  and  ventricular  muscles.  It  occurs  after  exertion,  during 
overaction  (mental  excitement,  the  early  stages  of  fevers,  etc.)  and  in 
ventricular  hypertrophy. 

The  first  heart  sound  is  diminished  in  intensity,  assumes  the  quality  of 
the  second  sound,  in  protracted  fevers  (typhoid,  etc.),  in  some  valvular 
diseases,  especially  in  mitral  insufficiency,  and  in  fatty  infiltration  or 
degeneration  of  the  myocardium.  The  muscular  element  becomes  dimin- 
ished and  it  assumes  a  "valvular"  quality,  owing  to  the  preponderance  of 
its  second  sound  component,  i.e.,  the  snapping  back  of  the  mitral  valve. 

Accentuation  of  the  second  sound  indicates  increased  rapidity  of  closure, 
and  this  in  turn  relatively  increased  vascular  pressure,  in  the  aorta  or 
pulmonary  artery.  The  sound  is  due  not  to  the  mechanical  act  of  valvu- 
lar closure,  but  to  sudden  increase  in  tension  and  subsequent  vibration 
of  the  valves. 

The  pulmonic  second  sound  is  normally  louder  up  to  twenty-five  or 
thirty  years  of  age,  after  which  the  aortic  tends  to  become  louder.  When 
auscultation  is  practised  (experimentally)  directly  over  the  vessels,  the 
.aortic  sound  is  the  louder.  In  90  per  cent,  of  all  children  under  ten  years 
of  age,  the  pulmonic  sound  is  the  louder  (the  artery  is  more  superficial), 
and  in  about  10  per  cent,  of  the  cases  a  splitting  of  the  second  sound  can 
be  recognized. 



The  second  jmlmonic  sound  is  louder  in  the  reciimhent  posture,  and  in 
conditions  which  increase  the  pressure  in  the  lesser  circulation — pulmo- 
nary consolidation,  pleural  effusion,  mitral  disease,  emphysema — provided 
the  right  heart  is  sufficiently  strong  to  maintain  the  increased  tension, 
i.e.,  the  tricuspid  valve  remains  competent.     When,  therefore,  ice  say  that 

Fig.  181. — Left  vextricular  htpertropht.  Extreme  hypertrophy  of  the  heart, 
especially  of  the  left  ventricle,  occurs  most  characteristically  in  aortic  valvular  disease,  or  as  a 
result  of  long-standing  arterial  hypertension.  It  is  clinically  characterized  by  1.  a  forcible, 
heaving  cardiac  impulse;  2.  displacement  of  the  apex  impulse  downward  and  to  the  left;  3.  a 
long,  low-pitched,  booming  first  sound;  and  4.  unless  the  aortic  valves  are  insufficient,  or 
myocardial  weakness  pronounced,  a  clear,  high-pitched,  ringing  accentuation  of  the  second 
sound  both  at  the  apex  and  at  the  aortic  area. 

the  second  sound  is  accentuated  ive  mean  that  it  is  relatively  louder  than  it 
should  be  in  relation  to  age  and  posture.  This  phenomenon  indicates  in- 
creased pressure  in  the  lesser  circulation. 

The  aortic  second  sound  is  increased  in  arterial  hypertension,  provided 
the  ventricular  strength  be  sufficient.    This  occurs  especiallj-  in  glomerulo- 


nephritis,  often  in  arterio-sclerosis  and  in  pregnancy  (increased  masslof 
blood  or  blood-pressure) .  It  is  always  louder  than  the  pulmonic  sound  after 
the  sixth  decade.  Accentuation  of  the  aortic  second  sound  can  be  demon- 
strated in  about  two-thirds  of  the  cases  of  arterial  hypertension.  The  fact 
that  it  is  not  demonstrable  in  all  the  cases  may  be  due  to  the  presence  of 
obesity,  pulmonary  emphysema,  etc.  Occasionally  a  clear,  loud  metallic 
sound  is  heard  in  cases  of  syphilitic  aortitis  even  with  a  normal  blood- 
pressure,  showing  that  arterial  hypertension  is  not  the  only  determining 
factor.  The  aortic  second  sound  is  diminished  in  intensity  in  arterial 
hypotension  and  in  conditions  associated  with  imperfect  filling  of  the  aorta 
— mitral  or  aortic  obstruction,  exhausting  diarrhea,  and  when  the  semi- 
lunar valves  have  lost  their  elasticity. 


Increase  in  the  pitch  of  the  first  sound  occurs  when  contraction  is 
rapid;  increased  pitch  of  the  second  sound  occurs  when  the  semilunar 
valves  close  under  higher  tension.  When  marked,  the  latter  imparts  a 
ringing,  high-pitched,  metallic  quahty  to  the  second  sound  which  is  quite 
as  indicative  of  increased  tension  as  is  the  actual  intensity  of  the  sound. 
When  air-containing  cavities  exist  near  the  heart  (pneumothorax,  pul- 
monary tuberculosis,  tympanitis,  etc.)  the  heart  sounds  may  also  take  on 
a  ringing,  metallic  quality  owing  to  the  resonating  properties  of  the  neigh- 
boring cavities. 

In  case  of  rapid  heart  action  and  low  blood-pressure — fevers^  muscular 
exertion,  etc. — the  first  sound  is  shorter,  more  snappy  and  higher  in 
pitch.  In  cardiac  hypertrophy  with  increased  blood-pressure  it  is  more 
booming  and  lower  in  pitch.  In  cardiac  dilatation  it  is  short,  sharp  and 
flapping.  A  weak  first  sound  may  be  due  not  to  lack  of  force  but  to 
slowness  of  muscular  contraction.  The  quicker  the  contraction  and  the 
more  sudden  its  termination,  the  louder  the  sound  (Krehl).  In  children 
the  first  sound  is  more  snappy  and  high-pitched,  owing  to  a  preponder- 
ance of  the  valvular  sound  components. 


Both  heart  sounds  are  composite.  If  any  one  of  the  component  ele- 
'ments  falls  out  of  time  a  reduplication  occurs,  two  sounds  instead  of  one 
being  heard.  If  the  time  interval  between  the  component  sound  elements 
is  a  short  one  we  speak  of  a  splitting  of  the  sound;  if  more  prolonged,  of 
a  reduplication.  The  introduction  of  some  abnormal  element  may  also 
cause  a  reduplication.  Instead  of  the  normal  lub-dupp  we  hear  tu-rub-b- 

Reduplication  of  the  first  sound  which  is  most  commonly  heard  at  the 
apex,  and  in  the  erect  posture,  is  probably  in  the  main  due  to  delayed 
contraction  of  the  papillary  muscles.  These  structures  being  supplied 
by  terminal  arteries,  are  readily  affected  by  fatigue  and  by  noxious  in- 
fluences. Reduplication  may,  however,  be  clue  to  a  late  production  of 
the  vascular  element  (expulsion  tone),  especially  if  the  presphygmic 
period  is  prolonged.  It  is  often  heard  in  children,  in  thin-chested  indi- 
viduals, and  pathologically  in  arterio-sclerosis,  etc. 

Reduplication  of  the  second  sound  may  be  due  to :  (a)  abnormal  pressure 
relations  and  markedly  asynchronous  closure  of  the  aortic  and  pulmonic 



valves;  (6)  conditions  hastening  or  preventing  a  sudden  increase  in  ten- 
sion of  the  semihmar  leaflets — stiff  valves. 

Example. — A  deep  inspiration  increases  the  blood  in  the  lungs,  and 
decreases  the  amount  in  the  left  ventricle.  The  pressure  in  the  aorta, 
therefore,  increases  disproportionately  to  that  in  the  left  ventricle  and 
the  valves  close  more  quickly.  This  also  occurs  in  mitral  stenosis, 
whereas  the  condition  is  reversed  in  mitral  insufficiency.  Splitting  of 
the  first  sound  yields  an  anapestic  rhythm  (intervene)  vj^^—.  Split- 
ting of  the  second  sound  yields  a  dactylic  rhythm  (merciful) — vjvj  (Cabot) . 

Intriven,tr-  loiyUr 

VolvL-me    of 

lVesijitoli,c  Gillop 
Split  |irst  sounj. 
SfUt  sewfil  souvi 




TT-LUB       DUB 




LUB      DUB      DA 







Fig.   182. 

-Illustrating  split  heart  sounds,  gallop  rhythms  and  their  phonetic  equivalent. 
(After  Hirschf elder.) 

Abnormal  accentuation  of  the  aortic  second  sound  indicates  increased 
arterial  pressure;  increased  intensity  and  pitch  of  the  pulmonic  second 
sound  points  to  increased  pressure  in  the  lesser  circulation. 


When  from  any  cause  the  heart  is  weakened  and  the  diastolic  pause 
shortened,  the  heart  sounds  tend  to  become  equally  spaced  and  valvular 
in  character.  This  condition  is  known  as  ''pendular  rhythm"  owing  to 
its  resemblance  to  a  ticking  clock.  It  is  generally'  due  to  prolongation  of 
ventricular  systole,  and  hence  to  a  delay  in  the  appearance  of  the  second 
sound.  When  this  pendular  rhj-thm  is  associated  with  a  rapid  pulse  a 
disproportionate  shortening  of  diastole  occurs,  and  the  rhythm  is  spoken 
of  as  embryocardia  (fetal  rhythm) .  It  is  generalh^  associated  with  a  mono- 
crotic pulse  and  heard  in  cases  of  cardiac  dilatation. 

The  Presystolic  Gallop  Rhythm  (v^ — v-»)  "  symbolic." — In  this  condi- 
tion a  third  sound  is  introduced  into  the  cardiac  cycle  which  occurs  just 
before  ventricular  systole.  It  takes  its  name  from  its  similarity  to  the 
footfall  of  a  galloping  horse,  and  is  generally  due  to  abnormally  and 
audibly,  asynchronous  contraction  of  the  right  and  the  left  ventricles — 
the  former  preceding.  It  is  sometimes  due  to  abnormally  loud  auricular 
contraction  and  hence  may  occur  when  these  chambers  are  hj^pertrophied 
as  in  the  early  stages  of  mitral  obstruction.  It  occurs  chiefly  in  cases  of 
arterial  hypertension  associated  with  a  dilating  hypertrophy.  Electro- 
cardiographically  it  is  almost  invariably  characterized  by  a  split  "R" 
wave.  Presystolic  gallop  rhythm  may  also  occur  in  the  course  of  acute 
infections,  especially  diphtheria,  scarlatina  and  rheumatic  fever.     It  is  a 



distress  signal  from  the  heart  and  prognosis  is  worse  if  it  occurs  with 
hypo-  than  hypertension. 

The  Protodiastolic  Gallop  Rhythm  (vjkj — )  ''intervene." — This  is 
simply  an  exaggeration  of  the  normal  third  sound  and  is  due  to  the 
sudden  upward  snap  of  the  auriculo-ventricular  valves  early  in  diastole. 
It  is  generally  best  heard  at  the  base  of  the  heart.     It  occurs  especially 

Fig.  183. — Advanced  pulmonary  tuberculosis  of  the  left  lung  with  retraction,  consolida- 
tion, cavitation  and  cardiac  displacement  of  an  hypertrophied  heart  to  the  left.  In  such 
cases  the  heart  sounds  are  often  clearly  heard  over  the  whole  affected  side,  owing  to  di- 
minished reflection  at  the  heart-  (solid)  lung  junction  and  to  the  resonating  properties  of  the 
cavities.  Furthermore,  the  lung  is  generally  contracted  exposing  a  large  cardiac  surface  to 
the  chest  wall.  Still  another  factor  is  the  concomitant  emaciation  of  the  patient  resulting 
in  diminished  superficial  tissue.  Conduction  of  the  heart  sounds  to  the  opposite  side  of  the 
chest  in  right-sided  pulmonary  tuberculosis  was  pointed  out  by  J.  M.  DaCosta  and  is  some- 
times described  as  "DaCosta's  sign." 

when  the  rate  is  slow  and  corresponds  to  the  appearance  of  the  "h"  wave 
in  the  phlebogram.  It  is  heard  especially  in  mitral  obstruction,  aortic 
insufficiency,  and  adhesive  pericarditis. 

Occasionally  the  sound  may  be  heard  in  mid-diastole,  owing  to  the 
fact  that  the  auricles  begin  to  contract  at  this  time.  This  generally  indi- 
cates a  high  grade  of  cardiac  asthenia,  as  in  very  toxic  and  prolonged 
cases  of  typhoid  fever. 


Acoustics. — Heart  murmurs  are  abnormal  sounds,  having  generally 
a  blowing  quality,  which  is  due  to  more  or  less  rhythmic  vibrations  of  the 
cardiac  or  arterial  tissues.  They  are  generally  produced  at  or  near  a 
valvular  orifice  by  abnormalities  in  contour  or  structure.  Such  condi- 
tions are  brought  about  (1)  either  by  organic  changes  which  result  in 
thickening,  stiffening,  roughening,  constriction,  dilatation,  perforation 
or  retraction  of  the  valvular  tissues  or  (2)  hy  functional  lesions  resulting 
in  loss  of  muscular  tonus.  The  latter  occur  chiefly  at  the  mitral  and 
tricuspid  orifices.  Heart  murmurs  may  be  produced  (1)  when  blood  flows 
from  a  cavity  into  a  cylinder;  (2)  when  blood  flows  from  a  cylinder  into 
a  cavity;  (3)  when  membranes  vibrate  in  the  blood  stream;  (4)  when  the 
endocardium  or  intima  are  roughened. 

"Whatever  contracts  an  orifice,  whatever  dilates  a  cavity,  whatever 
establishes  an  orifice  or  a  cavity  where  none  should  be,  will  disturb  the 
even  flow  of  blood,  and  produce  vibration  and  a  murmur"  (Gee).  The 
heart  sound  consists  of  a  single,  intense,  demarked  auditory  impression. 
A  heart  murmur  gives  us  the  effect  of  unevenly  composed  sounds  which 
arise  from  rapidly  varying,  irregular,  sound  production.  The  heart 
sound  has  been  compared  to  a  single  stroke  upon  a  drum;  the  murmur,  to 
the  sound  produced  by  blowing  into  a  pipe.  The  sound  bears  the  same 
relation  to  the  murmur  as  does  a  pistol  shot,  to  the  surge  of  the  sea. 
The  difference,  therefore,  consists  in  the  suddenness  of  onset  and  of  ending 
of  the  soundflas  cornpared  to  the  gradual  beginning  and  uncertain  termination 
of  the  murmur. 

The  fact  that  heart  murmurs  are  produced  by  vibrations  of  the 
tissues  and  not  by  the  vibrations  of  the  blood  stream  is  shown  by  the 
following  facts. 

I.  If  by  way  of  experiment  (Fig.  184)  we  introduce  a  flowing  stream  of 
water  by  means  of  a  tube  into  a  beaker  and  listen  with  a  stethoscope, 
(1)  above  the  fluid  level:  no  sound  is  heard.  (2)  If  the  bell  be  immersed, 
the  tube  mouth  being  at  "A" :  a  murmur  is  heard  at  "  C. "  (3)  If  the  tube 
be  raised :  the  murmur  becomes  feebler,  even  when  the  current  surrounds 
the  bell,  showing  that  the  sound  waves  are  not  produced  by  the  water 
directly,  but  by  the  vibrations  imparted  to  the  wall  of  the  beaker.  The 
sounds  increase  in  intensity,  the  nearer  the  tube  to  the  wall,  i.e.,  the  larger 
the  surface  contact  between  the  glass  and  the  fluid  vein.  On  withdrawal 
of  the  tube  all  sound  ceases,  despite  the  fact  that  the  current  still  per- 
sists'for  a  time.  That  this  cessation  is  not  due  merely  to  an  inadequately 
rapid  current  is  shown  by  the  fact  that  pouring  H2SO4  into  water,  which 
owing  to  greater  specific  gravity  and  the  generation  of  heat  must  cause 
much  more  rapid  currents,  does  not  alter  the  results. 

II.  Further,^  it  can  be  shown  mathematically  that  the  sounds  pro- 
duced in  the  heart  and  blood-vessels  are  far  too  low  in  pitch  to  be  due 
to  sonorous  vibrations  produced  in  chambers  of  such  small  dimensions. 




The  first  heart  sound  has  been  shown  by  Gerhardt  andFunke,  to  corre- 
spond to  198  vibrations  per  second.  To  produce  by  fluid  vibrations  a 
sound  of  a  corresponding  pitch  to  that  of  the  heart,  would,  according  to 
Helmholtz's  formula  call  for  a  ventricle  with  a  capacity  of  about  24  liters! 
Although  these  figures  are  doubtless  high  owing  to  the  fact  that  Helm- 
holtz's formula  presupposes  a  cavity  communicating  with  the  atmosphere, 
yet  even  allowing  liberally  for  such  facts,  it  would  be  quite  impossible  to 
produce  sounds  similar  to  those  of  the  heart  or  of  murmurs  by  vibrations 
of  the  blood  columns  in  the  heart  and  great  vessels. 

Unquestionably  then,  heart  sounds  and  murmurs  must  be  due  to  horizontal  vibrations 
of  the  heart  and  vessel  walls  (Williams,  Kiwisch,  Weber).  The  heart  walls  and  .the 
blood  stream  play  the  respective  parts  of  the  violin  string  and  the  bow  (Weber). 
The  mechanism  by  which  mural  vibrations  are  produced  is  as  follows: 
I.  In  flowing  from  "A"  to  "B"  (Fig.  185)  the  fluid  particles  deviate  from  their 
linear  course  and  produce  a  series  of  impactions  on  the  walls  of  "B,"  because  the  adhe- 
sion between  the  wall  and  the  outer  fluid  layer  is  greater  than  the  cohesion  between 


riC'Vy ■= — - 

Fig.   185. 

Fig.   184. 


Fig.  186 

Fig.   187. 

Fig.  Xi 

the  fluid  particles.  This  tends  to  create  a  vacuum  at  "C"  which  in  turn  causes  the 
elastic  walls  of  "B"  to  fall  inward.  Such  a  movement  temporarily  overcomes  the 
vacuum,  thus  again  allowing  the  walls  to  regain  their  original  position.  A  regularly 
recurring  series  of  such  events  sets  up  continuous  lateral  vibrations  of  the  vascular 
walls  in  the  expanded  section  ("B").  In  the  constricted  portion  ("A")  a  series  of 
vibrations  is  established  by  alternate  suction  and  compression  engendered  in  "B. " 
These  vibratory  waves  have  "D"  as  their  nodal  point.  Rapidity  of  flow  greatly 
favors  murmur  production.  Clinically  the  production  of  murmurs  through  expan- 
sion of  the  blood  channels  finds  many  exemplifications — valvular  lesions,  aneurisms, 

II.  The  reverse  condition,  in  which  there  is  a  sudden  contraction  ofithe  blood 
channels,  may  also  produce  murmurs  (Fig.  186). 

Here  the  constriction  at  "  D"  raises  the  pressure.  This  tends  to  force  the  stenotic 
opening  apart.  When  this  has  been  accomplished  pressure  temporarily  falls  again. 
Such  alterations  of  pressure  throw  the  vascular  walls  in  both  sections  "A"  aud  "B" 
into  alternate  transverse  vibration.  The  ideal  conditions  for  the  production  of  a 
murmur  exist  in  case  of  fluid  flowing  through  a  constriction  (Fig.  186a)_. 

III.  Membranous  diaphragms,  e.^.,  heart  valves  or  vegetations  in  the  blood 
stream,  may,  by  flapping  like  a  sail  in  the  wind,  be  thrown  into  vibration,  and  may  be 
a  further  cause  in  the  production  of  murmurs  (Fig.  187).     (Compare  Fig.  212.) 


IV.  With  sufficient  rapidity  of  the  blood  current,  even  smooth-walled  vessels  of 
uniform  caliber  may  be  thrown  into  vibration  (this  has  been  demonstrated  by 
Weber),  for  no  vessel  is  absoluteh'  smooth;  and  slight  degrees  of  roughening  are  equiva- 
lent to  minute  stenoses.  Only  in  this  sense  can  murmurs  be  said  to  result  from 
"friction  of  the  blood  stream"  (Geigel).  "Fluid  of  any  kind,  flowing  at  any  speed 
through  a  cylindrical  tube,  will  not  cause  a  murmur,  even  if  the  tube  be  curved,  so 
long  as  it  retains  its  cylindrical  form"  (McLennan). 


I.  Place  the  bell  of  the  stethoscope  firmly  in  the  fourth  interspace  or 
over  the  fifth  rib  just  within  the  cardiac  impulse.  Ignore  the  respiratory 
sounds  and  determine  which  is  the  first  sound.  This  is  accomplished  by 
observing  (1)  that  it  is  synchronous  with  the  cardiac  impulse;  (2)  that  it 
follows  the  long  pause;  (3)  that  it  is  a  lower  pitch  as  well  as  longer  and 
louder  than  the  second  sound.  The  last  criterion  is,  of  course,  not  always 

Note  its  :  (1)  rate,  (2)  rhythm,  (3)  intensity,  (4)  quality,  (5)  duration, 
(6)  pitch  and  (7)  mode  of  beginning  and  of  termination. 

II.  Examine  the  sounds  heard  over  the  aortic,  pulmonic  and  tri- 
cuspid areas  in  a  similar  manner  (Fig.  187). 


Considerable  individual  variation  in  the  loudness  of  heart  sounds 
exists.     The  sounds  are: 

(a)  Decreased  in  recumbenc}-,  in  adiposity,  in  men  with  great  mus- 
cular development,  in  women  with  large  mammae,  in  anasarca,  in 
pericardial  or  left-sided  pleural  effusions,  in  pulmonary  emphysema,  in 
m^'ocardial  weakness  and  in  the  agonal  period.  Faint  irregular,  incoor- 
dinated  sounds  are  sometimes  heard  for  a  time  after  death  and  probably 
result  from  auricular  contractions,  since  the  right  auricle  is  the  last  part 
of  the  heart  to  die.  The  heart  sounds  may  be  verj'  faint  and  muffled 
even  in  perfect  health. 

(b)  Increased,  during  cardiac  overaction — phj'sical  exertion,  mental 
excitement ;  if  the  lungs  are  small,  or  if  they  are  retracted,  or  consolidated 
in  the  neighborhood  of  the  heart;  or  if  the  heart  is  h\^pertrophied. 

Occasionalh"  the  heart  sounds  can  be  heard  all  over  the  chest.  Changes 
in  the  relative  intensity  of  the  first  and  second  sounds  are  much  more  im- 
portant than  mere  changes  in  the  actual  intensity  of  both  sounds. 

Certain  facts  have  been  demonstrated  experimentally  ichich  have  prac- 
tical clinical  significance.  (1)  A  murmur  is  more  easil}"  produced,  if 
the  walls  of  the  tube  be  thin,  if  the  inner  surface  be  rough,  if  the  tube  be 
rigid,  and  if  viscosity  is  increased.  (2)  Increased  tension  has  veiy  little 
effect  provided  the  rate  remains  the  same.  (3)  Increasing  the  compres- 
sion of  the  tube  will  increase  the  murmur  up  to  a  maximum,  after  which 
it  tends  to  chsappear.  (4)  With  a  certain  grade  of  rapidity  and  com- 
pression, the  murmur  becomes  finer  and  more  musical  (T.  Weber). 

From  the  standpoint  of  physics  no  sharp  distinction  can  be  drawn 
between  heart  sounds  and  murmurs  because  physically  speaking  both  are 
murmurs.  Heart  sounds  are  due  to  a  single  impulse  giving  rise  to  vibra- 
tions of  the  cardiac  or  vascular  wall;  a  murmur  is  due  to  repeated  vibra- 
tory impulses.  The  difference  is  similar  to  that  of  plucking  or  stroking 
a  violin  string.     Hence  sounds  are  generally  shorter  in  duration,  but  this 



is  not  an  essential  difference:  a  murmur  may  be  short  and  a  sound  long 
(for  example,  the  sound  of  a  kettle  drum  and  a  tuning  fork,  although 
each  is.  produced  by  a  single  blow).  The  real  difference  lies  in  the  fact 
that  in  the  case  of  the  sound,  the  first  vibration  is  the  greatest,  whereas  in  the 
case  of  the  murmur,  we  have  at  the  outset  for  a  time,  a  continuous  series  of 
equal  vibratory  excursions. 

Impure  sounds  are  a  mixture  of  heart  sound  and  heart  murmur  with  no 
very  definite  preponderance  of  either.  Thus  in  a  given  case  one  observer 
would  say  "the  first  sound  is  murmurish,  impure,"  while  another  might 
with  equal  justice  and  correctness  say  there  is  "a  faint,  short  systolic 
murmur."  Impure  sounds  are  occasionally  heard  in  health,  but  indicate 
a  functionally  if  not  structurally  imperfect  valve  (roughness,  relaxation 
or  stiffness).  Under  exercise  they  often  develop  into  definite  murmurs. 
Sounds  are  to  a  certain  extent  conducted  along  the  arterial  wall,  but 
probably  not  to  any  great  degree  when  the  vessels  are  surrounded  by 
good  conducting  media.  There  is  also  some  conduction  by  the  fluid 


Heart  murmurs  may  be  caused  by  perforation,  constriction,  dilatation, 
or  roughening  of  the  blood  channels,  especially  the  valvular  orifices. 
The  lesions  furnishing  these  conditions  may  be : 

1.  Organic. 

(a)  Obstruction  to  the  onward  flow  of  blood — stenosis. 

(b)  Valvular  insufficiency,  allowing  an  escape  of  blood  backward — 

regurgitation,  incompetency. 

2.  Functional  (without  structural  alterations)  insufficiency  of  the: 

(a)  Se7nilunar  valves — increased  arterial  pressure  and  dilatation  of  the 
aortic  or  pulmonic  rings. 

(b)  Cuspid  valves — relaxation  of  the  mitral  or  tricuspid  sphincters,  or 
improper  functionation  of  the  papillary  muscles. 

Relative  insufficiency  is  much  more  common  in  case  of  the  cuspid 
than  in  that  of  the  semilunar  valves.  Of  the  former,  the  tricuspid  is 
structurally  a  much  less  perfect  valve  than  is  the  mitral,  and  hence  is 
much  more  prone  to  leak  under  conditions  of  strain,  in  which  case  it 
acts  to  a  certain  extent  as  a  safety  valve  to  the  right  heart,  with  a  second 
line  of  defense  in  the  not  far  distant  liver,  against  which  the  blood  thrust 
of  the  right  heart  is  delivered. 

The  murmur  of  a  stenosis  is  produced  by  a  current  travelling  the 
normal  direction,  and  is  sometimes  spoken  of  as  an  onward  murmur.  It 
occurs  at  the  time  when  the  valve  should  be  open. 

The  murmur  of  an  insufficiency  is  produced  by  a  reflux  of  blood  and 
occurs  at  a  time  when  the  valve  should  be  closed — backward  murmur,    j 

The  Time  Relations  of  Valvular  Murmurs 

Systolic                                    Diastolic 




Pulmonary  artery 

Aorta  ' 

Pulmonary  artery 



The  Differentiation  of  Valvular  Murmurs. — Several  murmurs  are 
often  coincidently  present  in  a  given  case  and  on  the  other  hand  the  same 
murmur  may  Ije  heard  over  different  areas  of  the  precordium.  In  such 
cases  loe  judge  of  the  identity  or  non-identity  of  such  murmurs  by  the  follow- 
ing criteria:  (1)  location,  (2)  time,  (3)  transmission,  (4)  quality,  (5) 
pitch,  (6)  duration,  (7)  intensity.  Among  these,  place,  time,  and  direc- 
tion of  conduction  are  by  far  the  most  important. 

The  Location  of  Murmurs. — A  murmur  is  generally  best  heard  at 
the  point  of  the  chest  wall  which  is  nearest  to  the  orifice  at  which  it  is 
produced.  The  location  at  which  the  different  valvular  sounds  are  best 
heard  has  already  been  considered  (p.  217).  The  same  rules  govern  the 
audibility  of  murmurs. 

The  Time  of  Murmurs. — It  is  essential  to  determine  the  exact  time 
and  duration  of  a  nmrnmr  in  its  relation  to  the  cardiac  cycle — whether 
it  occurs  in  sj'stole,  diastole  or  presystole.  This  is  accomplished  by 
noting  the  relation  of  the  murmur  to  the  (1)  apex  impulse,  (2)  first  sound, 
(3)  long  pause.  The  terms  protosy "italic,  mesosystolic  and  telesystoHc 
are  applied  to  murmurs  which  occupy  respectively  only  the  beginning, 
middle  or  end  of  systole. 

The  Transmission  of  Murmurs. — Murmurs  are  transmitted,  that  is 
they  are  heard  at  certain  areas  of  the  periphery  other  than  those  overlying 
the  location  of  their  origin,  or  of  their  normally  greatest  intensity. 
Murmurs  are  conducted  to  different  regions  generally'  in  the  direction  of 
the  blood  current,  just  "as  wind  carries  sound."  Murmurs  are,  however, 
not  merely  conducted  to  the  surface  by  the  nearest  possible  route.  The 
sound-carr^dng  quality  of  the  neighboring  tissues  also  plays  a  most  im- 
portant role.  Thus  the  murmur  of  aortic  insufficiency  may  be  loudest 
over  the  ensiform  cartilage  whence  it  is  conducted  from  the  second 
right  interspace;  whereas  the  mitral  regurgitant  murmur,  produced 
deep  within  the  mediastinum,  is  conducted  in  an  opposite  direction  to 
that  of  the  blood  flow,  by  means  of  the  papillary  muscles,  to  the  region  of 
the  cardiac  apex,  the  axilla,  or  the  scapular  angle. 

The  Quality  of  Murmurs. — Murmurs  vary  in  quality  and  are  hence 
described  as  being  musical,  non-musical;  harsh,  soft;  blowing,  scraping; 
squeaking,  etc.  The  pitch  is  also  of  great  importance.  These  facts  are 
significant  since  they  aid  one  in  distinguishing  between  murmurs  when 
two  or  more  are  present.  It  is  to  be  remembered,  however,  that  a  mur- 
mur may  undergo  modification  dependent  upon  the  point  at  which  one 
auscults ;  and  further,  that  the  same  murmur  may  change  very  considera- 
bl}^  in  quality  as  a  result  of  numerous  conditions  such  as  myocardial 
weakness,  exercise,  posture,  blood-pressure,  etc.  One  cannot  judge  of 
the  type  or  seriousness  of  a  lesion  by  the  quality  or  intensity  of  the  mur- 
mur. Indeed,  a  loud  murmur  may  denote  a  good  heart  muscle  and  a 
weak  murmur,  myocardial  weakness.  When  the  latter  is  marked  an 
organic  murmur  previously  present  may  disappear  entirely  to  reappear 
when  compensation  improves.  As  a  general  rule,  however,  musical  and 
scratchy  endocardial  murmurs  are  rarely  functional.  When  an  organic 
lesion  is  progressive,  the  murmur  increases  in  intensity  up  to  a  certain 
point,  beyond  which  it  recedes,  either  as  the  result  of  muscular  weakness 
or  on  account  of  the  extent  of  the  valvular  damage.  Systolic  murmurs 
are  generally  louder  than  diastolic  murmurs,  especially  in  recumbency. 
On  account  of   their  faintness  and  low  pitch,   diastolic  murmurs  are 



easily  overlooked.  Systolic  murmurs  may  be  present  when  the  patient 
lies  down  and  may  disappear  when  he  is  erect.  Obstructive  murmurs 
are  generally  louder  in  the  erect  posture.  Aortic  and  pulmonic  murmurs 
are  less  affected  by  posture  than  those  produced  at  the  mitral  or  tricuspid 
orifices.  Most  murmurs  are  louder  after  exertion,  and  some  may  require 
physical  exercise  to  make  them  audible.  Hemic  murmurs  resulting 
either  from  anemia  alone,  or  from  anemia  together  with  a  dilatation  of 



Fig.  188. — Diagram  illustrating  heart  sounds  and  murmurs. 

A:  Normal  heart  sounds.  A,  auricular  systole;  V,  ventricular  systole;  D,  ventricular 
diastole.     The  sounds  begin  and  end  abruptly. 

B:  Systolic  murmur  following  first  sound.     The  first  sound  terminates  gradually. 

C:  Systolic  murmur  accompanying  first  sound.  The  first  sound  is  "impure"  and  fades 
away  gradually. 

D:  Systolic  murmur  replacing  first  sound.  The  first  sound  is  supplanted  by  a^blowing 

E:  Diastolic  murmur  following  the  second  sound.  The  second  sound  is  followed  by  a 
blowing  sound. 

F:  Diastolic  murmur  accompanying  the  second  sound.  The  second  sound]fades  away 

G:  Diastolic  murmur  replacing  the  second  sound.  Instead  of  a  clear-cut  second  sound 
one  hears  a  blowing  sound.  This  is  often  low  pitched  and  heard  with  diSiculty.  The  ab- 
sence of  the  second  sound  always  suggests  careful  investigation. 

H:  Late  diastolic  murmur. 

I:  Continuous  systolic  and  diastolic  murmur  in  patent  ductus  arteriosus. 

the  pulmonary  artery,  are  best  heard  at  the  pulmonic  area.  They  are 
soft  and  blowing,  low  in  pitch,  variable  in  character,  indefinite  in  trans- 
mission. Murmurs  are  also  described  as  being  crescendo  or  diminuendo 
in  character,  the  terms  being  used  in  the  musical  sense  to  indicate  a 
continuous  increase  or  decrease  respectively'  of  their  intensity.  The 
murmur  of  mitral  stenosis  is  often  typically  crescendo,  that  of  aortic 
insufficiency  often  diminuendo,  in  quality. 


Even  organic  murmurs  may  be  variable  in  quality  and  iiitensity 
to  the  point  of  actual  disappearance,  either  constantly  or  intermittently 
in  a  series  of  successive  cardiac  cycles.  Such  variation  is  not  uncommon 
in  auricular  fibrillation,  extrasystole  and  heart  block  owing  to  variable 
degrees  of  auriculo-ventricular  coordination  and  rate  of  blood  flow.  With 
the  onset  of  auricular  fibrillation  or  of  paroxysmal  tachycardia,  murmurs 
often  •  disappear  entirely,  to  return  when  the  normal  rhythm  is 

Fig.  189. — Aortic  obstkuction.  The  aortic  leaflets  are  fused  together  as  the  result  of 
inflammatory  adhesion,  leaving  only  a  small  elliptical  opening.  The  arrow  indicates  the 
direction  of  blood  flow.  The  physical  signs  of  aortic  obstruction  are  a  systolic  thrill  and  a 
loud  crescendo  murmur  at  the  base  of  the  heart,  the  latter  being  transmitted  into  the 
carotid  arteries.  The  pulse  is  small  in  volume  and  the  systolic  plateau  shows  a  long,  slow, 
gradual  ascent  and  descent. 

The  left  ventricle  becomes  greatly  hypertrophied  and  hence  the  cardiac  impulse  is  dis- 
placed downward  and  outward,  and  the  longitudinal  diameter  of  the  heart  is  increased 
When,  as  is  usually  the  case,  mitral  insufficiency  exists,  the  vertical  diameter  is  also  in- 
creased.    (See  Fig.  172.) 


1.  The  systolic  aortic  murmur  results  from  roughening  or  obstruction 
at  the  aortic  orifice,  or  dilatation  of  the  aorta.  It  is  best  he^ard  at  the 
second  or  third  left  intercostal  space  and  is  transmitted  into  the  carotid 
arteries.     Phonetic  equivalent:  Lu-f-f-f-Dupp. 

2.  The  diastolic  aortic  murmur  results  from  insufficiency,  retraction, 
separation  'vegetations)  or  perforation  of  the  aortic  leaflets.  It  is  best 
heard  at  second  right  or  fourth  left  intercostal  space,  close  to  the  sternum, 
and  is  transmitted  toward  the  apex  and  to  the  ensiform  cartilage.  It  is 
sometimes  clearly  audible  over  the  spinous  processes  of  the  first  and 



Fig.  190. — Aortic  roughening  and  calcification.  The  aortic  valves  are  stiffened  and 
calcareous,  the  mouths  of  the  coronary  arteries  are  involved  in  the  arterio-sclerotic  process. 
The  left  ventricles  and  papillary  muscles  are  hypertrophied. 

Physical  signs.  A  systolic  aortic  murmur  transmitted  into  the  carotid  arteries.  A 
forcible  heaving,  cardiac  impulse  displaced  downward  and  to  the  left.  A  loud  booming  first 
sound;  a  clear-cut,  ringing,  high-pitched,  accentuated  aortic  second  sound.  This  lesion  is 
very  common  in  advanced  years  and  is  often  erroneously  diagnosticated  as  aortic  obstruction. 

Fig.  191. — -Aortic  obstruction.  The  dotted  areas  indicate  the  locations  over  which  the 
systolic  aortic  murmur  may  be  heard.  On  the  precordium  has  been  drawn  a  diagram  to 
illustrate  the  relationship  of  the  murmur  to  the  heart  sounds. 


second    thoracic    vertebrae.     Phonetic    equivalent:   Lub    Duf-f-f    (Fig. 

3.  The  systolic  mitral  murmur  is  clue  to  valvular  insufficiency,  which 
may  result  from  retraction,  perforation  or  vegetations  upon  the  valvular 
curtains;  also  from  shortening  of  the  chordfe  tendinese;  or  from  dilatation 
of  the  mitral  sphincter.  It  is  best  heard  at  the  mitral  area  and  is  con- 
ducted toward  the  left  axilla  and  sonietimos  to  the  angle  of  the  left 

Fig.  192. — Aortic  aneurism.  Showing  a  heart  with  the  left  ventricle  exposed,  the 
aortic  valves,  and  beyond  them  a  large  aortic  aneurism.  Such  a  sudden  widening  of  the 
blood  channel  (aorta)  sets  up  eddies  in  the  blood  stream  and  will  cause  a  systolic  murmur  if 
the  current  is  sufficiently  rapid  and  if  the  aneurism  is  not  filled  with  a  blood  clot.  In  many 
cases  of  aneurism  the  aortic  valves  are  incompetent,  owing  to  dilatation  of  the  aortic  lumen 
and  thus  a  diastolic  (regurgitant)  murmur  is  superadded.  The  double  and  more  or  less 
continuous  murmur  with  a  rhythmic  accentuation  due  to  systole  is  known  as  a  bruit. 

scapula.  The  former  is  in  reverse  of  the  direction  of  the  blood  stream, 
and  is  mainly  due  to  conduction  by  means  of  the  papillary  muscles. 
"The  chordae  tendineae  transmit  the  mitral  murmur  from  the  mitral  seg- 
ments to  those  portions  of  the  heart  into  which  they  are  inserted."^  The 
murmur  heard  in  the  left  axilla  in  mitral  insufficiency  is  chiefly  due  to 
^De  Satttelle  and  Grey:  Arch,  Int.  Med.,  December,  1911. 



the  proximity  of  the  insertion  of  the  anterior  papillary  muscle  and  de- 
pends only  in  small  part  upon  conduction  by  means  of  the  ventricular 
wall.  The  experimental  transplantation  of  a  papillary  muscle  alters  the 
direction  of  murmur  transmission.  The  posterior  papillary  muscle  often 
conducts  the  mitral  regurgitant  murmur  to  the  scapular  angle.  At  times 
the  murmur  produced  at  an  incompetent  mitral  orifice  is  heard  over  the 
dilated  left  auricular  appendage — in  the  third  left  intercostal  space. 
Phonetic  equivalent:  Luf-f-f  Diipp. 

4.  The  presystolic  mitral  murmur  is  the  result  of  mitral  obstruction. 
It  is  heard  best  at  or  just  within  the  apex.     Often  one  of  its  chief  char- 

FiG.  193. — Cardiac  hypertrophy.  The  cor  hovinum  occurs  characteristically  in  aortic 
disease.  It  is  clinically  manifested  by:  displacement  of  the  cardiac  impulse,  downward  and 
to  the  left;  a  forcible  heaving  impulse,  and  a  loud,  low-pitched  booming  first  sound.  It 
generally  results  from  aortic  insufficiency  beginning  in  early  life. 

acteristics  is  its  crescendo  quality,  which  has  been  ascribed  to  (a)  powerful 
diastolic  ventricular  suction,  (6)  to  auricular  systole,  (c)  to  increased 
pressure  in  the  pulmonary  circulation.  It  is  often  associated  with  a 
snappy,  high-pitched  first  sound.  It  is  rough  and  rumbling  in  character, 
and  often  followed  by  a  systolic  murmur — because  a  valve  which  is  suffi- 
ciently indurated  to  produce  an  obstruction  is  generally  incapable  of 
complete  systolic  closure  (insufficiency).  It  is  generally  accompanied 
by  a  fine  presystolic  thrill,  and  if  the  right  heart  is  competent  by  an 



accentuated  pulmonic  second  sound.  The  murmur  is  most  intense  when 
blood  flow  is  most  rapid — when  the  differential  pressure  between  auricle 
and  ventricle  is  greatest.  Hence,  the  murmur  of  mitral  obstruction  may 
occupy  any  part  of  the  diastolic  interval.  Thus  with  a  slowly  beating 
heart  and  a  powerful  auricle  the  murnun-  appears  in  presystole.     If,  how- 

FlG.     194. AOKTIC    AXU    MITRAL    I XSUFFICIEXCY    DUE    TO    ACUTE    ENDOCAKDITIS.        Fresh 

vegetations  are  seen  on  the  respective  valves.  The  heart  is  hypertrophied,  the  aorta  normal. 
The  arrows  indicate  the  direction  of  the  regurgitant  blood  stream.  The  murmur  is  trans- 
raitted  from  the  aortic  valves  downward  toward  the  apex,  in  the  direction  of  the  blood 
flow.  In  the  case  of  the  mitral  valve  it  is  conducted  in  a  reverse  direction  to  that  of  blood 
flow,  toward  the  axilla  and  the  angle  of  the  scapula,  by  means  of  the  papillary  muscles. 
A,  anterior  and  P,  posterior,  papillary  muscle.     L.A.A.,  left  auricular  appendix. 

Physical  signs.  A  heaving  impulse,  displaced  downward  and  to  the  left,  pulsating  caro- 
tid arteries,  a  water-hammer  pulse  Cardiac  dulness  enlarged  to  the  left.  A  diastolic  aortic 
murmur  transmitted  to  the  ensiform  cartilage;  a  systolic  murmur  conducted  to  the  axUla 
and    the  scapular  angle.      (Compare  Figs.  172,  181.) 

ever,  stenosis  is  marked  and  the  pulse  rate  rapid,  "an  early  diastolic 
rumble  may  be  added;  the  period  of  silence  between  the  two  murmurs 
corresponds  to  the  period  when  filling  is  at  its  slowest"  (Lewis).  The 
intensity  of  the  murmur  is  in  most  instances  increased  by  exercise  or  the 
recumbent  posture,  which  factors  increase  the  cardiac  output. 

In  addition  to  the  rumbling  presystolic  murmur  heard  near  the  cardiac 



apex  in  mitral  obstruction,  a  soft,  blowing,  early  diastolic  murmur  is 
often  heard  along  the  left  sternal  margin.  This  murmur  is  due  to  dilata- 
tion of  the  pulmonary  artery  which,  if  sufficiently  marked,  causes  an  in- 
sufficienc}'  of  the  pulmonary  leaflets.     (.Graham-Steell  murmur.) 

Fig.  195. — Diagram  illustrating  the  direction  of  the  regurgitant  blood  stream  in  aortic 
insufficiency.  The  murmur  is  best  heard  at  the  second  right  costo-sternal  articulation  and 
is  transmitted  toward  the  ensiform  cartilage  and  toward  the  cardiac  apex. 

Fig.  196. — Aortic  insufficiency.  The  dotted  areas  indicate  the  locations  over  which 
the  diastolic  murmur  may  be  heard.  The  circle  contains  a  diagrammatic  representation 
of  the  murmur  in  relation  to  the  first  and  second  heart  sounds 

Thus  mitral  stenosis  complicated  by  relative  pulmonary  insufficiency 
may  closely  simulate  aortic  insufficiency  with  a  Flint  murmur.  But  in 
the  latter  case  left  ventricular  hj^pertrophy  is  greater,  the  blood-pressure 
picture  is  quite  characteristic,  and  other  pulsatory  phenomena  such  as  a 
capillary  pulse,  Duroziez's  murmur,  etc.,  will  establish  the  diagnosis. 

The  difficulty  so  many  students  have  in  recognizing  or  even  being 
able  to  identify  presystolic  murmurs  is  due  to  the  fact  that  they  expect 


to  hear  a  swishing  sound  similar  to  that  produced  by  systohc  or  diastoUc 
murmurs.  The  presvstoHc  murmur  is  a  sound  very  different  in  quahty. 
It  is  a  rumble  somewhat  Uke  a  short  roll  on  the  drum,  which  precedes  and 
gradually  merges  into  the  first  sound  of  the  heart. 

When  the  heart  becomes  dilated  and  the  auricle  paralyzed  the  mur- 
mur disappears,  and  fibrillation  of  the  auricle  makes  its  appearance.  The 
crescendo  quality  while  clinically  characteristic  has  been  shown  to  be  due, 
not  to  an  inherent  quality  of  the  murnnu-  but  chiefly  to  the  proximity  of 

Fig.  197. — Mitral  ixsufficiexcy.  The  mitral  curtains  are  thickened,  and  are  the  seat 
of 'numerous  vegetations.  Some  of  the  chordae  tendinese  are  ruptured,  all  of  them  are 
thickened  and  shortened.  The  left  ventricle  is  hypertrophied.  The  murmur  of  mitral 
insufficiency  is  systolic  in  time.  It  is  transmitted  toward  the  left  axilla  and  scapula*  in 
reverse  of  the  direction  of  the  blood  stream  by  the  papillary  muscles  and  the  chordae  ten- 
dinese.    The  arrow  indicates  the  direction  of  the  regurgitant  blood  stream. 

the  first  heart  sound.  If  the  auricle  goes  into  a  state  of  fibrillation  or  if 
it  loses  its  contractile  force  because  of  extreme  dilatation,  the  presystolic 
murmur  disappears  and  instead  of  it  a  murmur  is  heard  earlj^  in  diastole. 
Pure  presystolic  murmurs  can  arise  only  at  the  auriculo-ventricular  ori- 
fices. Phonetic  equivalent:  R-R-R-upp,  Dupp  (presystolic  rumble); 
Rup-Tut-Rarou  (mid-diastolic  rumble)  (see  Fig.  202). 

5.  The  systolic  tricuspid  murmur  is  heard  at  the  tricuspid  area,  be- 
cause both  the  right  auricle  and  ventricle  lie  immediately  beneath  this 
point.     It  is  also  often  heard  over  the  mitral  area,  and  cannot  always  be 


differentiated  from  the  murmur  of  a  mitral  insufficiency,  with  which  it 
is  usually  associated.  The  presence  of  marked  right  heart  dilatation, 
of  a  positive  venous  pulse,  of  an  enlarged  or  even  pulsating  liver,  pulmo- 
usltj^  congestion,  ascites,   etc.,   enable  us  to  definitely   state   that   the 

Fig.  198. — AIiteal  insufficiency.  The  left  ventricle  is  hypertrophied,  the  left  auricle 
dilated.  The  direction  of  the  regurgitant  blood  flow,  as  indicated  by  the  arrow,  is  upward 
and  backward,  but  the  murmur  is  transmitted  chiefly  downward  and  forward  through  the 
vibrating_  chordae  tendinese  and  the  papillary  muscles.  A,  aorta;  L.A.,  left  auricle;  R.A., 
part  of  right  auricle;  P,  portal  vein;  R.P.,  right  pulmonary  artery;  L.P.,  left  pulmonary 
artery;  T,  trachea;   S.A.,  right  subclavian  artery;   S.V.,  right  subclavian  vein. 

tricuspid  valve  is  incompetent.  A  diagnosis  of  tricuspid  insufficiency, 
based  merely  upon  the  fact  that  a  systolic  murmur  is  clearly  audible  at 
the  tricuspid  area  is  not  justified.  Such  a  diagnosis  may  on  the  con- 
trary be  eminenth^  warranted  in  the  absence  of  a  tricuspid  murmur  if 



the  presence  of  a  positive  venous  pulse  or  a  pulsating  liver  can  be 
demonstrated.     Phonetic  equivalent:  Luf-f-f  Dup  (see  Figs.  211,  400). 

6  The  presystolic  tricuspid  murmur  is  heard  at  the  tricuspid  area  and 
results  from  obstruction  of  that  orifice  (see  Fig.  202) .  This,  as  an  isolated 
lesion,  is  very  rare.     It  is  usually  associated  with  mitral  obstruction  and  is 

Fig.  199. 

Fig.  200. 

Figs.  199  and  200. — Mitral  ixsufficiencv.    The  dots  indicate  the  area  over  which  the 

systolic  mitral  murmur  is  generally  audible.     The  small  circle  indicates  the  accentuated 

pulmonic  second  sound   (pulmonary   arterial  hypertension).     The  large  circle  contains  a 

diagrammatic  representation  of  the  relation  of  the  murmur  to  the  heart  sounds.    When  loud 

'  it  is  often  audible  at  the  angle  of  the  left  scapula. 

of  "rheumatic"  origin.  A  large  "a"  wave  in  the  liver  pulse  is  said  to  be 
suggestive  of  the  condition.  A  few  cases  have  been  diagnosticated  during 
life;  mc  3t  of  the  cases  found  at  autopsy  go  to  the  table  with  a  diagnosis 
of  "mitral  obstruction." 

7.  The  systoUc  pulmonic  murmur  if  organic  in  nature  is  generally  due 
to  a  congenital  deformity  of  this  orifice  which  results  in  obstruction.     It 


is  loud  and  best  heard  at  the  pulmonic  area  and  may  be  transmitted  to 
the  subclavicular  region  (along  the  pulmonary  arteries) .  It  is  associated 
with  marked  cyanosis,  clubbing  of  the  fingers,  dyspnea  and  if  the  child 
lives  long  enough,  often  with  pulmonary  tuberculosis.  It  is  accompanied 
by  a  systolic  thrill  at  the  base  of  the  heart,  a  weak  pulmonic  second  sound, 
and  hypertrophy  of  the  right  heart.  Phonetic  equivalent:  Luf-f-f  Dup 
(see  Figs.  1,  209,  329). 

Many  functional  murmurs  arise  at  the  pulmonary  orifice,  and  most 
pulmonic  murmurs  are  functional.  Experimentally,  when  the  heart  is 
exposed,  the  slightest  compression  or  traction  upon  the  artery  is  sufficient 

Fig.  201. — Mitral  obstkuction.  showing  the  area  over  which  the  diastolic  (presys- 
tolic) mitral  murmur  is  generally  audible,  together  with  a  diagrammatic  illustration  of  its 
relation  to  the  heart  sounds.  Accentuation,  splitting  or  reduplication,  of  the  pulmonic 
second  sound  is  an  invariable  accompaniment  of  this  lesion  until  compensation  fails. 

to  produce  a  murmur.  Such  pressure  may  easily  be  produced  in  health 
by  change  of  posture,  forced  held  inspiration,  slight  pleural  adhesions, 
etc.  The  pulmonary  area  was  named  by  Balfour  the  "region  of  romance" 
because  so  many,  variable,  inconsequential  murmurs  may  be  heard  in 
this  region.  There  are,  however,  some  cases  of  mitral  insufficiency  in 
which  the  regurgitant  murmur  is  heard  near  the  second  left  intercostal 
space,  owing  to  the  proximity  of  the  left  auricular  appendage  (Figs. 
163,  170). 

A  diagnosis  of  pulmonary  stenosis  based  solely  upon  the  presence  of  a 
systolic  murmur  at  the  second  left  intercostal  space  is  absolutely  un- 
justified. Pulmonary  stenosis  is  a  rare  and  nearly  always,  congenital 
lesion  which  is  associated  with  cyanosis,  clubbed  fingers,  cardiac  hyper- 
trophy and  a  feeble  second  sound. 

8.  The  diastolic  pulmonic  murmur  (pulmonary  insufiiciency)  may 
result  from  congenital  disease,  or  from  ulcerative  endocarditis;  in  either 
case  it  is  a  rare  lesion.     It  may  be  due  to  functional  dilatation  of  the  pul- 



monarv  orifice  under  severe  strain  which  leads  to  increased  blood-pressure 
in  the  lesser  circulation.  The  Graham-Sleell  murmur  is  a  diastolic 
murmur  heard  best  at  the  third  left  intercostal  space.  It  is  usually  soft 
and  blowing  in  character,  replaces  the  pulmonic  second  sound,  and  is 
often  heard  onlv  in  recumbency.  It  may  be  influenced  by  respiration, 
and  by  stethoscopic  pressure  (Goodman^)  and  may  occupy  part  or  w-hole 
of  the' diastolic  period.  It  is  due  to  enlargement  of  the  pulmomc  ring  and 
associated  with  dilatation  of  the  right  ventricle.     It  is  of  clinical,  im- 

FiG.  202. — Aortic,  mitral  axd  tricuspid  obstructiox.  The  lesions  depicted  are  the 
end  result  of  acute,  generally  rheumatic,  endocarditis.  The  mitral  orifice  shows  a  tj-pical  but- 
tonhole deformity  with  induration  and  calcification.  The  tricuspid  orifice  shows  a  uniform 
constriction,  while  the  aortic  leaflets  are  fused  together  and  sclerotic,  with  secondarj-  cal- 
careous infiltration.  Tricuspid  stenosis  as  an  isolated  lesion  is  rare.  It  may  be  due  to  the 
same  etiologic  factors  as  the  mitral  lesion  (generally  rheumatic  fever)  or  may  be  the  result 
of  the  mitral  lesion,  which  by  overstraining  the  right  ventricle  leads  to  edema,  hemorrhage 
and  subsequent  fibrosis  of  the  tricuspid  curtains. 

The  physical  signs  consist  of  a  presystolic  thrill  and  murmur,  a  right-sided  cardiac  en- 
largement, marked  cyanosis  and  a  presystolic  liver  pulsation.  An  intravitam  diagnosis 
is  rarely  made,  owing  to  the  similarity  of  the  physical  signs  with  those  of  mitral  obstruction. 
(After  Xorris'  "Studies  in  Cardiac  Pathology.") 

portance  inasmuch  as  aortic  insufficiency  with  a  Flint  murmur  may  pre- 
sent identicalh-  the  same  acoustic  phenomena  as  mitral  stenosis  with  a 
Graham-Steell  murmur.  It  is  differentiated  from  the  aortic  regurgitant 
murmur  by  the  fact  that  it  is  not  transmitted  to  the  ensiform  cartilage 
nor  toward  the  apex,  and  that  it  is  unassociated  with  a  Corrigan  pulse, 
and  with  the  blood-pressure  picture  so  characteristic  of  the  latter  lesion. 
Phonetic  equivalent:  Lub-Duf-f-f. 

1  Goodman",  E.  H. :  "The  Graham-Steell  Murmur  in  Mitral  Stenosis."  Am.  Jour. 
Med.  Soc,  Feb.,  1919,  206. 



Fig.  203. — ^Mitral  stenosis.  This  lesion  generally  occurs  in  early  adult  life,  and  results 
from  rheumatic  endocarditis.  The  illustration  shows  enormously  thickened  and  contracted 
mitral  curtains,  thickened,  shortened  and  adherent  chordse  tendineae,  and  as  a  result,  a 
funnel-shaped  mitral  stenosis. 

The  most  characteristic  physical  signs  of  mitral  obstruction  are:  a  presystolic  thrill  ard 
murmur  at  the  apex,  with  a  snappy  first  sound,  and  accentuation  of  the  pulmonary  second 
sound.  The  pulse  is  small  in  volume  and  frequently  irregular.  The  heart  enlarges  toward 
the  right. 


Fig.  204. — Illustrating  the  direction  of  blood  flow  in  mitral  obstruction. 



f "  All  these  rules  are  subject  to  exceptions  due  to  cardiac  displacement, 
etc.  Murmurs  themselves  are  variable  and  often  multiple  and  compU- 
cated  bv  pericardial  or  respiratory  sounds.     Occasionally  murmurs  are 










Fig.  205. — The  right  heart  and  it.s  tributary  bi^uod  channels.  Pulsation  is 
readily  transmitted  to  the  liver  either  (1)  directly  from  the  right  ventricle  or  (2)  indirectly,  as 
the  result  of  tricuspid  regurgitation,  the  inferior  vena  cava  being  short.  In  the  latter 
instances  the  pulsation  instead  of  being  more  or  less  localized  to  the  epigastrium  is  general 
and  expansile  in  character.    The  liver  shows  sphygmographically  a  positive  venous  pulse. 

The  blood  pathway  from  the  jugular  veins  into  the  right  auricle  is  also  a  very  direct 
one,  hence  jugular  tracings  (phlebograms)  readily  depict  pressure  changes  in  the  auricle, 
especially  when  the  subject  is  recumbent  and  gravity  assists  in  the  stasis  of  venous  flow. 
R.B.,  right  bronchus;  R.P.A.,  right  pulmonary  artery;  B.L.N.,  bronchial  lymph  node; 
L.A.,  left  auricle;  I.V.C,  inferior  vena  cava;  S.V.C,  superior  vena  cava;  R.A. A.,  right 
auricular  appendage;  R.A.,  right  auricle;  A.T.,  anterior  tricuspid  leaflet;  V.A.M.,  vena 
azygos  major. 

subjectively  audible  to  the  patient  himself,  or  they  may  be  heard  by  the 
examiner  at  quite  a  distance  from  the  patient.  Both  of  these  statements 
apply  chiefly  in  case  of  certain,  loud,  high-pitched,  musical  murmurs. 



filled  with 
serous  exu- 

lung  (part 
of  right 
lower  lobe) 

f  Rt.  internal 

■',    ugular 



vena  cava  / 

Fig.  206. — Right-sided  hydrothorax.  Frozen  section  from  a  case  of  cardiac  anasarca 
similar  to  that  depicted  in  Figs.  211,  381.  Almost  the  entire  pleural  cavity  was  filled  with 
serous  effusion.  The  lung  which  was  completely  collapsed  and  compressed,  has  been  re- 
moved in  the  proximal  sections,  leaving  only  small  areas  in  this,  the  last  section  cut.  The 
heart  is  pushed  forward,  the  diaphragm  and  liver  downward.  The  inferior  vena  cava  is 
greatly  distended,  the  right  auricle  dilated.  The  liver  is  engorged  and  has  the  typical 
"nutmeg"  appearance.  The  complemental  space  anteriorly  and  posteriorly  was  filled 
with  fluid.  The  patient,  who  suffered  from  rheumatic  mitral  obstruction  and  insufficiency, 
and  tricuspid  insufficiency  with  auricular  fibrillation,  died  with  cyanosis,  orthopnea  and 
general  anasarca.  L.A.,  left  auricle;  R.A.,  right  auricle;  B,  bronchus;  P. A.,  pulmonary 



The  term  "functional"  murmur  is  applied  to  various  (almost  uni- 
versally systolic)  sounds  which  cannot  be  explained  by  demonstrable 
structural  lesions.  The  term  is  an  unfortunate  one  because  murmurs 
are  physical  phenomena  and  must  result  from  physical  causes.  A  valve 
may  leak  from  mere  lack  of  tonus  of  the  surrounding  muscular  ring. 
While  this  may  be  temporary,  remecUable  and  inconsequential,  neverthe- 
less it  is  a  leak.  It  would  seem  better  therefore  to  drop  the  term  ''func- 
tional" altogether  and  assign  the  murmur  to  its  cause — endocarditis, 
myocardial  dilatation,  anemia.  Cardiac  displacement  and  exophthalmic 
goitre  are  often  associated  vdih  s\"stolic  murmurs,  as  are  also  the  various 
forms  of  anemia. 

Fig.  207. — Mitral  and  trici.-ii.  :n>  kficiency.  The  heart  is  enlarged,  as  is  also  the 
liver,  which  is  tender  and  which  pulsates.  The  dotted  areas  show  the  regions  over  which  the 
systolic  mitral  and  tricuspid  murmurs  are  heard. 

The  cardiac  murmurs  heard  in  anemia  have  certain  characteristics 
which,  as  a  rule,  serve  to  distinguish  them  from  murmurs  duetoanatom- 
ical  changes  in  the  heart. 

1.  They  are  definitely  associated  with  the  heart  and  while  they  may 
be  heard  at  any  one  of  the  valvular  orifices,  they  are  most  frequently 
encountered  over  the  pulmonary  area,  at  the  second  costal  cartilage  or 
third  interspace  on  the  left.  Next  to  the  pulmonary  area  the  region  of 
the  apex  of  the  heart  is  the  most  frequent  site.  Occasionally  a  hemic 
murmur  is  heaid  over  the  aortic  and  tricuspid  areas. 

2.  They  are  not  transmitted  but  are  sharply  localized. 



3.  They  are  always  systolic  in  time,  but  often  terminate  before  the 
end  of  systole. 

4.  They  are  frequently  associated  with  a  hemic  murmur  either 
in^'the  veins  or  the  arteries. 

5.  They  are  uniformly  low-pitched;  the  sound  is  soft  in  character, 
and  variable  in  quality  and  intensity.  The  sound  produced  by  a  hemic 
murmur  never  has  the  rough  or  occasional  musical  quality  of  an  organic 
murmur.  At  times  these  murmurs  are  loudest  when  the  patient  is  in 
the  recumbent  posture  and  in  some  cases  this  is  the  only  position  in 
which  it  can  be  elicited.  The  murmur  is  apt  to  be  loudest  immediately 
after  lying  down,  before  the  vessels  have  accommodated  themselves  to  the 
change  in  gravity.     The  murmur  may  be  intensified  by  violent  cardiac 

Fig.  208. — Locations  at  which  non- organic  murmurs  are  most  frequently  heard. 

action  due  either  to  nervous  excitement  or  exertion.     Hemic  murmurs 
in  the  vessels  of  the  neck  are  most  marked  in  the  erect  posture. 

Transitory  Murmurs  Due  to  Exertion. — Accidental  murmurs  ap- 
parently endocardial  in  origin  are  frequently  developed  as  the  result  of 
violent  exertion.  They  are  very  transitory  and  are  rarely  heard  beyond 
a  few  minutes  succeeding  the  exertion.  In  an  examination  of  1552 
students  at  Cornell  University,  Munford  encountered  murmurs  of  this 
character  in  117,  or  7.48  per  cent.,  after  the  student  had  been  required 
to  "chin"  himself  as  often  as  possible.^     They  are  generally  ascribed  to 

^  R.  T.  McKenzie  found  that  among  266  apparently  healthy  students  74  (27.8  per 
cent.)  developed  cardiac  murmurs  under  vigorous  exercise.  Of  these  35  were  of  the 
pure  pulmonic  systolic  type.  If  the  cases  are  included  in  which  this  murmur  occurred 
in  association  with  other  murmurs  it  was  present  in  64  cases,  only  10  men  out  of  the 
74  failing  to  show  it.     Murmurs  were  slightly  more  common  among  the  non-athletic 


loss  of  muscle  tone  affecting  chiefly  the  mitral  sphincter  and  hence  are 
more  common  in  individuals  who  are  not  "in  training." 

Heart  miirnuirs  are  very  easily  produced.  The  vascular  dilatation 
induced  by  prolonged  sweat  baths  is  of  itself  sufficient  to  cause  the 
appearance  of  murmurs  in  the  majority  of  cases. ^ 


1.  Inspiration  causes  the  lungs  to  overlap  the  heart  and  thus  tends 
to  make  murmurs  more  feeble. 

Fig.  209. — Pulmonary  obstruction,  or  dilatation.  Indicating  the  area  over  which 
systolic  pulmonary  murmurs  are  heard,  with  a  diagrammatic  illustration  of  the  relationship 
between  the  murmur  and  the  heart  sounds. 

2.  Inspiration  favors  blood  flow  into  and  out  of  the  right  heart. 
During  rapid  breathing  it  hinders  blood  flow  in  the  left  heart,  by  retain- 
ing more  in  the  lungs.  During  slow  breathing  this  effect  is  only  manifest 
during  the  first  half  of  the  act,  because  in  the  last  half  the  pulmonary 
vessels  dilate  no  further. 

3.  Expiration  acts  in  the  reverse  manner,  hindering  blood  flow  in 
the  right  and  favoring  it  in  the  left  heart,  especially  with  rapid  or  forced 
breathing.  These  facts  may  be  used  to  help  in  the  differentiation  of 
right-  or  left-sided  valvular  lesions. 

students.     These  murmurs  were  more  frequent,  more  intense  and  sometimes  present 
only  in  recumbency. 

1  Howell,  F.  :  "Physiological  Heart  Murmurs  Produced  by  Electric  Light  Baths." 
Boston  Med.  &  Surg.  Jour.,  April  3,  1902. 




Duroziez's  Murmur.- — If  the  femoral  artery  be  slightly  indented  by 
pressure  of  the  stethoscope  during  auscultation,  a  systolic  murmur  will 
be  heard  which  results  from  vibration  of  the  vessel  walls  due  to  the  local 
constriction  of  the  blood  stream.     In  aortic  insufficiency,  where  blood 

Fig.  210. — Aortic  and  mitral  insufficiency.  Aortic  and  mitral  insufficiency  with  left 
ventricular  hypertrophy  and  dilatation,  also  a  small  pericardial  effusion. 

The  aortic  valves  are  shrivelled  and  retracted,  the  left  ventricle  is  hypertrophied  and 
dilated,  this  dilatation  affecting  the  mitral  orifice.  The  apex  impulse  is  displaced  down- 
ward and  to  the  left.  T,  trachea;  A,  aorta;  P. 4.,  pulmonary  artery;  L.A.A.,  left  auricular 
appendage;  iW.L.,  mitral  leaflets ;P,  pericardial  sac;  S.V.,  subclavian  vessels;  S.V.C.,  superior 
vena  cava;  A.L.,  aortic  leaflets;  R.A.,  right  auricle. 

Physical  signs:  A  heaving  impulse,  a  booming  first  sound,  a  systolic  mitral  murmur 
transmitted  to  the  axilla.  A  faint,  low-pitched  aortic  diastolic  murmur  transmitted  toward 
the  cardiac  apex  and  to  the  ensiform  cartilage.  Pulmonic  second  sound  accentuated.  Pul- 
sating carotid  and  brachial  arteries,  a  water-hammer  pulse,  Duroziez's  murmur,  blood- 
pressure:  systolic  180,  diastolic  55  mm.  Hg. 

flow  is  rapid  and  where  the  current  flows  alternately  forward  and  back- 
ward, a  double  murmur  may  be  heard  over  the  femoral  artery.  This 
is  known  as  Duroziez's  murmur.  It  is  suggestive  but  not  pathogno- 
monic of  aortic  insufficiency.  It  may  occur  in  other  conditions  associ- 
ated with  vasomotor  relaxation. 



Traube's  Sound. — In  some  cases  of  aortic  insufficiency  with  marked 
hypertrophy  and  a  hirge  systoUc  output,  the  sudden  distention  of  the 
arteries  produces  a  cracking  noise  known  as  a  pistol-shot  sound.  This 
may  be  heard  even  in  the  absence  of  aortic  insufficiency  if  the  pulse  pres- 
sure be  large,  and  the  diastolic  pressure  low.  In  some  cases  of  aortic 
and  tricuspid  insufficiencii  a  double  sound  of  this  character  (Traube's sound) 
may  be  heard  over  the  femoral  vessels.  This  has  been  shown  to  consist 
of  a  venous  as  well  as  an  arterial  element.  It  is  due  to  sudden  distention 
of  the  femoral  artery,  and  to  sudden  backward  pressure  upon  the  femoral 
venous  valves  The  latter  element  precedes  the  former  because  the  blood 
from  the  leaking  tricuspid  valve  begins  to  regurgitate  during  the  period 

Skodaic  tympany,  exag- 
gerated breath  sounds, 
crackling  rales. 

Dulness,  feeble  breath 
sounds,  fremitus  and 
vocal    resonance. 


Pulsating  liver  tender- 

Bulging    flanks,    succus 
sion  wave. 

Pulmonic    second   sound 


Apex   impulse  displaced, 

downward  and    outward 


Systolic  murmur  replaces 

first  sound. 

Pitting  of  the  abdominal 
wall,  edema  of  arms, 
glossy  skin. 

Fig.  211. — Cardiac  dkopsy.  A  case  of  general  dropsy  (anasarca)  following  dilata- 
tion of  the  heart,  due  to  mitral  and  tricuspid  disease.  Orthopnea,  cyanosis,  right-sided 
hydrothorax,  passive  congestion  of  the  lungs,  liver  and  spleen,  ascites,  etc.  The  patient,  a 
girl  of  fovxrteen  years,  shows  emaciation  and  retarded  development  due  to  the  cardiac 
lesion.  Also  pitting  of  tne  abdominal  wall  due  to  subcutaneous  edema.  A  character- 
istic picture  of  broken  cardiac  compensation  with  tricuspid  insufficiency  is  presented 
(comp.  Figs.  176,  206). 

of  valvular  closure  (beginning  of  systole)  while  the  arterial  distention 
does  not  take  place  until  the  end  of  this  period.^ 

The  Flint  Murmur. — This  murmur  is  presystolic  in  time;  it  is  best 
heard  within  and  above  the  cardiac  apex.  It  occurs  in  some  cases  of 
aortic  insufficiency.  There  has  been  much  dispute  about  its  etiology 
and  significance,  but  it  is  generally  believed  to  be  due  to  the  flapping 
of  the  anterior  mitral  curtain  between  two  blood  streams,  i.e.,  between  the 
normal  flow  from  the  left  auricle  and  the  regurgitant  flow  from  the 

i^Schultze:  Deut.  Med.  Woch.,  1905,  xxxv. 



aortic  leaflets  into  the  left  ventricle.  Hirschfelder  has  shown  that  in  the 
excised  heart,  if  the  ventricular  pressure  is  increased,  the  mitral  valve 
opens  only  along  part  of  its  line  of  closure,  and  that  therefore  an  actual 
functional  stenosis  may  exist.  The  importance  of  this  murmur  lies  in 
the  fact  that  it  may  fresent  the  exact  acoustic  yhenomena  of  organic 
mitral  ste7iosis.  It  may  be  differentiated  from  the  last-named  condition 
•by  the  fact  that  it  is  not  associated  with  a  marked  presystolic  thrill,  an 

Fig.  212. — The  Flint  murmur.  The  aortic  and  the  mitral  valves  are  contiguous 
-structures.  The  Flint  (presj-stolic)  murmur  is  produced  bj'  the  regurgitation  of  blood 
through  the  aortic  orifice.  The  curtains  of  the  mitral  valve  are  caught  between  two  blood 
currents — that  just  mentioned  and  that  streaming  in  from  the  left  auricle — and  flap  like  a 
loose  sail  in  the  wind. 

enlarged  right  heart,  a  snappy  first  sound  and  a  small,  well-sustained 
pulse.  The  Flint  murmur  is  found  in  conjunction  with  other  signs  of 
aortic  insufficiency  such  as:  a  pulse  which  is  large  in  volume  and  col- 
lapsing in  type — the  diastolic  pressure  being  low  and  the  pulse  pressure 
large;  left  ventricular  hypertrophy  and  the  vascular  and  pulsatory 
phenomena  so  characteristic  of  an  incompetent  aortic  valve^  (see  Fig.  212). 

^  The  relative  frequency  of  pulsatory  phenomena  in  124  cases  of  aortic  insufficiency 
■was  found  to  be  as  follows:  Corrigan  pulse  9.5  per  cent.,  capillary  pulse  90  per  cent., 
Duroziez  murmur  88  per  cent.,  visible  arterial  pulsation  76  per  cent.,  femoral  snap 
45  per  cent.,  Traube's  sign  24  per  cent.,  visible  venous  pulse  7  per  cent.  (Tice). 


Rogei's  murmur  is  sometimes  heard  in  cases  of  patulous  inter- 
ventricular septum.  It  is  continuous  throughout  systole  and  diastole 
with  an  ictus  or  reinforcement  during  the  former.  It  has  a  rhythmic, 
somewhat  musical  character  with  a  periodic  intensification  like  the 
whirring  of  a  foot-propelled  knife-grinder's  wheel.  It  is  best  heard  in 
the  upper  third  of  the  precordium  over  the  median  portion  of  the  septum 
itself.  It  is  not  transmitted  but  gradually  fades  out  in  all  directions  as 
the  point  of  maximum  intensity  is  receded  from.  Phonetic  equivalent: 
Whir  -r  -r  -r  -r  (Fig.  88,  I). 


In  the  large  arteries  near  the  heart  (subclavian,  etc.)  certain  sounds 
may  be  faintly  heard.  They  may  be  due  to:  (1)  stretching  and  vibra- 
tion of  the  vessel  walls,  or  to  (2)  conduction  of  the  second  heart  sound. 
In  the  distant  arteries  one  maj^  have  murmurs  from  stethoscopic  pres- 
sure, or  murmurs  conducted  from  the  aortic  orifice,  etc.  Very  often  a 
systolic  murmur  is  heard  over  the  vertex  of  the  skull  of  children  from 
the  third  month  to  the  sixth  j'ear.     It  is  without  significance. 

Systolic  murmurs  in  arteries  may  be  due  to:  (a)  roughening  of  the 
intima;  (b)  narrowing  of  lumen;  (c)  dilatation — fevers,  vasomotor  par- 
esis; (d)  aneurism. 

Subclavian  murmurs  are  generally  short  in  duration  and  always 
systolic  in  time.  Often  a  harsh  S3'stolic  whiff  is  heard,  especially  during 
inspiration,  generally  on  the  left  side,  and  most  commonly  in  men  at 
the  junction  of  the  middle  with  the  outer  third  of  the  clavicle.  The 
murmur  is  increased  by  deep  inspiration,  sometimes  audible  only  during 
forced  inspiration  and  modified  by  the  position  of  the  arm.  It  may 
be  inconstant.  Subclavian  murmurs  possess  7io  pathologic  significance; 
they  are  generally  due  to  constriction  of  the  artery  between  the  clavicle 
and  the  first  rib,  although  a  similar  constriction  may  be  produced  by 
fibroid  disease  of  the  pleura.  Hence  thej^  are  frequently  encountered  in 
cases  of  pulmonary  tuberculosis.  Landis  found,  among  31  cases  studied, 
that  the  murmur  was  associated  with  pulmonary  tuberculosis  in  20. 
The  fact  that  the  murmur  is  heard  more  frequently  on  the  left  than  the 
right  side,  even  in  cases  in  which  the  pulmonary  disease  is  more  extensive 
on  the  right  side,  suggests  that  the  real  explanation  lies  in  some  anatomi- 
cal variation  of  the  two  arteries.  Furthermore,  subclavian  murmurs 
have  been  frequently  noted  in  individuals  healthy  in  every  respect. 
While  probably  of  but  little  importance  the  presence  of  a  subclavian 
murmur  should  suggest  a  careful  examination  of  the  apices  of  the  lungs. 

Carotid  Murmurs. — Sj'stolic  murmurs  heard  in  the  carotid  arteries, 
especially  the  right,  are  not  uncommon.  As  a  rule  the  murmur  is  trans- 
mitted, having  its  origin  in  disease  of  the  aortic  leaflets  (stenosis  or 
roughening)  or  in  disease  of  the  first  part  of  the  aorta  (roughening  from 
atheromatous  plates  or  slight  dilatation).  The  latter  conditions  are  by 
far  the  most  frequent  sources  of  the  murmur.  Occasionally  a  systolic 
murmur,  due  to  anemia,  is  heard  in  the  carotids.  An  aneurism  may 
produce  a  similar  murmur. 

Murmurs  are  frequently  heard  over  the  enlarged  thyroid  gland  in 
exophthalmic  goitre.     They  may  be  systolic  or  diastolic  in  time. 



Sounds  and  murmurs  are  frequently  audible  over  the  larger  arteries 
of  the  body,  both  in  health  and  in  disease.  Regarding  the  etiology 
of  the  "sounds"  there  is  a  difference  of  opinion.  According  to  one  view 
these  sounds  originate  in  the  heart;  the  first  sound  resulting  from  mitral, 
the  second  from  aortic  closure,  and  are  conducted  by  the  blood  stream 
and  the  vascular  wall.  The  opponents  of  this  hypothesis  maintain 
that  the  first  sound  arises  locally,  as  a  result  of  distention  and  subsequent 
vibration  of  the  vascular  wall;  and  that  the  second  sound  is  transmitted 
from  the  aortic  valve.  Sounds  originating  at  the  aortic  orifice  are 
usually  audible  in  the  carotid,  subclavian  and  sometimes  brachial  and 
femoral  arteries.  The  height  of  blood  pressure  seems  to  have  but  little 
effect  upon  conduction  unless  the  pulse  pressure  is  large,  in  which  case 
the  hkelihood  of  local  arterial  sound  production  is  much  enhanced.  It  is 
of  course  important  to  determine  whether  the  sound  heard  occurs  only 
over  the  artery  or  generally  over  the  surrounding  tissues  as  well. 

There  seems  to  be  no  great  difference  in  regard  to  whether  the 
arteries  are  normal  or  sclerotic,  although  experimentally  glass  and  elastic 
metals  conduct  sounds  further  than  rubber,  but  this  depends  to  a  con- 
siderable extent  upon  the  character  of  the  surrounding  media.  If  the 
tissues  surrounding  a  tube  are  physically  more  or  less  similar  to  the  tube 
the  sound  will  be  diffused  in  all  clirections,  and  far  less  of  it  will  reach  a 
distant  point  than  if  the  tube  is  surrounded  by  a  medium  of  different 
density,  such  as  air.  The  statement  is  often  made  that  sounds  are  con- 
ducted better  in  the  direction  of  the  blood  stream.  This  factor  is  of  but 
little  importance.  Sounds  are  conducted  by  the  vascular  wall  and  by 
the  column  of  blood,  the  direction  of  the  blood  flow  is  unimportant. 

Murmurs  heard  in  the  arteries  may  be  conducted  from  the  heart, 
but  before  assuming  this  one  must  be  sure  that  they  have  not  been  arti- 
ficially produced  by  local  pressure  of  the  stethoscope  upon  the  arterial 
wall.  The  murmur  of  aortic  obstruction  is  often  well  and  widely  heard 
in  the  large  arteries  but  it  is  sometimes  extensively  heard  over  other 
tissues  as  well.  Occasionally  heart  sounds  may  be  advantageously 
studied  in  the  carotid  artery  when  they  are  almost  inaudible  in  cases  of 
emphysema  or  over-shadowed  by  pericardial  friction  sounds  (Roberts^). 
Local  abnormalities,  aneurisms,  especially  the  arterioveneus  variety,  or 
neighboring  tumors  causing  arterial  constriction,  of  course  also  give  rise 
to  arterial  murmurs.  Nearby  veins  may  give  rise  to  bruits  which  may 
be  mistakenly  attributed  to  the  arteries. 


Venous  nmrmurs  (bruit  de  diable,  nun's  murmur,  souffle,  venous  hum) 
were  formerly  considered  an  indication  of  anemia.  They  consist  of  soft, 
low-pitched  continuous  humming  sounds  of  variable  quality  and  inten- 
sity with  a  rhythmic  accentuation.  They  are  heard  in  the  large  veins 
above  the  clavicles  in  50  per  cent,  of  all  children.  They  are  loudest 
during  auricular  diastole  (faster  flow),  in  the  erect  or  sitting  postures,  and 
on  the  right  side  behind  the  lower  margin  of  the  sternomastoid  muscles. 

1  Roberts,  S.  R.  :  "A  Study  of  Arterial  Sounds."  /.  A.  M.  A.,  Ixix,  Sept.  15,  1917, 


The  right  internal  jugular  vein  is  almost  a  linear  continuation  of  the  right 
innominate  vein,  the  internal  jugular  is  held  open  by  the  cervical  fascia 
and  hence  cannot  diminish  in  calibre  when  the  amount  of  blood  lessens; 
hence  a  fluid  vein  is  produced  and  a  murmur  results.  The  condition  is 
increased  by  h3^dremia  (anemia)  (Figs.  136,  212). 

Another  explanation  is  that  based  on  a  constriction  of  the  vein. 
"By  having  the  patient  turn  the  head  upward  and  away  from  the  side 
auscultated  the  internal  jugulars  are  made  tense  and  compressed  against 
the  transverse  processes  of  the  lower  cervical  vertebrae  with  which  they 
are  in  relation.  In  this  way  the  calibre  of  the  vein  is  narrowed  and  the 
flow  of  blood  accelerated."^  ^lany  explanations  as  to  the  exact  cause 
of  venous  hums  have  from  time  to  time  been  offered.  Xone  are  invariably 
satisfactory.  The  diagnostic  value  of  venous  murmurs  froyn  any  standpoint 
is  very  slight. 

It  is  said  that  a  venous  hum  may  be  heard  in  the  femoral  veins  under 
the  same  conditions  in  which  it  is  heard  in  the  jugulars,  but  we  have 
never  been  able  to  verify  this  statement. 

Eustace  Smith's  Sign.- — Occasionally  a  venous  hum  is  heard  over  the 
sternum  just  beneath  the  notch.  The  murmur  is  elicited  by  tilting  the 
head  back  and  is  supposedly  produced  in  the  left  innominate  vein,  which 
passes  from  left  to  right  with  a  slight  obliquity  downward  behind  the 
upper  part  of  the  sternum,  b}-  reason  of  the  vein  being  pressed  upward 
by  enlarged  bronchial  lymph  nodes.  This  explanation  appears  to  be 
erroneous.  The  bronchial  h'mph  nodes  at  the  bifurcation  of  the  trachea 
are  too  far  above  the  heart  to  cause  pressure  on  the  large  vessels.  The 
pressure  is  probablj'  caused  by  an  enlarged  persistent  thymus  gland' 
(Gittings).  When  the  murmur  is  present  over  the  sternum  it  is  also 
heard  in  the  jugulars,  where  in  all  probabihty  it  originates. 

Although  frequenth^  referred  to  as  a  sign  of  some  value  in  the  recogni- 
tion of  enlarged  bronchial  lymph  nodes  in  children,  we  have  rarely  been 
able  to  elicit  it  even  in  cases  in  which  there  were  other  signs  pointing 
strongly  to  this  condition. 


(Cardio-pulmonary,  pseudo-cardial,  cardio-pneumatic,  sj-stoUc  vesicu- 
lar murmurs.) 

Cardio-respiratory  murmurs  are  interrupted  or  abnormal  breath 
sounds  produced  by  the  movement  of  the  heart  upon  the  surrounding 
lung  tissue.  The  respiratory  sounds  ma}'  be  interrupted  by  a  series  of 
periodic  interruptions  or  increments  of  intensit}'  (puffs  or  ''cogs")  which 
may  be  heard  even  when  the  breath  is  held.  They  often  vary  with  the 
cardiac  or  respirator}-  rate  and  phase.  They  are  generally  loudest  near 
the  cardiac  apex  and  along  the  left  border  of  the  heart,  but  they  may  be 
heard  along  the  right  border,  in  the  scapular  region  and  elsewhere.  They 
are  influenced  by  respiration,  being  generally'  louder  during  deep  inspira- 
tion. They  are  apt  to  be  affected  b}'  change  of  posture;  the}-  generally 
disappear  in  recumbency,  and  nearly  always  during  apnea.  They  are 
not  accurately  synchronous  with  the  heart,  but  often  appear  in  the  middle 
of  systole,  being  distinctly  separated  from  the  first  sound.     Theyoften^ 

1  Landis  and  IvArrMAx:  Arch.  Pediatrics,  Feb.  12,  1912. 



begin  and  end  suddenly,  are  sharply  localized  and  seem  close  to  the  ear 
of  the  examiner.  They  are  not  transmitted  in  the  directions  which  are 
characteristic  of  endocardial  murmurs.  They  are  often  intermittent, 
associated  with  rales,  and  influenced  by  stethoscopic  pressure.  They 
may  occur  in  perfectly  normal  individuals,  but  are  especially  common  in 
pulmonary  tuberculosis,  especially  when  the  pleura  has  been  extensively 
involved,  and  in  atelectatic  lungs,  as  well  as  in  patients  who  have  had 
pleuritis  or  pneumonia,  or  in  those  suffering  from  paroxysmal  tachy- 

Gerhartz  has  shown  that  cardiac  murmurs  are  generally  due  to 
vibrations  of  about  the  same  rate  as  those  which  correspond  to  the  lower 
range  of  the  respiratory  sound  (60  to  80  vibrations  per  second).     The 

Fig.  213. — The  distribution  of  cardio-respiratory  murmurs  in  48  cases.  Composite 
pictures  "  constructed  by  shading  the  affected  area  of  each  chest  upon  the  same  diagram 
by  lines  approximately  equidistant."  The  actual  numerical  frequency  is  shown  by  the 
attached  leaders.      {After  Thomas  Leivis,  Quart.  Jour.  Med.,  Jan.,  1909.) 

fact  that  the  two  types  of  sound  have  about  the  same  pitch  accounts  for 
the  difficulty  which  sometimes  attends  their  differentiation.  Cardio- 
respiratory murmurs  have  no  pathologic  significance  except  that  they  may 
indicate  pleural  adhesions;  their  importance  merely  lies  in  the  fact  that 
they  may  be  mistaken  for  endocardial  murmurs  or  pericardial  frictions. 

Succussion  splash  synchronous  with  the  heart  may  be  heard  in  the 
neighborhood  of  the  precordium.  It  is  generally  produced  in  the  stom- 
ach, although  it  may  be  due  to  hydropneumothorax,  or  to  hydropneumo- 

Hepatic  murmurs  may  be  heard  over  the  liver  or  in  the  epigastrium 
in  some  (rare)  cases  of  hepatic  cirrhosis.  They  are  generally  venous  in 
origin  (blood  flowing  from  small  into  larger  veins,  or  sinuses)  and  maybe 
continuous  or  intermittent  in  character. 


In  the  early  stages  of  pericarditis  the  serous  membrane  which 
is  normally  smooth  and  moist  becomes  roughened  as  a  result  of  con- 
gestion and  exudation.  The  exudate,  instead  of  noiselessly  gliding  over 
the  neighboring  pericardium,  now  produces  a  rough,  scratching  or  scrap- 


ing"sound,"similar  in  quality  to  that  heard  over  an  inflamed  pleura.  This 
sound  is  known  as  a  pericardial  friction.  It  often  has  a  dry,  creaking 
or  shuffling,  leathery  quality,  is  heard  during  both  systole  and  diastole 
and  is  therefore  described  as  being  "to  and  fro."  It  is  frequently  ac- 
companied by  local  pain,  seems  close  to  the  ear  and  is  intensified  by  pres- 

FiG.  214. — Acute  sero-fibrixous  pericarditis.  The  pericardial  sac  is  stretched'and 
has  been  greatly  distended  by  serous  exudati.  Both  the  mural  and  the  visceral  surfaces  are 
covered  with  fibrinous  exudate  (cor  villosum,  bread  and  butter  pericardium).  Such  a  heart 
would  yield  loud  friction  sounds  in  the  early  stages  of  inflammation.  Later  when  the 
serous  surfaces  were  separated  by  liquid  effusion  the  friction  would  disappear,  except  per- 
haps at  the  base,  while  the  heart  sounds  would  be  muffled  and  distant.  {From  Xorris' 
'Cardiac  Pathology.") 

sure.  It  remains  localized,  isnot  transmitted  in  the  directions  character- 
istic of  endocardial  murmurs,  and  is  often  loudest  over  the  middle  of  the 
precordium  where  the  heart  is  uncovered  by  lung  tissue.  It  may  be  dif- 
ferentiated (1)  from  a  pleural  friction  by  the  fact  that  it  is  synchronous 



with  the  heart,  and  not  with  respiration  and  that  it  does  not  disappear 
during  the  Valsalva  experiment;  and  (2)  from  endocardial  sounds,  by  the 
fact  that  it  is  not  accm-ately  synchronous  with  either  systole  or  diastole, 
but  often  overlaps  them  both  because  the  greatest  systolic  excursion  of 
the  cardiac  surface  corresponds  to  the  expulsion  time  and  not  to  either 
systole  or  diastole.  A  further  difference  lies  in  the  fact  that  the  friction 
tends  to  vary  in  qualit}^  and  intensitj'  not  only  in  the  course  of  a  few 

Fig.  215. — Peeic.\kdl^l  effusion:  the  body  being  frozen  in  the  recumbent  posture  and 
views  from  behind.  The  heart  is  hypertrophied  and  dilated.  Both  lower  pulmonar 
lobes  are  compressed,  the  left  by  the  effusion,  the  right  by  the  congested  liver  which  has 
been  forced  upward  as  the  result  of  ascites  (recumbent  posture).  The  physical  findings 
are  shown  in  Fig.  216.     (Compare  Figs.  175,  377,  378.) 

hours,  but  even  at  times  from  one  heart  beat  to  another.  Leaning  for- 
ward or  lying  on  the  left  side  tends  to  intensify  the  sound  while  the  right 
lateral  decubitus  often  diminishes  it.  The  pericardial  friction  may  have 
a  shuffling  triple  rhythm  very  similar  to  gallop  rhj^hm. 

Pericardial  "Knock." — During  the  recent  war  much  interest  was 
aroused  by  the  "pericardial  knock, "^  a  choking  ^sound  heard  over  the 
precordium  in  certain  cases  of  penetrating  chest  wounds,  in  the  neigh- 
borhood of  the  pericardium.     This  sound  is  sometimes  audible  not  onl}^ 

IS.  M    Smith:  Br.  Med.  Jour.,  .Jan.  19,  1918. 




by  the  patient  himself,  l)ut  also  by  the  examiner  at  some  distance  from 
the  patient.  A  clear  cut  metalhc  click,  usually  double  in  rhythm  and 
synchronous  with  the  heart;  often  transient  and  influenced  by  respira- 
tion, it  is  best  heard  near  the  cardiac  apex.  The  genesis  of  this  rather 
startling  sound  has  been  ascribed  to  (a)  emphysema  of  the  mediastinal 
connective  tissue  or  (5)  free  air  in  the  interstitial  connective  tissue  of  the 

Pericardial  Effusion.- — Unless  the  pericardial  inflammation  is  promptly 
arrested,  the  exudate  poured  out  into  the  pericardial  sac  increases  and 
becomes  more  liquid  in  character — serum,  pus  or  blood.  Such  a  peri- 
cardial effusion  muffles  the  heart  sounds  so  that  they  become  feeble  or 
even  inaudible.     Under  such  circumstances  the  friction  sound  disappears. 

Exaggerated     breath 

sounds,  scattered 


Muffled  breath 
sounds,  distant  bron- 


small  pleural 


To  and^fro  friction 
sound, synchronous 
with  the  heart 

Apex  impulse  feeble, 
sounds  muffled,  a 
distant  systolic  mur- 
mur is  heard 

Fig.  216. — Percussion  outlines  in  case  whose  heart  is  depicted  in  Fig.  215.  The  heart 
dulness  is  very  large  and  merges  with  that  of  the  liver;  it  is  somewhat  pyriform  in  shape. 
The  cardiohepatic  angle  is  obtuse.  The  abdomen  is  distended  and  bulges  in  the  flanks 
(ascites).  The  patient  suffers  from  orthopnea — the  shoulders  are  raised  and  the  accessory 
muscles  of  respiration  brought  into  play.  The  breath  sounds  were  harsh  and  exaggerated 
and  associated  with  crackling  rdles  (congestion).  The  scar  between  the  umbilicus  and 
pubis  results  from  paracentesis  abdominalis. 

Such  a  condition  is  associated  with  an  increase  of  heart  dulness,  which 
forms  an  obtuse  cardio-hepatic  angle.  The  inflammation  and  effusion 
cause  a  softening  and  distention  of  the  pericai'dium,  which  in  some  cases 
may  become  so  large  as  to  simulate  a  pleural  effusion  and  may  produce 
compression  of  the  left  lung  with  associated  dulness  and  bronchial  breath- 
ing. In  children,  bulging  of  the  precordium  ma}^  occur.  Cardiac  dul- 
ness extends  further  to  the  left  beyond  the  apex  impulse  than  is  the  case 
in  hypertrophied  hearts.  Dulness  in  the  fifth  right  intercostal  space 
near  the  sternum  (Rotch's  sign)  is  sometimes  demonstrable  quite  early 
in  the  effusion  stage.     Stress  is  sometimes  laid  upon  the  fact  that  the 



heart  dulness  in  pericardial  effusions  tends  to  be  pyriform,  but  this  is 
certainly  not  always  the  case.  An  area  of  percussion  dulness  at  the 
angle  of  the  left  scapula  together  with  bronchial  breathing,  etc.,  fre- 
quently results  from  pressure  of  a  large  pericardial  effusion  upon  a 
portion  of  the  lung  (Etvarfs  sign). 

Changing  the  patient's  posture  from  the  erect  to  the  right  lateral 
position  tends,  in  pericardial  effusion,  to  produce  a  greater  displacement 
of  the  heart  to  the  right  than  is  the  case  in  simple  hypertrophy. 

Progressive  enfeeblement  of  the  heart  sounds,  especially  when  a 
friction  sound  has  been  heard  or  suspected,  may  have  distinct  diagnostic 

Fig.  217. — Precordial  bulging  as  a  result  of  (rheuraatir-)  pericardial  effusion  in  a  lad  of  13 


It  should  be  remembered  that  small  pericardial  effusions  are  fre- 
quently overlooked  and  it  has  been  stated  that  no  effusion  is  demon- 
strable by  physical  signs  until  it  amounts  to  150  c.c.  One  should  be 
constantly  on  the  lookout  for  evidences  of  pericarditis  when  deaHng 
with  rheumatic  fever  and  lobar  pneumonia  (see  Figs.  377-382  inch). 

An  X-ray  examination  may  throw  much  useful  light  upon  doubtful 

There  is  considerable  variation  regarding  the  ■position  of  (he  heart  in 
pericardial  effusions,  as  well  as  difference  of  opinion  regarding  its  cause. 
It  seems  that  the  position  depends  upon  the  size  of  the  heart,  which  in 
turn  depends  upon  the  amount  of  blood  it  contains,  which  is  in  turn  de- 
termined by  the  stage  of  compensation.  When  the  heart  is  w^ell  filled 
with  blood  its  position  is  relatively  normal,  but  when  it  is  small  and  partly 
collapsed  it  may  fall  backward  against  the  posterior  pericardial  wall;  the 
apex  being  more  or  less  displaced  toward  the  right.     Occasionallj^  it  may 


remain  in  an  anterior  position,  in  which  it  is  maintained  bj-  the  elasticity 
of  the  great  vessels. 

Effusions  amounting  to  750  c.c.  may  be  sufl&cient  to  cause  the  dis- 
appearance of  all  friction  sounds  even  at  the  base,  but  on  the  other  hand 
a  friction  may  persist  with  effusions  of  1000  c.c.  or  more. 

Pleuro-pericardial  sounds  are  due  to  roughening  of  the  external  sur- 
faces of  the  pleura  and  the  pericardium.  They  are  heard  best  at  the  left 
anterior  pulmonary  border,  are  often  affected  by  respiration,  posture,  etc. 

Fig.  218. — Pericabdi.\l  adhesions.  The  illustration  shows  dense,  localized,  fibrous 
adhesions  near  the  apex  of  the  heart  (which  is  dilated),  the  result  of  antecedent  pericardial 
inflammation.  Such  a  condition  is  suggested  by  localized  systolic  retraction  of  the  chest 
wall,  especially  if  associated  with  diminished  postural  mobility  of  the  heart,  with  symptoms 
of  cardiac  insufficiency  out  of  proportion  to  the  demonstrable  physical  signs,  lack  of  response 
to  the  usual  methods  of  treatment  (digitalis,  rest,  etc.),  especially  if  coupled  with  a  history 
of  a  previous  attack  of  rheumatic  fever  or  pneumonia.  (From  A'orris'  "Cardiac  Path- 


In  examining  the  heart,  observations  should  always  be  made  in  both 
the  erect  and  in  the  recumbent  posture.  The  results  thus  obtained  are 
often  variable,  and  physical  signs  absent  in  one  position  may  be  readily 
demonstrable  in  the  other.  When  the  findings  are  recorded,  the  position 
should  be  stated. 

In  the  erect  posture  the  apex  beat  is  lower,  the  cardiac  dulness  is  less- 
ened, the  aortic  second  sound  is  louder  than  the  pulmonic  (after  twenty- 
five  years  of  age),  the  splitting  of  the  second  sound  if  previously  present 
tends  to  disappear;  the  murmurs  of  aortic  insufficiency  and  mitral  ob- 
struction become  louder,  as  does  also  the  venous  vascular  hum. 


In  recumbency  the  apex  beat  is  higher,  the  cardiac  dulness  is  generally 
more  marked  and  the  pulmonic  second  sound  louder  than  the  aortic,  even 
in  adults.  Reduplication  of  the  second  sound  is  often  present;  the  mur- 
murs of  mitral  insufficiency,  tricuspid  insufficiency,  aortic  obstruction, 
and  most  functional  murmurs  become  more  intense.  The  differences 
are  chiefly  due  to  the  effects  of  gravity  upon  the  position  of  the  heart  and 
upon  the  blood  flow. 

It  is  often  advisable  to  have  the  patient  indulge  in  some  form  of  exer- 
cise, provided  his  physical  condition  permits  of  it,  such  as  climbing  a 
flight  of  stairs,  or  "dipping"  (touching  the  floor  with  the  finger  tips,  by 
flexion  of  the  knees  and  thighs).  These  procedures  will  often  develop 
latent  murmurs,  irregularities  or  cardiac  erythism.  It  is  always  well, 
especially  in  high-strung  individuals,  to  count  the  pulse  while  the  patient 
is  resting  quietly,  before  the  clothes  have  been  removed,  and  to  repeat 
both  the  pulse  count  and  the  blood-pressure  estimation  at  the  end  of  the 
examination,  after  the  patient  has  become  tranquilized. 

It  should  be  borne  in  mind  that  functional  murmurs  are  of  frequent 
occurrence,  and  that  organic  heart  murmurs  are  nearly  always  accom- 
panied by  demonstrable  cardiac  enlargement,  increased  pulse  rate  or 
other  abnormalities.  Further  that  "a.  disease  of  the  valves  is  not  a  dis- 
ease of  the  heart";  in  other  words  as  long  as  the  myocardium  is  healthy 
the  prognosis  is  relatively  good  regardless  of  valvular  leakage  or  ob-  . 

Regarding  hlood-pressure  estimations  we  should  bear  in  mind  that  the 
initial  reading  is  often  fallaciously  high,  especially  in  patients  unused  to 
this  examination.  Subsequent  examinations  made  after  the  patient  has 
learned  the  harmless  and  painless  nature  of  the  procedure  are  much  more 
accurate.  In  these  "psychic"  elevations,  however,  the  diastolic  pressure 
is  practically  unaffected,  even  when  the  systolic  pressure  has  been  tem- 
porarily elevated  15  or  20  mm.  Hg.  Systolic  pressures  above  160  mm. 
and  diastolic  readings  above  100  mm.  Hg  are  abnormal  at  any  age.  The 
most  frequent  cause  of  persistent  arterial  hypertension  is  chronic  glo- 
merulo-nephritis.  An  examination  of  the  urine  is  always  essential  since 
the  cardiorenal  relationship  is  a  close  and  important  one. 

An  examination  of  the  thyroid  gland  will  often  explain  cardiac  ab- 
normalities such  as  tachycardia,  hypertrophy,  dyspnea  and  lability  of 
the  pulse  and  of  blood-pressure.  Shght  edema  of  the  extremities  at  the 
end  of  the  day  point  to  cardiac  fatigue  and  insufficiency.  The  possible 
presence  of  an  aortic  aneurism  should  always  be  borne  in  mind,  in  patients 
who  complain  of  precordial  pain,  oppression,  cough,  dyspnea  or  other 
cardiac  or  respiratory  symptoms  without  evident  cause. 

Upon  discovering  the  existence  of  a  murmur  the  examiner  should 
determine  (1)  the  area  over  which  it  is  loudest;  (2)  its  time  in  relation 
to  the  cardiac  cycle;  (3)  the  direction  in  which  it  is  transmitted;  (4)  its 
character  and  constancy  in  relation  to  respiration,  posture  and  exercise. 
It  must  be  remembered  that  many  entirely  normal  persons  may  present 

The  effect  of  deep  forced  inspiration  and  expiration,  each  act  being 
held  for  a  number  of  seconds,  should  be  noted.  Functional  and  cardio- 
respiratory murmurs  will  be  much  affected  by  these  procedures  and  may 
indeed  disappear  entirely  during  one  or  the  other  phase.  Organic 
murmurs  are  much  less  or  not  at  all  affected.     Furthermore,  individuals 


with  organic  lesions  generally  cannot  hold  their  breath  as  long  as  normal 
people  without  discomfort,  distention  of  the  jugular  veins  or  cyanosis. 
The  effect  of  chaiige  of  posture  from  the  erect  to  the  recumbent  position, 
and  of  exercise  such  as  dipping,  should  always  be  noted  not  only  in 
regard  to  the  murmur  but  also  upon  the  pulse  rate,  respiration  and  blood- 
pressure.  The  less  marked  and  the  more  brief  the  changes  produced, 
the  less  serious  generally,  the  lesion.  If  the  pulse  rate  remains  high  and 
the  blood-pressure  falls  after  moderate  exercise,  the  individual  is  at  least 
not  in  good  training,  and  people  with  organic  lesions  naturally  show  the 
effect  of  a  lack  of  it  more  than  those  with  normal  hearts. 

Functional  heart  murmurs  are  never  diastoUc  in  time,  they  are  not 
accompanied  by  other  abnormalities  such  as  hypertrophy,  accentua- 
tion of  the  second  sounds,  arrhythmia,  cyanosis,  edema,  etc.,  and  they 
generally  occur  at  the  pulmonary  area — the  "region  of  romance"  of 

Functional  murmurs  are  not  conducted  in  the  same  direction  nor  to  the 
degree  as  organic  murmurs.  Thus  a  mitral  systolic  murmur  if  conducted 
to  the  angle  of  the  scapula  may  be  considered  not  only  organic  but  the 
result  of  a  well-marked  lesion.  A  forcible  cardiac  impulse  associated  with 
a  weak  radial  pulse  bespeaks  structural  disease.  The  inteiisity  of  a  mur- 
mur is  not  an  index  of  the  severity  of  the  lesion,  often  quite  to  the  con- 
trary. Thus  in  failing  compensation  the  murmurs  become  fainter  and 
may  entirely  disappear,  while  the  area  of  cardiac  dulness  increases;  the 
apex  beat  becomes  weaker  and  more  diffuse,  although  sometimes  more 
readily  visible.  Epigastric  pulsation  as  well  as  that  over  the  upper  pre- 
cordium  becomes  more  intense,  and  accentuation  of  the  pulmonic  second 
sound  disappears.  It  is  frequently  impossible  to  make  an  accurate  diag- 
nosis of  the  valvular  lesions  during  broken  compensation. 

The  history  of  an  antecedent  attack  of  rheumatic  fever,  chorea  or 
tonsillitis  is  evidence  in  favor  of  an  organic  lesion,  especially  in  case  of 
the  mitral  valve ;  while  the  history  of  syphilitic  infection  or  the  presence 
of  a  positive  Wassermann  reaction  more  or  less  definitely  settles  the  origin 
of  a  diastolic  aortic  murmur.  The  presence  of  marked  anemia  should 
make  one  very  chary  of  declaring  a  murmur  to  be  due  to  valvular  disease. 

It  is  to  be  remembered  that  aortic  and  pulmonary  stenosis  are  rare 
lesions,  whereas  systolic  murmurs  over  these  areas  are  very  common. 
At  the  aortic  area  systolic  murmurs  are  usually  due  to  a  mere  roughening 
or  stiffening  of  the  valves  or  to  a  shght  aortic  dilatation.  At  the  pul- 
monary area  systolic  murmurs  may  result  from  the  most  trivial  causes, 
such  as  pressure  of  the  lung,  traction  of  pleural  adhesions,  dilatation  of 
the  artery.  Pulmonary  stenosis  is  practically  always  a  congenital 
lesion,  associated  with  marked  cyanosis,  clubbed  fingers,  right-sided 
hypertrophy,  congestion  of  the  lungs,  a  weak  second  sound  and  thrills. 
Without  some  of  these  findings  a  diagnosis  of  pulmonary'  stenosis  should 
never  be  made. 

A  diagnosis  of  tricuspid  insufficiency  cannot  be  made  on  the  presence 
of  a  murmur  alone.  A  positive  venous  pulse,  pulmonary  congestion  or 
hepatic  enlargement,  edema,  ascites,  a  pulsating  liver,  cough,  dyspnea, 
if  not  orthopnea — at  least  some  of  these  symptoms  must  exist  before  the 
diagnosis  of  tricuspid  insufficiency  is  justified. 

The  presystoUc  murmur  of  mitral  stenosis  is  generally  characteristic 
and  readily  recognized  owing  to  its  rumbling  quality  and  to  the  mitral 


pulse.  It  can  be  confused  only  with  a  Flint  murmur  or  with  the  murmur 
of  tricuspid  stenosis.  The  former  is  usually  easily  identified  by  means 
of  the  blood-pressure  picture,  the  marked  left  ventricular  hypertrophy 
and  the  pulsatory  phenomena.  Much  more  difficult  is  the  diagnosis 
between  early  mitral  obstruction  and  a  normal  heart,  with  a  loud  pre- 
systolic element  of  the  first  sound,  especially  in  cases  of  the  Efful  syn- 
drome, see  p.  221.  In  some  cases,  even  if  the  historj^,  the  symptoms, 
and  the  physical  signs  are  most  carefully  considered,  experienced  physi- 
cians will  differ  in  their  diagnosis  and  only  time  will  decide  the  problem. 
Tricuspid  stenosis  is  a  rare  lesion,  which  when  encountered  is  generally 
associated  with  mitral  stenosis.  But  few  cases  have  been  correctly 
diagnosticated  during  life.  For  obvious  reasons  they  are  generally 
"signed  out"  as  mitral  stenosis.  The  presence  of  an  "a"  wave  in  the 
liver  pulse  is  said  to  be  characteristic  of  tricuspid  stenosis. 



By  H.  R.  M.  Landis,  A.  B.,  M.  D. 



An  acute  catarrhal  inflammation  of  the  mucous  membrane  of  the 
trachea,  large  and  medium-sized  bronchi.  In  healthy  adults  it  is,  as  a 
rule,  a  harmless  affection,  but  in  the  very  young  and  very  old  it  is  often 
a  serious  matter.  In  the  latter  age  periods  the  inflammation  shows  a 
decided  tendency  to  extend  downward  into  the  fine  bronchi,  leading 
eventually  to  a  capillary  bronchitis,  or,  as  it  is  preferably  called,  a 

Etiology. — As  met  with  under  ordinary  conditions,  acute  bronchitis 
is  of  itself  of  relatively  little  importance,  and  except  under  the  condi- 
tions above  mentioned,  it  is  rarely  serious.  It  should  be  kept  in  mind, 
however  that  it  is  very  commonlj^  associated  with  the  acute  infections, 
particularly,  typhoid  fever  and  malaria,  even  from  the  beginning  of 
these  fevers.  Acute  bronchitis  is  so  universally  associated  with 
measles  that  it  should  be  considered  a  symptom  rather  than  a  compli- 
cation. During  the  course  of  an  epidemic  of  measles  or  influenza  the 
bronchial  inflammation  may  be  very  severe.  In  such  instances  the  condi- 
tion is  characterized  by  a  profuse,  purulent  bronchorrhea  and  the  con- 
stitutional evidences  of  a  severe  toxemia.  Secondly  broncho-pneumonia, 
lobar  pneumonia  or  pleural  involvement  often  occurs.  The  presence 
of  adenoids  and  enlarged  tonsils  are  important  predisposing  factors  in 
children  (Holt). 

It  is  of  the  greatest  importance  to  keep  in  mind  that  tuberculosis 
often  begins  acutely,  and  may  for  a  few  weeks  resemble  an  attack  of 
acute  bronchitis.  Two  facts  should  be  borne  in  mind,  first  that  acute 
bronchitis  runs  its  course  in  about  three  weeks,  and  secondlj^  that  it  is  a 
bilateral  affection,  while  a  beginning  tuberculosis  is  unilateral  and  almost 
invariably  located  at  the  summit  of  one  or  the  other  lung.  It  cannot 
be  too  strongly  emphasized  that  a  cough  which,  without  complications, 
has  persisted  for  six  weeks  or  more  should  be  carefully  investigated; 
the  majority  of  such  cases  will  be  found  to  be  tuberculous.  It  is  worth 
noting  that  individuals  with  tuberculosis  not  infrequently  give  a 
history  of  being  subject  to  repeated  colds. 

Acute  bronchitis  is  especially  prevalent  in  the  changeable  weather 
encountered  in  the  spring  and  late  autumn.  In  some  instances  it  is  the 
result  of  becoming  chilled,  in  others  it  follows  an  ordinary  coryza,  the 



latter  being  in  many  instances  an  acute  infection  transferred  from  person 
to  person.  Individuals  who  are  habitually  closely  confined,  or  who  com- 
monly visit  crowded  places  of  amusement,  or  use  public  convej-ances 
are  especiallv  prone  to  "acute  colds."  On  the  other  hand,  those  who  live 
an  outdoor  life  and  are  subjected  to  all  sorts  of  inclement  weather  are 
comparatively  free  from  these  disorders.  The  contagiousness  of  acute 
colds  was  noted  by  Benjamin  Franldin,  a  century  and  a  half  ago. 

The  bacteriological  findings  in  cases  of  acute  catarrhal  bronchitis  are 
varied.  Occasionally  some  one  organism  predominates  or  even  occurs 
alone,  but  this  is  rare.  Among  the  organisms  encountered  maybe  men- 
tioned the  micrococcus  catarrhalis,  influenza  bacillus,  streptococcus  and 

An  attack  of  acute  bronchitis  may  be  precipitated  by  the  inhalation 
of  dust  or  chemical  irritants,  such  as  ether,  chlorine  gas,  ammonia,  etc. 

Morbid  Anatomy. — Acute  bronchitis  is  practically  always  a  bilateral 
affection  although  the  distribution  of  the  inflammatory  process  is  not 
uniform.  As  a  rule,  certain  portions  of  the  bronchial  tree  are  more  affected 
than  others.  Not  only  are  the  bronchi  affected  but  in  most  instances  the 
trachea  and  larynx  as  well;  indeed  in  some  instances  the  process  may  be 
limited  to  the  larynx,  trachea  and  main  branches  of  the  bronchial  tree 
(see  Fig.  219).  When  the  infection  manifests  itself  principally  in  the 
smaller  tubes  there  are  apt  to  be  small  areas  of  broncho-pneumonia. 
The  latter  may  or  may  not  be  sufficiently  marked  to  be  recognized 

In  simple  catarrhal  bronchitis  the  mucous  membrane  is  reddened  and 
swollen.  It  is  covered  with  a  sticky  exudate  which  is  greyish  in  color 
and  mucoid  in  character.  In  the  later  stages  the  exudate  often  becomes 
mucopurulent  or  purulent. 

Symptoms. — The  onset  is  frequently  with  coryza,  which  as  it  extends 
downward,  successive!}'  causes  some  irritation  of  the  pharynx,  at  times 
hoarseness,  often  marked  in  character,  and  finally  symptoms  indicating 
involvement  of  the  tracheal  and  bronchial  mucous  membranes,  namely, 
a  sense  of  oppression  in  the  chest,  substernal  soreness  and  cough.  The 
latter  is  dry  at  first  and  often  occurs  in  paroxysms  which  cause  marked 
pain  beneath  the  sternum  and  lower  part  of  the  chest.  Fig.  219  illus- 
trates very  clearly  why  this  should  be  so.  The  expectoration  is  at  first 
scanty,  viscid  and  difficult  to  raise.  After  four  or  five  days  the  cough 
tends  to  become  looser,  and  the  sputum  becomes,  first  mucopurulent, 
later  purulent,  and  is  apt  to  be  profuse. 

Slight  fever,  which  may  range  from  100°  to  102°F.  or  higher,  occurs  in 
the  severer  cases.  The  ordinary  case  is  not  febrile  for  more  than  a  week 
or  so.  Later  than  this  the  temperature  becomes  a  valuable  sign  in  dis- 
tinguishing the  condition  from  tuberculosis.  Most  individuals  experience 
a  sense  of  oppression  and  languor.  Pain  in  the  back  and  bones,  not 
unlike  those  encountered  in  grippe,  also  occurs  with  varying  intensity. 

Physical  Signs.^ — Unless  the  smaller  tubes  are  involved,  as  in  the  aged 
or  very  young,  there  is  no  increase  in  the  respiratory  rate.  Aside  from 
the  evidences  indicative  of  an  acute  febrile  state,  inspection  is  negative. 
Percussion  shows  no  changes.  On  palpation  there  maj^  be  noted  a  rhon- 
chal  fremitus. 

The  physical  signs  are  almost  entirely  auscultatory  in  character.  At 
first  the  rales  are  sibilant  in  character,  are  heard  over  both  sides  of  the 

Fig.  219. — Intense  acute  bronchitis  due  to  influenza  bacillus.  Upper  lobe  shows 
cavity  at  apex,  great  thickening  of  pleura.  Adhesions  between  lobes.  (Jefferson  Medical 
College  Museum.) 


chest,  and  are  very  changeable,  appearing  and  disappearing,  especially 
after  cough.  Later  as  the  cough  loosens  the  rales  have  a  moist  sound  and 
a  bubbling  quality.  While  the  almost  universal  rule  is  that  acute 
bronchitis  is  a  bilateral  affection,  it  occasionally  happens  that  the  physical 
signs  are  confined  to  one  side.  It  is  needless  to  say,  however,  that  such 
<3ases  are  unusual  and  that  such  a  condition  is  strongly  suggestive  of 
tuberculosis.  Until  the  latter  can  be  ruled  out  positively,  a  diagnosis  of 
acute  bronchitis  is  indefensible. 

Still  another  variation,  and  one  that  is  relatively  common,  is  for  the 
inflammation  to  be  confined  to  the  trachea  alone.  In  these  cases  all  of 
the  symptoms  of  acute  bronchitis  are  present  with  an  absence  of  any 
physical  signs  in  the  chest. 

A  diagnostic  error  is  sometimes  committed,  owing  to  the  fact  that  a 
true  acute  bronchitis  occurs  in  association  with  an  incipient  tuberculosis, 
the  more  serious  affection  thus  becoming  masked.  Even  in  those  cases 
where,  from  the  symptoms,  one  may  suspect  tuberculosis,  the  latter  is 
difficult  to  demonstrate  until  the  bronchitis  has  cleared  up.  After  the 
symptoms,  and  especially,  the  physical  signs,  of  acute  bronchitis  have 
disappeared  the  tuberculous  lesion  may  be  detected. 

Diagnosis. — The  chief  features  of  acute  catarrhal  bronchitis  are 
coryza,  some  irritation  in  the  throat,  substernal  soreness,  cough  and  ex- 
pectoration. For  a  few  days  there  is  usually  a  slight  elevation  of  the 
temperature.  If  the  process  is  limited  to  the  trachea  and  large  tubes 
there  will  be  no  physical  signs;  if  the  medium-sized  bronchi  are  involved, 
rales  will  be  heard  over  both  lungs.  Of  itself  acute  bronchitis  is  a  trivial 
affection.  It  is  always  worthy  of  consideration,  however,  as  it  is  often 
the  forerunner  of  more  serious  trouble.  In  children  and  in  those  of 
advanced  years  the  possibility  of  the  inflammatory  process  extending  to 
the  finer  bronchi  and  air  cells  must  always  be  borne  in  mind. 

In  children  catarrhal  infiammation  of  the  conjunctiva  and  nasal 
mucous  membrane  associated  with  cough  and  expectoration,  may  be 
the  prodromal  symptoms  of  measles.  The  mucous  membrane  of  the 
mouth  should  be  examined  for  the  presence  of  Koplik's  spots.  The 
symptoms  in  the  early  stage  of  ichooping-cough  are,  as  a  rule,  those  of 
an  acute  cold,  the  characteristic  whoop  not  appearing  until  later.  In 
the  presence  of  an  epidemic  of  whooping  cough  an  acute  "cold"  should  be 
looked  upon  as  possibly  being  the  prodromal  stage  of  pertussis. 

Not  infrequently  patients  who  develop  lobar  -pneumonia  will  give  a 
history  of  having  had  a  ''bad  cold"  for  some  days  before  the  onset  of  the 
pneumonia.  Acute  bronchitis  is  so  constantly  present  in  cases  of 
typhoid  fever  as  to  constitute  a  symptom  of  the  disease.  It  may  occur 
early  in  the  attack  of  typhoid  fever.  In  an  individual  suffering  from  what 
appears  to  be  an  attack  of  acute  bronchitis  and  in  whom  the  fever  persists 
and  prostration  is  marked,  typhoid  fever  should  be  thought  of. 

The  differentiation  between  acute  bronchitis  and  early  tuberculosis 
is  considered  on  page  326. 


Etiology. — As  a  primary  affection,  chronic  bronchitis  is  encountered 
much  less  frequently  than  is  usually  thought,  and  while  it  is  commonly 
taught  that  repeated  attacks  of  acute  bronchitis  may  develop  into  the 


chronic  form  of  the  disease,  such  is  rarely  the  case.  Indeed  there  are 
some  who  refuse  to  recognize  the  existence  of  a  primary  chronic  bron- 
chitis under  any  circumstances.  It  is  certain  that  many  cases  so  desig- 
nated are  in  reaUty  instances  in  which  a  much  more  serious  affection  is 
present  the  bronchitis  being  only  a  secondary  manifestation  There  is 
one  class  of  cases,  however,  in  which  chronic  bronchitis  is  very  frequently 
a  primary  affection,  namely,  those  in  which  there  has  been  a  prolonged 
exposure  to  dust,  such  as  is  seen  in  millers,  stone  cutters,  coal  miners,  etc. 
In  these  cases  the  constant  irritation  produced  by  the  dust  particles, 
which  at  first  produces  a  mild  acute  inflammatory  condition  of  the 
bronchial  mucous  membrane,  finally  brings  about  a  chronic  condition. 
It  is  worth  bearing  in  mind,  however,  that  the  morbidity  from  tuber- 
culosis is  very  high  among  such  w^orkers,  and  care  must  be  exercised 
not  to  mistake  a  latent  tuberculosis  for  chronic  bronchitis. 

Chronic  bronchitis  is  rarely  encountered  in  the  young;  on  the  other 
hand,  it  is  very  frequent  among  those  past  the  middle  period  of  life. 
The  winter  cough  so  frequently  encountered  in  those  of  advanced  years 
is  usually  one  of  the  indications  of  a  faulty  circulation,  a  chronic  renal 
lesion  or  some  chronic  pulmonary  condition  such  as  asthma  or  emphy- 
sema. Indeed,  it  is  in  association  with  these  latter  conditions  that 
chronic  bronchitis  is  most  frequently  met  with.  In  such  individuals 
climatic  changes  have  an  important  bearing;  they  are  extremely  suscepti- 
ble to  sudden  changes  in  the  weather.  In  the  warm  summer  months 
they  are  almost  entirely  free  from  their  pulmonary  symptoms,  and  resi- 
dence in  a  warm  climate  during  the  winter  months  also  assures  them  of 
freedom  from  their  symptoms. 

Gout,  chronic  alcoholism,  certain  skin  lesions  and  obesity  also  are  not 
uncommonly  accompanied  with  chronic  bronchitis.  Rarely  a  tumor  or 
aneurism  of  the  aorta,  through  pressure  on  the  bronchi,  may  bring  about 
a  catarrhal  inflammation  of  the  bronchial  mucous  membrane,  and  finally 
a  chronic  bronchitis.  It  is  thus  seen  that  in  the  vast  majority  of  instances 
the  condition  is  secondary  to  some  other  affection,  and  until  disease  of  the 
heart,  kidney  or  other  pulmonary  lesions  are  excluded  a  diagnosis  of 
chronic  bronchitis  alone  is  untenable. 

Morbid  Anatomy. — The  condition  is  characterized  by  a  venous  hy 
peremia  and  swelling  of  the  bronchial  mucous  membrane  with  increased 
secretion  of  mucus,  and  the  exudation  of  serum  and  pus  cells.  As  the 
disease  progresses  the  mucous  membrane  may  hypertrophy  in  places, 
and  in  others  become  atrophied,  so  that  the  longitudinal  bands  of  elastic 
tissue  are  readily  seen.  The  membrane  is  also  frequentl}^  denuded  of 
its  epithelium  and  the  glandular  tissues  atrophied.  Of  the  end  results, 
cylindrical  dilatation  of  the  medium  and  smaller  bronchi  is  frequent, 
while  some  degree  of  emphysema  is  constantly  met  w^ith. 

Symptoms." — The  chief  manifestations  are  as  follows:  Shortness  of 
breath  on  the  slightest  exertion,  which  is  sometimes  accompanied  by  a 
fit  of  coughing,  with  or  without  expectoration.  These  symptoms,  espe- 
cially the  shortness  of  breath,  are  commonly  due  to  the  associated  emphy- 
sema; in  some  cases  cardiac  weakness  is  the  exciting  factor.  The  cough, 
as  already  stated,  is  variable,  being  much  influenced  by  the  weather 
conditions.  In  the  summer  it  is  very  slight,  or  even  disappears  alto- 
gether. Even  in  the  winter  it  is  not  apt  to  be  constant,  and  during  this 
season  may  occur  only  in  the  morning,  or  there  may  be  a  paroxysm  at 


night.  The  expectoration  also  varies  greatly  in  different  cases;  in  some 
it  is  entirely  absent.  As  a  rule,  however,  it  is  rather  abundant  and  muco- 
purulent in  character. 

There  is  no  pain  nor  fever,  and  rarely  any  marked  deterioration  of 
health.  The  most  serious  feature  of  the  disease  is  the  fact  that  it  prac- 
tically always  results  in  emphysema,  and  in  some  instances,  leads  to  a 
severe  grade  of  bronchiectasis. 

Physical  Signs. — ^Chronic  bronchitis,  primary  in  character,  like  the 
acute  form  has  few  physical  signs,  and  those  are  entirely  auscultatory. 
Inasmuch,  however,  as  the  disease  is  nearly  always  associated  with  some 
emphysema,  and  occasionally  with  well-marked  dilatation  of  the  bronchi, 
the  physical  signs  vary  in  individual  cases. 

In  the  ordinary  case  with  slight  emphysematous  changes,  the  follow^- 
ing  points  may  be  noted : 

hispedion. — Barrel-shaped  chest  with  little  or  no  lateral  expansion, 
the  chest  moving  up  and  down.  The  apex  beat  of  the  heart  is  usually 
not  seen  because  of  the  distended  lung.  These  signs  may  be  very  marked, 
or  hardly  evident,  depending  entirely  on  the  amount  of  emphj^sema 

Palpation. — Palpation  confirms  the  character  of  the  expansion. 
Vocal  fremitus  is  normal  or  slightly  diminished.  A  rhonchal  fremitus 
may  be  detected  at  different  points. 

Percussion. — The  percussion  note  is  normal  or  hyperresonant  in  ac- 
cordance with  the  amount  of  emphysema  present.  It  may  also  have  a 
tympanitic  qualitj^  at  the  bases  as  the  result  of  pulmonary  relaxation, 
or  if  the  secretion  is  profuse,  the  note  may  be  slightly  impaired  in  the 
same  situation. 

AuscuUation. — The  auscultatory  signs  will  vary  in  accordance  with 
the  amount  of  secretion  present.  Thus  in  the  summer  months  when  the 
patient  is  free  from  cough,  the  lungs  may  reveal  no  adventitious  sounds 
whatever,  and  aside  from  a  slight  diminution  of  the  intensity  of  the  respira- 
tory murmur  and  prolonged  expiration  show  no  marked  deviation  from 
the  normal.  During  the  active  stage,  however,  the  lungs  are  usually 
filled  with  mixed  rales,  both  large  and  small,  and  at  one  time  or  another 
they  are  heard  everywhere  throughout  both  lungs.  At  the  bases  of  the 
lungs  the  rales  are  quite  apt  to  be  of  the  small  moist  variety.  At  times 
the  rales  are  so  numerous  and  loud  as  to  entirely  obscure  the  respiratory 
murmur.     Vocal  fremitus  may  be  normal  or  diminished  in  intensity. 

Diagnosis. — The  recognition  of  chronic  bronchitis  is  not  difficult. 
The  important  thing  to  bear  in  mind  is  that  it  is  almost  invariably  a  sec- 
ondary condition  and  is  only  too  often  one  of  the  manifestations  of  a 
much  more  serious  affection. 


This  disease  is  also  referred  to  as  plastic,  croupous  or  pseudo-mena- 
branous  bronchitis  and  bronchial  croup.  The  essential  feature  of  this 
form  of  bronchitis  is  the  formation  in  the  bronchial  tubes  of  fibrinous 
casts,  which  are  expelled  after  a  paroxysm  of  dyspnea  and  cough.  It 
is  a  rare  affection  and  although  known  to  Galen  and  other  ancient  authors 
the  number  of  cases  recorded  in  the  literature  is  not  much  over  two 
hundred.  The  disease  may  occur  either  as  an  acute  or  a  chronic  mani- 
festation; the  latter  is  by  far  the  most  frequent. 


Bronchial  casts  may  be  formed  secondarily  to  diphtheria  in  the 
pharynx  or  larynx  or  to  croupous  pneumonia.  Casts  occurring  in 
association  with  these  two  diseases  will  not  l)e  considered  here. 

Etiology. — The  cause  of  fibrinous  bronchitis  is  as  yet  wholly  unknown 
and  there  is  no  evidence  to  show  that  it  is  in  any  way  dependent  on  a 
bacterial  infection.  The  disease  occurs  most  frequently  between  the 
ages  of  ten  and  thirty.  Males  are  affected  about  twice  as  frequently  as 
females.  In  common  with  other  forms  of  bronchitis  this  form  of  the 
disease  occurs  more  frequently  in  the  colder  months  of  the  year. 

The  immediate  exciting  causes  are  probably,  in  great  measure,  the 
same.  In  one  instance  a  simple  bronchitis  develops;  in  the  other  a 
fibrinous  exudation  is  later  superadded. 

Fibrinous  bronchitis  has  been  described  as  occurring  in  association 
with  a  variety  of  conditions  but  in  most  instances  the  connection  is  to  be 
regarded  as  no  more  than  a  coincidence.  It  has  been  noted  in  the  course 
of  the  acute  infections  such  as  measles,  scarlet  fever,  erysipelas,  typhoid 
fever,  influenza,  etc.  The  inhalation  of  irritant  fumes  and  gases  such  as 
steam,  smoke  and  ammonia,  has  at  times  been  followed  by  the  expulsion 
of  fibrinous  casts.  Among  other  conditions  reported  may  be  mentioned 
asthma,  pulmonary  edema  following  thoracentesis,  pulmonary  actino- 
mycosis and  aspergillosis  and  various  skin  diseases. 

The  largest  number  of  instances  have  been  met  with  in  individuals 
affected  with  heart  disease  and  pulmonary  tuberculosis.  In  regard  to 
tuberculosis  the  frequency  of  the  association  varies  tremendously  among 
different  observers.  West'  refers  to  the  association  of  fibrinous  bronchitis 
and  tuberculosis  in  7  out  of  51  cases.  Lehmann-]Model-  found  tubercu- 
losis at  autopsy  in  3  of  6  cases  observed  by  him  and  refers  to  26  autopsies 
in  the  literature  in  which  tuberculosis  was  found  in  10.  I  recall  no  in- 
stance of  bronchial  casts  occurring  among  the  ward  patients  in  the  Phipps 
Institute  over  a  period  of  thirteen  years  nor  have  such  casts  ever  been 
found  in  any  of  the  662  autopsies  on  tuberculous  individuals.  Walshe^ 
also  emphasizes  the  fact  that  he  had  never  seen  the  true  disease  either  in 
life  or  in  death  in  an  actively  phthisical  person.  It  is  probably  fair  to 
assume  that  pulmonary  tul^erculosis  pla>'s  no  part  in  the  formation  of  the 
casts  and  that  the  association  of  the  two  conditions  is  a  mere  coincidence. 
The  same  may  be  said  of  the  association  with  heart  disease. 

In  a  certain  number  of  instances  the  disease  occurs  in  robust,  healthy 
individuals  in  whom  there  is  no  apparent  causative  factor. 

Morbid  Anatomy. — The  bronchi  involved  usually  represent  a  circum- 
scribed area  but  occasionally  the  disease  occurs  in  a  diffuse  form.  While 
any  part  of  the  bronchial  tree  may  be  involved  the  bronchi  of  the  lower 
lobes  are  most  frequently  affected  (West).  The  process  as  a  rule,  com- 
mences in  the  medium-sized  bronchi  and  extends  downward.  There  is 
little  tendency  to  spread  upward.  While  it  is  known  that  the  diph- 
theria bacillus  b}'  extension  downward,  may  produce  a  fibrinous  cast  in 
the  trachea  and  large  bronchi  and  that  the  pneumococcus  may  lead  to 
the  formation  of  casts  in  the  small  bronchi  during  an  attack  of  pneumonia, 
there  is  no  evidence  to  show  that  fibrinous  casts  occurring  either  idio- 
pathically  or  in  association  with  other  conditions,  are  bacterial  in  origin. 

'  "Diseases  of  the  Respiratory  Organs." 
^  Inaugural  Dissertation,  Freiburg,  1890. 
'  "Diseases  of  the  Lungs,"  4th  ed.,  1871. 



As  to  the  bronchi  themselves  there  is  no  constantly  associated  lesion. 
Occasionally  a  case  has  been  reported  in  which  at  the  site  of  the  cast, 
there  has  been  a  caseous  infiltration,  an  ulcer  or  desquamation  of  the- 
epithelium.  In  none  of  these  cases,  however,  is  it  clear  that  the  change 
in  the  bronchi  bore  any  causal  relation  to  the  formation  of  the  cast.  In. 
the  chronic  form  of  the  disease,  emphysema  of  the  lungs  sometimes- 

The  casts  are  pearly  gray  or  white  in  color  and  of  fairlj^  firm  consist- 
ency. They  vary  in  length  from  fragments  }y^  inch  long  up  to  complete 
casts  of  6  or  7  inches,  with  branches  corresponding  to  the  divisions  of  the 
bronchi  from  which  they  have  been  expelled  (Fig.  220).     The  casts  from. 

Fig.  220. 

-Fibrinous  bronchitis  cast  expectorated;  three-fourths  natural  size.     {Milton 
Bettmann,  in  American  Journal  of  the  Medical  Sciences.) 

the  larger  bronchi  are  hollow  and  present  a  laminated  appearance  as  the 
result  of  successive  deposits  of  fibrin  or  mucus.  The  smaller  casts  are 
solid  and  often  terminate  in  spirals. 

Bronchial  casts  are  usually  composed  chiefly  of  fibrin,  but  in  some 
instances  the  main  constituent  is  mucus  and  in  others  the  fibrin  and 
mucus  occur  together  in  varying  proportions.  At  times  the  cast  is 
streaked  with  blood.  The  number  expelled  varies  from  one  every  day 
or  so  to  a  large  number  daily.  They  may  be  coughed  up  as  a  lump  or 
pellet  or  may  be  surrounded  by  sputum.  Occasionalh^  the  cast  may  be 
expelled  in  the  form  of  elongated  cylinders  resembling  macaroni  or 
vermicelli.  The  discovery  of  the  cast  is  often  accidental.  The  patient 
may  be  led  to  examine  the  pellet,  as  in  a  case  recently  observed,  or  the 


true  nature  of  the  small  lumps  may  be  revealed  in  the  course  of  the 
examination  of  the  sputum.  The  sputum  may  be  scanty  or  very  profuse. 
In  addition  to  the  presence  of  casts  the  sputum  may  contain  Charcot- 
Leyden  crystals,  Curschmann's  spirals  and  eosinophilic  cells,  indicating 
a  condition  of  the  mucous  membrane  similar  to  that  in  asthma 

Symptoms. — Two  forms  of  the  disease  are  recognized,  the  acute  and 
the  chronic.  The  acute  form  which  is  rare,  may  begin  abruptly  with  a 
chill,  fever,  cough,  pain  in  the  chest  and  dj'spnea.  It  is  more  apt,  how- 
ever, to  be  associated  with  one  of  the  acute  infections,  in  which  case, 
after  a  preliminarj'  bronchitis  the  paroxysms  of  coughing  become  more 
and  more  severe  and  the  dyspnea  increases.  The  fibrinous  casts,  the 
presence  of  which  alone  make  the  diagnosis  possible,  may  be  coughed  up 
at  once  or  after  the  existence,  for  some  days,  of  what  seems  to  be  a  simple 

The  duration  of  the  acute  cases  is  from  a  few  daj'S  to  several  weeks. 
In  the  favorable  cases  the  fever  declines  b}'  Ij'sis,  the  cough  and  dyspnea 
diminish,  the  expectoration  of  casts  ceases  and  there  is  complete  and 
permanent  recover^^  In  severe  cases  death  often  occurs  with  all  the 
symptoms  of  suffocation. 

Rarely  the  acute  form  may  become  chronic  but  this  is  verj'  unusual. 
The  chronic  variety  is  often  preceded  bj'  the  ordinarj'  chronic  form  of 
bronchitis  although  in  some  instances  the  disease  maj^  assume  the  fibrin- 
ous type  from  the  outset.  The  attacks  tend  to  recur  at  certain  definite 
intervals  for  months  or  years.  In  some  instances  the  size  of  the  casts  is 
identical  in  each  attack  and  this  fact  in  association  with  the  location  of 
the  physical  signs,  points  to  the  involvement  of  the  same  portion  of  the 
bronchial  tree.  During  the  attack  the  cough  assumes  a  paroxysmal 
character  and  dj'spnea  is  marked. 

Hemoptysis  has  been  noted  in  a  number  of  cases.  The  amount  of 
blood  expectorated  is  usually  small  and  may  consist  of  nothing  more  than 
some  blood  streaks  on  the  cast.  Epistaxis,  diarrhea  and  albuminuria 
have  been  noted  during  an  attack.  In  the  chronic  form  there  is 
rarely  any  fever  or  any  other  evidence  of  constitutional  disturbance 
and  the  general  nutrition  is  well  maintained.  Emphysema  often 

In  the  chronic  form  the  attack,  consisting  of  paroxysms  of  dyspnea 
and  coughing  followed  by  the  expulsion  of  a  cast,  may  last  from  a  few 
days  to  weeks  or  even  months.  The  separate  paroxysm  is  usually  short 
although  it  may  be  preceded  by  some  hours  of  coughing.  The  attacks 
vary  greatly  in  duration  even  in  the  same  patient. 

Once  the  chronic  form  develops  the  patient  is  usualh'  liable  to  attacks 
the  remainder  of  life.  The  disease  has  been  noted  to  recur  over  a  period 
of  twenty-five  years.  The  interval  between  the  attacks  varies.  In 
some  instances  the  attacks  recur  regularly  at  certain  times,  as  for  instance 
at  the  menstrual  periods;  in  others  it  comes  irregularly  and  there  may  be 
an  interval  of  years  in  which  the  patient  is  free  from  the  disease. 

Physical  Signs. — The  physical  signs  do  not  give  definite  information. 
If  but  a  small  area  is  involved  the\'  may  be  entirely  normal.  In  many 
instances  the  physical  findings  are  those  of  acute  or  chronic  bronchitis. 
If  a  sufiiciently  large  area  is  involved  there  may  be  deficient  expansion 
on  the  affected  side,  a  weakened  or  absent  respiratory  murmur,  dulness 


and  the  presence  of  rales  both  large  and  small.  These  atelectatic  areas 
disappear  with  the  expulsion  of  the  cast. 

The  abnormal  physical  signs  are  commonly  found  at  the  bases  of 
the  lungs  and  usually  on  one  side  only.  The  only  physical  sign  peculiar 
to  fibrinous  bronchitis  is  a  curious  flapping  sound  beginning  in  the  middle 
of  inspiration  and  continuing  to  the  end.  It  is  apparently  produced 
by  the  presence  of  partially  separated  casts.  Its  value  is  limited, 
however,  as  it  is  present  in  but  a  small  minority  of  cases. 

Diagnosis. — A  diagnosis  of  fibrinous  bronchitis  is  possible  only  by 
the  detection  of  the  casts.  These  may  be  so  surrounded  by  the  sputum 
as  to  escape  notice.  As  already  stated  they  may  be  accidentally  dis- 
covered by  the  patient  or  they  may  be  detected  in  a  routine  sputum 
examination.  The  condition  is  to  be  suspected  in  patients  who  give  a 
history  of  recurring  attacks  of  paroxysmal  cough  and  dyspnea.  In 
individuals  seen  during  the  first  attack,  however,  the  finding  of  a  bronchial 
cast  is  the  only  criterion. 

The  following  case  is  an  excellent  example  of  the  so-called  idiopathic 
fibrinous  bronchitis:  The  patient  was  a  robust,  healthy  male,  aged 
47,  referred  to  me  because  of  suspected  tuberculosis.  The  family  history 
was  negative  and  he  had  never  had  any  illness.  Four  weeks  prior  to 
his  coming  under  my  observation  he  had  caught  "cold."  The  trouble 
started  as  a  coryza  and  in  a  few  days  he  developed  a  severe  paroxysmal 
cough  and  some  dyspnea.  For  the  first  two  weeks  the  sputum,  which 
was  moderate  in  amount,  was  thick  and  whitish  in  color,  later  it  had  a 
greenish  tinge.  On  one  occasion  after  a  paroxysm  of  coughing  he  spat 
into  his  handkerchief  a  small  hard  pellet  which  on  examination  proved 
to  be  a  cast  from  one  of  the  medium-sized  bronchi.  There  was  a  slight 
elevation  of  temperature  during  the  attack.  The  sputum  was  negative 
for  tubercle  bacilli  but  contained  both  pneumococci  and  streptococci. 
With  the  exception  of  one  day  spent  in  bed  he  attended  to  his  professional 
work,  although  with  some  effort.  His  appetite  was  good  and  he  had 
lost  no  weight. 

On  physical  examination  there  was  deficient  expansion  at  the  right 
base,  impairment  of  the  percussion  note,  suppressed  breath  sounds,  both 
large  and  small  rales  and  in  addition  a  "flapping  sound"  heard  at  the 
end  of  inspiration.  The  patient  was  sent  to  the  seashore  and  when  seen 
two  weeks  later  there  was  nothing  abnormal  to  be  noted  over  the  area 
previously  affected. 

The  localization  of  the  physical  signs,  usually  at  the  base  of  one  lung, 
should  serve  to  differentiate  the  condition  from  simple  bronchitis.  The 
lodgment  of  a  foreign  body  in  one  of  the  medium-sized  bronchi  is  apt  to 
give  rise  to  localized  physical  signs  over  the  lower  lobe  of  one  lung  but 
in  such  cases  the  evidences  of  pulmonary  mischief  are  permanent  and 
in  addition  casts  are  not  expelled  in  the  sputum.  Owing  to  the  par- 
oxysmal character  of  the  attacks  and  the  dyspnea  fibrinous  bronchitis 
may  be  mistaken  for  asthma.  In  the  latter  condition  the  physical  signs 
are  bilateral  and  the  respiratory  difficulty  is  expiratory  in  nature.  The 
finding  of  bronchial  casts  is  the  deciding  factor  in  all  cases. 


In  1906  Castellani'^  called  attention  to  a  special  form  of  bronchitis  due 
to  spirochetes.     Enormous  numbers  of  these  organisms  may  be  present 

^Lancet,  May  19,  1906. 


in  the  sputum.  Examples  of  this  infection  have  been  observed  in  India, 
Ceylon,  the  Philippine  Islands  and  the  West  Indies.  During  the  past  two 
years  a  number  of  cases  have  been  reported  by  French,  Italian  and 
Belgian  Medical  officers.  It  is  their  behef  that  the  infection  was  in- 
troduced among  the  allied  soldiers  by  the  Asiatic  troops. 

Etiology. — Castellani  and  Chalmers  describe  several  varieties  of 
spirochetes.  The  commonest  type  is  a  thin,  delicate  spirochete  with 
numerous  small,  uniform  coils;  one  of  the  extremities  may  be  blunt 
while  the  other  is  pointed.  A  few  of  the  organisms  are  thick,  quite  long 
and  with  irregular  coils,  while  others  are  thin  and  deUcate  with  irregular 
coils.  Spirochetes  resembling  the  S.  refringens  of  Schaudinn  may  also 
be  present.     The  disease  appears  to  be  markedl}'  contagious. 

Symptoms. — The  disease  may  occur  in  an  acute  and  in  a  chronic  form. 
In  the  acute  form  the  patient  has  fever,  feels  weak,  has  a  cough  and  usually, 
scanty  expectoration.  According  to  Castellani  and  Chalmers  the  con- 
dition is  not  serious.  Violle^  in  reporting  30  cases  states  that  the  sputa 
were  nearly  always  red  in  color  and  resembled  raspberry  juice.  The 
disease  was  relativelj"  benign  and  had  a  duration  of  about  a  month,  but 
relapses  were  frequent.  Other  observers  have  noted  that  the  sputum, 
in  addition  to  being  hemorrhagic  in  character,  maj'  be  intensel.y  fetid. 

The  chronic  form  of  the  disease  may  result  from  an  acute  attack  but 
more  often  there  is  no  such  antecedent  history,  the  affection  having  a 
slow,  insidious  onset.  In  this  tj'pe  of  the  disease  the  patient  has  a  chronic 
cough,  usually  most  severe  in  the  morning,  and  the  sputum  is  abundant 
and  muco-purulent  in  character.  The  sputum  may  be  blood  streaked 
and  at  times  small  hemoptyses  occm\  The  fever  does  not  conform  to  any 
definite  tj^pe.  It  may  be  absent,  or  hectic  in  type,  or  it  may  be  present 
in  the  morning  and  disappear  in  the  afternoon.  In  still  other  instances 
fever  is  present  onh'  at  irregular  intervals.  The  course  of  the  disease 
may  be  prolonged.  Castellani  has  observed  one  case  in  which  the  infec- 
tion had  existed  for  five  3'ears. 

The  general  health  ma}'  be  but  slightly  affected  although  some  anemia 
is  usually  present.  Occasionally  marked  emaciation  may  occur.  The 
prognosis  is,  in  the  great  majority  of  cases  favorable. 

Physical  Signs. — Examination  of  the  chest  does  not  give  any  very 
definite  information.  Little  or  nothing  abnormal  may  be  detected  aside 
from  the  presence  of  rales. 

Diagnosis. — It  is  obvious  that  the  condition  is  most  apt  to  be  confused 
with  pulmonary  tuberculosis.  A  spirochetal  infection  is  to  be  thought 
of  in  individuals  suffering  from  a  prolonged  cough,  muco-purulent 
expectoration  and  hemoptyses,  but  in  whom  neither  the  tubercle  bacillus 
nor  any  one  of  the  less  famiUar  organisms  can  be  demonstrated.  The 
possibility  of  this  infection  being  present  may  be  suggested  also  by  the 
occurrence  of  respiratory  symptoms  in  those  who  have  returned  from 
the  far  East. 


Our  knowledge  of  this  condition  is  of  recent  origin.  Occlusion  of  the 
finer  bronchi,  independent  of  other  marked  lesions  of  the  lung,  was  first 
described  by  Lange^  in  1901.     The  following  year  Frankel'^  reported  the 

1  Bui.  de  V Academic  de  Medicine,  June,  4,  1918. 
^Deut.  Arch.f.  kl.  Med.,  Bd.  Ixx,  p.  342. 
^Ibid.,  1902,  Ixxii,  p.  484. 


first  case  in  which  the  diagnosis  was  made  during  hfe  and  a  few  years 
later  he'^  reported  three  additional  cases. 

Etiology. — In  one  of  Frankel's  cases  the  condition  followed  the 
inhalation  of  nitrogen  tetroxide  fumes,  in  another  the  inhalation  of  lime 
and  other  dust;  in  his  remaining  two  cases  the  cause  was  not  definitely 
established.  Edens-  observed  a  case  resulting  from  the  inhalation  of  the 
fumes  from  a  mixture  of  hydrochloric  and  nitric  acid.  In  addition  to 
these  cases  the  causation  of  which  is  reasonably  clear,  similar  pathological 
changes  have  been  reported  as  having  followed  measles,  whooping  cough, 
syphilis,  uncomplicated  catarrhal  inflammation  of  the  finer  tubes  and 
the  aspiration  of  a  foreign  body.  It  would  seem,  therefore,  that  any 
condition  capable  of  causing  inflammation  of  the  finer  bronchi  and 
bronchioles  may  be  followed  by  occlusion  of  this  portion  of  the  bronchial 
tree.  On  the  other  hand  either  such  an  occurrence  is  rare,  except  in  the 
case  of  irritating  gases,  or  it  is  not  generally  recognized. 

Morbid  Anatomy. — -In  the  cases  reported  by  Frankel  and  Edens, 
following  the  inhalation  of  a  toxic  gas,  the  lungs  presented  the  appearance 
usually  seen  after  such  accidents  (see  p.  521).  In  addition  the  cut  sur- 
face showed  numerous  small  grayish-white  nodules  from  1  to  2  mm.  in 
diameter  which  closelj^  resembled  miliarj^  tubercles.  On  examination 
with  a  hand  glass  these  small  nodules  are  seen  to  differ  from  miliary 
tubercles  in  that  they  are  angular  or  stellate  in  form.  Futhermore 
they  are  found,  on  dissection,  to  be  the  terminal  portion  of  the  smaller 
bronchi.  Microscopically  the  finer  bronchi  show  marked  epithelial 
desquamation,  the  cells  often  blocking  the  tube.  In  addition  there  is 
an  ingrowth  of  connective  tissue  which  may  completely  occlude  the 
lumen  or  reduce  it  to  a  small  slit.  The  connective  tissue  apparently 
takes  its  origin  from  the  bronchial  wall.  Connective-tissue  invasion  of 
the  adjacent  alveoli  may  take  place  also. 

Symptoms. — The  dominant  symptoms  are  intense  dyspnea  and 
cyanosis.  If  the  inhalation  of  irritating  vapors  has  occurred  there  may 
be  present  also  cough  and  the  expectoration  of  reddish-brown  sputum. 
The  pulse  is  very  rapid.  The  percussion  note  is  hyperresonant  as  the 
result  of  emphysema  and  on  auscultation  numerous  fine  rales  are  heard. 
In  one  of  Frankel's  cases  the  symptoms  developed  sixteen  days  after  the 
inhalation  of  an  irrespirable  gas;  death  occurred  three  days  later.  In 
Edens'  case  the  symptoms  developed  ten  days  after  the  inhalation  of 
gas,  death  taking  place  on  the  twenty-sixth  day.  It  would  seem  that 
the  appearance  of  the  dyspnea  and  cyanosis  coincide  with  the  subsidence 
of  the  acute  inflammation  and  the  occlusion  of  the  bronchioles  as  the 
result  of  connective  tissue  proliferation. 

Diagnosis. — In  an  individual  who  is  known  to  have  inhaled  a  poison- 
ous gas  and  in  whom  there  is  a  temporary  amelioration  or  subsidence  of 
the  symptoms,  a  diagnosis  of  bronchitis  or  bronchiolitis  obliterans  may 
be  ventured  if  there  develops  severe  dyspnea  and  cyanosis  associated 
with  hyperresonance  and  fine  rales.  If,  however,  the  condition  follows 
measles,  whooping  cough,  or  any  condition  associated  with  a  catarrhal 
inflammation  of  the  finer  bronchi  a  correct  diagnosis  would  be  a  matter 
of  luck.  Acute  miliary  tuberculosis  and  broncho-pneumonia  may  mani- 
fest themselves  in  the  same  way.     In  the  great  majority  of  cases  the 

1  Berliner.  M.  Woch.,  1909,  xlvi,  6. 

2  Deuf.  Arch.  f.  kl.  Med.,  1906,  Ixxx,  598. 


condition  must  be  looked  upon  as  of  pathological  interest.  "  It  is  quite 
possible,  however,  that  some  cases  which  have  been  diagnosed  as  miliary 
tuberculosis  of  the  lungs  b,y  the  X-rays  and  which  subsequently  recovered, 
are  of  this  nature.  Inasmuch  as  the  nodules  present  a  strong  resem- 
blance to  miliary  tubercles  when  the  lung  is  exposed  to  direct  inspection 
it  can  be  readily  understood  how  easily  a  mistake  could  be  made  in  inter- 
preting an  X-ray  plate.  I  have  knowledge  of  one  case  in  which  a  diag- 
nosis of  miliary  tuberculosis  was  made  because  of  the  presence  in  the 
plate  of  numerous  small  nodules  which  were  taken  for  tubercles.  The 
patient  is  alive  and  well  after  an  interval  of  four  years. 


This  disease  is  primarily  a  tracheo-bronchitis  which  is  characterized 
by  a  series  of  violent  spasmodic  coughs  which  end  in  a  long  drawn  inspira- 
tion or  "whoop."  It  is  allied  to  other  forms  of  broncliitis  but  differs  from 
them  in  that  it  has  a  definite  specific  cause,  the  Bordet-Gengou  bacillus, 
and  also  because  of  the  paroxysmal  cough  followed  by  spasm  of  the  glot- 
tis  during  inspiration. 

Whooping  cough  was  at  one  time  looked  upon  as  a  relatively  harm- 
less affection  and  is  still  regarded  as  such  by  many  of  the  laity.  It 
cannot  be  too  strongly  emphasized  that  it  is  a  most  dangerous  disease  in 
young  children.  The  custom  of  deliberateh^  exposing  children  to  this 
infection  with  the  idea  that  it  is  a  necessarj^  episode  in  childhood  should 
be  discouraged.  In  recent  years  departments  of  health  have  repeatedly 
warned  people  in  this  regard.  Of  itself  the  disease  is  distressing,  chiefly 
because  of  the  violence  of  the  paroxysms  of  coughing.  Its  danger  lies  in 
the  complications  and  sequels  which  occur  so  frequently,  the  most 
serious  of  which  are  broncho-pneumonia  and  tuberculosis. 

Etiology. — It  is  essentially  a  disease  of  young  children.  The  largest 
proportion  of  cases  occur  between  the  first  and  second  dentition.  It 
may  occur,  however,  in  infants  but  a  few  weeks  old  and  not  infrequently 
it  is  encountered  in  adults.  One  attack  almost  invariably  confers  perma- 
nent immunity.  A  second  attack  occurs  very  rarely.  The  disease 
usually  manifests  itself  in  more  or  less  widespread  epidemics,  particularly 
in  the  winter  and  spring  months.  In  large  communities,  however,  iso- 
lated cases  are  apt  to  be  encountered  at  all  times.  The  disease  appears 
to  be  most  contagious  during  the  first  or  catarrhal  period.  It  has  long 
been  noted  that  epidemics  of  whooping  cough  and  measles  bear  a  curious 
relation  to  each  other.  The  appearance  of  either  one  of  these  diseases 
is  often  preceded  or  followed  by  the  other.  Less  frequently  the  same 
is  true  of  scarlet  fever. 

The  exciting  cause  of  whooping  cough  is  now  quite  generally 
admitted  to  be  the  minute  bacillus  described  by  Bordet  and  Gengou, 
commonly  known  as  the  Bordet-Gengou  bacillus.  The  proof  seems  to  be 
conclusive.  With  this  organism  Mallory,  Hornor  and  Henderson^  have 
been  able  to  produce  the  characteristic  lesion  of  the  disease  in  young 
animals  and  to  recover  the  bacillus  in  pure  culture.  Cultural  methods 
have  been  made  available  for  diagnostic  purposes.  Chievitz  and  Meyer^ 
in  a  study  of  the  sputum  by  their  method  found  the  bacillus  present  in 

1  Jour.  Med.  Res.,  March,  1913. 

2  Ann.  de  I'Inst.,  Pasteur,  1916,  30,  503. 


practically  all  cases  when  the  catarrhal  stage  is  well  established.  The 
results  obtained  by  Olmstead  and  Luttinger^  in  a  study  of  the  comple- 
ment fixation  test  in  111  cases  of  whooping  cough  or  suspected  whooping 
cough  also  support  the  claim  that  the  Bordet-Gengou  bacillus  is  the  true 
etiological  factor. 

Morbid  Anatomy. — The  characteristic  lesion  of  the  disease  is  found 
in  the  trachea  and  bronchi,  especially  the  former.  The  opportunity  of 
studying  the  pathological  changes  in  the  acute  stage  of  the  disease  does 
not  happen  very  frequently  as  death  is  most  apt  to  occur  at  a  later 
period.  In  the  few  cases  studied  by  Mallory  and  Hornor^  the  micro- 
scopic examination  showed  large  numbers  of  minute  bacteria  between 
the  cilia  of  many  of  the  cells  lining  the  trachea.  The  cilia  of  single  cells 
or  large  groups  of  cells  may  be  affected.  The  organisms  usually  reach  the 
base  of  the  cilia  but  may  extend  only  part  way.  They  frequently  cause 
a  lateral  spreading  or  mushrooming  of  the  cilia  covering  a  single  cell. 
In  many  places  the  cilia  are  reduced  to  short  stubs  or  are  entirely  want- 
ing. The  action  of  the  bacteria  appears  to  be  largely  mechanical  leading 
to  interference  with  the  normal  movements  of  the  cilia  by  sticking  them 
together.     In  this  way  the  microorganisms  furnish  a  continual  irritation. 

The  most  serious  of  the  effects  of  whooping  cough  are  to  be  found  in 
the  complications.  A  common  cause  of  death  is  broncho-pneumonia 
which  is  often  tuberculous  in  character.  Areas  of  atelectasis,  either 
alone  or  in  association  with  broncho-pneumonia,  are  frequently  seen. 
Enlargement  of  the  bronchial  lymph  nodes  is  a  common  result  of  whoop- 
ing cough,  and  in  many  cases  areas  of  caseation  due  to  tuberculosis  are 
present.  The  paroxysms  of  coughing  may  lead  to  over  distention  of  the 
lungs  (emphysema).  Among  the  more  unusual  complications  may  be 
mentioned  an  acute  form  of  bronchiectasis  (bronchiolectasis,  see  page  296), 
interstitial  and  mediastinal  emphysema  and  pneumothorax,  the  last- 
named  conditions  being  caused  by  the  rupture  of  the  lung. 

Symptoms. — It  is  customary  to  divide  the  clinical  manifestations  of 
whooping  cough  into  three  stages:  (1)  The  prodromal  or  catarrhal; 
(2)  the  paroxysmal  or  spasmodic ;  and  (3)  the  stage  of  gradual  disappear- 
ance of  the  cough  and  spasm.  This  division  is  somewhat  arbitrary  and 
does  not  hold  true  for  all  cases.  In  some  instances  the  disease  may  begin 
with  violent  paroxysms  of  coughing;  in  others  the  characteristic  whoop 
may  be  wanting. 

Between  the  time  of  exposure  and  the  appearance  of  the  first  sj^mp- 
toms  there  is  a  variable  incubation  period  of  from  seven  to  ten  days.  In 
the  catarrhal  stage  the  symptoms  are  those  of  an  ordinary  cold.  There 
is  slight  fever,  running  at  the  nose,  injection  of  the  conjunctiva  and  a 
cough.  Even  at  this  time  the  cough  may  be  spasmodic  but,  as  a  rule,  it 
is  such  as  occurs  in  an  attack  of  simple  bronchitis.  There  is  this  distinc- 
tion, however,  that  the  cough  is  somewhat  more  frequent  and  obstinate, 
both  in  children  and  adults,  and  that  the  patient  has  a  more  troublesome 
sensation  of  tickling  in  the  throat  and  inside  the  trachea  (Trousseau). 
The  catarrhal  stage  lasts  from  a  week  to  ten  days. 

The  paroxysmal  stage  dates  from  the  time  of  the  first  "whoop, "  The 
cough  now  assumes  a  definite  paroxysmal  character.  The  paroxysm 
is  often  preceded  by  pain  beneath    the   sternum   and   a  sensation  of 

1  Arch   Int.  Med.,  July,  1915. 

2  Jour.  Med.  Res.,  November,  1912. 


tickling  or  pricking  in  the  larynx  and  trachea.  The  coughing  fit 
commences  with  a  noisy  expiration  followed  by  a  series  of  from  fifteen 
to  twenty  forcible,  short  coughs  of  increasing  intensity.  During  this 
time  no  inspiratory  effort  is  made  and  as  the  result  of  the  expulsion  of 
the  air  from  the  lungs  there  are  signs  of  defective  aeration  of  the  blood. 
The  face  becomes  swollen  and  congested  or  it  may  be  deeply  cyanotic ; 
the  veins  are  prominent  and  the  eyes  may  protrude  and  are  injected  and 
watery.  The  sjaiiptoms  and  signs  are  those  of  asphyxiation.  The 
attack  terminates  with  a  long,  convulsive  inspiration  or  whoop;  occasion- 
ally the  fit  ends  with  sneezing.  The  seizure  lasts  from  a  few  seconds  to 
a  few  minutes  and  is  apt  to  be  more  frequent  at  night  than  during  the 
day.  Crying,  emotion  of  any  Idnd  or  the  inhalation  of  dust  often  pre- 
cipitates an  attack.  With  the  entrance  of  air  into  the  lungs  the  color  is 
restored  and  the  child  breathes  normally.  Vomiting  very  commonly 
follows  the  paroxysm  and  this  may  recur  so  often  that  the  child  becomes 
emaciated  from  lack  of  food.  Relaxation  of  the  vesical  and  rectal 
sphincters  may  occur  in  a  severe  paroxysm.  Occasionally  an  ulcer  is 
formed  on  the  under  surface  of  the  tongue  from  rubbing  on  the  teeth. 

Owing  to  the  intense  distress  the  child  learns  to  dread  succeeding 
attacks.  "At  first  he  tries  to  avert  the  paroxysm.  Instead  of  breathing 
naturally  and  expanding  his  lungs  to  the  full,  as  he  was  doing  just  before, 
he  holds  his  breath,  for  it  seems  to  him  that  the  full  current  of  air,  by 
entering  his  larynx,  will  produce  the  exhausting  cough  of  which  he  has 
had  a  sad  experience  ....  The  fit  takes  place.  You  at  once  see 
the  patient  look  around  for  a  support  to  which  he  may  cling.  If  he  is  a 
child  at  the  breast,  he  throws  himself  into  the  arms  of  his  mother  or 
nurse.  If  he  is  older  and  standing  up,  you  notice  him  stamping  in  a 
state  of  complete  distress.  If  he  is  lying  down,  he  sits  up  quickly  and 
clutches  hold  of  the  bed  curtains  or  of  the  rails"  (Trousseau^).  In  a  case 
of  ordinary  severity  there  are  usually  a  half  a  dozen  paroxysms  a  day. 
At  times  several  paroxysms  succeed  each  other  rapidly  until  some  tena- 
cious sputum  is  expelled.  Usually  this  consists  of  a  small  mass  or  shreds 
of  glairy  mucus.  In  very  severe  cases  there  may  be  a  paroxysm  every 
half  hour  and  death  may  result  from  exhaustion. 

In  unusually  severe  cases  rupture  of  the  capillaries  or  even  of  large 
blood-vessels  may  occur.  Epistaxis,  subconjunctival  bleeding,  hemop- 
tysis, convulsions  due  to  capillary  hemorrhages,  and  hemiplegia  have 
been  noted.  Rarely  death  takes  place  as  the  result  of  a  subdural  hemor- 
rhage. The  spasmodic  stage  may  terminate  within  three  weeks;  more 
often  it  lasts  for  four  or  five  weeks.  Occasionally  the  disease  seems  to 
become  more  or  less  chronic,  as  the  paroxysmal  stage  may  last  two  or 
more  months. 

The  third  stage  is  only  imperfectly  defined.  The  paroxysms  gradually 
decrease  in  number  and  severity",  especially  at  night.  The  cough  be- 
comes looser  and  the  sputum  becomes  mucopurulent  in  character.  In 
children  the  cough  may  persist  for  some  time  as  a  result  of  irritability 
of  the  larynx.  The  duration  of  the  disease  is  rarely  under  six  weeks. 
Occasionally  the  spasmodic  period  persists  for  two  months  or  more. 
The  complications  usually  manifest  themselves  during  the  stage  of 

Complications   may  arise,   however,   during   the   paroxysmal   stage. 

1  "Clinical  Lectures, "~vol.  i,  New  Sj'denham  Soc,  p.  664. 


Trousseau  expressed  the  opinion  that  when  it  is  noted  that  the  fits,  which 
have  been  numerous,  suddenly  cease,  an  inflammatory  compHcation  is 
to  be  suspected. 

Physical  Signs. — There  are  no  physical  signs  peculiar  to  whooping 
cough  other  than  the  change  in  the  character  of  respiration  during  the 
paroxysmal  stage.  In  the  catarrhal  stage  there  may  be  no  chest  signs 
whatever  or  there  may  be  rales  as  in  cases  of  simple  bronchitis.  During 
the  paroxj^sms  the  percussion  note  may  be  slightly  elevated  and  of  short 
duration  owing  to  the  diminished  air  content  of  the  lungs.  There  is  no 
inspiratory  sound  and  the  expiration  is  imperfectly  heard.  Following 
the  "whoop"  the  breath  sounds  are  distant  owing  to  the  gradual  ingress 
of  the  air.     A  few  rales  may  be  present. 

Diagnosis. — In  the  catarrhal  stage  the  diagnosis  is  not  possible 
although,  in  the  presence  of  an  epidemic  or  known  exposure,  the  possi- 
bility of  whooping  cough  should  suggest  itself.  Catarrhal  symptoms  also 
occur  as  prodromes  in  measles  and  as  these  two  infections  commonly 
precede  or  follow  each  other  both  should  be  kept  in  mind.  In  such 
cases  the  mouth  should  always  be  examined  for  Koplik's  spots. 

Once  the  ''whoop"  has  appeared  the  diagnosis  is  easy.  In  doubtful 
cases,  especially  those  in  which  the  ''whoop"  is  absent  or  not  character- 
istic, the  complement  fixation  test  may  aid  in  the  diagnosis. 

When  broncho-pneumonia  occurs  the  symptoms  and  physical  signs 
of  that  condition  dominate  the  picture.  A  very  serious  sequel  is  tubercu- 
losis. This  condition  is  to  be  suspected  in  children  who  are  delicate  and 
in  whom  fever  persists  and  emaciation  and  weakness  gradually  become 
more  and  more  marked.  In  these  cases  the  whooping  cough  serves  to 
arouse  into  activity  a  latent  tuberculous  process  already  present.  Many 
of  the  fatal  cases  of  broncho-pneumonia  following  pertussis  are  tubercu- 
lous in  character. 


By  the  term  bronchial  asthma  is  meant  a  form  of  paroxysmal  dyspnea 
the  characteristic  feature  of  which  is  marked  diminution  or  arrest  of  the 
respiratory  movements  with  prolonged  expiration.  The  condition  is 
sometimes  referred  to  as  spasmodic  asthma.  Among  the  older  writers 
manj^  affections  characterized  by  paroxysmal  attacks  of '  dj^spnea  were 
referred  to  as  asthma,  often  having  the  prefix  cardiac,  renal,  etc.  The 
use  of  the  term  asthma  should  be  restricted  to  the  bronchial  type  of  the 

Etiology. — The  disease  may  manifest  itself  at  any  age,  but  shows  a 
decided  preponderance  in  favor  of  the  earlier  years  of  life.  The  follow- 
ing table  shows  the  age  distribution  in  225  cases  collected  bv  Hyde 

Cases  Per  cent 

During  first  year 11  \  01    n 

From    ItolO....- 60/  "^   ^" 

From  10  to  20 30  13.3 

From  20  to  .30 39  17.3 

From  30  to  40 44  19.0 

From  40  to  50 24  1.1 

From  50  to  60 12  5.0 

From  60  to  70 4  1.4 

From  70  to  80 1  0.7 

1  "Asthma,"  London,  1868. 


In  regard  to  sex  males  are  more  subject  to  the  disease  than  females 
in  the  proportion  of  nearly  2  to  1. 

It  has  long  been  recognized  that  the  condition  is  often  hereditary. 
In  a  very  considerable  proportion  of  cases  there  is  a  direct  transmission  of 
the  predisposition  to  asthma  or  hay  fever,  the  latter  condition  being  closely 
allied  to  asthma  both  in  its  causation  and  in  its  clinical  manifestations. 
The  influence  of  climate  is  uncertain  although  in  most  instances  an 
asthmatic  is  less  subject  to  attacks  in  a  warm  equable  region  than  in 
one  which  is  cold  and  subject  to  marked  variations  in  the  temperature. 
In  regard  to  location  the  disease  often  manifests  the  most  curious  vagaries. 
I  once  knew  a  man  residing  in  a  city  not  far  removed  from  Philadelphia 
who  suffered  severely  from  asthma  and  who  became  free  from  his  attacks 
on  removing  to  the  latter  city.  In  such  cases  it  is  probable  that  some 
irritant,  to  which  the  individual  has  been  susceptible,  has  been  present 
in  one  place  and  not  in  the  other. 

In  certain  instances  the  asthmatic  attacks  seem  to  be  related  in 
some  way  to  the  presence  of  nasal  polypi,  nasal  spurs,  deviation  of  the 
nasal  septum  or  hypertrophy  of  the  turbinates.  Very  often  the  removal 
or  correction  of  these  defects  is  followed  by  a  disappearance  of  the 
asthmatic  attacks. 

It  is  a  matter  of  common  observation  that  asthmatics  rarely  develop 
tuberculosis  and  most  authorities  state  that  asthma  rarely  occurs  in 
tuberculous  individuals.  Occasionally,  however,  tuberculous  patients 
suffer  from  asthmatic  attacks  at  the  onset  of  or  during  the  course  of  their 
malady.     I  have  seen  two  examples  of  this. 

Exciting  Causes. — In  practically  all  individuals  who  are  susceptible 
to  attacks  of  asthma  or  hay  fever  there  is  nearly  always  some  other 
factor  needed  to  precipitate  a  seizure.  Rackemann^  classifies  the  causes 
of  asthma  as  follows:  (1)  Extrinsic  or  those  due  to  the  inhalation  of  horse 
dandruff,  plant  pollens,  feather  dust,  etc.  (2)  Intrinsic  or  those  due  to 
pathological  conditions  in  the  nose  or  throat,  uterine  disorders,  gastro- 
intestinal disturbances,  etc.  In  the  intrinsic  group  is  included  a  variety 
of  conditions  the  correction  of  which  has  brought  about  a  cure  of  the 
asthma.  Cooke-  distinguishes  the  two  groups  respectivelj^  as  (1) 
Specific  or  anaphylactic  and  (2)  nonspecific  or  not  demonstrably 

The  effect  of  the  inhalation  of  various  dusts  or  odors,  particularly 
the  odors  emanating  from  animals,  is  one  of  the  most  remarkable  features 
of  asthma.  In  one  individual  the  emanations  from  the  horse  provoke 
a  seizure;  in  another  the  presence  of  a  cat  will  give  rise  to  an  attack;  while 
in  still  others  rabbits  or  guinea-pigs  are  the  offending  animals.  A  medical 
friend  previously  free  from  the  disease,  always  developed  asthmatic 
attacks  after  a  visit  to  the  animal  room  of  the  laboratory  in  which  he 
worked.  Exposure  to  the  emanations  of  the  animals  even  for  a  few 
minutes,  would  lead  to  some  difficulty  in  breathing.  Not  knowing  which 
animal  was  the  cause  of  his  trouble  he  made  cutaneous  tests  with  the 
serum  of  the  different  animals.  The  serum  from  the  rabbit  gave  a  slight 
reaction,  while  that  from  the  guinea-pig  in  the  course  of  a  few  minutes, 
produced  at  the  site  of  the  inoculation,  a  marked  urticarial  swelling.     The 

^Archives  of  Internal  Medicine,  Oct.,  1918. 
^Medical  Clinics  of  N.  Amer.,  Nov.,  1917. 


skin  test  is  also  employed  in  the  case  of  hay  fever  patients  to  determine 
which  particular  pollen  is  the  offender. 

The  sensitiveness  of  many  inchviduals  to  the  pollen  of  various  weeds 
and  flowers  has  long  been  recognized  and  in  the  case  of  a  susceptible 
individual  the  inhalation  of  pollen  may  give  rise  to  an  attack  of  hay  fever 
or  asthma  or  both.  In  other  instances  the  inhalation  of  pungent  odors, 
such  as  that  given  off  bj^  mustard,  will  lead  to  an  attack.  Finally,  expo- 
sure to  an  excessive  amount  of  dust,  of  whatever  nature,  will  often  produce 
a  seizure. 

The  studies  of  Walker  and  his  associates  at  the  Peter  Bent  Brigham 
Hospital  have  thrown  much  light  on  the  cause  of  asthma.  Thej'  have 
shown  the  frequency  with  which  the  asthmatic  is  hypersensitive  to  some 
protein  substance.  Wliile  in  some  instances  the  offending  protein  is 
readily  detected,  as  for  example  in  the  cases  of  so-called  horse  asthma, 
in  others  the  search  may  be  long  and  devious.  Careful  study  of  the 
patient  and  his  smToundings  usually  suggests  the  clue  while  the  skin  test 
completes  the  incriminating  e^adence.  In  150  cases  carefully  studied 
by  Walker  55  per  cent,  were  found  sensitive  to  some  protein.  Of  this 
group  horse  hair  and  horse  dandruff  were  the  causes  in  about  20  per  cent. ; 
wheat  proteins  in  15  per  cent.;  bacteria,  staphylococcus  aureus,  in  15 
per  cent.;  pollens  of  spring  flowers  in  15  per  cent.;  pollens  of  autumnal 
flowers  in  10  per  cent.;  the  cat  in  5  per  cent.;  etc. — (Fourth  Annual 
Report  of  Peter  Bent  Brigham  Hospital,  1918).  Walker  and  others 
have  shown  that  patients  are  commonly  sensitive  to  the  proteins  of 
several  types  of  hair  or  pollens  and  in  such  cases  the  immunizing  treat- 
ment should  be  directed  toward  the  protein  which  gives  the  greater 
degree  of  sensitization. 

T\Tiile  the  inhalation  of  the  protein  is  the  most  common  mode  of 
introduction  into  the  body  it  has  been  shown  that  asthmatic  seizures 
may  be  caused  by  the  ingestion  of  certain  foods,  notably  the  cereal 
grains.  Walker^  states  that  of  20  patients  who  were  sensitive  to  wheat 
alone,  15  were  relieved  of  asthma  when  wheat  was  omitted  from  the  diet 
and  Tm^nbulP  found  that  individuals  sensitive  to  pollens  experienced  a 
diminution  of  their  symptoms  by  abstaining  from  bread  and  boiled 
cereals.  Other  articles  of  food  which  may  be  mentioned  in  this  con- 
nection are  eggs,  potatoes,  fish  and  casein. 

Hypotheses  as  to  the  Cause  of  Asthma. — Of  the  many  hypotheses  which 
have  been  advanced  to  explain  the  cause  of  an  asthmatic  attack  but  two 
are  worthy  of  serious  consideration,  namely:  (1)  spasm  of  the  circular 
fibers  of  the  bronchial  wall;  and  (2)  a  rapid  swelling  of  the  mucous  mem- 
brane of  the  bronchi.  While  the  first  hypothesis  is  the  one  most  gener- 
ally accepted  as  the  immediate  cause  of  the  attack  it  is  probable  that  the 
second  factor  also  plays  a  part  and  that  both,  rather  than  either  one 
alone,  are  concerned  in  producing  the  phenomena  of  an  asthmatic  seiz- 
ure. Asthma  is  caused  by  a  disturbance  of  function,  the  immediate 
manifestation  of  which  is  a  characteristic  form  of  paroxysmal  dyspnea. 
There  is  no  disease  of  the  bronchi  or  pulmonar\^  tissue,  although  repeated 
attacks  over  a  long  period  of  years  usually  lead  to  secondary  changes. 

The  most  rational  explanation  of  the  asthmatic  seizure  is  to  be  found 
in  the  phenomenon  of  OMaphylaxis  which  may  be  produced  experimentally 

_  ^Archives  of  Internal  Medicine,  Oct.,  1918. 
^Boston  Med.  and  Surg.  Jour.,  Oct.,  191S. 


in  animals  by  the  injection  of  an  alien  proteid.  If,  for  instance,  a  guinea- 
pig  be  given  a  subcutaneous,  intraperitoneal  or  intravenous  injection  of 
normal  horse  serum,  and  then,  after  an  interval  of  ten  days  or  more  this 
injection  be  repeated,  it  is  found  that  in  the  elapsed  time  the  animal  has 
become  sensitized,  and  that  while  the  first  injection  has  been  without 
noticeable  harmful  effect,  the  second  injection  causes  a  very  violent 
poisoning.  Both  the  symptoms  and  the  anatomical  changes  resulting 
from  this  poisoning  are  predominantly  respiratory  in  nature.  An  ani- 
mal so  poisoned  will  within  a  minute  or  so  after  the  second  injection, 
vigorously  rub  its  nose,  frequently  give  a  spasmodic  sneeze  and  then 
begin  to  breathe  rapidly.  Quickly  following  this  it  is  noted  that  the 
sides  of  the  chest  sink  in  with  each  inspiration  and  finally  the  respira- 
tions become  very  slow  and  labored.  The  animal  shortly  shows  tonic 
and  clonic  convulsions,  the  mucous  membranes  of  the  mouth  and  tongue 
become  bluish  and  often  a  spurt  of  urine  is  seen.  After  a  brief  interval 
in  which  respiration  ceases  entirely  the  breathing  is  resumed,  the  respira- 
tions being  slow  and  causing  but  little  movement  of  the  chest ;  gradually 
the  respirations  become  weaker  and  weaker  and  finally  cease  entirely. 
Auer  and  Lewis  state  that  the  characteristic  feature  of  anaphylaxis,  as 
seen  in  the  guinea-pig,  is  extreme  distention  and  immobilization  of  the 
lungs.     Anatomically  the  following  condition  is  found: 

"The  diaphragm  is  much  less  arched  than  in  normal  animals  after 
death.  On  opening  the  chest  the  lungs  present  a  striking  sight;  the 
lungs  do  not  collapse,  as  normal  lungs  do  when  the  thoracic  cavity  is 
opened,  but  remain  almost  fully  distended.  They  look  pale  bluish  pink, 
and  apparently  form  a  cast  of  the  thoracic  cavity.  Even  when  excised 
in  toto  there  is  practically  no  collapse  and  the  posterior  surfaces  often 
clearly  show  the  markings  of  the  ribs.  The  lungs  are  light,  soft  and 
spongy  and  float  on  water  like  a  cork.  On  cutting  away  pieces  of  lung 
tissue  these  pieces  do  not  collapse,  but  remain  distended;  the  cut  surface 
is  usually  dry  and  on  pressure  a  good  amount  of  air  may  be  expressed. 
Occasionally  this  pressure  reveals  some  small  foci  of  white  foam,  as  if 
there  were  beginning  pulmonary  edema;  occasionally  small  hemorrhages 
w^ere  seen  on  the  surface  of  the  lungs.  The  trachea  and  bronchi  usually 
were  dry,  but  showed  often  a  marked  congestion  of  the  mucosa." 

The  explanation  of  this  extreme  inflation  of  the  lungs  in  association 
with  the  difficulty  in  breathing  is  to  be  ascribed  to  a  tetanic  contraction 
of  the  muscles  of  the  finer  bronchioles  so  that  the  air  is  imprisoned  in  the 
alveolar  sacs.  Auer  and  Lewis  state  that  the  anatomical  basis  for  this 
is  clear  and  that  the  condition  can  be  easily  recognized.  The  finer 
bronchioles  are  practically  nothing  but  muscular  tubes  and  muscle  fibers 
are  also  present  in  the  alveolar  ducts.  The  contraction  of  their  struc- 
ture, therefore,  must  have  a  profound  effect  upon  the  volume  of  air  pass- 
ing to  and  from  the  alveoli  and  the  condition  may  be  still  farther  aggra- 
vated by  submucous  edema  of  the  bronchi.  The  opportunity  to  examine 
the  lungs  of  an  individual  who  has  died  during  an  asthmatic  attack 
rarely  occurs  so  that  it  is  not  possible  to  compare  the  conditions  found  in 
man  and  experimental  animals  from  the  anatomical  standpoint.  We  do 
know,  however,  that  in  man  both  the  symptoms  and  physical  signs  point 
strongly  to  marked  over-distention  of  the  lungs;  that  the  air  is  taken  in 
with  difficulty  and  expelled  with  even  greater  cUfficulty;  and  that  the 
condition  abruptly  ceases  either  spontaneously  or  often  as  the  result  of 


an  injection  of  atropine.  Everything  points,  therefore,  to  spasm  of  the 
bronchioles  as  being  the  immediate  cause  of  the  phenomenon. 

Taking  up  next  the  exciting  cause  of  the  attack  it  will  be  recalled 
that  in  considering  the  etiology  we  pointed  out  that  an  asthmatic  seizure 
or  an  attack  of  hay  fever  was  often  precipitated  by  the  inhalation  of 
some  form  of  dust  or  animal  odor.  In  the  anaphylactic  phenomenon  as 
seen  in  animals,  "The  reaction  of  intoxication  would  seem  to  be  a  cellular 
one,  dependent  upon  a  heightened  power  of  assimilation  on  the  part  of 
cells  which  have  been  subjected  to  the  anaphylactic  substance  over  a 
definite  period  of  incubation"  (Gay  and  Southard).  As  a  general  rule 
we  have  no  knowledge  of  how  man  has  become  sensitized  to  various 
substances,  exposure  to  which  induces  an  attack.  That  sensitization 
has  taken  place,  however,  there  can  be  no  doubt  as  contact  with  certain 
animals,  the  inhalation  of  certain  pollens,  etc.,  promptly  induces  in  some 
individuals,  an  attack  of  asthma  or  hay  fever  or  both.  Attacks  which 
are  induced  by  overeating  or  constipation  may  also  be  explained  on  the 
ground  of  proteid  intoxication.  In  those  instances  in  which  attacks 
occur  in  one  locality  and  not  in  another  it  is  probable  that  the  particular 
substance  to  which  the  individual  is  sensitive  is  present  in  one  place  and 
not  in  another.  This  assumption  is  amply  borne  out  by  the  fact  that 
hay  fever  patients  either  escape  an  attack  entirely  or  have  their  symp- 
toms greatly  modified  by  residence  in  a  locality  which  is  free  from  the 
pollen  to  which  they  are  especially  susceptible. 

Finally,  we  have  to  consider  the  question  of  heredity  upon  which 
much  stress  has  been  laid.  It  has  become  traditional  to  ascribe  to  the 
majority  of  individuals  who  suffer  from  asthma  or  hay  fever,  a  neurotic 
tendency.  This  hypothesis  it  seems  to  me  has  no  real  basis  in  fact  and 
to  perpetuate  it  is  a  mistake.  If  we  accept  the  theory  that  the  primary 
cause  of  asthma  or  hay  fever  be  a  cellular  hypersensitiveness  to  certain 
substances,  it  can  easily  be  seen  that  this  sensitiveness  may  very  readily 
be  transmitted  from  parent  to  child.  And  here  again  the  experimental 
data  may  be  applied  to  the  disease  as  seen  in  man.  Thus  it  has  been 
shown  in  animals  that  if  the  female  be  sensitized  to  an  alien  proteid,  such 
as  normal  horse  serum,  susceptibilitj'  to  this  proteid  is  transmitted  to 
her  offspring. 

Admitting  that  there  are  instances  in  which  it  is  not  possible  to  deter- 
mine the  exciting  cause  and  admitting  also  that  an  asthmatic  attack 
rarely  if  ever  ends  fatally  it  must  be  conceded  that  the  fulminant  type 
of  respiratory  distress  which  may  be  produced  experimentally  in  animals 
bears  a  close  analogy  to  the  asthmatic  seizures  which  occur  in  man. 

The  so-called  anaphylactic  reactions  of  asthma,  etc.,  are  commonly 
regarded  as  exceptional  and  pathological  events,  but  we  must  suspect 
a  qualitatively  similar,  if  quantitatively  different,  biological  response 
whenever  the  sensitized  being  breathes  air  containing  the  appropriate 
excitant   (Sewall) . 

Symptoms. — The  essential  feature  of  asthma  is  a  paroxysmal  attack 
of  dyspnea.  The  attack  may  occur  with  explosive  suddenness  or  it  may 
be  preceded  by  premonitory  symptoms.  The  latter  are  varied  in  charac- 
ter and  occur  in  about  one-half  of  the  cases.  An  individual  subject  to 
the  disease  can  often  predict  an  attack  because  of  drowsiness,  neuralgia, 
itching,  irritability  or  sneezing.  In  other  instances  the  attack  is  pre- 
ceded by  flatulency  or  marked  diuresis.     I  have  already  referred  to  the 


role  played  by  odors,  exposure  to  which  will  bring  on  a  seizure  within  a 
a  few  minutes. 

The  first  evidence  of  the  attack  itself  is  a  feeling  of  tightness  or 
oppression  in  the  chest.  This  may  be  present  for  a  day  or  so  or  it  may 
manifest  itself  suddenly.  The  attack  may  occur  at  any  time  but  it  has 
long  been  noted  that  it  is  apt  to  manifest  itself  in  the  night.  The  patient 
goes  to  bed  feehng  perfectly  well,  when  he  is  suddenly  awakened  by  a 
feehng  of  suffocation  or  constriction  about  the  chest.  The  difficulty  in 
breathing  rapidly  increases  and  often  reaches  an  extreme  degree.  The 
face  is  pale  and  anxious  and  may  be  covered  with  a  cold  perspiration. 
Owing  to  the  deficient  oxygenation  of  the  blood  the  lips  are  usually  of 
a  dusky  hue  and  in  a  severe  attack  the  face  maj^  also  be  of  a  leaden  or 
dusky  color.  The  eyes  may  protrude  and  the  nostrils  may  be  dilated. 
In  the  effort  to  obtain  more  air  the  patient  may  rush  to  an  open  window. 
More  often,  however,  he  assumes  a  fixed  position.  This  may  be  standing 
up  with  the  hands  grasping  some  support  or  sitting  up  in  bed  with  the 
hands  pressed  upon  the  bed.  In  either  case  the  object  is  to  give  an  addi- 
tional purchase  to  the  accessory  muscles  of  respiration.  The  head  may 
be  thrown  back  or  it  may  be  thrust  forward  and  sunk  between  the 
shoulders,  "turtle-like." 

The  mechanical  difficulty  in  asthma  is  in  expelling  the  air  from  the 
lungs.  The  lungs  are  greatly  distended  and  owing  to  the  spasm  of  the 
finer  bronchi  the  air  vesicles  are  incapable  of  emptying  themselves. 
The  inspirations  are  reduced  in  frequency,  sometimes  to  one-half  the 
normal.  The}'  are  jerky  in  character  and  much  shortened  in  duration, 
the  normal  ratio  between  inspiration  and  expiration  being  in  extreme 
cases,  reversed.  In  spite  of  the  desperate  efforts  on  the  part  of  the  patient 
the  chest  scarcely  moves  because  the  lungs  are  already  fully  distended. 
The  supraclavicular  and  suprasternal  depressions  are  more  pronounced 
and  the  intercostal  spaces  are  sunken. 

During  the  attack  the  pulse  may  be  small  but  usually  it  is  but  little 
affected  and  the  temperature  is  normal. 

The  duration  of  an  attack  may  be  from  10  or  15  minutes  to  several 
days,  but  when  prolonged  beyond  several  hours  the  severity  of  the 
symptoms  is  usually  diminished. 

There  is  no  disease  in  which  during  the  height  of  an  attack,  the 
symptoms  are  so  distressing  and  alarming  and  yet  at  the  same  time  are 
so  free  from  danger.  Death  rarely,  if  ever,  occurs  as  the  result  of  an 
attack  of  spasmodic  asthma. 

There  ma}'  be  a  short  dry  cough  at  the  onset  but  during  the  height 
of  the  attack,  cough  is  inconspicuous.  As  the  paroxj^sm  subsides  expec- 
toration usually  begins  and  this  is  attended  with  a  cough.  The  sputum 
at  first  occurs  in  the  form  of  small  grayish  pellets.  Later  it  gradually 
becomes  more  and  more  copious  and  also  changes  from  the  tenacious 
mucous  to  a  thin  froth}-  material.  In  very  violent  attacks  the  sputum 
may  be  blood-streaked.  Any  considerable  amount  of  blood,  however, 
is  probably  an  indication  of  some  associated  pulmonary  lesion.  Micro- 
scopically the  sputum  is  seen  to  contain  many  eosinophiles,  Charcot- 
Leyden  crystals  and  Curschmann's  spirals. 

I  have  already  referred  to  the  close  relationship  which  exists  between 
bronchial  asthma  and  hay  fever.  Individuals  who  are  subject  to  hay 
fever  as  a  rule  suffer  no  inconvenience  except  during  the  fall  of  the  year 


when  exposure  to  A'arioiis  pollens  is  common.  In  the  majority  of  hay 
fever  patients  the  symptoms  are  those  of  an  aggravated  attack  of  coryza. 
In  addition  they  are  apt  to  be  subject  to  sneezing,  a  paroxysmal  cough 
and  considerable  depression.  Disturbance  of  the  respiratory  function 
varies  greatly.  It  may  consist  of  nothing  more  than  a  slight  feehng  of 
constriction  or  it  may  be  indistinguishable  from  true  asthma.  Again, 
in  the  same  individual  the  coryza  symptoms  may  predominate  one  year 
while  at  another  time  the  asthmatic  sj'mptoms  are  the  most  severe. 
Occasionally  the  inhalation  of  the  poUens  will  give  rise  to  acute  gastro- 
intestinal disturbances  in  addition  to  hay-fever-like  manifestations.  An 
example  of  this  is  reported  by  de  Besche.^ 

Paroxysmal  attacks  of  sneezing  are  also  to  be  looked  upon  as  a  minor 
manifestation  of  irritation  of  the  finer  bronchi.  Finalh',  there  is  to  be 
considered  urticaria  which  usually  occurs  alone  but  maj'  be  associated 
with  asthma.  It  will  be  recalled  that  urticaria  is  a  well-recognized 
anaphylactic  phenomenon  and  frecjuently  is  seen  after  the  injection  of  a 
foreign  proteid.  Within  the  past  few  years  the  attempt  has  been  made 
to  show  that  eczema  is  a  manifestation  of  anaphylaxis  but  the  eAddence 
so  far  assured  is  far  from  conclusive. 

Attacks  of  bronchial  asthma  may  occur  at  intervals  for  years  without 
producing  changes  in  the  bronchi  or  pulmonarj'  tissue.  Cases  of  this 
type  are,  as  a  rule,  those  which  arise  as  the  result  of  exposure  to  some 
irritant  such  as  the  pollen  of  flowers  or  weeds  or  animal  odors.  In  many 
instances,  however,  the  attacks  occur  early  in  life  and  tend  to  increase 
in  severity.  Under  these  circumstances  the  individual  becomes  definitely 
"asthmatic."  Both  the  severity  and  the  duration  of  the  seizures  gradu- 
ally bring  about  permanent  over-distention  of  the  lungs  so  that  in  addi- 
tion to  being  subject  to  attacks  of  spasmodic  dyspnea  the  individual 
becomes  emphysematous. 

Physical  Signs. — Inspection. — The  general  features  of  an  attack  of 
asthma  have  been  dealt  with  in  describing  the  symptoms.  The  physical 
appearance  of  the  patient  will  depend  largely  on  the  duration  of  the 
disease.  If  chronic  and  of  long  standing  the  chest,  as  a  result  of  the 
associated  emphysema,  will  present  the  characteristic  barrel  shape  of 
the  latter  disease.  On  the  other  hand,  those  who  suffer  from  asthmatic 
attacks  only  occasionally,  or  who  have  but  recently  developed  the  disease, 
will  show  no  change  in  the  contour  of  the  chest. 

During  an  attack  there  are  two  striking  features  to  be  noted  by 
inspection:  (Ij  The  over-distention  of  the  chest,  and  (2)  the  very 
slight  expansile  movement  of  the  thorax.  This  is  in  striking  contrast  to 
the  forcible  action  of  the  accessory  muscles  of  respiration.  The  dia- 
phragm is  depressed  and  the  abdominal  muscles  rigid.  During  inspira- 
tion, which  is  short  and  quick,  the  intercostal  spaces  are  drawn  in.  In 
most  cases  the  prolongation  of  expiration  is  apparent  on  inspection. 

Palpation. — This  confirms  the  deficiency  of  the  expansible  movement 
of  the  chest  noted  on  inspection.  Vocal  resonance  may  be  normal  but 
if  the  attack  is  a  severe  one  it  may  be  greatly  diminished  partly  because 
of  the  over-distended  lung  and  partly  because  of  the  inabihty  of  the 
patient  to  speak  loudly. 

Percussion. — -'On  percussion  the  note  will  A^ary  from  that  which  is 
normal  to  one  which  is  markedly  hyperresonant.     The  degree  of  exaggera- 

^Jour.  Infect.  Dis.,  1918,  22,  p.  594. 


tion  of  the  resonant  quality  of  the  percussion  note  depends  on  the  amount 
of  associated  emphysema/  If  the  latter  condition  is  a. prominent  feature 
the  percussion  note  will  be  hyperresonant  all  over  the  chest  and  the 
area  of  cardiac  dulness  absent. 

Auscultation. — During  the  height  of  the  attack  the  vesicular  murmur 
is  usually  inaudible  and  instead  a  to-and-fro  wheezing  sound  is  heard. 
As  the  attack  begins  to  subside  innumerable  rales  are  heard  throughout 
the  chest.  At  first  the  rales  are  sibilant  and  sonorous  in  character  and 
may  be  both  low-  and  high-pitched.  Later  fine  moist  crepitant  and 
subcrepitant  rales  are  heard,  especially  over  the  lower  portions  of  the 
lungs.  The  short,  jerky  character  of  the  inspiratory  effort  and  the  pro- 
longation of  the  expiratory  act  are  plainly  evident  on  auscultation.  The 
vocal  fremitus  may  be  normal  or  exaggerated,  but  as  a  rule  the  distress 
of  the  patient  is  such  that  the  use  of  the  voice  is  not  attempted. 

Diagnosis.— The  term  asthma  should  be  restricted  to  that  form  of 
spasmodic  dyspnea  in  which  the  chief  feature  is  the  difficulty  in  emptying 
the  lungs,  that  is,  it  is  an  expiratory  form  of  dyspnea.  In  all  other  forms 
of  dyspnea  the  principal  difficulty  is  in  getting  air  into  the  lungs.  In 
those  instances  in  which  there  is  an  obstruction  in  the  upper  respiratory 
tract  there  may  be  trouble  both  in  inspiration  and  expiration.  Obstruc- 
tion most  commonly  occurs  in  the  larynx  or  trachea  and  may  be  brought 
about  by  edema  of  the  larynx,  diphtheria,  inflammatory  swelling  of  the 
larynx  due  to  some  irritant  or  the  obstruction  may  result  from  pressure 
without  as  by  tumors,  enlarged  lymph  nodes  or  a  thoracic  aneurism. 
In  such  cases  the  dyspnea  is  usually  quite  plainly  inspiratory  in  character 
and  is  also  apt  to  be  accompanied  by  a  stridor.  Aphonia  due  to  paralysis 
of  the  vocal  cords  may  occur  also.  These  cases,  as  a  rule,  offer  no  difla- 
culty,  but  in  an  individual  suffering  from  the  first  asthmatic  attack,  the 
various  causes  of  dj-spnea  should  be  borne  in  mind. 

Cases  of  chronic  heart  disease  frequently  suffer  from  dyspnea.  In 
some  instances  the  dyspnea  may  appear  suddenly  and  in  a  paroxysmal 
form.  The  inspiration  is  free,  and  the  expiration  is  not  prolonged. 
Examination  of  the  heart  will  give  the  correct  clue  to  the  origin  of  the 
trouble.  Attacks  of  paroxysmal  difficulty  in  breathing  which  appear 
first  after  middle  life  are  quite  commonly  cardiac  in  origin.  In  some  of 
these  cases  the  dyspnea  is  enhanced  by  the  coincident  presence  of 

Attacks  of  dyspnea,  sometimes  characterized  by  a  sudden  onset  are 
not  infrequent  in  cases  of  nephritis.  The  presence  of  edema,  a  high 
blood-pressure,  a  ringing  second  aortic  sound  and  the  urinary  findings 
serve  to  establish  the  true  nature  of  the  dyspnea. 

Having  established  the  fact  that  the  case  is  one  of  true  bronchial 
asthma  it  is  equally  important  to  determine,  if  possible,  whether  the 
exciting  cause  is  a  protein  and  if  so  the  particular  protein  for  on  this  fact 
depends,  to  a  great  extent,  our  ability  to  reheve  the  patient.  In  the  case 
of  hay  fever  or  of  asthmatic  attacks  obviously  related  to  exposure  to 
flowers  or  weeds,  skin  tests  made  with  the  extracts  of  the  pollen  from 
various  plants  will  usually  indicate  the  one  to  which  the  patient  is  alone 
or  most  susceptible.  If  an  animal  protein  is  the  offender  the  historj'  of 
the  case  will  usually  indicate  its  source.  Of  the  food  proteins  it  is  to  be 
borne  in  mind  that  wheat  is  the  most  common  offender.  In  those  in- 
stances in  which  the  more  common  protein  cannot  be  imphcated  a 


careful  study  should  be  made  of  the  patient's  environment;  especially 
as  regards  dust  exposure  and  also  his  cHetary  habits. 


In  individuals  who  have  suffered  from  one  of  the  various  inflam- 
matory affections  of  the  lungs  or  bronchi  some  degree  of  bronchial  dila- 
tation is  not  an  infrequent  finding  in  the  autopsy  room.  The  usual 
teaching  is  that  clinically  bronchiectasis  is  relativel}^  uncommon.  This, 
I  believe,  to  be  a  mistake.  The  currently  accepted  view  that  bronchiec- 
tasis is  always  characterized  by  large  quantities  of  very  foul  smelling 
sputum  and  that  it  is  almost  invariably  an  affection  of  the  lower  lobes, 
must  be  revised.  As  a  rule,  only  those  cases  are  recognized,  in  which 
the  condition  has  become  distinctly  apparent  and  in  which  the  symptoms 
are  typical;  and  even  in  these  cases  the  true  nature  of  the  trouble  is 
often  overlooked  in  the  belief  that  tuberculosis  is  present. 

Etiology.- — Dilatation  of  the  bronclii  is  practically  always  a  secondarj^ 
affection  and  may  be  traced  to  some  preceding  disease  of  the  bronchi, 
lungs  or  pleurge.  In  the  great  majority  of  cases  of  broncliiectasis  the 
condition  is  chronic  and  its  evolution  gradual.  Occasionally  it  is  met 
within  an  acute  form.     (See  article  on  Influenza.) 

In  considering  the  exciting  factors  the  classification  suggested  by 
Fowler^  is  the  most  satisfactory. 

A.  Intrinsic,  or  conditions  acting  directly  through  the  bronchi. 

1.  Bronchitis,  acute  or  chronic.  The  chronic  form  of  bronchitis  is 
most  likeh^  to  lead  to  bronchiectasis  as  the  long-standing  inflammatory 
process  tends  to  weaken  the  bronchial  wall.  As  the  result  of  severe 
attacks  of  coughing  the  weakened  wall  is  unable  to  resist  the  pressure  of 
air  and  hence  the  bronchi  dilate.  Another  factor  is  the  mechanical 
plugging  of  the  bronchioles  b}^  the  catarrhal  secretions.  A  slight  degree 
of  dilatation  of  the  bronchi  is  not  infrequently  met  with  in  cases  of  emphj^- 
sema  and  asthma  owing  to  the  fact  that  those  two  pulmonary  affections 
are  almost  constantly  associated  with  a  chronic  bronchitis. 

In  my  experience  one  of  the  most  frequent  causes  of  bronchiectasis 
is  the  prolonged  exposure  to  inorganic  dust.  At  first  the  dust  produces  an 
irritation  of  the  mucous  membrane  of  the  upper  respiratory  tract.  Later 
it  induces  a  subacute  inflammation  of  the  bronchial  mucous  membrane 
and  in  addition  leads  to  connective  tissue  proliferation  in  the  interlobular 
septa.  Of  21  potters  whom  I  have  had  under  observation  the  evidences 
of  dilatation  of  the  bronchi  were  present  in  10.  Dilatation  of  the 
bronchi  has  also  been  noted  very  frequently  in  cases  of  anthracosis. 

Of  the  microorganisms,  the  influenza  bacillus  seems  to  be  the  most 
important  as  a  causative  agent. 

2.  Xarrowing  of  the  lumen  of  the  bronchus.  This  may  be  caused 
by  a  gumma,  a  foreign  body,  or  by  pressure  from  without  as  in  the  case 
of  an  aneurism  or  a  tumor.  As  the  result  of  the  stricture  the  bronchial 
secretions  accumulate,  changes  in  the  bronchi  and  peribronchial  tissues 
take  place  and  the  surrounding  pulmonar}'  tissue  becomes  indurated. 
These  conditions  tend  to  weaken  the  bronchial  wall  and  if  there  be  added 
violent  expiratory  efforts  dilatation  ensues. 

Chevalier  Jackson^has  emphasized  the  importance  of  bearing  in  mind 

^  Fowler  and  GoDLEE :  "Diseases  of  the  Lungs,"  1898. 
-  Penna.  Med.' Jour.,  August,  1916. 


that  a  foreign  body  is  often  the  cause  of  bronchiectasis.  For  this  reason, 
all  cases  of  bronchiectasis  of  the  lower  lobes  should  have  an  X-ray 
examination  made. 

B.  Extrinsic,  or  causes  external  to  the  feronc/ms.— While  dilatation  can 
occur  as  the  result  of  changes  in  the  bronchus  alone  the  condition  is 
more  apt  to  develop  if  there  are,  in  addition,  associated  changes  in  the 
pulmonary  tissues. 

(a)  Tuberculosis. — In  a  very  considerable  number  of  cases  of  chronic 
ulcerative  tuberculosis  some  dilatation  of  the  bronchi  is  encountered, 
although  this  is  usually  not  recognized  clinically.  The  more  chronic 
the  tuberculosis  and  the  greater  the  amount  of  fibrous  tissue  present, 
the  more  certain  is  there  to  be  some  evidence  of  bronchiectasis.  In 
197  consecutive  cases  autopsied  at  the  Phipps  Institute  the  bronchi  were 
noted  as  being  dilated  in  the  upper  lobes  in  20  instances;  in  the  middle 
lobe  of  the  right  lung  9  times  and  in  the  lower  lobes  9  times.  In  6 
additional  cases  the  dilatation  was  sufficiently  marked  to  constitute  a  true 
bronchiectasis;  of  this  number  4  occurred  in  the  lower  lobes. 

(6)  Syphilis  may  cause  dilatation  of  the  bronchi  in  one  of  two  ways: 
(1)  In  the  form  of  a  gumma  obstructing  the  lumen  of  the  bronchus.  This 
has  been  considered  among  the  intrinsic  causes.  (2)  The  occurrence  of 
pulmonary  fibrosis  as  the  result  of  syphilis.  L.  A.  Conner^  in  a  study 
of  syphilitic  stenosis  of  the  trachea  and  bronchi  found  that  bronchiectasis 
did  not  occur  in  more  than  20  per  cent,  of  the  cases.  Just  as  in  tubercu- 
losis and  other  chronic  pulmonary  affections  he  considered  that  "much 
more  potent  factors  are  the  changes  occurring  in  the  bronchial  wall  and 
in  the  adjacent  lung  tissue,  by  which  the  muscular  and  elastic  tissue  of 
the  bronchi,  upon  which  their  strength  and  resilience  depend,  is  replaced 
by  inflammatorj^  tissue." 

(c)  Compression  of  the  Lung. — The  most  frequent  cause  of  compres- 
sion of  the  lung  is  a  pleural  effusion,  either  serous  or  purulent  in  character. 
If  the  effusion  is  unrecognized  and  the  lung  remains  compressed  for  some 
time  a  proliferation  of  connective  tissue  takes  place  in  the  collapsed  lung 
and  the  bronchi  also  dilate.  It  is  probable  that  the  dilatation  occurs, 
more  as  the  result  of  the  distending  force  of  the  cough,  acting  on  bronchi 
deprived  of  their  normal  support,  rather  than  the  associated  fibroid 
changes  in  the  lung. 

(d)  Croupous  and  Broncho-pneumonia. — Although  delayed  resolution 
following  croupous  pneumonia  is  frequently  given  as  one  of  the  exciting 
causes  of  pulmonary  fibrosis  and  bronchiectasis,  there  is  some  question 
as  to  whether  such  a  thing  as  "delayed  resolution"  ever  occurs.  If  it 
does  it  is  extremely  rare.  In  the  vast  majority  of  instances  what  is 
taken  for  delayed  resolution  is  in  reality  an  effusion.  As  a  result  the 
lung  becomes  compressed  and  if  the  compression  is  exerted  sufficiently 
long,  pulmonary  fibrosis  and  dilatation  of  the  bronchi  ensue. 

Bronchial  dilatation,  in  some  instances,  apparently  originates  in  an 
attack  of  broncho-pneumonia.  Under  these  circumstances  the  dilata- 
tion seems  to  arise  partly  as  the  result  of  the  associated  inflammatory 
condition  of  the  bronchi  and  adjacent  alveoli  and  partly  as  the  result 
of  collapse  of  air  vesicles  adjacent  to  the  pneumonic  process.  As  a  rule 
the  collapsed  vesicles  become  reexpanded  after  recovery  from  the  acute 

1  Am.  Jour.  Med.  Sc,  1905,  vol.  cxxx. 



attack.  If,  however,  the  change  is  permanent  the  atelectatic  areas 
undergo  a  fibroid  change  and  the  smaher  bronchi  dilate. 

(e)  Fibrosis  of  the  Lung. — This  will  be  considered  in  detail  under 
another  heading.  It  may  be  stated  here,  however,  that  in  practically 
every  case  in  which  there  is  an  overgrowth  of  fibrous  tissue  in  the  lungs, 
there  is  also  dilatation  of  the  bronchi. 

(6)  Inflammation  of  the  Pleura. — Marked  thickening  of  the  pleura 
is  a  frequent  finding  in  cases  of  bronchiectasis.  Some  observers  hold  the 
view  that  a  chronic  adhesive  pleurisy  is  one  of  the  factors  capable  of 
bringing  about  dilatation  of  the  bronchi,  but  this  is  difficult  to  prove. 

Fig.  221. — Fibrosis  of  the  right  upper  lobe  with  dilatation  of  the  bronchi.     Such  a  case 
would  give  the  signs  of  a  cavity. 

Inasmuch  as  the  two  conditions  not  infrequently  occur  independently 
of  each  other,  it  is  quite  probable  that  when  they  are  associated  they 
have  nothing  in  common. 

A  consideration  of  the  above  etiological  factors  shows  that  while 
weakening  of  the  bronchial  wall  is  the  essential  feature  in  all  cases  that, 
as  a  rule,  one  or  more  additional  factors  are  at  work  in  any  given  case. 
Besides  disease  of  the  bronchial  walls,  therefore,  the  effect  of  increased 
intrapulmonary  pressure,  the  pressure  of  accumulated  secretions  within 
the  bronchi,  and  various  chronic  affections  involving  the  parenchyma  of 
the  lung,  are  also  to  be  taken  into  consideration. 


Morbid  Anatomy.— Although  at  the  autopsy  table  a  large  number 
of  the  tubes  arc,  as  a  rule,  found  to  be  affected,  the  disease  in  the  early 
stage  is  much  more  limited.  The  successive  involvement  of  previously 
healthy  tubes  is  brought  about  by  the  inhalation  of  the  secretions,  mter- 
current  attacks  of  bronchitis,  septic  broncho-pneumonia  and  frequent 
cough.  The  condition  may  be  limited  to  one  lung  or  both  may  be 
affected.  In  35  cases  seen  in  the  Brompton  Hospital,  Fowler  states  that 
in  23  cases  (or  65  per  cent.)  both  lungs  were  affected;  the  lesion  was 
limited  to  one  lobe  in  only  8.  In  52  autopsies  Lebert  found  that  the 
condition  was  limited  to  one  lung  in  52  per  cent,  and  that  in  48  per  cent, 
both  were  involved.     It  is  usually  believed  that  the  lower  lobes  are  most 

Fig.   222. — The  bronchiectatic  cavities  have  been  laid  open,  revealing  their  wide  extent 
and  intercommunication.      {Jefferson  Medical  College  Musemn.) 

commonly  mvolved  and  that  localized  dilatation  of  the  bronchi  in  the 
apices  of  the  lungs  is  unusual.  Lebert,  however,  found  unilateral  upper 
lobe  involvement  in  11  per  cent,  of  his  cases.  In  chronic  non-tuberculous 
affections  bilateral  involvement  is  the  most  frequent  while  in  tuberculous 
cases  unilateral  and  apical  involvement  is  the  most  common.  Apical 
involvement  is  also  quite  common  in  cases  of  pneumoconiosis.  McCrae 
and  Funk^  have  reported  5  cases  of  apical  bronchiectasis,  4  of  which 
were  associated  with  tuberculosis  (see  Fig.  222). 

Two  main  varieties  of  bronchiectasis  are  recognized,   namely,   the 
cylindrical  and  the  globular  or  sacculated. 

1  Jour.  Am.  Med.  Assoc,  Oct.  7,  1916. 


In  the  cylindrical  form  the  dilatation  is  uniform,  the  smaller  bronchi 
retaining  the  size  of  the  larger  division  instead  of  diminishing  in  diameter. 
The  bronchi  tend  to  progressively  increase  in  size  toward  their  terminal 
extremities,  thus  giving  rise  to  an  appearance  resembling  that,  of  the 
fingers  of  a  glove  (Wilson  Fox) .  This  type  of  the  disease  is  well  illustrated 
in  Fig.  222.  A  subvariety  of  the  cylindrical  form  is  the  fusiform  type,  in 
which  the  dilated  bronchi  taper  somewhat  toward  their  terminal  extremity. 

Fig.  224. — An  unusual  example  of  fibroid  phthisis  with  extensive  dilatation  of  the  bronchi. 

{Pennsylvania  Hospital.) 

The  sacculated  type  shows  the  most  extreme  degree  of  dilatation. 
In  this  form  the  tube  may  dilate  at  a  single  point,  forming  a  pseudo- 
cavity.  A  number  of  these  may  occur  in  one  tube,  the  caliber  of  the  inter- 
vening portions  remaining  approximately  normal.  The  sacculation 
may  involve  only  one  side  of  the  tube,  the  remainder  of  the  circumference 
retaining  its  normal  shape.  A  subvariety  of  the  sacculated  form  is 
that  in  which  the  affected  bronchus  presents  a  number  of  bead-like  dila- 
tations which  have  been  Hkened  to  a  rosary  (Fox). 


The  cylindrical  type  of  dilatation  is  usually  found  in  the  larger  and 
medium-sized  tubes.  While  the  sacculated  type  may  occur  in  the 
larger  tubes,  it  is  most  commonly  encountered  in  the  terminal  bronchi. 
All  types  of  dilatation  may  be  seen  in  one  lung. 

The  largest  and  most  extensive  bronchiectases  are  encountered  in 
lungs  which  have  undergone  marked  fibroid  changes  (see  Figs.  223  and 

Associated  Changes  in  the  Lungs. — The  pulmonary  changes  have 
been  very  tersely  expressed  by  Walshe  as  follows:  "The  surrounding 
tissue  is  either  slightly  condensed  by  pressure,  hardened  by  chronic 
pneumonia,  rarefied  by  emplwsema  or  perfectly  natural."  A  septic 
{3roncho-pneumonia  due  to  inhalation  of  the  secretions  is  not  an  infre- 
quent terminal  event  and  occasionally  gangrene  of  the  lung  occurs  as 
the  result  of  perforation  of  the  bronchial  dilatation. 

Changes  in  Other  Organs. — Dilatation  of  the  right  heart  may  occur  as 
the  result  of  the  obstructed  circulation  in  the  lungs.  Owing  to  the  stag- 
nation of  septic  material  in  the  bronchial  tubes  the  absorption  of  toxins 
frequently  leads  to  amyloid  change  in  the  liver  and  kidne^-s.  Abscess 
of  the  brain  not  infrequently  has  its  origin  in  a  bronchiectasis. 

Changes  in  the  Extremities. — One  of  the  peculiar  features  of  the  disease 
is  the  remarkable  change  which  takes  place  in  the  extremities.  While 
clubbing  of  the  fingers  and  toes  occurs  in  other  conditions,  it  is  seen  in 
its  most  extreme  form  in  bronchiectasis.  And  the  same  is  true  of  hyper- 
trophic pulmonary  osteoarthropathy.  These  two  conditions,  which  are 
almost  exclusively  associated  with  diseases  of  the  lungs,  will  be  considered 
under  a  separate  heading. 

Symptoms. — It  can  be  readily  understood  that  the  symptoms  vary 
greatl}'  in  difTerent  cases.  In  many  instances  the  symptoms  are  so 
slight  or  are  so  masked  by  associated  changes  in  the  bronchi  or  lungs 
th-at  the  presence  of  bronchiectasis  is  not  even  suspected.  Keeping  in 
mind  the  various  conditions  with  which  the  condition  is  commonly  asso- 
ciated will  often  lead  to  a  correct  diagnosis.  In  a  small  proportion  of 
cases  the  diagnosis  can  be  made  from  the  presence  of  two  symptoms, 
namely,  a  paroxysmal  cough  which  maj^  occur  but  two  or  three  times  a 
day  and  the  expectoration  of  large  quantities  of  purulent  sputum  which 
may,  in  some  cases,  be  horribly  fetid.  Coughing  paroxysms  are  most 
marked  in  the  morning  and  again  at  night  when  the  patient  lies  down. 
This  often  serves  to  empty  the  cavities  and  it  is  not  until  they  again  fill 
up  that  the  paroxysm  is  repeated.  The  sputum  may  be  raised  easily  or 
it  may  be  brought  up  only  after  a  severe  coughing  attack. 

The  sputum,  which  msiy  amount  to  20  ounces  or  more  in  24  hours,  is 
usually  yellowish  in  color  and  on  standing  separates  into  three  layers. 
The  lower  layer  is  opaque  and  grayish  in  color;  the  middle  consists  of  a 
thin,  turbid  fluid,  and  on  top  of  this  is  a  frothy,  brownish-colored  layer. 

In  cases  of  long  duration  the  sputum  often  has  a  horribly  fetid  odor. 
There  is  probably  no  disease  in  which  the  sufferer  becomes  such  an  ob- 
ject of  aversion  to  his  family  as  bronchiectasis.  I  recall  one  patient,  a 
lad  of  seventeen,  who  practically  became  an  outcast  because  of  his 
affliction.  In  this  case  the  whole  house  became  permeated  with  the 
gangrenous  odor  of  his  sputum  after  a  coughing  attack.  In  another  case 
in  which  the  bronchiectatic  cavities  were  emptied  during  the  adminis- 

Fig.  223. — Carnification  of  the  lung  -^-ith  dilatation  of  the  bronchi  as  the  prominent 
featiire.  This  lung  on  section  presented  the  appearance  of  a  series  of  coalesced  rings 
measuring  from  5  to  15  mm.  in  diameter.      (Case  No.  4702,  Phipps  Institute.) 


tration  of  an  anesthetic,  the  odor  was  so  nauseating  that  several  of  the 
onlookers  vomited  at  once. 

Sputum  of  the  type  described  is  not  bj'  any  means  the  rule,  however. 
Among  a  very  considerable  number  of  cases  of  bronchiectasis  I  have 
seen  there  were  but  four  or  five  in  which  the  sputum  was  fetid.  It  is 
rarely  so  if  the  bronchiectasis  is  conjGined  to  the  apices  as  the  drainage 
is  freer  and  the  secretions  do  not  stagnate  in  the  bronchi. 

Blood-streaked  sputum  and  even  small  hemoptyses  are  of  not  in- 
frequent occurrence  and  occasionally  death  is  produced  by  a  large  pul- 
monary hemorrhage.  The  smaller  hemorrhages  are  due  to  ulceration 
of  the  bronchial  wall;  the  larger  ones  to  an  erosion  of  a  branch  of  the 
pulmonary  artery.  Dyspnea  is  usually  a  prominent  symptom  when  the 
disease  becomes  well  established.  It  niay  be  due  to  a  variety  of  causes; 
dilatation  of  the  right  side  of  the  heart,  emphysema,  extensive  fibrosis 
of  the  lung,  fixation  of  the  diaphragm,  etc. 

Pain  may  occm^  during  the  course  of  the  disease  from  extension  of 
the  pleural  inflammation. 

As  the  chsease  progresses  circulatory  chstm'bances  are  apt  to  become 
more  and  more  marked  until  finally  all  the  evidences  of  failing  compen- 
sation develop. 

In  spite  of  the  large  amount  of  septic  material  wiiich  is  more  or  less 
constantly  stagnating  in  the  bronchi,  constiivMonal  symptoms  are  not 
marked.  As  a  rule  cases  of  bronchiectasis  are  afebrile  although  thej"  are 
apt,  at  times,  to  have  periods  of  fever  due  to  intercurrent  attacks  of  bron- 
chitis or  broncho-pneumonia  as  the  result  of  the  invasion  of  a  new^  area  of 
bronchial  or  pulmonary  tissue.  During  these  attacks  the  cough  is  more 
severe  and  night  sweats  commonly  occur. 

For  varying  periods  of  time  the  general  health  is  httle  if  any  impaired 
but  as  time  goes  on  there  is  a  gradual  deterioration  in  strength  and 
nutrition  and  finally  death  ensues  as  the  result  of  cardiac  failure,  general 
cachexia,  or  some  terminal  infection. 

Physical  Signs. — Inspection. — Extreme  clubbing  of  the  fingers  is 
so  commonlj^  associated  vnXh  dilatation  of  the  bronchi  as  to  be  of  decided 
value  in  diagnosis.  The  toes  maj'  be  clubbed  also  and  in  some  instances 
the  end  of  the  nose  becomes  bulbous  in  appearance. 

Owing  to  the  fact  that  dilatation  of  the  bronchi  is  secondary-  to  such 
a  variety  of  diseases  and  the  changes  produced  by  these  diseases  are  so 
chverse  in  character,  the  ph3'sical  signs  vary  tremendously.  In  some 
instances  the  bronchiectasis  is  deep  seated  and  gives  rise  to  no  signs  what- 
soever. A  case  of  this  t^^pe  was  seen  recently  at  the  Phipps  Institute. 
The  patient  complained  of  cough  and  expectoration  but  the  examination 
of  the  chest  failed  to  reveal  any  abnormalitA'.  Several  weeks  later  the 
patient  died  as  the  result  of  a  brain  abscess.  At  the  autops}-  deep-seated 
dilatation  of  the  bronchi  was  found  in  the  lower  lobe  of  the  right  lung. 

The  cases  which  most  frequenth^  escape  detection  are  those  in  which 
the  affection  is  bilateral  and  associated  with  chronic  bronchitis,  emphy- 
sema, or  diffuse  bilateral  fibrosis  of  the  lungs;  or  in  which  tuberculosis 
and  bronchiectasis  coexist.  In  these  cases  the  emphysema  or  tuber- 
culosis tends  to  mask  the  bronchial  affection.  The  condition  may  be 
suspected  if  marked  clubbing  of  the  fingers  is  present,  in  what  seenis  to 
be  a  case  of  emphysema,  or  if  cavity  signs  are  more  marked  in  the  lower 


In  the  bilateral  cases,  the  chest  shows  no  discrepancy  between  the 
two  sides;  it  may  be  normal  in  appearance  or  of  the  emphysematous 


The  type  of  bronchiectasis  which  is  most  freciuently  recognized  is  that 
which  involves  a  part  or  all  of  one  lung.  In  these  cases  there  is  marked 
retraction  of  the  affected  side  and  expansion  is  greatly  diminished  or 
entirely  absent.  The  heart  is  usually  displaced  towards  the  affected 

Palpation. — If  emphj-sema  is  present  the  tactile  fremitus  is  reduced. 
In  unilateral  involvement  associated  with  pulmonary  fibrosis  the  fremitus 
is  increased. 

Percussion. — The  character  of  the  percussion  note  will  depend  almost 
entirely  on  the  nature  of  the  associated  pulmonary  changes  and  the 
location  of  the  dilatations.  In  deep-seated  broncliiectases  without  any 
change  in  the  parenchyma  of  the  lung,  the  note  is  normal;  if  emphysema 
is  present,  it  is  hyperresonant,  and  if  consolidation  has  occurred  as  the 
result  of  a  chronic  interstitial  pneumonia,  the  note  will  be  dull. 

When  the  disease  is  confined  to  one  side  the  opposite  lung  is  usually 
hypertrophied  as  the  result  of  compensatory  emphysema.  This  is  in- 
dicated bj-  the  fact  that  the  pulmonary  resonance  extends  beyond  the 
middle  line  anteriorly;  in  addition  loud  puerile  breathing  will  be  heard 
on  this  side. 

Superficially  placed  dilatations  will  give  rise  to  a  high-pitched  tym- 
panitic note.  If  the  dilatations  are  numerous  a  distinct  tympanitic 
quality  may  be  lacking  but  will  influence  the  other  percussion  changes 
by  raising  the  pitch.  In  unilateral  cases  the  area  about  the  angle  of  the 
scapula  is  where  one  is  most  apt  to  elicit  a  tympanitic  note. 

Auscultation. — The  auscultatory  signs  present  the  greatest  variations. 
If  the  condition  is  bilateral  the  respiratory  sounds  may  be  identical  with 
those  heard  in  emphysema  or  they  may  be  slightly  suppressed  with  a 
bronchovesicular  ciuality,  especially  during  expiration.  In  the  unilateral 
cases  associated  with  fibrosis,  the  breath  sounds  are,  for  the  most  part, 
suppressed  but  in  certain  areas  are  definitely  cavernous.  The  latter 
type  of  breathing  is  very  frequenth'  heard  at  the  angle  of  the  scapula. 
Over  the  area  in  which  cavernous  breathing  is  heard  bronchophony  and 
whispering  pectoriloquy  may  be  marked.  Skoda  s  veiled  puff  is  often 
referred  to.  This  sound  occurs  at  the  end  of  inspiration  and  sounds  as 
though  a  puff  of  air  were  entering  a  cavity  situated  just  beneath  the  ear. 
In  my  experience  this  sign  is  not  often  present. 

Rales  of  every  description  may  be  heard.  When  coarse  and  metallic 
in  quahty  they  are  strongly  suggestive  of  cavity  formation  or  bronchial 

A  systolic  murmui-  at  the  base  of  the  heart  is  freciuently  present.  In 
the  later  periods  of  the  disease  a  mitral  murmur  of  relative  insufficiency 
is  often  present  in  addition  to  other  evidences  of  failing  compensation. 

Diagnosis. — In  \dew  of  the  number  of  diseases  associated  with 
bronchiectasis  it  is  not  surprising  that  the  condition  is  so  frequently 
overlooked  clinically.     The  following  conditions  must  be  considered: 

Tuberculosis.- — If  the  bronchiectasis  occurs  in  the  lower  lobes  there 
should  be  no  confusion  as  tuberculosis  almost  invariably  starts  at  the 
apex  and  extends  downward.  If  the  bronchi  of  the  upper  lobe  are 
dilated  it  is  not  possible  to  distinguish  the  two  conditions,  inasmuch  as 


a  tuberculous  excavation  and  the  dilated  bronchi  give  rise  to  the  same 
physical  signs.  Fig.  221  illustrates  very  clearly  how  a  mistake  might 
occur.  When  one  entire  lung  is  involved  or  both  lungs  are  implicated 
the  true  nature  of  the  trouble  cannot  be  determined  without  a.  sputum 
examination;  and  in  any  case  this  always  should  be  done.  The  ma- 
jority of  mistakes  are  due  to  neglect  of  this  simple  procedure.  In 
examining  the  sputum  it  is  important  to  keep  in  mind  that  acid-fast 
streptothrix  organisms  not  infrequently  occur  in  bronchiectasis.  To  the 
inexperienced  these  organisms  could  be  mistaken  very  readily  for  tubercle 
bacilli.  In  a  case  under  observation  at  the  Phipps  Institute,  my  colleague, 
Paul  Lewis,  found  that  the  sputum  contained  a  streptothrix  which 
in  the  size  of  the  individual  organism  closely  resembled  the  tubercle 
bacillus.  Instead  of  being  clumped,  however,  the  organisms  were  ar- 
ranged in  long  chains  and  interlacing  filaments.  They  resisted  a  20  per 
cent,  sulphuric  acid  solution  but  were  readily  decolorized  with  30  per  cent, 
nitric  acid.  Guinea-pigs  inoculated  with  the  sputum  failed  to  develop 
tuberculosis.  When  both  tuberculosis  and  bronchiectasis  coexist  it  is 
often  impossible  to  recognize  the  presence  of  dilated  bronchi.  They  are 
to  be  suspected  if  extreme  clubbing  of  the  fingers  is  present  and  if  in  addi- 
tion, there  are  signs  of  a  cavity  in  the  area  about  the  angle  of  the  scapula. 
Tuberculosis  alone  does  not  produce  extreme  clubbing  of  the  fingers.  The 
history  of  the  case  will  also  indicate  in  some  instances,  that  the  bron- 
chiectasis antedates  the  tuberculous  infection. 

Moore^  has  studied  25  cases  of  bronchiectasis  by  means  of  roentgen  rays. 
He  states  that  a  definite  diagnosis  of  the  condition  was  made  by  this 
means  in  19  cases,  a  diagnosis  of  probable  bronchiectasis  in  2,  while  in 
four  cases  the  roentgen  diagnosis  was  incorrect.  He  distinguishes  three 
types,  namely,  the  infiltrative,  the  cylindrical  and  the  sacculated.  The 
infiltrative  type  appears  in  the  roentgenogram  as  a  more  or  less  stringy 
increase  in  density  along  the  course  of  the  bronchi,  usually  localized  in  the 
lower  lobes  and  radiating  outward  from  the  hilus  to  the  periphery  of  the 
lung.  This  type  is  not  distinctive  and  is  readily  mistaken  for  simple 
thickening  of  the  bronchial  wall. 

Abscess  of  the  Lung. — In  abscess  of  the  lung  the  characteristic  feature 
is  the  sudden  expectoration  of  a  large  quantity  of  mucopurulent  material, 
often  of  a  sweetish  odor.  In  the  majority  of  cases  of  abscess  the  patient 
is  acutely  ill  or  has  recently  recovered  from  an  acute  illness.  In  bronchi- 
ectasis the  development  of  the  disease  is  gradual  and  not  sudden  as  in 
abscess.  In  the  case  of  a  small  chronic  abscess  the  distinction  is  difficult. 
An  X-ray  examination  may  be  of  service.  In  case  of  doubt  an  explora- 
tory operation  should  be  advised  as  an  abscess,  if  present,  can  be  cured 
if  proper  drainage  is  secured. 

Loculated  Empyema. — At  times  an  encysted  empyema,  especially  when 
situated  between  the  lobes  of  the  lung,  ruptures  into  a  bronchus.  Under 
these  circumstances  it  is  essentially  the  same  as  a  pulmonarj^  abscess. 

Gangrene  of  the  Lung. — Pulmonary  gangrene  is  usually  sudden  in  onset 
and  may  be  one  of  the  sequels  of  a  pulmonary  infarct,  croupous  or  bron- 
cho-pneumonia or  tuberculosis.  If  gangrene  of  the  lung  occurs  in  an 
individual  with  a  history  of  long  standing  bronchitis  it  may  be  very  diffi- 
cult to  distinguish  it  from  bronchiectasis  with  gangrenous  changes  in 

^Amer.  Jour.  Roentgenology,  Nov.,  1916. 


the  bronchi.     The  presence  of  elastic  tissue  in  the  sputum  would  be  in 
favor  of  pulmonary  gangrene. 

Chronic  Brotichitis.—As  a  rule  the  presence  of  dilated  bronchi  m  a 
case  suffering  from  chronic  bronchitis  can  only  be  surmised.  It  should 
be  suspected  if  there  is  marked  clubbing  of  the  fingers  and  there  is  in  addi- 
tion the  expectoration  of  thin,  mucopurulent  material  with  a  fetid  odor. 
There  may  also  be  signs  indicative  of  a  cavity  especially  in  the  lower  lobes 
of  the  lungs. 

Fetid  or  Putrid  Bronchitis 

In  those  cases  in  which  bronchiectasis,  gangrene,  or  cavities  contain- 
ing a  fetid  secretion  can  be  excluded  and  in  which  there  are  the  physical 
signs  of  bronchitis,  it  has  been  customary  to  designate  the  condition  as 
fetid  or  putrid  bronchitis.  The  affection  is  in  reality  a  form  of  bron- 
chiectasis. In  such  cases  the  dilatation  of  the  bronchi  is  not  sufficiently 
marked  to  give  the  physical  signs  commonly  associated  with  bronchi- 
ectasis. Since  the  introduction  of  the  X-rays,  however,  it  has  become 
apparent  that  cases  which  in  former  times,  would  have  been  classed 
as  fetid  bronchitis  are  in  reality  examples  of  bronchiectasis.  By  means 
of  stereoscopic  plates  small  dilatations  of  the  bronchi  can  be  shown. 
Aside  from  the  physical  signs  the  clinical  features  of  fetid  bronchitis 
are  essentially  the  same  as  those  occurring  as  the  result  of  well-marked 
dilatation  of  the  bronchi.  The  cough  may  be  paroxysmal  in  charac- 
ter and  followed  by  the  expectoration  of  a  foul  smelling  sputum.  The 
expectorated  matter  is  usually  thin,  grayish-white  in  color  and  on 
standing  separates  into  three  layers:  the  upper  layer  is  frothy  and  often 
of  a  greenish  color,  the  middle  layer  is  serous  in  character  and  slightly 
cloudy  and  the  third  layer  consists  of  a  sediment  in  which  may  sometimes 
be  found  small  dirty  yellow  masses  known  as  Dittrich's  plugs.  As  in 
the  case  of  true  bronchiectasis  abscess  of  the  brain  is  not  an  uncommon 
terminal  event. 


This  term  is  applied  to  a  form  of  bronchiectasis  in  which  the  patho- 
logical changes  are  limited  to  the  bronchioles.  Although  this  type  of 
the  disease  was  described  many  years  ago  by  Carr,i  ^f  England,  it  has 
been  almost  entirely  overlooked  in  this  country. 

Etiology. — The  condition  is  not  common  and  occurs  almost  exclusively 
in  young  children  who  are  poorly  nourished,  syphihtic  or  rachitic.  The 
exciting  cause  is  generally  some  one  of  the  acute  infections  such  as  whoop- 
ing cough,  measles,  diphtheria,  etc.  Bronchiolectasis  is,  as  a  rule,  an 
acute  affection. 

Morbid  Anatomy. — The  condition  is  bilateral  and  may  involve  a 
large  part  or  even  all  of  both  lungs.  The  lungs  are  usually  bulky  and 
scattered  over  the  surface  there  may  be  a  number  of  small  transparent 
bladder-like  elevations  which  correspond  to  the  small  cavities  within  the 
lungs.  On  section  the  lungs  present  a  worm-eaten  or  honeycombed 
appearance  due  to  the  numerous  small  cavities.  The  cavities  are  small, 
the  largest  about  the  size  of  a  pea,  have  smooth  walls  and  contain  either 
air  or  a  frothy  mucus.  The  bronchi  are  unaffected.  In  addition  to  the 
dilatation  of  the  bronchioles  there  is  usually  present  a  peribronchial  in- 
1  Practitioner,  1891,  vol.  xlvi ,  p.  87. 


flammation,  patches  of  broncho-pneumonia  and  some  compensatory 

Occasionally  a  chronic  form  of  the  disease  occurs.  In  such  cases 
chronic  interstitial  changes  take  place  in  the  pulmonary  tissue  surround- 
ing the  dilated  bronchioles.  This  leads  to  fibrosis  of  the  affected  parts 
with  retraction  of  the  lung. 

Symptoms. — Cough  is  the  most  prominent  symptom  and  as  the 
disease  advances  tends  to  become  paroxysmal.  It  may  resemble  whoop- 
ing cough.  In  very  young  children  there  may  be  no  expectoration  as  it 
is  swallowed,  but  if  the  child  vomits,  pus  may  be  mixed  with  the  stomach 
contents.  Fever  may  be  absent  but  with  the  successive  development  of 
patches  of  broncho-pneumonia  the  temperature  often  rises  to  103°  or 

Anemia  and  emaciation  are  usually  marked  features  in  children  who 
develop  this  condition. 

As  a  rule  the  disease  is  acute  and  death  may  occur  as  early  as  two 
weeks  from  the  onset.  In  some  instances  it  becomes  chronic  and  may 
exist  for  three  or  four  years  or  longer. 

Physical  Signs. — In  the  chronic  cases  marked  clubbing  of  the  fingers 
may  be  noted.  As  the  disease  is  bilateral  in  most  instances  there  is  no 
noticeable  difference  in  the  two  sides.  Scattered  rales  throughout  both 
lungs  may  be  heard  and  they  may  be  of  all  varieties.  If  they  have  a 
ringing  metallic  quality  they  are  very  suggestive  of  cavities.  The 
percussion  note  and  breath  sounds  may  show  little  if  any  abnormality. 
If  the  process  is  more  or  less  localized  in  one  or  both  lower  lobes  the 
percussion  note  may  be  impaired  or  it  may  have  a  tympanitic  quality. 
Under  these  circumstances  the  breath  sounds  may  be  suppressed,  broncho- 
vesicular  or  even  bronchial,  depending  somewhat  on  the  presence  of  an 
associated  pneumonic  process. 

Diagnosis.- — Acute  tuberculosis  is  the  condition  most  likely  to  be 
confused  with  bronchiolectasis.  The  physical  signs  in  both  conditions 
may  simulate  each  other  closely.  Fowler  has  pointed  out  that  in  bron- 
chiolectasis the  general  symptoms  are  not  nearly  so  severe  as  one  would 
expect  from  the  physical  signs  and  that  improvement  of  the  child  may  be 
noted  while  the  evidences  of  pulmonary  damage  are  increasing. 

In  acute  tuberculosis  fever  is  nearly  always  a  marked  feature,  and 
emaciation  is  progressive  and  marked.  If  sputum  cannot  be  obtained 
the  pus  in  the  vomited  matter  should  be  examined  for  tubercle  bacilli. 


The  aspiration  of  a  foreign  body  into  the  air  passages  is  now  recog- 
nized as  a  relatively  common  accident.  But  while  the  number  of  in- 
stances reported  in  the  literature  is  in  the  aggregate  fairly  large,  the 
opportunity  of  seeing  many  of  these  cases  does  not  often  fall  to  the  lot 
of  individual  observers.  The  first  detailed  study  of  the  results  of  foreign 
bodies  lodging  in  the  air  passages  was  that  made  by  Stokes.^  In  1854 
Gross ^  contributed  a  monograph  on  the  subject.  Since  that  time  there 
have  been  a  number  of  contributions.     In  1909  Eicken^  reported  303 

1  "Diseases  of  the  Chest,"  New  Sydenham  Society. 

2  "Foreign  Bodies  in  the  Air  Passages." 

3  Deut.  Klinik,  vol.  xii,  1909. 


cases  in  which  the  bronchoscope  had  been  used  to  extract  a  foreign  body. 
The  most  comprehensive  presentation  of  the  subject  in  American  litera- 
ture has  been  made  by  Chevalier  Jackson.  ^ 

Etiology.- — A  great  variety  of  articles  may  gain  entrance  into  the 
air  passages.  The  object  may  be  one  normally  taken  into  the  mouth, 
such  as  an  article  of  food;  or  it  may  be  one  held  in  the  mouth  for  con- 
venience, such  as  a  pin;  or,  as  in  the  case  of  small  children,  toys  or  other 
small  objects  may  be  placed  in  the  mouth.  The  aspiration  of  the  foreign 
bod}'  usually  follows  some  sudden  and  unexpected  inspiratory  effort 
such  as  may  accompany  coughing,  laughing,  a  fright  or  a  blow  on  the 
back.  Under  these  circumstances  the  foreign  body  may  enter  the  larynx 
during  ''what  may  be  termed  a  moment  of  surprise  on  the  part  of  the 
epiglottis  while  raised  in  the  act  of  a  sudden  deep  inspiration."  The 
most  frequent  mannei-  in  which  a  foreign  body  gets  past  the  protective 
mechanism  and  into  the  air  passages  is  described  by  Jackson  as  follows: 
The  intruder  is  detected  escaping  downward  over  the  dorsum  of  the 
tongue  into  or  toward  the  pharynx.  The  tongue  and  muscles  of  the 
fauces  and  pharynx  make  a  robust  effort  to  catch  and  extrude  the  in- 
truder, resulting  in  gagging,  hawking,  choking  or  coughing.  These 
movements  are  followed  by  a  sudden  and  deep  inspiration.  It  is  this 
inspiration  blast  that  carries  the  intruder  into  the  lower  air  passages, 
the  protective  mechanism  being  held  in  abeyance  by  the  coordination 
usual  during  the  inspiratory  phase.  In  other  instances,  insensibility  of 
the  upper  air  passages  as  the  result  of  sleep,  narcosis  or  coma  may  permit 
the  entrance  of  a  foreign  body.  Occasionally  a  foreign  body,  in  the  form 
of  food,  enters  the  larynx  during  the  act  of  vomiting. 

Of  590  cases  in  Jackson's  series,'-  492  (81.6  per  cent.)  were  patients 
under  fifteen  years  of  age.  Tliis  is  to  be  explained  by  the  fact  that  small 
children  have  a  habit  of  placing  all  sorts  of  objects  in  their  mouths. 

Any  article  capable  of  passing  the  glottis  may  be  drawn  into  the 
larynx  during  a  forced  inspiration.  Among  the  commoner  objects  may 
be  mentioned  needles,  pins  of  various  kinds,  tacks,  small  toys  or  parts  of 
toj's,  pieces  of  meat,  seeds  of  various  kinds,  especially  peanuts  and  frag- 
ments of  bones.  In  one  case  observed  by  me  an  extracted  tooth  entered 
the  larynx  during  nitrous  oxide  anesthesia. 

Morbid  Anatomy. — Complete  blocking  of  the  laryngeal  opening  by 
a  foreign  bod}'  is  fortunately  not  common,  although  such  accidents 
do  occur  and  ma}''  be  followed  by  death  within  a  few  minutes.  In  such 
cases  a  large  piece  of  meat  is  the  most  common  offender. 

Having  passed  the  glottis  the  foreign  body  may  lodge  in  one  of  the 
ventricles  of  the  larynx.  In  the  majority  of  instances  the  object  passes 
down  the  trachea  and  in  about  80  per  cent,  of  the  cases  enters  the  right 
bronchus.  Almost  invarial)ly  the  foreign  body,  if  it  passes  the  main 
branches  enters  the  lower  lobe  branch.  There  are  but  four  cases  re- 
corded in  which  an  upper  lobe  bronchus  was  invaded.  The  great  liability 
of  the  right  side  is  due  to  the  fact  that  the  right  primary  bronchus  is 
larger  and  straighter  than  the  left  (see  Figs.  225  and  226).  The  passage 
downward  of  the  foreign  body  is  facilitated  by  gravity  and  by  the  in- 
spiratory widening  of  the  trachea  and  main  bronchi.  The  rapidity 
with  which  the  foreign  substance  passes  downward  is  due  in  part  to  its 

1  "Peroral  Endoscopy  and  Laryngeal  Surgerj^,"  1915. 

-  Trans,  of  Sec.  on  Laryngology,  Otology  and  Rhinology,  1917,  p.  36. 



size  and  part  to  the  shape  of  the  object.  In  any  case  there  is  produced 
irritation  and  spasm  of  the  larynx  and  trachea  and  more  or  less  severe 
paroxysms  of  coughing  in  the  effort  to  dislodge  the  object.  As  a  rule 
the  severity  of  the  symptoms  subside  with  the  final  lodgment  of  the 
foreign  body  in  one  of  the  larger  branches  of  the  bronchial  tree. 

Spontaneous  expulsion  of  the  foreign  substance  may  occur  at  an 
early  period  or  months  or  years  may  elapse.  In  one  case  under  my  care 
a  tooth  was  coughed  up  eighteen  months  after  it  had  aspirated  into  the 
bronchi;  in  another  case  a  brass-headed  tack  was  expelled  four  or  five 

Fig.  225. — Trachea  and  bronchi  viewed  from  behind.  Note  the  larger  size  of  the  right 
bronchus  and  its  straighter  course.  The  nail  shown  in  the  glass  tube  had  lodged  in  the 
right  bronchus  at  A  where  it  ulcerated  through  into  the  lung.  {Jefferson  Medical  College 

years  after  it  had  entered  the  bronchus.  In  124  cases  recorded  by  Dur- 
ham in  which  recovery  followed  spontaneous  expulsion,  the  interval  in  28 
of  the  cases  was  from  one  to  seventeen  years.  Jackson  has  reported 
cases  in  which  the  foreign  body  was  removed  some  years  after  the  initial 
accident;  in  one  case  an  interval  of  twenty-six  j^ears  had  elapsed. 

Spontaneous  expulsion  will  depend  on  the  nature  of  the  foreign  body. 
If  it  is  small  and  devoid  of  sharp  points  it  may  be  coughed  up  but  if  it 
is  long,  narrow  and  sharp-pointed,  such  as  a  hair  pin  or  a  safety  pin,  the 
only  hope  of  relieving  the  patient  lies  in  turgical  interference  or  the  use 
oi  the  bronchoscope. 

If  the  foreign  substance  remains  in  the  larynx  edema  may  develop 
later.     The  end  results  of  lodgment  in  one  of  the  bronchi  are  varied. 


The  first  change  is  simple  inflammatory  swelling  of  the  mucous  membrane. 
If  the  substance  remains  the  inflammation  persists,  eventually  becoming 
chronic  and  with  it  there  is  apt  to  be  some  ulceration.  As  bacteria  are 
commonly  carried  by  the  foreign  body  infection  occurs  and  this  may 
rupture  thi'ough  the  bronchus  giving  rise  to  a  localized  abscess.  In 
addition  there  is  usually  more  or  less  of  an  inflannnatory  change  or  abscess 
formation  in  the  surrounding  pulmonary  tissue.  This  eventually  becomes 
chronic  and  gives  rise  to  fibrosis  with  or  without  dilatation  of  the  bronchi 
in  the  affected  portion.  Partly  as  the  result  of  inflammatory  changes 
which  swell  the  mucous  membrane  and  partly  as  the  result  of  the  foreign 
bodv  itself  the  bronchus  is  obstructed,  ending  in  an  abscess  below  the 

Fig.  226. — Xo.  1-191-1  (Phipps  Institute).  Child  age  six.  Cough,  3  years.  Physical 
signs  of  a  chronic  inflammatory  condition  at  right  base.  Onset  of  symptoms  indefinite. 
X-ray  showed  fibrosis  of  lung  and  dilated  bronchi,  due  to  a  bent  hatpin  measuring  2)>^ 
inches  in  length  with  the  head  down  and  the  point  up. 

foreign  body.  Later  sloughing  or  ulceration  follows  in  the  tissues  sur- 
rounding the  foreign  body  and  permitting  the  slow  escape  of  the  pus. 
The  bronchial  wall  may  be  destroyed  by  ulceration  and  chondrial 
necrosis.  In  some  cases  the  foreign  body  may  fall  to  the  bottom  of  the 
abscess  cavity  or  as  the  result  of  being  firmly  imbedded  it  maj'  remain 
fixed  in  its  original  site.  Although  the  bronchial  stenosis  is  usually 
followed  by  dilatation  of  the  bronchi  below  the  point  of  obstruction  the 
air  passages  may  remain  normal  in  size  although  filled  with  pus.  The 
term  "drowned  lung"  has  been  suggested  for  this  condition.  Later,  if 
the  obstruction  is  not  removed,  a  true  bronchiectasis  may  develop. 
In  the  case  of  a  rounded  object  complete  occlusion  of  a  bronchus  may 


occur  ^Yith  collapse  of  the  lung  tissue  to  which  the  bronchus  is  dis- 
tributed. In  some  instances  a  fibrinous  or  serofibrinous  pleurisy  occurs. 
Rarely  the  visceral  layer  of  the  pleura  is  perforated  and  an  empyma  or 
pneumothorax  develops. 

Broncho-pneumonia  or  lobar  pneumonia  sometimes  develops  within 
a  few  daj's  of  the  aspiration  of  a  foreign  body.  If  the  foreign  substance 
consists  of  a  bolus  of  food  and  the  particles  enter  the  finer  bronchi  a 
septic  bronchopneumonia  is  almost  certain  to  occur. 

Symptoms. — The  symptoms  produced  by  the  aspiration  of  a  foreign 
body  into  the  air  passages  may  be  divided  into  primary  and  secondary 
manifestations,  between  which  a  period  of  comparative  latency  may 

Immediately  following  the  entrance  of  the  foreign  bod}^  into  the 
larj'nx  the  patient  is  seized  with  a  paroxysm  of  cougliing,  becomes 
dyspnoic  and  cyanosed.  In  most  instances  the  patient  experiences  the 
sensation  of  suffocation.  If  the  body  is  large  the  patient  may  present 
the  appearance  of  one  strangling  to  death.  The  eyes  protrude,  the 
face  becomes  livid,  and  there  may  be  vomiting,  convulsions  and  finally 
loss  of  consciousness.  Death  may  occur  within  a  few  minutes — but 
fortunately  this  accident  is  relatively  rare.  The  violence  of  the  initial 
symptoms  may  last  from  a  few  minutes  to  an  hour  or  more  and  may 
recur  at  intervals. 

Succeeding  the  acute  symptoms  there  may  be  some  hoarseness  if  the 
vocal  cords  have  been  injured  or  the  foreign  body  remains  in  the  larynx. 
There  maj'  be  a  sense  of  soreness  beneath  the  sternum  and  very  often 
the  tenderness  is  referred  to  the  right  of  the  sternum.  Expectoration, 
if  present,  is  scanty  and  may  be  blood-tinged.  Dyspnea  and  cough  may 
persist,  recur  in  paroxysms  or  entirely  disappear  for  a  time. 

Price^  in  reporting  30  cases  from  Chevalier  Jackson's  clinic  states  that 
the  immediate  effect  produced  by  the  foreign  body  was  choking  spells  in 
21;  coughing  in  14;  dyspnea  in  14;  dyspnea  occurring  later  in  4,  cyanosis 
in  5,  spasmodic  cough  in  4,  bloody  expectoration  in  5,  inspiratory  crow- 
ing in  2  and  aphonia  in  1.  Jackson  emphasizes  the  importance  of  these 
initial  symptoms.  In  a  number  of  cases  observed  by  him  the  possibility 
of  a  foreign  body  being  present  had  been  ridiculed  or  ignored.  It  must 
not  be  forgotten  that  a  foreign  body  may  lodge  in  the  bronchi  without 
causing  sj^mptoms,  even  cough,  for  an  interval  of  a  number  of  weeks 
between  the  initial  choking  and  the  vague  onset  of  bronchial  and  later, 
general  symptoms.  Thorn vaP  has  reported  16  cases  some  of  which 
had  no  symptoms  whatever  until  some  time  had  elapsed.  All  but  2 
of  these  cases  were  children. 

The  secondary  manifestations  develop  insidiousl3^  The  cough  gradu- 
ally becomes  w^orse  and  is  attended  with  considerable  mucopurulent 
expectoration.  In  some  cases  tuberculosis  is  suspected  because  of  the 
hectic  type  of  fever,  sweating  and  loss  of  weight.  In  others  there  is  a 
gradually  developing  fibrosis  of  the  affected  portion  of  the  lung,  dilata- 
tion of  the  bronchi  and  all  the  symptoms  of  bronchiectasis,  namely: 
a  paroxysmal  cough,  large  quantities  of  purulent  sputum,  some  fever 
and  clubbing  of  the  fingers.  The  sudden  expectoration  of  a  large  quan- 
tity of  purulent  material  may  be  the  first  intimation  of  a  pulmonary 

^  Penna.  Med.  Jour.,  December,  1915. 
^  Ugeskrift  for  Laeger,  Dec.  23,  1915 


abscess.  Exertion  or  change  of  posture  sometimes  brings  on  a  paroxysm 
of  coughing. 

No  matter  what  the  particular  lesion  is,  permanent  lodgment  of  a 
foreign  body  in  the  lung  is  usually  attended  with  cough,  the  expectora- 
tion of  purulent  sputum,  some  fever  and  often  with  loss  of  weight. 

If  the  patient  is  seen  within  a  day  or  so  of  the  accident  the  upper  air 
tract  should  be  examined  with  a  laryngoscope.  If  there  is  available 
one  who  can  use  the  bronchoscope  this  method  should  also  be  utilized. 
In  all  cases  stereoscopic  X-ray  plates  of  the  chest  should  be  made. 

Physical  Signs. — As  a  rule  there  is  nothing  distinctive  in  the  physical 
signs  which  may  he  encountered  in  cases  with  a  foreign  body  in  the  lungs. 
The  signs  are  usually  those  of  some  other  familiar  condition  such  as 
fibrosis  of  the  lung,  bronchiectasis,  abscess,  empyema,  or  pneumothorax. 

Jackson^  has  described  a  new  sign,  the  asthmatoid  wheeze,  which 
he  believes  will  be  of  great  value,  especially  in  those  instances  in  which 
the  foreign  body  is  permeable  to  the  X-rays.  The  asthmatoid  wheeze 
is  elicited  by  oral  auscultation,  the  ear  of  the  examiner  being  placed 
close  to  the  open  mouth  of  the  patient.  It  resembles  the  wheezing  of  the 
asthmatic  patient,  but  is  drier.  It  is  best  elicited  during  forced  and 
prolonged  expiration  or  following  coughing.  In  many  cases  it  is  readily 
detected  during  mirror  laryngoscopy  in  older  children  and  adults. 

Diagnosis. — In  the  absence  of  any  history  of  the  accident  one  should 
always  be  alert  to  the  possibility  of  a  foreign  body  in  cases  simulating 
tuberculosis  but  in  which  the  physical  signs  are  limited  to  one  of  the 
lower  lobes.  The  same  is  true  of  bronchiectasis.  In  the  presence  of 
these  two  conditions  a  foreign  body  is  constantly  overlooked. 

In  some  instances  the  foreign  body  may  completely  block  one  of 
the  large  bronchi  and  cause  collapse  of  all  or  a  large  portion  of  a  lower 
lobe.  In  such  cases  the  absence  of  breath  sounds  and  dulness  may  lead 
to  a  diagnosis  of  fluid. 

Inasmuch  as  a  variety  of  conditions  maj-  be  caused  by  the  lodgment 
of  a  foreign  substance  in  the  bronchi  or  pulmonary  tissue  the  physical 
signs  give  no  direct  clue  as  to  its  presence.  The  occurrence  of  such  a 
possibility,  however,  is  always  to  be  borne  in  mind  when  the  signs  are 
limited  to  the  lower  lobes,  especially  the  right  lower  lobe.  We  have  made 
it  a  routine  practice  at  the  Phipps  Institute  to  have  an  X-ray  examina- 
tion made  in  all  cases  of  this  nature  and  every  now  and  then  are  rewarded 
with  the  finding  of  a  foreign  body.  Even  if  the  X-rays  fail  to  show  a 
foreign  body,  valuable  evidence  is  often  obtained  by  the  showing  of  a 
localized  inflammator}^  area  in  the  lung  which  may  suggest  the  true 
nature  of  the  trouble.  As  the  value  of  the  X-rays  is  limited  chiefly  to 
metallic  objects  the  bronchoscope  should  be  emploj-ed  whenever  possible. 
By  using  the  latter  instrument,  pieces  of  bone,  beans  or  other  articles  of 
food  may  be  discovered  which  will  often  escape  detection  in  the  X-ray 
plate.  In  the  hands  of  a  skilled  operator  bronchoscopy  is  the  method  of 
choice,  as  it  is  possible  to  directly  locate  the  foreign  body  and  at  the  same 
time  remove  it.  Price  warns  against  the  use  of  the  bronchoscope  by 
those  not  possessing  the  requisite  skill.  He  reports  three  cases  in  which 
broncho-pneumonia  followed  the  trauma  produced  by  unsuccessful 
attempts  to  use  the  instrument. 

1  A7ner.  Jour.  Med.  Sc,  Nov.,  1918. 



"Consumption  of  the  lungs  may  be  traced  with  certainty  in  the  writ- 
ings of  every  period  as  far  back  as  the  earhest  attempts  of  the  ancient 
world  to  deal  with  medicine  according  to  method.  Historj^  does  not 
inform  us,  however,  of  the  extent  to  which  the  maladj^  had  been  prevalent 
during  former  times  in  various  parts  of  the  world  ....  But  there  can 
be  no  question  that  pulmonary  consumption  has  held  at  all  times  and 
among  all  civilized  peoples  a  foremost  place  among  the  national  diseases. 
In  our  own  age,  at  all  events,  it  occupies  one  of  the  leading  positions  in 
the  statistics  of  mortality."^ 

The  above  quotation  holds  as  true  to-daj^  as  when  written  fortA"  j^ears 
ago  and  in  spite  of  the  fact  that  the  mortality  rate  of  this  disease  has 
been  steadily  falling,  tuberculosis  must  still  be  looked  upon  as  one  of 
the  great  scourges  of  civilization.  In  this  country  it  is  the  cause  of  about 
one-tenth  of  the  deaths  annuallj^ 

So  far  as  diseases  of  the  chest  are  concerned  a  thorough  knowledge 
of  the  various  manifestations  of  tuberculosis  is  essential.  The  term 
"protean"  is  often  applied  to  other  diseases  but  in  no  instance  is  the 
designation  more  applicable  than  in  the  case  of  tuberculosis.  In  every 
individual  who  presents  himself  with  symptoms  referable  to  the  thorax  the 
possibility  of  the  trouble  beiruj  due  to  tubercidosis  must  always  be  considered, 
no  matter  whether  the  affection  is  acute  or  chronic. 

Not  only  is  tuberculosis  the  most  important  single  disease  the  practic- 
ing physician  has  to  deal  with  but  in  addition  it  possesses  the  greatest 
interest  to  the  sanitarian  by  reason  of  its  widespread  prevalence  among 
domestic  animals.  Tuberculosis  is  not  uncommonly  found  in  pigs,  and 
among  cattle  it  is  very  prevalent.  As  we  derive  all  of  our  milk  and  a 
large  proportion  of  our  meat  from  bovine  sources,  it  is  essential  that 
measures  be  taken  to  prevent  the  spread  of  the  disease  bj^  the  adequate 
inspection  of  abattoirs  and  daily  herds  and  further,  by  the  pasteuriza- 
tion of  all  milk. 

Three  types  of  tuberculosis  of  the  lungs  are  recognized:  (1)  chronic 
pulmonary  tuberculosis;  (2)  acute  pulmonary  tuberculosis;  and  (3) 
fibroid  tuberculosis. 


Chronic  pulmonary  tuberculosis  is  also  known  as  tuberculosis  of  the 
lungs,  chronic  ulcerative  tuberculosis,  phthisis  and  consumption. 

Etiology. — The  cause  of  tuberculosis  is  the  tubercle  bacillus,  the  source 
of  which  is,  in  the  vast  majority  of  cases,  the  sputum  from  human  cases 
and,  to  a  lesser  extent,  the  milk  from  tuberculous  cows. 

The  tubercle  bacillus  gains  entrance  into  the  body  in  a  number  of  waj^s : 

1  Hirsch's  "Handbook  of  Geographical  and  Historical  Pathology,"  1876. 



(1)  The  most  important  modeof  infection  is  by  ?'«/ia/a^/o/i.  In  the  great 
majority  of  instances  the  infection  occurs  from  the  inhalation  of  dust  in 
which  are  carried  the  tubercle  bacilli.  Careless  habits  on  the  part  of  a 
consumptive  are  entirely  responsible  for  this.  The  sputum,  which  is 
recognized  as  the  principal  source  of  infection,  is  not  dangerous  in  the 
moist  state  and  if,  in  every  instance,  it  was  destroyed  in  this  condition, 
the  disease  practically  could  be  stamped  out.  Spitting  on  the  floor  in 
the  house  or  the  immediate  surroundings  of  the  home  or  in  working  places 
permits  of  the  sputum  becoming  dried  and  mixed  with  the  dust.  Houses 
or  working  places  which  are  dark  and  badly  ventilated  are  especially 
favorable  to  prolonging  the  life  of  the  tubercle  bacillus  which  quickly 
succumbs  when  exposed  to  the  light  and  air. 

Flligge  advanced  the  theory  that  the  chief  source  of  infection  was 
through  the  minute  droplets  which  are  expelled  during  coughing.  These 
he  believed  are  inhaled.  "While  they  may,  in  some  instances,  play  a  part, 
it  is  now  generally  accepted  that  the  inhalation  of  infected  dust  is  the 
chief  source  of  the  disease  in  adults. 

In  most  instances  exposure  to  the  disease  must  be  prolonged  and  under 
the  conditions  mentioned  above.  There  is  no  danger  from  the  expired 
breath  of  consumptives  nor  from  associating  with  those  who  are  careful 
in  their  habits.  For  this  reason  a  tuberculosis  sanatorium  is  probably 
the  safest  place  one  can  be  so  far  as  the  danger  of  infection  is  concerned. 
Statistics  dealing  with  those  who  have  been  employed  for  years  in  tuber- 
culosis sanatoria  show  that  infection  practically  never  occurs  among 
these  workers. 

Until  the  study  of  marital  injection  by  Pope  and  Pearson^  appeared 
it  was  generally  believed  that  the  infection  of  a  wife  by  her  husband 
or  vice  versa,  was  very  common.  These  observers  from  an  analysis 
of  a  large  number  of  cases,  concluded  that  while  there  was  some  slight 
danger  from  this  source  the  majority  of  such  instances  could  be  ascribed 
to  infection  from  other  sources,  to  the  presence  of  the  necessary  diathesis 
and  to  assortive  mating. 

2.  For  some  years  there  was  a  tendency  to  minimize  the  danger  from 
inhalation  and  place  infection  by  ingestion  in  the  first  place.  Infection 
through  the  digestive  tract  undoubtedly  plays  an  important  part  but 
not  to  the  extent  once  believed.  The  point  of  entrance  maj-  be  through 
the  tonsils  or  the  intestinal  mucous  membrane.  The  tonsillar  and  in- 
testinal routes  are  more  common  in  childhood  than  adult  life.  In  young 
children  the  intestinal  mucous  membrane  seems  to  be  especially  per- 
meable and  many  children  are  known  to  become  infected  by  being  fed 
milk  containing  bovine  tubercle  bacilli. 

3.  Localized  injection  may  occm'  in  those  who  perform  autopsies. 
in  butchers,  in  handlers  of  hides,  or  in  those  who  handle  clothing  or 
utensils  used  by  consumptives.  As  a  rule  the  infection  takes  the  form 
of  a  small,  localized,  reddened,  granulation  mass  on  the  fingers  or  hand. 
Occasionally  the  infection  may  not  appear  at  the  point  of  inoculation 
but  is  carried  to  the  group  of  lymph  nodes  in  the  axilla. 

4.  The  rarest  mode  of  infection  is  the  direct  transmission  of  the 
disease  from  the  mother  to  the  fetus.  This  is  so  unusual  as  to  be 
negligible.  To  date  only  fifty-one  cases  of  undoubted  congenital  tubercu- 
losis are  on  record.     An  investigation  in  Copenhagen  showed  that  of  317 

^  "Marital  Infection,"  Draper's  Company  Research  Memoirs,  1908. 

DISEASES    OF    THE    LUNGS  305 

newborn  infants  not  one  was  tuberculous.  Occasionally,  however,  the 
disease  will  show  itself  comparatively  shortly  after  birth  as  the  result 
of  intense  exposure.  There  has  recently  been  reported  two  prematurely 
born  infants  both  suckled  by  their  consumptive  mothers.  One  developed 
signs  of  pulmonary  tuberculosis  a  month  after  birth,  the  other  three 
months  later. 

Theobald  Smith  has  pointed  out  that  though  a  strictly  bacterial 
disease  and  introduced  into  the  body  by  the  tubercle  bacillus,  which  is 
always  derived  from  some  preexisting  case  of  the  disease,  tuberculosis 
differs,  nevertheless,  from  most  diseases  in  many  important  particulars. 
Its  unknown  beginnings  in  the  body  and  its  insidious  march  after  it  has 
once  gained  a  foothold  are  responsible  for  the  existence  of  a  large  number 
of  cases  in  all  stages  of  the  disease.  In  the  earlier  stages,  while  the  dis- 
ease is  still  restricted  to  a  single  focus,  the  individual  is  to  all  outward 
appearances  in  perfect  health.  The  disease  may  remain  in  this  quiescent 
stage  indefinitely  and  then  for  one  reason  or  another  become  active.  If 
the  generally  accredited  theory  be  accepted,  namely,  that  an  initial 
implantation  takes  place  early  in  life  in  the  majority  of  people,  what  is 
it  that  determines  that  one  individual  will  later  in  life  become  tuberculous 
while  another  escapes?  The  following  factors  must  be  taken  into 
account : 

1.  We  have  to  consider  the  question  of  resistance.  Were  it  not  for 
the  fact  that  the  great  majority  of  people  possess  an  immunity  to  tubercu- 
losis the  death  rate  would  far  exceed  what  it  is  at  present.  The  degree 
of  immunity  possessed  by  the  particular  individual  varies  greatly.  In 
many  it  is  probably  absolute;  in  many  more  the  susceptibility  to  the 
infection  is  very  marked  and  they  readily  fall  victims  to  the  disease. 
The  great  majoritj^  of  people,  in  all  probability,  possess  sufficient  resis- 
tance to  the  growth  of  the  tubercle  bacillus  providing  this  resistance 
is  not  lowered  by  other  causes. 

Another  factor  which  must  be  considered  is  the  degree  of  virulence 
of  the  tubercle  bacillus.  It  is  well  known  that  different  strains  of  the 
organism  vary  tremendously  in  virulence;  some  possess  very  little  power 
for  mischief  while  others  are  capable  of  producing  very  destructive 
lesions.  While  we  lack  sufficient  proof  as  to  the  effect  of  a  strain  of 
known  virulence,  it  is  not  unreasonable  to  assume  that  when  the  disease 
progresses  but  slowly  and  extends  over  a  period  of  years,  the  resistance 
of  the  individual  is  marked  and  that  in  addition  the  virulence  of  this 
particular  strain  is  not  great.  On  the  other  hand  rapidly  progressing 
cases  probably  represent  instances  in  which  the  resistance  is  slight  and 
the  virulence  of  the  organism  is  marked.  As  I  have  pointed  out  in  the 
discussion  of  the  pathology  of  the  disease  resistance  to  the  tubercle 
bacillus  is  expressed  in  the  capacity  of  the  lung  tissue  to  form  a  fibrous 
wall  about  the  lesion.  Thus  in  those  with  good  resistance  the  progress 
of  the  disease  is  entirely  arrested  or  greatly  retarded  by  the  formation 
of  fibrous  tissue.  This  is  often  well  seen  in  the  structure  of  the  individual 
tubercle  about  which  a  fibrous  wall  is  built.  In  the  acute  cases,  those 
obviously  of  low  resistance,  the  absence  of  fibrous  tissue  is  a  striking 
feature  of  the  lesions. 

In  addition  to  the  resistance  of  the  individual  and  the  virulence  of 
the    tubercle  bacilli  Cobbett^  believes,   and  I  think  rightly,  that  the 

1  "The  Causes  of  Tuberculosis,"  1917. 



dose  has  an  important  bearing.  Resistance,  he  believes,  varies  in  dif- 
ferent individuals  and  in  the  same  individual  at  different  times.  A  dose 
fatal  to  one  may  be  innocuous  to  another.  The  dose  is  often  too  small  to 
infect  anyone;  at  other  times  so  large  that  it  kills  in  spite  of  resistance. 
Large  doses  are  to  be  looked  for  in  those  in  close  proximity  to  a  tuber- 
culous patient  whose  cough  is  spraying  tubercle  bacilli  into  the  air  con- 
stantly or  whose  carelessness  in  spitting  fills  the  air  with  those  organisms 
or  as  the  result  of  a  draught  of  milk  from  a  cow  with  a  tuberculous 

That  the  white  races  have  acquired  a  certain  degree  of  immunity 
during  the  centuries  to  which  they  have  been  exposed  to  the  disease  is 
consistent  with  what  we  know  of  other  infectious  diseases.  Two  races, 
which  in  their  primitive  state  were  free  from  tuberculosis,  have  paid  a 
heavy  toll  through  association  with  the  white  race.  The  North  American 
Indian  has  been  especiall}^  susceptible,  tuberculosis  being  one  of  the 
most  potent  causes  of  the  rapid  decimation  of  this  race.  For  the  year 
1915  the  greatest  single  cause  of  death  among  the  Indians  was  tuberculosis 
which  was  responsible  for  35.08  per  cent,  of  all  deaths.  The  Negro  is 
another  example  of  a  race  which  has  been  exposed  to  the  disease  but  a 
short  period  and  in  which  sufficient  time  has  not  elapsed  to  establish 
much  immunity.  Not  only  is  the  negro  extremely  susceptible  but,  as 
a  rule,  the  disease  pursues  a  much  more  acute  course  than  in  the  white 
man.  The  death  rate  from  tuberculosis  among  negroes  is  from  three 
and  a  half  to  four  times  that  of  the  whites. 

A  recent  report  by  Marralile^  illustrates  the  virulence  of  tuberculosis 
when  introduced  on  virgin  soil.  He  states  that  up  to  1900  tuberculosis 
was  unknown  in  Central  Persia.  Introduced  into  a  village,  from  an 
outside  source,  100  cases  developed  between  1900  and  1908.  Two  facts 
stand  out:  first,  the  rapidity  of  the  disease;  rarely  did  it  last  more  than 
six  months,  never  more  than  a  year,  secondly,  its  mortality,  all  died. 

2.  Heredity.- — Until  comparatively  recently  it  was  taught  that 
tuberculosis  was  an  inherited  chsease.  The  basis  for  this  belief  lay  in 
the  fact  that  it  was  a  common  observation  that  the  children  of  tuberculous 
parents  very  frequently  developed  the  disease.  We  now  know  that 
direct  inheritance  of  the  disease  is  extremely  rare,  so  much  so  as  to  be 
practically  negligible.  The  real  cause  of  tuberculosis  being  a  family 
affection  is  due  to  its  transmission  from  the  infected  parent  to  the  child 
after  birth.  This  may  occur  as  the  result  of  the  careless  disposal  of  the 
sputum  in  the  home;  by  kissing;  or  by  infection  of  the  child's  food. 
Owing  to  the  more  intimate  contact  between  the  mother  and  the  child 
it  is  well  recognized  that  a  tuberculous  mother  is  more  dangerous  to  her 
children  than  a  tuberculous  father. 

Although  a  child  is  rarely  born  tuberculous,  there  is  reason  to  believe 
that,  in  some  instances,  the  children  of  tuberculous  parents  are  more 
susceptible  than  others  and  that  when  exposed  to  infection  they  offer 
little  resistance.  Karl  Pearson,  especially,  has  been  insistent  on  the 
importance  of  a  tuberculous  diathesis. 

3.  Reinfection. — As  already  stated  many  authorities  place  the  time 
of  infection  during  the  early  years  of  life,  the  belief  being  that  the  bacilli 
lie  dormant  until  some  time  later  when,  for  one  reason  or  another,  the 
individual's  resistance  becomes  lowered  and  the  disease  becomes  active. 

1  Dublin  Jour,  of  Med.  Sc,  July,  1917. 

DISEASES    OF    THE    LUNGS  307 

An  individual  may,  however,  become  reinfected  in  adult  life  and  succumb 
to  this  second  implantation  of  the  tubercle  bacilli.  Paul  Lewis^  is  of 
the  belief  that  the  primary  infection  in  early  life  has  little  influence  on 
the  disease  as  it  presents  itself  in  adults.  This  judgment  is  based  on  his 
experience  with  bovine  vaccination  where  the  immunity  seems  not  to 
persist  much  longer  than  do  living  bacilli  introduced  as  a  preventive. 
Apphed  to  the  human  type  of  the  disease  this  fact  m.&y  be  interpreted 
as  follows :  There  is  a  high  incidence  of  infection  in  early  childhood,  very 
possiblj'  owing  to  an  especial  permeability  of  the  intestinal  mucous  mem- 
branes in  that  period.  By  the  adolescent  period,  however,  most  of  the 
infected  children  are  either  cured  of  the  disease  or  have  died  of  it.  Fol- 
lowing the  twentieth  j^ear  a  fresh  period  of  high  incidence  occurs,  prob- 
ably owing  in  part  to  the  failing  natural  immunity  of  the  lungs  and  in 
part  to  increased  exposure.  There  can  be  no  doubt  that  infection  in 
adult  hfe  is  far  more  frequent  than  is  ordinarily  taught.  This  is  apparent 
from  the  fact  that  healthy  adults,  with  no  history  of  tuberculosis  in  the 
famih",  not  infrequently  acquire  the  disease  by  moving  into  a  house 
infected  by  a  former  tenant. 

4.  Insanitary  Surroundings. — For  years  it  has  been  recognized  that 
tuberculosis  is  essentiall3'  a  house  disease.  It  is  in  the  home,  in  the 
vast  majorit}^  of  instances,  that  the  disease  is  acquired  and  here  from  its 
inception  to  its  close  the  entire  drama  is  played.  The  worse  the  living 
conditions  are,  the  higher  will  be  the  incidence  of  tuberculosis,  and  this 
apphes  to  the  isolated  country  house  as  well  as  the  congested  city  slum. 
In  considering  the  influence  of  the  home  surroundings,  two  factors  must 
be  taken  into  account:  first,  the  home  itself;  and  secondly,  the  habits 
of  the  people. 

]\Iuch  emphasis  has  been  placed  on  the  badly  ventilated  and  hghted 
house  as  a  predisposing  cause  of  the  disease,  and  of  this  there  can  be  no 
doubt.  Another  factor,  and  one  which  is  not  so  w^ell  recognized,  is  the 
unhygienic  habits  of  the  people  themselves.  In  a  study  made  by  the 
Phipps  Institute^  it  was  found  that  many  houses  which  had  little  to  com- 
mend them  were  inhabited  by  people  who  were  cleanly  in  their  habits; 
on  the  other  hand,  model  houses  were  often  found  to  be  tenanted  by 
people  who  made  no  pretense  of  observing  the  simplest  rules  of  hygiene. 
Perhaps  the  greatest  lesson  which  the  crusade  against  tuberculosis  has 
taught  is  the  importance  of  hj^giene.  Not  only  must  better  houses  be 
provided  but  in  addition  the  people  themselves  must  be  impressed  with 
the  dangers  of  insanitary  habits.  They  must  be  taught  that  irregular 
meals,  food  of  poor  qualitj^,  insufficient  sleep  and  dissipation  in  any  form 
lead  to  a  lowering  of  the  resistance  and  thus  render  the  individual  more 
susceptible  to  infection.  In  an  occupational  study  made  at  the  Phipps 
Institute^  it  was  shown  that  among  those  workers  who  took  their  meals 
irregularh',  and  among  those  who  did  not  get  sufficient  sleep  the  incidence 
of  tuberculosis  w^as  much  higher  than  in  the  case  of  those  leading  a  regular 

In  regard  to  the  influence  of  insanitary  dwellings  the  experience  of 
Liverpool  is  instructive.  The  municipal  government  tore  down  large 
sections  of  defective  dwellings  and  erected  in  their  place  sanitary  houses. 

^  Journal  of  the  Outdoor  Life,  February,  1916. 

2  Eleventh  Report,  1915. 

3  Eighth  Report,  1915. 


The  same  people  were  housed  in  the  new  dwellings  who  had  occupied 
the  old  ones.  In  this  reconstructed  district  the  death  rate  from  tuber- 
culosis fell  from  4  per  1000  to  1.9  per  1000.  A  very  striking  example  of 
the  effect  of  destroying  a  slum  district  was  noted  after  the  great  fire  in 
San  Francisco.  Prior  to  the  fire  in  1905  the  death  rate  from  tuberculosis 
in  that  citv  was  27-4  per  100,000;  two  vears  later  it  had  fallen  to  179  per 
100,000.     In  1912  it  had  fallen  still  farther  to  153  per  100,000. 

Poverty  and  tuberculosis  go  hand  in  hand.  This  is  due  to  the  fact 
that  lack  of  money  forces  the  very  poor  into  the  most  insanitary  districts 
and  in  addition  does  not  permit  of  their  obtaining  suitable  food.  Both 
of  these  factors  lower  the  resistance  and  make  the  individual  a  ready 
victim  of  the  disease.  The  effects  of  privation  and  food,  insufl&cient 
in  quality  or  quantity,  has  been  shown  strikingly  in  the  devastated  regions 
of^France  and  Belgium  during  the  recent  war.  Indeed  the  effects  have 
been  felt  also  in  the  neutral  European  countries  and  in  uninvaded 
portions  of  the  warring  countries.  Reports  from  nearly  all  the  European 
countries  during  the  past  three  j'ears  all  tend  to  show  that  tuberculosis 
is  on  the  increase. 

5.  Occupation. — The  influence  of  occupation  as  a  predisposing  cause 
of  tuberculosis  has  been  emphasized  over  and  over  again.  There  are 
many  employments  which  are  credited  with  being  bad,  but  which  in 
reality  are  not,  much  of  the  evil  that  is  associated  with  them  being  the 
result  of  contributory  factors  which  are  not  directly  connected  with  the 
work  itself.  It  is  well  to  remember  that  in  the  badh^  ventilated  state  of 
one  factory  compared  with  another,  the  home  life  and  surroundings  of 
the  work  people,  poverty,  heredity,  age  and  sex  are  to  be  found  condi- 
tions that  favor  the  production  of  ill  health,  and  are  therefore,  not  to  be 
ignored.  Usually  it  is  a  gradual  deterioration  of  health  that  is  produced. 
It  cannot  be  emphasized  too  strongly  that  it  is  imyossihle  to  determijie  the 
effect  of  a  given  occupation  as  a  predisposing]  cause  of  tuberculosis  xnthout 
a  knouiedge  of  ivJiere  and  hoic  the  worker  lives. 

6.  Acute  and  Chronic  Infections. — As  the  result  of  some  acute  or 
chronic  disease  the  individual  may  be  rendered  more  susceptible  to 
reinfection  with  tuberculosis,  or  as  the  result  of  lowered  resistance,  a 
quiescent  tuberculous  lesion  may  become  active.  Acute  catarrhal  con- 
ditions of  the  upper  respiratory  tract,  measles,  whooping  cough,  etc.,  are 
not  infrequently  followed  by  tuberculosis. 

The  importance  of  damp  soil  and  damp  houses  was  emphasized  many 
years  ago  by  Henry  I.  Bowditch,  who  showed  that  such  conditions  were 
productive  of  catarrhal  affections  of  the  respiratory  tract  and  that  they 
in  turn  predisposed  to  tuberculosis.  Sims  Woodhead  also  has  pointed  out 
that  in  pulmonary  tuberculosis  the  most  important  predisposing  cause 
appears  to  be  a  catarrh.  This  is  most  apt  to  occur  in  portions  of  the  lung 
where  expansion  and  contraction  are  weak  or  imperfect,  as  at  the  apices. 

Among  the  chronic  diseases  in  which  tuberculosis  is  often  a  terminal 
infection  may  be  mentioned  diabetes,  arterio-sclerosis,  thoracic  aneurism, 
and  cirrhosis  of  the  liver. 

7.  Pregnancy  and  the  Puerperal  Period. — Many  women  first  manifest 
evidences  of  pulmonary  tuberculosis  during  or  immediatel}^  after  the 
termination  of  pregnancy.  That  the  incidence  of  pregnane}^  and  tuber- 
culosis is  a  frequent  one  is  shown  by  the  figures  given  by  Bacon.     In 

1  Oliver's   "  Dangerous  Trades." 



1913  he  estimated  that  32,000  tuberculous  women  became  pregnant 
annually  in  the  United  States,  and  added  that  between  44,000  and 
48,000  women  of  child-bearing  age  die  of  tuberculosis  every  year.  When 
the  disease  becomes  active  during  pregnancy  it  is  probably  due  to  the 
increased  demands  made  on  the  woman's  vitality.  When  it  first  shows 
itself  during  the  puerperal  period  or  undergoes  an  acute  exacerbation  at 
this  time,  it  is  due,  in  large  measure,  to  the  violent  efforts  attending  the 
deUvery  of  the  child.     It  is  noteworthy  that  among  women  a  very  large 

0-9    10.19l20.29i 













































DEATHS  FROM  t'ub'eRCUiIos'iS    | 
















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Fig.  227. — Tuberculosis;  all  forms.  Registration  area  of  the  United  States.  The 
dotted  line  represents  the  number  of  deaths  for  the  disease  specified  for  different  decades 
per  10,000  persons  living  at  corresponding  decades.  The  solid  line  represents  the  ratio  of 
deaths  from  a  particular  disease  at  different  decades  to  the  whole  number  of  deaths  at 
all  ages  from  the  same  disease.  The  broken  line  in  Chart  represents  the  ratio  of  deaths 
from  tuberculosis  at  any  decade  to  the  total  number  of  deaths  from  all  causes  at  the  corre- 
sponding decade.      [Montgomery   Amer.  Jour.  Med.  Sc,  Sept.,  1915.) 

number  date  the  onset  of  their  pulmonary  trouble  from  a  pregnancy.  In 
a  study  of  tuberculous  pregnant  women  made  at  the  Phipps  Institute 
by  C.  C.  Norris  and  myseK^  we  found  that  about  20  per  cent,  of  mild, 
quiescent  cases  and  70  per  cent,  of  more  advanced  cases  exhibit  exacer- 
bations during  pregnane}^  or  the  puerperium. 

A  consideration  of  the  above  etiological  factors  makes  it  apparent 
that  over  and  above  the  implantation  of  the  tubercle  bacillus  in  the  body 
something  additional  is  needed,  in  the  vast  majority  of  cases,  to  cause 
the  individual  to  develop  clinical  tuberculosis. 

1  Jour.  Amer.  Med.  Assoc,  Feb.  9,  1918. 


For  some  years  past  I  have  been  able  to  fix  on  the  determining 
factor  in  the  great  majority  of  private  patients.  In  one  it  has  been  ex- 
cessive mental  anxiety  over  business  affairs;  in  another  the  nursing  of 
a  relative  in  a  long  and  tedious  illness;  in  still  another,  a  period  of  over- 
work and  lack  of  sufficient  sleep.  Among  the  lower  class  the  prolonged 
exposure  to  insanitary  surroundings  and  poor  food  are  to  be  looked  upon 
as  the  most  potent  causes. 

As  already  pointed  out,  no  race  is  exempt  from  the  disease  and  it  is 
to  be  met  under  all  sorts  of  climatic  conditions.  Tuberculosis  occurs  at 
all  age  periods  but  the  chronic  ulcerative  type  affecting  the  lungs  is 
essentially  a  disease  of  adult  life.  Statistics  show  that  the  highest  in- 
cidence of  pulmonar}'  disease  is  between  the  twentieth  and  fortieth 
years.  ^Montgomer}-,^  however,  has  called  attention  to  the  fact  that  if 
the  death  rate  is  computed  for  the  different  age  periods  in  relation  to 
those  living,  the  disease  is  as  prevalent  among  those  of  advanced  years 
as  in  early  adult  life. 

Fig.  227  pictures  the  mortality  curve  for  all  forms  of  tuberculosis 
in  the  registration  area  of  the  United  States,  and  shows  what  has  long 
been  known,  but  is  frequently  overlooked,  that  tuberculosis  continues 
unabated  its  extensive  ravages  even  among  elderly  perons,  though  the 
absolute  number  of  deaths  from  tuberculosis  is  actually  diminishing. 
Among  those  who  have  emphasized  the  high  mortahty  from  tuberculosis 
among  the  aged  are  Wilson  Fox  and  Cornet.  A  pamphlet  issued  by 
the  ^Maryland  State  Department  of  Health  entitled  "A  Brief  Review 
of  the  Tuberculosis  Campaign,  1904-1914,"  shows  that  "in  the  white 
population  beginning  with  the  twentieth  year  of  life  all  persons  are  equally 
liable  to  death  from  tuberculosis." 

Morbid  Anatomy. — A  knowledge  of  the  pathology  of  tuberculosis  as 
it  affects  the  lungs,  is  absoluteh'  essential  in  order  to  gain  a  clear  concep- 
tion of  its  various  manifestations. 

In  both  its  pathological  and  clinical  aspects  the  disease  may  exhibit 
the  widest  extremes.  It  maj',  on  the  one  hand,  run  an  acute  course,  the 
duration  of  which  is  measured  in  weeks  or,  on  the  other  hand,  it  may 
pursue  a  chronic  latent  course  lasting  for  years.  The  very  acute  and  the 
very  chronic  cases,  however,  form  but  a  small  proportion  of  the  total 
number.  The  overwhelming  majorit}'  of  cases  of  pulmonary-  tuberculosis 
is  comprised  of  the  type  referred  to  as  chronic  ulcerative  tuberculosis; 
more  commonl}"  known  as  phthisis  or  consumption.  In  this  type  of  the 
disease  the  course  is  rarely  continuous  but  is  almost  invariably  charac- 
terized b}^  periods  of  activity  which  are  succeeded  by  periods  of  quies- 
cence or  indeed  complete  arrest  of  the  disease,  which  may  last  for  twenty 
years  or  even  longer.  The  too  commonly  accepted  belief  that  pulmonary 
tuberculosis  has  an  average  duration  of  from  two  and  a  half  to  three 
years,  is  no  longer  tenable.  In  the  vast  majority  of  cases  the  symptoms 
which  seem  to  indicate  the  beginning  of  the  trouble,  are  in  realitj'  ante- 
dated by  years  bj-  some  symptom  or  group  of  symptoms  which  either  have 
been  ignored  or  have  been  attributed  to  some  other  disease.  This  may 
be  illustrated  by  the  following  case  which,  while  extreme,  is  by  no  means 

A  banker,  aged  fifty-two,  came  under  observation  for  the  first  time  with 
a  laryngeal  tuberculosis  and  physical  signs  which  clearly  indicated  an 

1  Amer.  Jour.  Med.  Sc,  September,  1915.  . 


infiltrating  process  involving  the  upper  third  of  the  left  upper  lobe.  He 
stated  that  he  had  been  perfectly  well  up  to  three  months  previously. 
His  history,  however,  showed  that  he  had  had  at  the  age  of  twenty-two 
years  several  pulmonary  hemorrhages  for  which  he  was  confined  to  bed 
for  a  few  days.  Ten  years  later  he  had  a  severe  attack  of  pleurisy  which 
laid  him  up  for  a  week.  This  was  followed  by  no  ill  effects.  Here 
then  we  have  a  case  in  which  the  disease  gave  warnings  of  its  presence 
thirty  and  twenty  years  prior  to  his  becoming  definitely  tuberculous. 
During  this  long  period  his  health  was  good  and  he  finally  succumbed  to 
the  infection  because  his  resistance  became  lowered  through  overwork 
and  financial  worries  during  a  business  panic.  This  man  made  a  com- 
plete recovery  and  is  at  the  present  time  perfectly  well  (seven  years  later). 

A  knowledge  of  the  fact  that  this  type  of  tuberculosis  is  subject  to 
the  occurrence  of  periods  of  shght  activity  which  subside  spontaneously, 
is  of  considerable  practical  importance  as  it  inchoates  that  the  disease  is 
more  or  less  latent  and  chronic  and  that  the  patient's  resistance  is  good. 
In  this  type  of  case  the  prospect  of  recovery  is,  as  a  rule,  a  great  deal  more 
promising  than  in  that  with  an  acute  onset  and  no  antecedent  history 
of  trouble. 

The  acuteness  or  chronicity  of  every  tuberculous  infection  is  to  a 
great  extent  determined  by  two  factors.  On  the  one  hand,  we  have  the 
invading  tubercle  bacilli  striving  to  multiply  and  spread  and  destroy 
tissue.  Opposed  to  this  invasion  are  the  resources  of  the  host  which 
strive  to  hold  in  check  the  invaders.  While  some  of  the  tubercle  bacilli, 
may  be  destroyed  by  the  phagocytes,  the  chief  defense  against  them  lies 
in  the  formation  of  fibrous  tissue  which  surrounds  the  tubercles  and 
completely  or  partially  arrests  the  process.  That  this  is  true  is  evident 
from  the  fact  that  the  acute  types  of  the  disease  show  little  or  no  evidence 
of  fibrous  tissue  about  the  lesions,  while  in  the  more  chronic  forms  of  the 
disease  an  extensive  overgrowth  of  fibrous  tissue  constitutes  the  chief 
characteristic  of  the  pulmonary  lesions.  In  chronic  ulcerative  phthisis, 
therefore,  the  rapichty  or  slowness  of  the  progress  of  the  disease  is  deter- 
mined, largely,  by  the  capacity  of  the  lung  to  undergo  fibroid  changes. 

Sims  Woodhead  has  described  the  initial  changes  as  follows:  The 
first  stage  is  an  apical  catarrh;  that  is,  a  congestion  of  the  blood-vessels 
of  the  mucous  membrane,  accompanied  by  a  slight  proliferation  of  the 
epithelial  cells  lining  the  air  cells  with  an  increased  pouring  out  of  fluid 
and  an  emigration  of  a  large  number  of  white  cells.  This  catarrhal 
change  is  noted  in  portions  of  the  lung  where  expansion  and  contraction 
are  weak  or  imperfect,  as  at  the  apices  in  adults  or  about  the  hilus  in 

This  breeding  ground  for  the  tubercle  bacillus  may  gradually  increase 
in  size.  If,  however,  the  tissues  are  well  nourished,  fibrous  tissue  is 
formed.  Building  up  the  resistance  of  the  patient  by  proper  treatment 
aids  in  bringing  this  about.  If  this  is  accomplished,  the  bacilli  become 
inactive  and  the  degenerative  tissue  is  partly  absorbed  and  partly  trans- 
formed into  scar  tissue.  If,  however,  the  process  does  not  become 
arrested  at  this  point,  the  disease  spreads  beyond  its  original  focus  and  a 
considerable  area  of  tuberculous  consolidation  may  be  the  result.  The 
degenerated  or  caseous  material  may  then  become  softened  and  it  is 
during  this  stage  of  softening  that  secondary  infection  goes  on  perhaps 
most  readily. 


The  initial  deposit  as  seen  at  the  autopsy  table  in  individuals  dying 
from  other  causes  may  consist  of  a  single  small  peribronchial  focus  (see 
Fig.  228)  or  it  may  consist  of  several  areas  the  size  of  a  hazel  nut.  buch 
foci  represent  the  coalescence  of  a  small  group  of  tubercles.  From  these 
areas  the  disease  spreads  or  healing  may  take  place  (see  Fig.  229). 

In  those  instances  in  which  the  disease  gains  the  upper  hand  the 
tubercles  which  at  first  are  discrete,   coalesce  and  in  addition  spread 

Fig.   228. — Solitary   peribronchial    tubercle   indicated   by   arrow.      Rest   of   lung   normal, 
{Jefferson  Medical  College  Museum.) 

beyond  their  original  boundaries.  Thus  at  the  apex  where  the  original 
deposit  occurred  the  infiltration  becomes  more  and  more  dense  and 
furthermore  the  tubercles  spread  downward  until  the  entire  lung  is 
involved  although  in  the  lower  portions  the  infiltration  is  usually  widely 

This  constitutes  the  second  or  moderately  advanced  stage.  Fig. 
230  shows  this  very  well.  It  will  be  noted  that  at  the  extreme  apex  the 
infiltration,  while  very  dense,  has  not  replaced  entirely  all  of  the  pulmon- 



ary  tissue  so  that  some  vesicular  element  will  be  retained  in  the  respira- 
tory sounds.  The  infiltration  becomes  less  and  less  marked  as  the  base 
of  the  lung  is  approached.  The  lower  third  is  apparently  free  from 

The  chief  characteristic  of  chronic  ulcerative  tuberculosis  is  the 
formation  of  cavities.  As  a  rule  a  cavity  is  an  indication  that  the  dis- 
ease has  progressed  to  the  third  or  advanced  stage  of  the  disease.     This 

Fig.  229. — Below  the  apex  are  seen  several  calcareous  nodiiles  surrounded  by  fibrous 
tissue.  These  represent  small  deposits  of  tubercles  which  have  become  walled  off.  It  is 
in  this  way  that  tuberculosis  is  often  healed. 

i^  not  invariably  true,  however.  The  original  focus  may  break  down  and 
empty  out  through  a  bronchus  and  the  disease  become  arrested  at  this 
point;  and  the  same  is  true  of  the  second  or  moderateh^  advanced  stage. 

In  the  advanced  stages  of  the  disease  it  is  almost  the  rule  to  find  a 
cavity  at  one  or  both  apices  and  in  addition  smaller  cavities  may  be 
present  in  other  portions  of  the  lungs. 

The  excavation  may  be  represented  by  a  single  large  cavity  with  a 
well-defined  wall  or  it  may  present  a  honeycombed  appearance  in  which 
the  cavities  are  small  and  communicating  with  ragged,  necrotic  walls. 


The  former  type  is  characteristic  of  the  chronic  type  of  the  disease,  the 
latter  of  the  more  acute  forms  (see  Acute  Puhnonary  Tuberculosis). 

It  is  the  present  belief  that  the  formation  of  a  cavity  is  due  in  large 
part,  to  the  presence  of  secondary  infections  with  the  various  pus-produc- 
ing organisms.  These  organisms  produce  a  liquefying  necrosis  of  the 
caseous  areas  and  thus  hasten  their  breaking  down.  The  final  stage  in 
the  formation  of  a  cavity  is  the  rupture  of  the  caseous  and  necrotic  area 
into  a  bronchus.     As  a  rule  there  is  but  one  such  communication;  but 

Fig.  230. — ^Dense  infiltration  of  upper  lobe.     Areas  of  conglomerate  tubercles  in  upper 

part  of  lower  lobe. 

there  may  be  two  or  three,  in  which  case  the  ph3'sical  signs  are  apt  to  be 
indefinite  and  imperfect. 

The  longer  the  tuberculous  process  lasts  the  more  certainly  is  excava- 
tion apt  to  occur  although  this  is  not  an  invariable  rule,  particularly  in 
the  chronic  fibroid  cases.  Recently  formed  cavities  have  an  irregular 
outline,  are  ill-defined,  the  interior  is  ragged  and  there  is  an  absence  of  a 



distinct  wall.  When  the  process  is  not  acute  or  has  remained  localized 
for  some  time,  a  more  or  less  well-formed  wall  of  fibrous  tissue  develops. 
The  longer  the  cavity  has  existed  the  thicker  the  fibrous  tissue  about  it. 
Furthermore,  the  caseous  lining  of  the  cavity  gradually  changes  into 
granulation  tissue  and  this  in  turn  may  be  replaced  by  smooth  fibrous 

Fig.  231  represents  a  chronic  type  of  infection.  The  cavity  is  sharply 
defined  and  from  its  shape  seems  to  have  been  formed  by  several  smaller 
excavations  which  have  united.  Below  the  cavity  is  a  scattered  infiltra- 
tion with  some  fibroid  changes  and  dilatation  of  the  bronchi. 

Fig.  231. — Cavity  in  apex  of  right  upper  lobe  and  a  smaller  one  anteriorly  gust 
beneath  the  clavicle.  In  addition  to  cavities  there  is  healthy  pulmonary  tissue  and  con- 
siderable fibrosis.     Illustrates  a  chronic  and  slowly  progressive  type  of  disease. 

Fig.  232  illustrates  how  extensive  the  pulmonary  excavation  may 
become.  In  this  instance  practically  the  entire  lung  has  been  reduced 
to  a  fibrous  shell  with  only  a  fringe  of  pulmonary  tissue  at  the  base. 

In  view  of  the  extension  ulceration  which  may  occur  it  is  remarkable 
that  perforation  of  the  chest  wall  so  rarely  occurs.  Several  such  cases 
have  been  reported.  In  one  case  seen  at  the  Phipps  Institute  perforation 
of  the  chest  wall  was  prevented  by  a  rib,  which,  however,  had  become 


markedly  necrosed.  In  another  case  seen  in  the  White  Haven  Sana- 
torium the  perforation  (a  half-inch  in  diameter)  had  extended  through 
the  internal  intercostal  muscle.  The  external  intercostal  was  ulcerated ; 
covering  this  was  the  pectoralis  minor  muscle  and  the  skin.  In  this 
case  there  was  during  each  inspection  a  distinct  bulging  about  the  size 
of  an  English  walnut  and  strongl}-  resembled  a  hernia  of  the  lung. 

Fig.   232. — Case  No.  238S  (Phipps  Institute).     Upper  three-fourths  of  lung  taken  up  by 
three  cavities  with  great  outgrowth  of  fibrous  tissue. 

Another  important  feature  of  cavities  is  that  those  of  any  considerable 
size  contain  in  their  walls  or  the  trabecula  traversing  them,  blood-vessels 
(Fig.  233).  As  a  rule  the  blood-vessels  in  and  about  the  cavity  become 
thrombosed  and  obliterated.  If  thej-  remain  patulous,  small  aneurismal 
dilatations  occur  in  their  walls  and  the  rupture  of  one  of  these  will  give 
rise  to  a  hemorrhage.  Fig.  234  represents  a  cavity  filled  with  blood  clot 
in  which  this  accident  occurred.     (See  also  Fig.  59.) 



In  addition  to  a  knowledge  of  how  the  disease  develops  it  is  important 
to  recognize  the  routes  it  follows  from  the  time  the  initial  deposit  of 
tubercles  occurs  to  the  final  stages.  The  proportion  of  cases  in  which 
the  apex  is  the  primary  site  of  the  disease  is  so  large  that,  generally  speak- 
ing, the  exceptions  can  be  disregarded.  Laennec's  brief  description  of 
the  successive  changes  is  worth  quoting:  "We  very  often  find  in  the 
same  lung  evident  proofs  of  two  or  three  successive  eruptions,  and  we 
can  then  nearly  always  make  out  that  the  primary  eruption  at  the  apex 
of  the  lung  has  already  become  excavated;  that  the  second,  situated 
around  the  first,  but  a  little  lower,  is  formed  by  tubercles  which,  in 
most  instances,  are  already  yellow,  though  still  small;  that  the  third, 
formed  by  gray  miliary  tubercles,  with  some  yellow  points  in  the  center, 
occupy  a  still  lower  zone." 

Fig.  233. — Large  cavity  in  upper  lobe  with  blood-vessels  laid  bare. 

These  features,  namely,  the  primary  deposit  in  one  or  the  other  apex; 
the  extension  downward  and  the  presence  of  the  greatest  damage  where 
the  disease  first  began,  are  characteristic  of  tuberculosis  and  serve  as 
valuable  aids,  inasmuch  as  the  physical  signs  will  be  more  marked  at 
the  summit  of  the  lung  and  while  continuous,  diminish  as  the  base  is 
approached.  This  distribution  of  the  disease  also  serves  to  distinguish 
tuberculosis  from  certain  chronic  inflammatory  diseases  of  the  lung,  which 
invade  the  base  rather  than  the  apex.  While  these  generalizations  are 
not  absolute,  "the  line  of  march"  in  the  great  majority  of  cases  un- 
doubtedly shows  a  great  similarity. 


Not  only  are  the  apices  usually  the  original  site  of  the  disease,  but  as 
Fowler  has  shown,  a  fairly  definite  area  in  the  apex  is  the  common 
starting  point.  This  point  is  about  1  inch  to  l^-i  inches  below  the  apex, 
and  corresponds  anteriorly  to  the  supraclavicular  fossa  or  the  middle  of 
the  clavicle.  Extending  from  this  point  the  disease  tends  to  spread 
backward.     As  the  process  spreads,  it  progresses  downward,  the  infil- 

FiG  234. — Right  lung.  Advanced  tuberculosis.  Several  cavities,  the  largest,  at  the 
bottom  of  the  upper  lobe  posteriorly  is  filled  with  blood  clot.  (Patient  died  of  hemoptysis.) 
Extensive  infiltration  and  fibrosis  of  both  lobes. 

tration  about  the  original  focus  increasing  and  gradually  thinning  out  as 
the  base  is  reached. 

A  less  usual  site  for  the  primary  infection  occurs  at  a  point  which 
corresponds  to  the  first  and  second  interspaces  below  the  outer  third  of 
the  clavicle. 



Of  almost  equal  importance  to  the  primary  infections  in  the  apex 
are  the  secondaiy  deposits  in  the  lower  lobes.  Fowler  points  out  that 
the  involvement  of  the  lower  lobe  maj^  be  verj-  early  in  the  disease  and 
that  although  it  follows  the  primary  apical  infection,  may  give  more 
definite  phj^sical  signs  because  of  the  doubtful  character  of  the  apical 
findings.  As  a  rule  the  apex  of  the  lower  lobe  is  first  involved.  This 
corresponds  to  a  point  opposite  the  fifth  dorsal  vertebra  im  the  inter- 
scapular region  (Fig.  235).  From  this  point  the  disease  tends'  to  spread 
downward  along  the  interlobar  septum,  which  is  roughh-iindicated  by 
the  inner  border  of  the  scapula,  when  the  hand  is  placed  on  the  opposite 


Fig.  235. — Specimen  showing  a  small  deposit  of  tubercles  in  posterior  aspect  of  right 
upper  lobe  and  in  the  apes  of  the  lower  lobe.  Corresponds  to  the  right  interscapular 
region  opposite  fourth  and  fifth  dorsal  vertebra. 

Following  the  invoh^ement  of  the  upper  lobe  the  disease  if  progressing, 
manifests  itself  in  the  opposite  apex;  less  commonly,  according  to  Fowler, 
in  the  upper  lobe  at  a  point  corresponding  with  the  apex  of  the  axilla. 
Disease  of  one  apex  with  secondary  manifestations  in  the  opposite  lower 
lobe  occasionally  occur. 

One  rarely  finds  during  the  terminal  stage  of  the  disease,  that  both 
lungs  are  equally  diseased.  The  lung  primarily  affected  is  generally 
more  extensively  involved  and  the  destruction  of  tissue,  as  manifested 
by  cavity  formation,  greater.  The  lung,  secondarily  affected,  may  be 
markedly  diseased  in  the  upper  lobe,  but  the  lower  will  be  free,  or  at  most 
contain  scattered  tubercles.  During  the  terminal  months  of  the  disease 
the  lower  part  of  one  or  the  other  lung,  which  undergoes  a  certain  amount 
of  compensatory  emphysema,  supplies  the  patient  with  most  of  his 
breathing  space  (Fig.  236;  see  also  Fig.  101  J. 


Another  change,  and  one  that  probably  follows  the  pulmonary  in- 
fection very  quickly,  is  a  low-grade  inflammation  of  the  apical  pleura 
which  results  in  the  obliteration  of  the  pleural  space  at  that  point. 
While  the  clinical  evidence  of  this  is  not  great,  it  is  an  almost  constant 
finding  that  in  individuals  who  have  died  of  chronic  tuberculosis  the 
apices  of  the  lungs  are  firmly  adherent  to  the  chest  wall  and  that  this  is 
most  noticeable  over  the  posterior  surface. 

As  the  pulmonary  infection  spreads  the  overlying  pleural  space  be- 
comes obliterated.     Involvement  of  the  pleura  in  tuberculosis  is  always 

Fig.  236. — Large  cavity  in  left  upper  lobe:  dense  in61tration  and  fibroid  changes  in 
lower  lobe.  Right  upper  lobe  densely  infiltrated  with  recently  formed  cavities.  Right 
lower  lobe  practically  free  from  disease. 

greatest  at  the  apex  where  the  trouble  originated  (Fig.  237).  At  the 
apex  the  thickening  is  dense,  gradually  thinning  out  as  the  base  of  the 
lung  is  reached.  While  often  dense  throughout  and  binding  the  entire 
lung  firmly  to  the  chest  wall,  the  adhesions  over  the  lower  part  of  the  lung 
are  more  commonly  lace-like  and  easily  broken  up.  (See  also  section  on 
Pleurisy,  p.  572.) 

Obliteration  of  the  pleural  space  is,  to  a  great  extent,  a  protective 
measure.  Were  it  not  for  this  a  pneumothorax  would  likely  occur  in 
the  majority  of  cases  of  tuberculosis   instead   of  being  relatively    un- 

DISEASES    OF    THE    LUNGS  321 

common.  A  more  extended  description  of  the  changes  which  occur  in 
tuberculous  pleurisies  and  in  pneumothorax  will  be  found  under  the  head- 
ings dealing  with  these  conditions. 

Dilatation  of  the  bronchi  is  dependent  on  the  amount  of  fibrous  tissue 
which  develops  during  the  course  of  the  disease.  If  the  process  is  acute 
the  bronchi  present  no  change.  On  the  other  hand,  in  the  chronic  types 
of  the  disease  with  the  formation  of  much  fibrous  tissue  dilatation  of  the 
bronchi  is  not  uncommon. 

Fig.  237. — Thickened  pleura  at  apex  in  tuberculosis. 

Deformity  of  the  chest  and  displacement  of  the  heart  depend  largely 
on  the  chronicity  of  the  disease.  If  chronic  and  there  is  much  fibroid 
tissue  present  the  affected  lung  shrinks  and  as  a  result  the  chest  wall 
becomes  retracted  and  the  heart  is  drawn  toward  the  diseased  side. 

Changes  in  Other  Organs. — In  addition  to  the  characteristic  changes 
which  are  seen  in  the  respiratory  organs,  tuberculosis  has  a  very  serious 
damaging  effect  on  other  organs  and  tissues  throughout  the  body.  The 
brief  account  which  follows  is  based  on  a  study  of  197  autopsied  cases 
by  C.  Y.  White.  ^     The  lesions  most  frequently  noted  are  the  presence  of 

1  Fifth  Report  of  Phipps  Institute,  1909. 



tubercles,  usually  the  result  of  a  terminal  infection;  congestion;  catarrhal 
changes;  fatty  and  fibroid  degenerative  changes  and  ulceration.  In 
some  situations  all  of  these  changes  may  be  noted  while  in  others  one  or 
more  are  apt  to  be  present. 

The  larijnx  is  frequently  the  seat  of  tuberculous  changes  in  dying 
cases.  Fetterolf^  in  a  special  study  of  100  cases  found  the  larynx  involved 
in  83  and  doubtfully  so  in  4.  In  the  trachea,  congestion  is  the  most  com- 
mon change  and  in  about  20  per  cent,  of  cases,  ulceration  is  present. 

ISIany  observers  hold  the  view  that  the  heart  in  tuberculosis  is  smaller 
than  normal  and  deduce  from  this  fact  that  the  size  of  the  heart  bears 
some  relation  to  susceptibility  to  the  disease.  Of  197  cases  the  weight  of 
the  heart,  for  both  males  and  females,  was  practically  that  of  the  average 
normal  heart.  Cardiac  changes  noted  at  the  autopsj^  table  in  tuber- 
culosis are  about  the  same  as  those  encountered  under  other  conditions. 
In  about  half  the  cases  there  are  to  be  seen  varying  degrees  of  hypertrophy 
or  dilatation,  usually  the  latter,  of  one  or  more  of  the  chambers.  A  small 
proportion  show  thickening  of  the  valve  leaflets  and  in  a  still  smaller 
proportion,  the  valve  orifices  are  incompetent  or  stenosed.  Tuberculous 
infection  of  the  heart  muscle  is  rare.  (See  also  section  on  Tuberculosis 
of  the  Pericardium,  p.  656.) 

Next  to  the  lungs  the  gastro-intestinal  tract  and  its  associated  organs 
are  most  seriously  damaged.  This  leads  to  serious  defects  in  metabolism, 
with  consequent  lowered  nutrition.  Some  of  the  lesions  are  tuberculous, 
but  most  of  them  are  of  a  secondary  nature  and  because  of  the  fact  that 
they  are  so  general  and  extensive,  are  far  more  serious  to  the  functional 
activity  of  these  organs  than  the  lesions  which  are  distinctly  tuberculous 
in  character.  The  intestinal  tract  is  the  site  of  ulcerative  changes  in  from 
80  to  90  per  cent,  of  fatal  cases.  In  some  instances  a  large  portion  of  the 
intestinal  mucous  membrane,  especially  the  lower  ileum,  may  be  the  site 
of  ulcerative  changes;  in  others  there  may  be  no  more  than  three  or  four 
ulcers.  The  stomach  is  the  site  of  an  ulcer  in  about  2  per  cent,  of  cases, 
which  is  about  the  usual  incidence  of  gastric  ulcer  under  all  conditions. 
Rarely  the  ulcer  is  tuberculous  in  character.  Pathological  changes  in 
the  esophagus  are  unusual.  Congestion  of  the  mucous  membrane  is 
occasionally  noted  and  in  a  few  instances  tubercle-like  nodules  are  seen 
(3  out  of  140  autopsies). 

The  secondary"  changes  noted  in  the  gastro-intestinal  tract  are  sub- 
acute and  chronic  gastritis;  gastro-enteritis,  chronic  catarrhal  enteritis 
and  colitis.  Anatomical  changes  also  occur.  Gastroptosis  was  noted 
in  62  out  of  197  cases;  ptosis  of  the  large  gut  was  encountered  in  but  two 

Tuberculous  changes  in  the  appendix  were  noted  in  10  out  of  1.97 
cases.  About  7  per  cent,  of  the  cases  showed  tuberculous  fistulae  in  the 
ischio-rectal  region.  IMicroscopical  examination  of  the  ischio-rectal 
region  also  showed  the  presence  of  a  high  percentage  of  tubercles  in  cases 
having  no  signs  of  fistula  or  abscess. 

The  parenchjmiatous  tissue  of  the  liver  and  pancreas  usually  shows 
widespread  lesions  varying  from  a  slight  cloudiness  to  complete  necrosis 
or  extensive  fatty  changes.  Accompanying  these  lesions  in  the  parenchy- 
matous tissue  there  is  generally  some  fibroid  change.  The  same  lesions 
are  noted  in  the  thyroid  and  suprarenal  glands,  both  of  which  are 
'  Trans.  Am.  Laryngological  Assoc,  1914. 


also  concerned  in  metabolism.  Amyloid  changes  in  the  liver  are  not 

Although  the  liver  occasionally  shows  large  caseous,  tuberculous  foci, 
this  is  rare.  The  presence  of  minute  pinpoint  and  microscopic  tubercles 
is  very  common  and  probably  represents  a  terminal  infection.  The  pan- 
creas is  quite  resistant  to  the  tubercle  bacillus  but  even  this  organ  occa- 
sionally shows  microscopic  tubercles.  Tubercles  are  also  noted  in  the 
thyroid  gland  and  especially  in  the  suprarenals.  The  latter  may  also  be 
the  seat  of  large  caseous  tubercles  which  may  entirely  destroy  the  organ. 

The  spleen  is  usually  slightly  enlarged  and  often  congested.  Miliary 
tubercles  were  noted  in  60  and  amyloid  changes  in  51  out  of  197  cases. 

Chronic  inflammatory  changes  in  the  kidneys  are  extremely  common 
but  these  changes  do  not  differ  essentially  from  those  found  in  the  kidneys 
of  individuals  dying  of  other  chronic  diseases.  The  changes  are  brought 
about  by  the  extra  work  thrown  upon  the  kidneys  in  the  elimination  of 
the  toxic  products  generated  by  the  tubercle  bacilli  or  the  organisms 
of  mixed  infections  so  frequently  found.  In  addition  to  evidences  of 
nephritis  a  very  considerable  proportion  of  the  kidneys  also  show  the 
presence  of  small  miliary  tubercles. 

Other  portions  of  the  genito-urinary  tract,  in  both  the  male  and 
female,  seem  to  be  less  liable  to  infection  with  the  tubercle  bacillus  even 
in  the  terminal  stages.  Tuberculosis  of  the  testicle  rarely  occurs  in 
the  course  of  the  chronic  ulcerative  type  of  tuberculosis.  When  seen  it 
usually  dominates  the  clinical  picture,  the  pulmonary  disease  being  of 
secondary  importance. 

Involvement  of  the  meninges  is  a  not  uncommon  event  in  the  chronic 
ulcerative  tj^pe  of  tuberculosis.  Meningeal  tuberculosis  is  most  often 
seen,  however,  in  acute  miliary  tuberculosis.  The  condition  is  relatively 
common  in  children  and  it  is  very  frequentlj^  the  terminal  event  in  cases 
of  tuberculosis  of  the  testicle. 

Symptoms.- — Pulmonary  tuberculosis  has  no  distinctive  mode  of 
onset  nor  is  there  any  single  symptom  which  is  absolutely  pathognomonic 
of  the  condition.  In  some  instances  there  is  a  danger  signal  in  the  form 
of  a  single  symptom;  in  the  majority  of  cases,  however,  the  onset  is 
insidious  and  the  disease  may  have  caused  considerable  damage  before 
its  true  nature  is  recognized. 

A  properly  taken  history  should  include  information  as  to  the  occu- 
pation of  the  individual,  the  presence  or  absence  of  tuberculosis  in  the 
family,  an  account  of  past  illnesses,  and,  lastly,  but  of  the  utmost  im- 
portance, an  account  of  the  present  illness.  It  is  no  exaggeration  to 
state  that  from  the  history  alone  the  vast  majority  of  cases  of  early 
tuberculosis  can  be  recognized  definitely,  or  at  least  the  presence  of  the 
disease  can  be  strongly  suspected.  The  mathematical  chances  of  tubercu- 
losis being  present  are  overwhelming  in  the  case  of  any  individual  who 
has  an  hemoptysis,  an  attack  of  pleurisy,  a  fistula  in  ano,  or  transient 
attacks  of  slight  hoarseness,  and  this  holds  true  in  the  face  of  previous 
good  health  and  excellent  physical  condition.  These  single  symptoms 
may  be  followed  very  shortly  by  other  evidences  of  pulmonary  disease. 
Very  often,  however,  they  ar  >  to  be  looked  upon  as  prodromal  symptoms, 
and  months  or  years  may  eL^^ose  before  the  disease  manifests  itself  in 
an  active  form.  For  one  who  is  to  become  tuberculous  the  most  fortunate 
thing  is  the  occurrence  of  one  of  these  single  isolated  symptoms,  as  they 

324       DISEASES   OF  THE  BROXCHI,   LUNGS.    PLELR,^,    .^'D   DIAPHR-\GM 

are  apt  to  appear  before  there  has  been  any  deterioration  in  health  and 
before  the  pulmonary-  lesion  has  become  extensive.  The  significance 
of  these  manifestations  is  being  constantly  overlooked,  partly  because 
of  the  absence  of  other  corroborative  s^Tnptoms,  but  largely  because  of 
a  paucity  or  even  entire  absence  of  physical  signs. 

The  onset  of  pulmonary-  tuberculosis  may  be  as  follows: 
1.  Hemoptysis  and  Blood-strealced  Sputum. — The  one  disease,  above 
all  others,  in  which  hemoptysis  most  frequently  occurs  is  pulmonary 
tuberculosis.  This  fact  has  been  emphasized  and  reemphasized  in  season 
and  out  of  season  and  yet  the  true  significance  of  this  s^Tnptom  is  being 
overlooked  constantly.  Blood  spitting  is  apt  to  occur  in  the  great 
majority  of  cases  of  pulmonar\'  tuberculosis  at  some  time  during  the 
course  of  the  disease.  Among  5856  cases  seen  at  the  Phipps  Institute 
the  occurrence  of  an  hemoptysis  was  acknowledged  by  2790  (47.6  per 
cent.)  at  the  time  of  their  first  visit.  The  difl&culty.  however,  hes  not 
with  the  seK-evident  case  of  phthisis  but  with  those  instances  in  which 
the  blood  spitting  occurs  as  the  initial  symptom  and  before  there  has 
been  any  deterioration  of  health  or  the  development  of  marked  physical 
signs.  It  is  extraordinarA-  how  frequently  the  source  of  the  blood  is 
ascribed  to  a  bleeding  point  in  the  upper  air  passages  in  spite  of  the 
fact  that  there  is  ample  proof  that  hemorrhage  from  this  region  is  ex- 
cessively rare.  Although  the  apparent  health  of  the  patient  and  the 
absence  or  paucity  of  physical  signs  must  be  looked  upon  as  strong  factors 
in  influencing  physicians  agaiost  a  diagnosis  of  tuberculosis,  the  most 
important  reason,  in  my  opinion,  is  moral  cowardice.  ]VIany  will 
admit  of  a  knowledge  of  the  significance  of  a  hemoptysis  of  obscure 
origin  but  in  particular  cases  are  unable  to  bring  themselves  to  make  a 
diagnosis  without  other  corroborative  s>TQptoms  and  signs.  In  this 
connection  Cabot's  admonition  is  worth  repeating:  "I  do  not  deny 
that  the  causes  of  hemoptysis  are  numerous,  but  I  assert  that  the  causes 
of  genuinely  obscure  hemoptysis  in  temperate  climates  may  be  reduced  to 
one — pulmonarj'  tuberculosis."  The  objection  may  be  raised  that 
among  the  conditions  which  simulate  tuberculosis  most  closely  blood 
spitting  is  a  ver\-  common  s\Tnptom.  So  it  is — and  among  such  condi- 
tions may  be  mentioned  the  various  mycotic  infections,  bronchiectasis, 
fibrosis  of  the  lungs,  mahgnant  disease  and  distomatosis.  The  last- 
named  has  a  fairly  distinct  geographical  distribution  and  is  to  be  en- 
countered in  this  part  of  the  world  in  imported  cases  only.  Of  the 
other  conditions  closer  study  wUl  show  in  them  certain  differences,  par- 
ticularly in  regard  to  the  physical  signs,  which  will  oft^n  serve  to  dis- 
tinguish them  from  tuberculosis.  The  real  test,  however,  Ues  in  the 
examination  of  the  sputum.  Cases  presenting  the  symptoms  and  physical 
signs  of  tuberculosis  without  the  presence  of  tubercle  baciUi  in  the  sputimi 
should  arouse  at  once  the  suspicion  of  some  other  origin  for  the  hemor- 
rhage. The  main  point  is  that  a  tentative  or  even  a  positive  diagnosis 
does  no  harm  in  case  the  source  of  the  hemorrhage  is  not  a  tuberculous 
infection.  On  the  other  hand,  a  negative  diagnosis  may  lull  the  patient 
into  a  false  secmity.  There  is  httle  to  be  said  in  favor  of  the  attitude 
of  mind  which  favors  withholding  a  diagnosis  of  tuberculosis  in  such 
cases  because  such  an  opinion,  if  wrong,  places  a  stigma  on  the  patient. 
Failure  to  give  due  heed  to  it  more  often  ends  in  the  disease  progressing 
to  hopeless  incurabiUty. 

DISEASES    OF    THE    LrXGS  325 

Figs.  23S  and  239  clearly  show  the  majority  of  the  causes  of  hemop- 
tysis. That  depicting  Strieker's  results  deals  with  a  body  of  men  pre- 
sumably healthy.     It  is  apparent  that  the  occtirrence  of  blood  spitting 


TRAUMA  ■§  n 






GRENE     OF    TH  E  -     I  5 

LUNG  i 




Fig.  23S — Causes   of  hemoptysis  in  Pm^an  soJdiers.     {Cabot,  "Differential  Diagnosis,'^ 

after  F.  Strieker.) 

■■^^^■^^■■■■i^HH^H^HH^H  1723 



PULMONARY    THROM-  i      ^^^^ 
BOSIS  OR   EMBOLISM  )'     ^^^™ 

OR   GANGRENE  /     ^^ 



ANEURYSM  ■  22 

TRAUMA  ■  17 


Fig.  239. — Causes  of  hemoptysis,  ^lassaehusetts  General  Hospital,     (Cahot,  "Differential 


in  such  individuals  points  overwhelmingly  to  tuberculosis,  the  percentage 
in  favor  of  this  diagnosis  being  95. S.  The  table  compiled  by  Cabot  from 
cases  admitted  to  the  IMassachusetts  General  Hospital  shows  a  wider 
distribution  of  the  underlvins  causes. 


It  is  to  be  borne  in  mind,  however,  that  cases  of  obvious  tuberculosis 
are  not  admitted  to  this  hospital  and  that,  as  in  the  case  with  most 
hospitals,  patients  suffering  from  failing  compensation  form  a  very  high 
percentage  of  the  total  admissions.  Even  so,  tuberculosis  occupies  first 
place  with  a  percentage  of  50.  Furthermore  it  is  a  fair  inference  that 
the  majority  of  those  classed  as  "undetermined"  properly  belong  under 
the  tuberculous  group,  which  would  raise  the  percentage  considerabl}-. 

2.  Pleurisy.- — It  is  becoming  more  and  more  appreciated  that  an 
attack  of  pleurisy  with  or  without  effusion  should  arouse  one's  suspicion 
as  to  the  existence  of  a  pulmonary  tuberculosis.  At  one  time  the 
occurrence  of  primary  pleurisy  was  looked  upon  as  relatively  common. 
The  attack  may  be  without  an  apparent  exciting  cause  or  it  may  follow 
exposure  to  cold.  In  any  event  it  is  now  recognized  that  at  least  80 
per  cent,  of  such  pleurisies  are  tuberculous  in  origin.  A  pleural  effusion 
which  develops  insidiously  and  attains  a  large  size  before  recognition 
is  almost  certainly  tuberculous. 

The  records  of  the  large  insurance  companies  show  that  the  death  rate 
from  tuberculosis  of  the  lungs  among  persons  who  have  had  pleurisy 
within  five  years  prior  to  insurance  is  three  times  the  average  rate  for 
individuals  without  such  a  history. 

3.  Ischio-rectal  Abscess  and  Fistula  in  Ano. — Proctologists  have  per- 
formed a  valuable  service  in  emphasizing  the  tuberculous  nature  of  the 
great  majority  of  abscesses  in  and  about  the  ischio-rectal  fossa.  The 
occurrence  of  a  pyogenic  infection  in  this  region  should  always  call  for 
a  careful  physical  examination  of  the  chest.  In  the  event  of  a  negative 
examination  the  patient  should  be  warned  as  to  the  possible  danger  and 
cautioned  as  to  his  mode  of  life.  Very  often  the  ischio-rectal  abscess 
will  precede  definite  pulmonary  symptoms  by  several  years. 

4.  Hoarseness. — This  may  be  the  very  first  intimation  of  pulmonary 
tuberculosis.  The  hoarseness  maj^  develop  without  definite  exposure 
to  cold  or  any  o'ther  known  cause.  It  may  be  persistent  from  the  onset 
but  more  often  is  transient  in  character,  being  present  for  a  few  days  and 
then  disappearing  and  reappearing  again.  Very  often  the  hoarseness  is 
noticeable  for  a  part  of  the  day  only;  either  on  getting  up  in  the  morning 
or  late  in  the  day  or  after  much  talking.  A  laryngological  examination 
is  imperative  in  these  cases.  Nothing  is  more  fatal  than  to  assume  that 
the  laryngitis  is  due  to  a  "cold." 

The  occurrence  of  any  one  of  the  above-mentioned  symptoms  fur- 
nishes the  most  valuable  information  possible  as  to  the  presence  of  a 
pulmonary  tuberculosis.  Unless  it  can  be  shown  conclusively  that  they 
are  produced  by  something  else  there  should  be  no  hesitation  in  making 
a  diagnosis  of  tuberculosis.  Furthermore,  it  cannot  be  too  strongly 
emphasized  that  the  phj-sical  appearance  of  the  patient  should  have  no 
influence  in  arriving  at  a  conclusion.  Only  too  frequently  physicians 
hesitate  to  commit  themselves  because  the  patient  presents  every 
appearance  of  health  and  the  pulmonary  signs  are  indefinite. 

Unfortunately  tuberculosis  is  far  more  often  characterized  by  an 
insidious  rather  than  an  abrupt  onset,  and  there  is  no  single,  striking 
symptom  upon  which  we  can  place  much  reliance.  Cases  with  an 
insidious  onset  msiy  manifest  themselves  in  a  variet}^  of  ways. 

1.  The  individual  catches  "cold"  which  instead  of  clearing  up  per- 
sists, or  just  as  it  seems  to  be  getting  better  a  fresh  "cold"  is  acquired. 


Associated  with  the  cough,  which  may  be  dry  and  hacking  in  character, 
there  are  loss  of  weight,  anemia,  malaise  and  at  times  the  sputum  may 
be  blood-tinged.  In  some  instances  patients  themselves  neglect  these 
"colds,"  in  other  instances  although  they  seek  advice,  they  are  told 
they  are  suffering  from  bronchitis. 

It  cannot  be  sufficiently  emphasized  that  a  cough  which,  without 
complications,  persists  over  six  weeks  or  two  months  is  suspicious  at 
least;  if  it  is  associated  with  loss  of  weight,  slight  fever,  and  malaise, 
it  is  almost  certainly  tuberculous  in  origin. 

2.  In  another  group  the  dominant  symptoms  are  referred  to  the 
g astro-intestinal  tract.  Anorexia  is  common,  or  the  appetite  is  variable, 
being  somietimes  very  good  and  at  others,  poor.  Symptoms  of  indiges- 
tion are  annoying  and  usually  take  the  form  of  distention  after  eating, 
with  a  sense  of  discomfort  or  even  well-marked  pain  in  the  epigastric 
region.  Constipation  is  usually  present.  In  this  group  malaise,  pallor 
and  loss  of  weight  also  occur.  Cough  may  be  present  or  absent.  If 
present  it  is  usually  not  marked  and  its  significance  is  lost  sight  of,  because 
of  the  marked  gastric  symptoms.  Stomach  coughs  were  once  common, 
but  fortunately  little  is  heard  of  them  nowadays.  Indigestion  occurring 
in  an  individual  previously  free  from  any  such  disturbance  and  associated 
with  malaise,  loss  of  weight  and  cough,  should  lead  one  to  take  a  careful 
history  of  the  case  and  above  all  make  a  thorough  examination  of  the 

3.  A  third  group  is  comprised  of  those  cases  in  which  the  onset  is 
so  insidious  that  there  is  nothing  which  definitely  attracts  attention.  The 
condition  is  often  described  by  the  expression  "generally  run  down." 
A  careful  analysis  of  the  symptoms  in  this  group  usually  reveals  the 
following  facts:  Malaise  is  marked  and  the  individual  has  a  feeling  of 
being  constantly  tired,  even  when  awakening  after  a  good  night's  sleep; 
there  is  loss  of  weight  which  may  amount  to  10  or  15  pounds,  so  gradual, 
however,  that  the  patient  has  not  been  conscious  of  it;  there  is  usually 
some  pallor,  which  is  more  marked  in  the  morning;  cough  may  be  absent, 
or  if  present,  is  confined  to  the  morning  on  awakening;  and  lastly,  there 
may  be  occasional  attacks  of  indigestion.  The  most  significant  features 
are  the  malaise  and  gradual  loss  of  weight.  Patients  in  this  group 
frequently  escape  detection  in  the  incipient  stage  of  the  disease. 

In  women  disturbances  of  the  menstrual  junction  are  among  the 
early  symptoms.  Either  the  flow  becomes  scanty  and  irregular  in  its 
appearance  or  it  ceases  entirely.  Under  the  same  circumstances  leukor- 
rhea  may  appear  or  if  already  present  become  greatly  aggravated. 

4.  The  attack  may  begin  more  abruptly  and  resemble  in  every  respect 
typhoid  fever.  The  patient  feels  tired  and  dragged  out  and  there  is  slight 
fever  which  finally  assumes  the  continuous  type  seen  in  typhoid  patients. 
Inasmuch  as  bronchitis  and  some  cough  are  commonly  present  in  typhoid 
fever  patients  the  true  nature  of  these  symptoms  are  overlooked.  I 
recall  one  patient  who  was  treated  for  nearly  three  weeks  for  typhoid 
fever,  without  a  suspicion  as  to  the  true  nature  of  his  trouble,  until  he 
had  a  fair-sized  pulmonary  hemorrhage  following  a  cold  bath.  This 
patient  had  a  moderately  advanced  lesion  in  the  right  upper  lobe  and 
tubercle  bacilli  in  the  sputum. 

I  think  there  can  be  but  little  doubt  that  tuberculosis  not  infrequently 
undergoes  an  acute  exacerbation  which  closely  resembles  an  attack  of 


typhoid  fever.  Very  often  the  acute  process  spontaneously  subsides  and 
the  patient  apparently  makes  a  perfect  recovery.  Out  of  5895  cases  of 
tuberculosis  seen  at  the  Phipps  Institute  1083  or  18.3  per  cent,  gave  a 
history  of  having  had  typhoid  fever.  It  is  quite  likely  that  not  a  few  of 
these  were  instances  of  an  acute  exacerbation  of  tuberculosis. 

5.  Occasionally  tuberculosis  first  manifests  itself  with  chills,  fever 
and  sweats  which  may  assume  a  periodicity  similar  to  that  seen  in  malaria. 
In  regions  where  both  diseases  coexist  mistakes  are  frequent. 

6.  What  is  known  as  Louis'  law  should  be  borne  in  mind,  namely, 
that  after  the  age  of  puberty  a  tuberculous  lesion  in  any  part  of  the  body 
is  almost  invariably  accompanied  by  pulmonary  tuberculosis.  There- 
fore, the  presence  of  a  tuberculous  testicle  or  of  tuberculous  lymph  nodes 
in  an  adult  should  suggest  a  careful  examination  of  the  lungs. 

7.  Finally,  the  following  precepts  of  Dieulafoy  should  be  kept  in 
mind :  Every  youth  or  adult,  who  wastes  much  or  rapidly,  with  or  without 
fever,  must  be  suspected  of  having  tuberculosis,  in  the  absence  of  diabetes 
or  Basedow's  disease. 

Every  girl  or  young  woman  who  has  neither  genuine  chlorosis, 
Bright's  disease  nor  syphilitic  anemia,  but  yet  has  the  appearance  of 
chloro-anemia,  must  be  suspected  of  having  tuberculosis. 

The  symptoms  detailed  above  in  the  various  modes  of  onset  also  form 
the  symptomatology  of  the  incipient  stage.  If  the  disease  is  arrested  at 
this  stage  the  symptoms  disappear.  If,  however,  the  disease  progresses 
the  symptoms  already  present  are  apt  to  become  more  marked;  the  ema- 
ciation becomes  more  pronounced,  the  cough  and  expectoration  more 
troublesome,  and  in  addition  new  symptoms  are  constantly  developing. 
By  the  time  the  terminal  stage  is  reached  the  patient  will  suffer  at  one 
time  or  another  from  all  of  the  symptoms  peculiar  to  the  disease. 

The  symptoms  of  tuberculosis  are  of  two  kinds:  (1)  the  general  or 
constitutional  symptoms  due  to  the  toxic  effects  of  the  infection;  and 
(2)  the  local  subjective  symptoms  due  to  pathological  changes  in  the 
various  organs. 

Constitutional  Symptoms. — Fever. — This  is  the  most  important  symp- 
tom in  tuberculosis  and  a  study  of  its  manifestations  yields  much  infor- 
mation, as  from  this  one  symptom  it  is  possible  to  trace  with  reasonable 
certainty,  the  destructive  process  of  the  disease  as  it  progresses  from  its 
incipiency  to  the  terminal  stages.  On  the  other  hand,  the  subsidence  of 
the  fever  is  the  most  reliable  evidence  we  have  that  the  disease  is  tending 
toward  arrest  or  quiescence. 

The  early  febrile  manifestations  of  tuberculosis  usually  consist  of 
slight  elevations  of  temperature  amounting  to  from  1°  to  2.6°F.  The 
fever  may  be  present  every  day  or  only  every  second  or  third  day  (see 
Fig.  240).  It  is  increased  63^  exercise  and  as  a  rule  quickly  subsides  after 
several  weeks'  rest  in  bed.  At  times  slight  fever  persists  in  an  early  case 
even  after  prolonged  rest  (see  Fig.  241),  This  is  usually  an  indication  of 
poor  resistance  or  the  presence  of  more  extensive  disease  than  the  physical 
signs  indicate. 

Very  often  the  febrile  stage  is  succeeded  by  a  period  of  subnormal 
temperature  during  which  time  the  patient  continues  to  improve  (see 
Fig.  242).  Gradually  the  temperature  curve  shows  less  marked  remis- 
sions and  becomes  normal.  Unless  a  relapse  occurs  or  there  is  some 
intercurrent  disturbance  the  temperature  then  remains  normal.     Sub- 



normal  temperatures  are  also  present  in  cases  witli  advanced  disease 
XXis  temporarily  cpiescent.  In  such  instances  the  vitality  is  usually 

102° : 






t     1 








1 — •■ — 

— ^ — 










1 , 

— Lj*- 


—■ — 

-    1 
— 1— 





1 — '— 


— ^ 


— H(- 


' i : 

j  i  1  1 


1 — 

T —  ' 

— 1— 






Fig.   240.— Temperature  in  an  early  case  with  lesion  at  right  apex. 

Fig.  241.— Persistent  slight  fever  in  an  early  case  after  prolonged  rest  in  bed. 



Fig.  242.— Subnormal  temperature  often  noted  after  subsidence  of  fever  in  early  case. 

\  pulmonarv  hemorrhage  may  be  followed  by  fever.  This  may  be 
due\o  an  acute  respiratory  infection  which  has  been  the  excitmg  cause  oi 
the  hemorrhage  or  it  may  result  from  smah  areas  of  broncho-pneumonia 
due  to  insufflation  of  blood. 


In  persons  who  have  become  afebrile,  an  abrupt  rise  in  the  tem- 
perature may  occur  and  last  for  a  day  or  so.  This  may  be  due  to  an  acute 
cold  (see  Fig.  243),  some  gastric  disturbance,  constipation,  slight  pleurisy, 
overexertion,  etc.  In  women  during  the  active  stage  of  the  disease  the 
temperature  may  abruptly  rise  some  days  prior  to,  or  with  the  onset  of, 
the  menstrual  period  (see  Fig.  244)  and  may  remain  elevated  until  the  flow 
ceases.     In  patients  who  have  been  afebrile,  and  in  whom  these  temporary 

























































1 , 





1  \ 




I  ! 



















,    ,  ' 

V       ■ 


/  \ 

-—  « 





.        \^ 

'  ^  ,■' 




\f     ' 


y  V 


'     ' 

»  / 




'  / 




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/ 1 




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i  i 





i   1  ,   1  1 


■ — ' 

— i — 

— j— 

H r- 




— I— 


, — 

1 — 1 




Fig.   243. — Afebrile  case.      Rise  in  temperature  due  to  an  acute  cold. 


i  ■  1 






lOl  ° 















99°  ^tJ 

«.        /      >L     !. 




\      \n        " 


/^v     \^ 



i  • 


I   A 





\  / 




-V  \- 

98°  1 — 1 — 1 — 


-:2— t 






H — 


Fig.  244. — Rise  in  temperature  due  to  menstruation. 

manifestations  of  fever  occur,  it  is  usually  an  indication  that  the  disease 
has  not  become  arrested  but  is  simply  quiescent.  When  thej^  can  pass 
through  such  episodes  without  a  febrile  reaction,  it  may  be  taken  as  one 
of  the  pieces  of  evidence  that  the  disease  is  apparently  arrested. 

When  the  disease  is  not  arrested  but  continues  to  spread  the  tem- 
perature is  moderately  high  and  inay  be  intermittent,  remittent  or 
continuous  (see  Fig.  245).  The  temperature  may  then  subside  and 
become  normal  or  show  but  slight  elevations  or  it  ma}'  pass  into  the  hectic 
type  which  is  characterized  by  marked  remissions  and  intermissions 



M   E 



M|  E 


M   E 

M   E 



M   E 




M\  E 

M;  E 



V !  E 


y  \  E 






— 1 — ' 

— ! — 

— r^ 


— r-«r 


— 1— 




)  1 






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1 , 



















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1  \ 



'•^  ■,  /^ 

















— ; — 




















•  i 

,  , 









^  1 


















































— f- 






— |  — 






— ; — 




Fig.  245. — Active  disease  progressing. 


M   E  M   E  M 




Te  M  E  m[ 

1                    1 



— r 














— ] 



-— t— 






M    E 

























-i. — U 


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i  1 

















Fig.   246. — Intermittent  and  remittent  type  of  temperature  seen  in  advanced  cases. 

^1    \L'. 

it!  ;^ 

ti  iti 

\^\  14- 

tj   ife;   Ui   |4i     L\   I M   !  (>:   i  k 

\h\   'V-J   i^l   i^l   !  f i   iH   :'^l   i*^!   "-^ 

6;       I    t         j  fc 

q^      iWJ      :v|      iv|      .ij 



/\  j     ■:      ::\A 


I      !      I 



I  :  I 

Fig.  247. — Rapidly  advancing  process  of  bronchopneumonic  type.     Also  shows  inverted 



(Fig.  246).  In  this  type  of  temperature,  which  is  always  present  in 
advanced  cases  which  are  progressing  toward  a  fatal  termination,  the 
difference  between  the  morning  and  evening  temperature  may  amount 
to  from  5°  to  8°F. 

When  new  areas  of  lung  tissue  are  being  invaded  the  temperature 
is  continuous  in  type,  sometimes  with  slight  remissions  and  in  other 
instances  there  are  marked  intermissions  (Figs.  247  and  248).     Such  tem- 



















M  1^ 



















_k  M  H 







f — 

1 — 




^ " 












1   '' 








)  i  • 




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,  / 

















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— 1 







Fig.  248. — Rapidly  advancing  type  of  disease.     Also  shows  inverted  temperature. 

103°  -T~ 

102°  — }-;> 




e|m|e  m 





M   E 

M   E 















99°  — ^ 

98°     r 

1          1          I 














Fig.  249. — Temperature  curve  resembling  that  of  lobar  pneumonia.     In  this  case  the 
temperature  fell  to  normal  in  three  weeks. 

perature  curves  always  indicate  marked  activity  of  the  disease.  Tem- 
peratures of  this  type  may  be  present  when  the  case  is  first  seen  or 
develop  after  a  period  of  slight  fever;  as  a  rule  they  change  into  the 
hectic  type  but  the  fever  may  gradually  subside  and  the  temperature 
become  normal.  Another  interesting  feature  to  be  looked  for  in  charts 
of  this  type  is  inversion  of  the  temperature,  that  is  the  morning  tempera- 
ture is  higher  than  that  in  the  evening.     An  inverted  temperature  is  com- 



monly  associated  with  miliary  tuberculosis  but  it  often  maj^  be  noted 
in  pulmonary  cases  in  which  the  disease  is  spreading  rapidly.  It  is  not 
constant  and  is  usually  observed  but  a  few  days  as  shown  in  both 
Figs.  247  and  248. 

Another  tj-pe  of  temperatm'e  is  that  seen  in  cases  with  an  acute  onset 
and  high  fever.  The  fever  may  subside  by  lysis  in  two  or  three  weeks 
(see  Fig.  249)  or  it  maj^  become  hectic  in  type.  Such  cases  are  not  in- 
frequently mistaken  for  lobar  pneumonia  because  of  the  sudden  onset, 
high  fever,  blood  in  the  sputum  and  signs  of  consolidation  over  an  upper 

A  continuous  type  of  temperature  which  is  broken  at  intervals  by 
marked  intermissions  (Fig.  248)  sometimes  leads  to  a  diagnosis  of  malaria, 
especiallj'  when  the  sudden  rises  in  the  temperature  are  accompanied  by 
chillv  sensations. 


?-!  h\   ?l   '^ 

^:      i^l      k 







1 — 









it|  H  >!   ^  '-^1  ^^ 
















\   '  r  : 

1    ' 

i            1 

'   1    '   (   '       i 





1            !      i 

'   I    ■   i    :       1 





1     i 

'    1    ■ 




r'l      ' 


,    ,  1                          ' 







1         1  \      '  ' ' '         '1            1       ' 

/  ' 

\   7','     1       .'     ' 

/             :                .                • 

iM     /li      III      ,'\l     . 




'  -      '/ 

7  t         i      '  \    '  . 

III'          M      / 


/      M'  '  \  ^' 


1   " 


1  V    /    ■  1   i         ' '  1     ' 

n    i 

\      »     Is    WW 


1 1\ 

/  W    • 


/ 1 

/                \  / 



7    \  /      :\    , 

'             \    1  \  1      Ui    1     1 


\'      \ 



1  «ft 


\          ■       '     . 

/       '     \  /    \  / 

'     : 

*  i     j 



;    / 

\    1     IW    i\/' 



1     ! 

\ ./ 

1      / 

/     V  • 







f    '  •  1 









^1   r    il 







.1  .1  1' 

^    1 


'    ' 










'  1 







1    i 


/\    / 

'  , 





■    ' 


\  ' 




















i     W: 



/  ' '. 



/  \    j 






1  ^ 


/  ' 






1        i 


1  ' 

/  1 




i     11/ 






M        ■ 

n-    -H-^-- 







.1      il ' 



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1  ^ 






1        1       j 


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1  / 





i    1 




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1  i 













;                1 




















— \ — ■ — ■ — 


■ 1 









— 1 


Fig.  250.- — Type  of  temperature  seen  in  terminal  stage  of  advanced  cases. 

In  the  terminal  stage  of  the  disease  the  temperature  is  characterized 
by  marked  irregularities,  such  as  shown  in  Fig.  250. 

The  diagnostic  and  'prognostic  value  of  temperature  observations 
cannot  be  overestimated.  The  clinical  thermometer  should  always  be 
used.  In  the  very  early  cases  when  the  symptoms  and  physical  signs 
are  inconclusive,  the  use  of  the  thermometer  three  or  four  times  a  day 
for  a  week,  will  often  determine  the  diagnosis.  Furthermore,  the  absence 
of  fever  in  cases  with  other  unequivocal  evidences  of  the  disease,  or  the 
rapid  subsidence  of  fever  are  the  best  evidences  we  possess  of  an  inactive 
type  of  disease.  The  temperature  should  always  be  taken  in  the  morning 
and  again  in  the  afternoon,  preferably  at  4  p.m.  Additional  observations 
may  be  made  at  noon  and  8  p.m.  if  thought  necessary. 

Although  the  use  of  the  clinical  thermometer  is  a  simple  procedure 
certain  precautions  should  be  observed.     Not  infrequently  I  have  been 


told  that  a  patient  had  no  fever  when  subsequent  observations  in  a  sana- 
torium showed  that  there  was  a  shght  rise  in  the  temperature  every 
afternoon.  In  order  to  detect  shght  rises  in  the  temperature  (99°  to 
99.3°F.)  the  thermometer  should  be  left  in  the  mouth  not  less  than  10 
minutes.  For  temperatures  over  100°F.  any  thermometer  will  register 
the  amount  of  fever  within  a  minute,  but  for  slight  elevations  even  the 
half  minute  and  minute  thermometers  will  often  fail.  Several  years 
ago  I  carried  out  a  series  of  observations  which  showed  that  a  3-minute 
thermometer,  if  kept  in  the  mouth  for  at  least  10  minutes,  was  for  prac- 
tical purposes,  as  accurate  as  the  quickly  registering  thermometers 
placed  in  the  rectum.  Mouth  temperatures  should  not  be  taken  within 
half  an  hour  if  the  patient  has  taken  anything  very  hot  or  very  cold  to 
eat  or  drink. 

Many  observers  recommend  the  rectal  use  of  the  thermometer  as  the 
only  reliable  method.  If  the  precautions  I  have  given  are  observed  this 
will  not  be  necessary.  Besides  it  is  less  convenient  and  often  patients 
object  to  it. 

Loss  of  Weight. — A  gradual  and  progressive  loss  of  weight  is  charac- 
teristic of  the  disease.  The  amount  lost  varies  greatly  in  different 
individuals  and  is  governed  to  a  large  extent  by  the  severity  of  the  infec- 
tion. In  the  acute  types  of  the  disease  the  loss  is  rapid  and  may  eventu- 
ally amount  to  a  third  or  more  of  the  normal  body  weight.  In  the 
chronic  forms  of  the  disease  the  loss  of  weight  is  rarely  extreme  and  in 
addition  it  is  apt  to  be  quickly  regained  if  the  patient  is  put  under  the 
proper  treatment.  A  progressive  loss  of  weight  which  continues  in  spite 
of  proper  treatment  is  always  of  serious  import.  On  the  other  hand,  a 
steady  gain  in  weight  is  one  of  the  most  favorable  prognostic  signs. 

Not  only  does  the  patient  show  emaciation  but  the  muscular  system 
becomes  more  and  more  atrophied  as  the  disease  progresses.  In  addi- 
tion the  muscles  become  unduly  irritable. 

Malaise. — In  many  cases  with  an  insidious  onset  a  sense  of  weariness 
with  or  without  exertion  of  any  kind  may  be  the  first  manifestation  of 
the  disease.  Very  often  it  is  the  only  symptom  the  patient  complains 
of  for  months.  It  is  the  one  symptom  that  has  walked  more  patients 
into  their  graves  than  any  other  because  of  the  fact  that  exercise  is 
almost  invariably  prescribed.  This  is  commonly  done  without  attempt- 
ing to  find  out  whether  there  are  any  associated  symptoms.  The  exer- 
cise is  prescribed  on  the  ground  that  inasmuch  as  it  makes  a  healthy 
man  feel  better  it  ought  to  make  the  individual  who  is  suffering  from 
languor  feel  twice  as  well.  Unfortunately  this  procedure  aggravates 
the  difficulty  instead  of  relieving  it.  As  the  disease  progresses  the  sense 
of  languor  and  tiredness  increases.  In  the  terminal  stages  of  the  disease 
it  is  due  to  the  extreme  emaciation  and  inability  to  absorb  the  proper 
amount  of  nourishment. 

Closely  allied  to  this  condition  of  general  malaise  is  neurasthenia.  It 
is  becoming  more  and  more  recognized  that  neurasthenia  is  rarely  a  pure 
functional  disturbance.  In  some  cases  of  tuberculosis,  neurasthenia  is 
a  very  marked  feature  of  the  disease  and  the  nervous  phenomena  may 
dominate  the  picture.  On  the  other  hand,  there  are  many  cases  of 
neurasthenia  which  are  considered  as  instances  of  a  functional  disturb- 
ance of  the  nervous  system  but  which  in  reality  are  due  to  a  latent  tuber- 
culous infection  which  escapes  notice.     I  recall  one  case  in  which  neuras- 

DISEASES    OF    THE    LUNGS  335 

thenia,  associated  with  profound  asthenia,  had  existed  for  four  years. 
Although  the  neurologist  in  charge  suspected  a  tuberculous  infection  it 
could  never  be  located.  Finally  the  occurrence  of  an  hemoptysis  pointed 
to  pulmonary  trouble  which  a  careful  physical  examination  showed  to  be 
present  in  the  apex  of  the  right  lung.  The  patient  was  then  treated  as  a 
case  of  tuberculosis  and  made  a  complete  recovery. 

Night  sweats  may  occur  at  any  time  during  the  course  of  the  disease 
but  are  not  usually  encountered  in  the  incipient  stage.  They  occur  very 
commonly  in  the  second  stage  but  as  a  rule  are  not  severe.  Sweating 
varies  greatly  in  different  individuals.  In  some  cases  it  is  the  most  dis- 
tressing and  harassing  manifestation  of  the  disease,  as  it  is  not  only  ex- 
hausting but  in  addition  causes  great  discomfort.  As  a  rule  night  sweats, 
which  do  not  disappear  after  the  patient  has  been  put  under  treatment, 
occur  in  the  acute  types  of  the  disease  and  in  the  terminal  stages  of  the 
chronic  form  when  fever  is  present.  Sweating  rarely  occurs  in  an  afeb- 
rile patient.  Night  sweats,  as  the  name  implies,  occur  at  night,  usually 
in  the  early  morning  hours. 

Axillary  sweating  is  very  common  in  tuberculous  subjects  even  in 
the  incipient  stage  of  the  disease.  A  tendency  to  sweat  after  the  least 
exertion  is  also  of  frequent  occurrence  during  the  early  stages  of  the 

Chills. — Sometimes  chills  occur  as  an  earh'  manifestation  of  the 
disease.  As  a  rule  chills  associated  with  fever  and  sweats,  occur  in  very 
acute  types  of  the  disease,  such  as  pneumonic  phthisis  and  acute  miliary 
tuberculosis.  In  the  terminal  stage  of  chronic  ulcerative  tuberculosis, 
while  chilly  sensations  are  not  infrequent,  distinct  chills  are  unusual. 

Anemia. — A  slight  degree  of  anemia  in  the  incipient  stage  of  tubercu- 
losis is  not  uncommon,  although,  as  a  rule,  it  is  more  apparent  than  real. 
Morning  pallor  is  often  very  noticeable;  this  is  apt  to  be  masked  in  the 
afternoon  by  flushing  of  the  cheeks  as  the  result  of  slight  fever. 

In  the  second  and  third  stages  of  the  disease  anemia  may  or  may  not 
be  present.  Sometimes  it  is  quite  marked.  In  other  instances  and  espe- 
cially in  individuals  who  have  been  under  appropriate  treatment,  there 
is  no  evidence  of  anemia;  on  the  contrarj^,  the  patients  often  present  a 
healthy,  ruddy  color. 

The  blood  picture  in  tuberculosis  has  a  slight  resemblance  to  that 
seen  in  chlorosis  in  that  the  hemoglobin  is  most  affected,  although  the 
reduction  of  the  hemoglobin  content  in  tuberculosis  is  never  as  marked  as 
in  chlorosis.  The  leukocytes  in  tuberculosis  are  not  increased  in  the 
first  and  second  stages;  in  the  third  stage  a  moderate  leukocytosis  is 
common,  probably  as  the  result  of  mixed  infection. 

Gastro-intestinal  Symptoms. — As  already  mentioned  these  symptoms 
may  overshadow  the  pulmonarj^  sj^mptoms  at  the  onset  of  the  disease. 
Anorexia  is  not  uncommon  in  the  beginning  and  may  persist  until  the 
end.  In  some  patients  gastric  disturbances  persist  or  recur  very  fre- 
quently throughout  the  course  of  the  disease  and  serioush'  interfere  with 
recovery.  The  majority  of  people  suffering  from  tuberculosis  give  both 
subjective  and  objective  evidence  of  the  injury  which  befalls  the  aU- 
mentary  canal  and  the  organs  which  have  to  do  with  nutrition.  A  coated 
or  dry  tongue,  loss  of  appetite,  nausea  and  A'omiting,  constipation,  and 
diarrhea  are  the  common  symptoms  which  are  encountered.  One  or  the 
other  of  them  exists  in  almost  CA^ery  case.     As  a  general  rule  it  can  be 


said  that  the  chances  of  recovery  are  very  poor  if  the  patient  either  can- 
not eat  because  of  marked  anorexia  or  because  the  least  thing  upsets  the 
stomach.  In  spite  of  extensive  disease  of  the  lungs  and  marked  symp- 
toms some  patients  continue  to  have  a  good  appetite  and  digest  their 
food  without  discomfort.  In  those  who  suffer  from  a  sense  of  fulness, 
often  with  considerable  epigastric  pain  after  eating,  the  trouble  is  rarely 
due  to  pathological  changes  in  the  stomach  but  to  alterations  in  the  char- 
acter of  the  gastric  juice.  The  gastric  juice  may  be  inefficient  because 
it  is  too  small  in  amount  or  too  poor  in  quality.  At  times  nausea  and 
vomiting  may  occur  but  more  often  the  patient  simply  feels  nauseated 
either  at  the  sight  of  food  or  after  eating.  Vomiting  more  often  results 
from  a  reflex  action  as  the  result  of  a  paroxysm  of  coughing.  In  the 
effort  to  build  the  patient  up  forced  feeding  is  sometimes  injudiciously 
employed  with  the  result  that  the  overfeeding  produces  a  typical  bilious 

Diarrhea  is  sometimes  a  very  troublesome  SN'mptom.  It  may  be 
due  simply  to  a  catarrhal  inflammation  of  the  intestinal  mucous  membrane 
or  as  the  result  of  intestinal  ulceration.  It  may  be  stated,  however,  that 
diarrhea  even  when  most  severe,  cannot  be  taken  as  an  indication  of 
tuberculous  ulceration  of  the  intestines.  Recently  Brown  and  Heise'  have 
shown  by  means  of  a  bismuth  meal  that  there  is  marked  hj^permotility 
of  the  intestines  when  ulceration  is  present,  the  gastro-intestinal  tract 
becoming  entirely  emptied  within  24  hours. 

Cardio-vascular  Symptoms. — Acceleration  of  the  pulse  is  a  very  fre- 
quent manifestation  in  tuberculosis.  It  maj^  occur  as  an  early  symptom 
and  without  fever.  Under  these  circumstances,  it  is  of  value  as  an  early 
diagnostic  sign.  As  the  disease  progresses  the  tendency  of  the  pulse 
rate  to  increase  becomes  more  marked.  In  some  instances  the  patient 
is  not  conscious  of  the  rapidly  beating  heart  but  at  times  an  annoying 
palpitation  occurs  with  the  tachj'carcha.  During  the  last  stage  of  the 
disease  the  pulse  rate  is  usually  very  high  rising  to  120  or  more. 

The  blood-pressure  in  tuberculous  subjects  is  usually  low.  If  the 
disease  undergoes  arrest  and  health  is  restored,  the  blood-pressure  returns 
to  normal.  Cardiac  weakness  is  not  uncommonly  present  and  occa- 
sionally is  the  cause  of  death. 

Edema  of  the  extremities,  especialh'  the  legs,  is  not  infrequentl}"  seen 
in  the  terminal  stage  of  tuberculosis.  It  is  alwaj's  an  indication  that  the 
end  is  near  at  hand.  Edema  may  be  due  to  cardiac  weakness,  a  com- 
plicating nephritis  or  both. 

A  violet  or  bluish  discoloration  of  the  nails  is  frequently  noted. 
When  it  occurs  in  the  earh^  stages  of  the  disease  it  is  usually  an  indica- 
tion that  the  infection  is  a  serious  one.  It  is  almost  invariablj^  present 
in  the  terminal  stage.  While  the  condition  resembles  cyanosis  due  to 
cardiac  weakness  it  occurs  independently  of  the  heart  and  is  apparently 
due  to  toxic  absorption.  True  C3'anosis  of  the  fingers  and  lips  is 
occasionally  noted. 

Skiyi. — In  the  early  stages  of  the  disease  the  skin  rarelj^  shows  any 
abnormality.  In  the  advanced  stages,  however,  it  is  nearly  always 
unduly  dry  or  moist  and  clammy.  Often  the  skin  has  a  scaly  appearance 
and  fine  bran-like  flakes  can  be  scraped  off.  In  those  who  are  uncleanly 
in  their  habits  pitATiasis  versicolor,  an  eruption  which  consists  of  yellow- 

'  Jour.  Amer.  Med.  Assoc,  July  12.  1919. 

DISEASES    OF    THE    LUNGS  337 

ish  or  orange-colored  patches,  is  commonly  seen  on  the  thorax  and  upper 

Jaundice  and  purpura  are  occasionally  noted  in  tuberculosis;  usually 
in  the  terminal  stage.  In  an  analysis  of  the  ward  patients  in  the  Phipps 
Institute,  Cruice  found  7  instances  of  jaundice  among  1748  cases  and  8 
of  purpura  among  1626  cases. 

A  hectic  flush  is  common  in  the  afternoon  even  in  patients  who  have 
a  very  slight  rise  in  the  temperature.  The  flush  is  usually  confined  to 
the  side  affected  or  if  both  lungs  are  involved  will  be  more  marked  on  the 
side  having  the  most  marked  disease. 

In  advanced  cases  the  hair  becomes  thin  and  presents  a  dry,  lusterless 

Urine. — In  the  early  cases  evidences  of  kidney  irritation  occur  with  no 
greater  frequency  than  is  encountered  in  the  general  run  of  individuals. 
As  the  tuberculous  process  advances,  however,  the  urinary  findings  show 
an  increasing  number  of  abnormalities.  Walsh  found  albumen  present 
in  47  per  cent,  of  advanced  cases  and  casts  are  nearly  as  frequently  present. 
In  a  small  percentage  of  cases  sugar  is  present.  It  was  noted  in  2  per 
cent,  of  656  cases  studied  at  the  Phipps  Institute.  In  some  instances 
it  is  due  to  a  true  diabetes;  in  others  it  is  to  be  looked  upon  as  a  mild 

Ehrlich's  diazo  reaction  was  considered  at  one  time  to  be  of  both 
diagnostic  and  prognostic  value.  As  it  is  often  found  in  conditions  other 
than  tuberculosis,  it  has  no  significance  as  a  diagnostic  sign;  and  the 
same  may  be  said  of  its  prognostic  value. 

Phosphaturia  is  often  present  when  the  patient  is  steadily  losing 
weight.     It  is  looked  upon  as  an  evidence  of  cell  destruction. 

Nervous  System. — The  mental  attitude  varies  greatly.  This,  however, 
has  little  to  do  with  the  disease  itself;  for  while  it  is  true  that  most  people 
are  depressed  at  the  onset,  they  rapidly  revert  to  their  normal  state  of 
mind.  This  may  be  optimistic,  pessimistic  or  indifferent  as  the  case 
may  be.  It  is  a  common  belief  that  the  spes  phthisica  is  of  frequent 
occurrence  in  tuberculous  subjects.  It  is  extraordinary  how  some  patients 
will  cheerfully  make  plans  for  the  future  even  when  they  are  a  few  days 
from  death.  Although  the  frequency  of  this  exaggerated  form  of  hope- 
fulness has  been  greatly  overestimated,  it  is  undeniably  true  that  cheer- 
fulness and  optimism  as  to  the  outcome,  is  more  often  present  than 
depression  and  pessimism. 

Tuberculosis  among  the  insane  is  very  common  but  no  more  so  than 
a  similar  group  of  individuals  living  under  like  circumstances.  On  the 
other  hand  the  development  of  a  psychosis  in  a  tuberculous  subject  is 
relatively  infrequent.  McCarthy  recognizes  a  small  group  of  psychoses 
due  to  tuberculosis  and  a  second  group  which  includes  the  usual  type 
of  insanity  determined  by  a  lowering  of  nutrition.  The  first  group  pre- 
sents a  symptom  complex  closely  resembling  paresis.  In  the  second  group 
the  psychosis  may  take  the  form  of  melancholia,  mania,  dementia  prsecox, 
hysterical  insanity  and  delusional  insanity.  Suicidal  tendencies  are  not 
uncommon  especially  in  those  who  become  depressed  and  melancholy. 

Hyper ceslhesia. — Points  of  tenderness  may  occur  in  various  parts 
of  the  body  and  in  some  instances  there  is  a  definite  neuritis. 

Herpes  zoster  is  occasionally  noted  in  tuberculosis  but  it  is  doubtful 
whether  the  condition  can  be  ascribed  to  the  tuberculous  infection.     Head- 



ache  is  not  infrequent.  It  is  commonly  due  to  eye  strain  and  is  usually 
encountered  in  those  confined  to  bed  and  who  read  a  great  deal.  Per- 
sistent headache  should  always  arouse  suspicion  as  to  the  presence  of  a 

Insomnia  of  a  mild  grade  is  not  uncommon;  it  is  rarel}^  severe  enough 
to  demand  treatment.  The  sleep  is  often  broken,  however,  by  night 
sweats  or  attacks  of  coughing. 

Arthritis,  generally  affecting  the  ankles,  is  in  my  experience  relatively 
common  in  advanced  cases.  The  ankles  become  slightly  swollen,  red- 
dened and  very  painful.  In  some  instances  the  pain  is  intense  and  even 
the  weight  of  a  sheet  is  unbearable.  A  number  of  French  observers 
look  upon  this  type  of  arthritis  as  being  tuberculous  in  origin. 

Menstrual  Function.— In  women  the  menstrual  function  is  affected 
sooner  or  later,  in  the  majority  of  cases.  Sometimes  suppression  of  the 
menses  is  one  of  the  earliest  manifestations  of  the  disease.  As  a  rule, 
the  menstrual  flow  first  becomes  irregular  and  scanty  and  finally  ceases. 
If  the  patient  is  restored  to  health  the  menstrual  function  gradually 
becomes  normal.  Leukorrhea  is  also  apt  to  develop  or  if  present  it 
becomes  much  worse. 

Local  Subjective  Symptoms. — Cough. — In  the  majorit}' of  cases  cough 
is  among  the  \evx  earliest  manifestations  of  the  disease  and  is  usually 
the  first  sj-mptom  that  the  patient  notices.  At  first  it  may  be  confined 
to  the  morning  on  awakening  or  it  may  be  absent  at  that  time  and  occur 
intermittently  during  the  day.  In  still  other  instances  it  is  most  marked 
on  going  to  bed.  Not  infrequently  what  is  at  first  believed  to  be  an 
acute  cold  continues  indefinitely.  It  is  a  safe  rule  to  view  any  cough 
which  persists  for  six  weeks  or  two  months  as  being  tuberculous  in  origin 
unless  the  contrary  can  be  proved  definitely.  As  the  disease  progresses 
the  cough  becomes  more  and  more  severe  and  tends  to  become  paroxysmal 
in  character. 

Occasionally  the  patient  has  a  number  of  symptoms  indicating  the 
existence  of  an  incipient  tuberculosis  and  no  cough  whatever.  The  cough 
is  due  to  the  irritation  of  the  bronchial  mucous  membranes  by  the  pul- 
monary secretions  and  is  almost  invariably  relieved  by  the  expulsion  of 
the  sputum.  Any  cough  which  is  unproductive  is  largely  unnecessary 
and  can  be  controlled  voluntarily  to  a  great  extent  by  the  patient. 

Expectoration. — As  a  rule  the  cough  and  expectoration  are  closely 
associated  and  the  one  is  almost  invariablj^  accompanied  bj^  the  other. 
There  may  be  considerable  expectoration,  however,  with  little  or  no 
cough,  the  sputum  being  brought  up  by  what  is  known  as  hawking  or 
clearing  the  throat.  In  the  early  stages  of  the  affection  the  sputum 
is  usually  slight  in  amount  but  as  the  disease  progresses  it  becomes  more 
and  more  profuse,  especially  after  the  formation  of  a  cavitj'. 

As  to  the  sputum  in  tuberculosis  it  can  be  said  that  it  has  no  dis- 
tinctive characteristic,  except  possibly  in  the  stage  of  excavation,  when 
the  so-called  nummular  sputum  occurs.  The  latter  is  brought  up  in 
the  form  of  irregularly'  shaped  grayish  or  greenish-gray  balls  which 
sink  in  water.  Sputum  with  similar  characteristics  may  occur  also  in 

Aside  from  this  form  of  sputum  the  secretion  may  consist  of  glairy 
transparent  material  with  black  specks  scattered  through  it;  it  may  be 
slightly  or  markedly  yellowish  in  color  and  later  it  ma}^  assume  a  greenish 


tinge.  From  time  to  time  blood  may  be  noted  in  the  sputum.  The 
blood  may  occur  in  the  form  of  a  few  minute  specks;  it  may  be  in  the  form 
of  streaks  or  the  blood  may  be  intimately  mixed  with  the  sputum  giving 
it  a  pinkish  or  reddish  color,  depending  on  the  amount  of  blood  present. 

Hemoptysis. — The  significance  of  hemoptysis  has  been  alluded  to  in 
considering  the  modes  of  onset.  Hemoptysis  occurs  in  about  one-half 
of  all  cases  of  pulmonary  tuberculosis,  although  some  observers  have 
placed  the  incidence  as  low  as  30  per  cent,  and  others  as  high  as  80  per 
cent.  Of  5856  cases  observed  at  the  Phipps  Institute  47.6  per  cent, 
had  had  an  hemoptysis  at  some  time  during  the  course  of  the  disease. 

Males  are  somewhat  more  liable  to  hemoptysis  than  females,  probably 
because  of  their  greater  physical  activity.  The  accident  occurs  most 
frequently  in  adults  who  are  suffering  from  the  chronic  ulcerative  type  of 
disease.  Hemoptysis  is  an  unusual  occurrence  in  children  nor  is  it  often 
noted  in  the  acute  types  of  the  disease  in  adults. 

The  amount  of  the  hemorrhage  varies  greatly.  It  may  consist  of  a 
few  flecks  or  streaks  of  blood  in  the  sputum  or  it  may  be  so  large  as  to 
cause  death  within  a  few  minutes.  The  sputum  may  be  constantly 
streaked  with  blood  or  pinkish  or  salmon-colored  for  weeks  or  even 
months.  When  the  hemorrhage  consists  of  an  ounce  or  so  of  pure  blood 
the  patient  may  expectorate  dark  clots  or  blood-streaked  sputum  for  a 
few  days.  A  single  hemoptysis  of  this  kind  may  be  the  only  manifes- 
tation of  blood  the  patient  ever  has.  Very  often,  however,  there  are 
recurrences  at  more  or  less  frequent  intervals.  Very  large  hemorrhages 
almost  invariably  occur  in  the  advanced  stages  of  the  disease  when  cavity 
formation  has  taken  place.  As  a  cause  of  death  hemorrhage  is  not  as 
frequent  as  ordinarily  believed.  In  a  study  of  the  cause  of  death  in  136 
cases  I  found  that  a  hemorrhage  was  the  immediate  or  exciting  cause  in 
11.  The  hemorrhage  may  be  so  large  as  to  immediately  cause  death  or 
it  may  give  rise  to  a  widespread  broncho-pneumonia  due  to  insufflation 
of  blood,  which  proves  fatal  in  a  few  days. 

In  the  early  stages  of  the  disease  the  source  of  the  bleeding  is  usually 
from  the  pulmonary  veins  and  the  blood  is  bright  red  in  color  due  to  the 
fact  that  the  pulmonary  veins  carry  arterial  blood.  In  the  moderately 
advanced  and  advanced  cases  the  blood  comes  from  the  pulmonary 
artery  and  is  dark  or  venous  in  color. 

In  many  instances  the  exciting  cause  of  the  bleeding  can  be  determined 
but  in  not  a  few  cases  it  suddenly  appears  without  apparent  cause. 
Recently  I  saw  a  man  who  had  been  discharged  from  the  White  Haven 
Sanatorium  ten  years  ago  with  his  disease  arrested.  During  all  this  time 
he  had  been  in  perfect  health  and  had  worked  at  his  trade  every  day. 
While  walking  along  the  street  he  suddenly  was  seized  with  an  attack  of 
coughing  and  spat  up  a  few  ounces  of  blood.  Aside  from  this  he  had  no 
other  symptoms  and  examination  of  his  chest  shows  no  change  from  that 
noted  ten  j^ears  ago. 

In  many  instances  the  exciting  cause  of  the  bleeding  is  an  acute 
respiratory  infection  commonly  manifesting  itself  as  an  ordinary  "cold." 
In  institutions  it  is  not  at  all  unusual  for  a  number  of  patients  to  have 
attacks  of  hemoptysis  within  a  few  days.  This  epidemic-like  occurrence 
is  undoubtedly  closely  related  to  some  infection.  Some  years  ago  Flick, 
Ravenel  and  Irwin  in  a  study  of  such  cases  were  able  to  show  the  almost 
constant  presence  of  pneumococci  in  the  expectorated  blood. 


As  an  exciting  cause  of  pulmonary  hemorrhage  exertion  of  some 
description  is  usually  considered  as  a  common  factor.  It  is  interesting  to 
note  that  Bang^  in  a  study  of  hemoptysis  found  that  the  hemorrhage  came 
on  while  the  patients  were  lying  in  bed  or  reclining  in  a  chair  in  69  per  cent, 
of  354  cases.  He  considers  congestion  or  stasis  to  be  the  most  important 
factor.  Thus  50  of  the  patients  had  been  constantly  febrile;  fever  had 
developed  just  prior  to  the  hemorrhage  in  45  and  immediately  afterwards 
in  31;  11  had  been  severely  chilled  and  10  had  received  an  injection  of 

Among  women  blood  spitting  may  be  present  just  before  or  during 
the  time  of  the  menstrual  period.  As  the  disease  tends  towards  arrest, 
the  bleeding  gradually  ceases. 

In  cavity  cases  large  hemorrhages  are  usually  the  result  of  rupture  of 
a  pulmonary  blood-vessel.  In  a  large  percentage  of  cavities  there  are 
present  in  the  walls  or  in  the  trabeculae  traversing  the  cavity,  blood- 
vessels. Small  aneurismal  dilatations  are  very  commonly  present  in 
the  vessels.  They  may  rupture  through  a  sudden  elevation  of  the  blood- 
pressure  or  the  disease  may  gradually  erode  through  the  arterial  wall. 
In  addition  to  hemorrhages  of  considerable  size  the  sputum  from  cavity 
cases  may  be  pinkish  or  salmon-colored  from  the  admixture  of  blood 
coming  from  ulcerations  in  the  wall  of  the  cavity  and  such  sputum  may  be 
the  precursor  of  a  large  hemorrhage. 

Pain. — Chest  pain  is  one  of  the  common  manifestations  of  tuber- 
culosis. The  character  of  the  pain  varies.  It  is  usually  subjective  but 
may  be  objective  only.  When  objective  it  is  usually  associated  with 
cavity  formation  in  the  lungs  and  is  noted  in  percussing  over  the  site  of 
the  cavity.  Often  there  is  no  subjective  evidence  of  pain  in  spite  of  an 
extensive  pleural  friction  rub.  In  such  cases  pain  can  usually  be  elicited 
by  pressure  with  the  finger  tips  over  the  site  of  the  friction. 

The  character  of  the  subjective  pain  varies  greatly.  It  may  be  sharp 
and  knife-like  as  the  result  of  a  severe  pleurisy  or  in  other  instances  it 
may  consist  of  a  feeUng  of  soreness.  Not  uncommonly  the  pain  or 
soreness  is  referred  to  the  region  of  the  shoulder  on  the  affected  side. 
This  fact  should  be  borne  in  mind  as  it  is  commonly  mistaken  for  a  rheu- 
matic manifestation. 

One  of  the  severest  forms  of  pain  occurring  during  the  course  of 
tuberculosis  is  that  sometimes  caused  by  pneumothorax.  The  pain  may 
be  the  only  indication  that  such  an  accident  has  occurred.  The  great 
majority  of  tuberculous  patients  have  some  manifestation  of  chest  pain  at 
one  time  or  another  during  the  course  of  the  disease.  Among  3007  cases 
at  the  Phipps  Institute  chest  pain  was  noted  in  2280  or  75.82  per  cent. 
Vague  and  indefinite  pain  which  has  no  fixed  location  and  no  ap- 
parent anatomical  basis  to  explain  its  cause  is  frequent  in  neurasthenic 
patients.  Among  dispensary  patients  of  Jewish  birth,  it  is  to  be  met 
with  constantly. 

Hoarseness. — ^Laryngeal  involvement  is  very  common  in  pulmonary 
tuberculosis.  At  one  time  it  was  looked  upon  as  an  absolutely  hopeless 
compUcation.  This  conception,  however,  took  into  account  only  ad- 
vanced laryngeal  lesions.  We  now  know  that  the  laryngeal  process 
develops  gradually  and  has  an  incipient,  a  moderately  advanced  and  an 
advanced  stage.     Furthermore,  just  as  in  the  lungs,  the  type  of  the  lesion 

1  Ugeskrift  for  Laeger,  March  23,  1916. 


has  considerable  bearing  on  the  outcome.  From  the  chnical  standpoint 
the  essential  thing  to  bear  in  mind  is  the  significance  of  hoarseness. 

Hoarseness  as  we  have  already  pointed  out  may  be  temporary  or 
persistent.  When  temporary  it  may  be  constant  for  a  few  weeks  and 
gradually  disappear,  especially  if  use  of  the  voice  is  prohibited.  In 
other  instances  it  occurs  only  in  the  morning  on  awakening  or  late  in  the 
day  if  the  voice  has  been  used.  Persistent  hoarseness  is  usually  indica- 
tive of  serious  damage  to  the  larynx;  it  may  be  associated  with  advanced 
pulmonary  lesions  or  may  itself  constitute  the  major  lesion. 

The  great  majority  of  fatal  pulmonary  cases  show  more  or  less  serious 
laryngeal  damage. 

Temporary  hoarseness  was  noted  in  1339  out  of  3007  cases  seen  at 
the  Phipps  Institute  while  persistent  hoarseness  was  noted  in  520  out  of 
4466  cases.  Fetterolf  in  a  clinical  post-mortem  study  of  the  larynx  in 
100  cases  dying  in  the  Phipps  Institute  found  that  it  was  tuberculous  in 
83;  non-tuberculous  in  13;  and  doubtful  in  4. 

Dysphagia. — Difficulty  in  swallowing  is  not  common  in  tuberculous 
patients  except  with  involvement  of  the  pharynx  or  larynx,  usually  the 
latter.  Involvement  of  the  epiglottis  is  especially  liable  to  interfere  with 
swallowing  because  of  pain  which  may  be  so  intense  as  to  prevent  even 
the  swallowing  of  water.  In  some  instances  diflBculty  in  swallowing  is 
due  to  interference  with  the  nervous  mechanism  governing  the  larynx. 
This,  however,  is  quite  rare. 

Dyspnea. — Shortness  of  breath  is  a  frequent  complaint  among  those 
suffering  from  tuberculosis.  Curiously  enough  the  degree  of  dyspnea 
bears  very  little  relation  to  the  amount  of  pulmonary  damage.  Little 
or  no  inconvenience  is  experienced  by  some  people,  except  on  exertion, 
in  spite  of  extensive  disease  while  in  others,  with  relatively  little  trouble, 
this  symptom  is  very  troublesome.  While  it  is  undoubtedly  true  that 
the  curtailment  of  the  breathing  space  has  some  influence  on  causing 
shortness  of  breath  there  are  other  factors  which  seem  to  exert  a  more 
marked  influence.  Shortness  of  breath  is  more  apt  to  be  present  if  there 
is  fever  and  is  apparently  dependent  also  on  the  nervous  condition  of  the 
individual.  Patients  who  are  nervous  and  apprehensive  about  their 
condition  are  more  apt  to  suffer  from  shortness  of  breath  and  tachycardia 
than  those  of  a  phlegmatic  temperament.  Immobility  of  the  diaphragm 
is  a  common  cause  of  the  shortness  of  breath.  Some  degree  of  shortness 
of  breath  was  noted  in  80  per  cent,  of  3007  cases  at  the  Phipps  Institute. 
As  a  rule  the  shortness  of  breath  becomes  noticeable  only  on  exertion, 
such  as,  going  upstairs,  climbing  a  hill,  or  walking  fast. 

Physical  Signs. — Before  taking  up  in  detail  the  physical  signs  it  may 
be  well  to  emphasize  the  importance  of  keeping  in  mind  the  morbid 
anatomy,  and  the  symptomatology  of  tuberculosis  in  their  relation  to 
the  physical  findings. 

The  three  factors  involved  in  the  art  of  physical  diagnosis  are  so 
dependent  on  one  another  that  it  is  not  possible  to  say  that  one  is  more 
important  than  the  other.  A  knowledge  of  all  three  is  essential.  It  is 
necessary,  for  instance,  to  know  what  portion  of  the  lung  is  first  involved, 
the  character  of  the  pathological  process  and  how  it  advances  or  retro- 
gresses, as  the  case  may  be.  Knowledge  of  this  sort  and  its  application 
to  physical  signs  is  to  be  learned  largely  in  the  deadhouse,  and  not  at  the 
bedside.     Austin   Flint   expressed   the   importance   of   this   association 


very  clearly  when  he  stated  that:  "The  significance  of  signs  which  repre- 
sent abnormal  physical  conditions  rests  on  the  uniformity  of  their  associa- 
tion with  the  latter — certain  phj'sical  signs  denote  certain  abnormal  condi- 
tions, because  clinical  experience,  inclusive  of  the  studj'  of  lesions  wdth 
the  scalpel,  has  sufficiently  estabhshed  the  fact."  And  again  he  states 
in  regard  to  physical  signs  that :  ''Invaluable  as  the}'  are,  their  importance 
is  greatly  enhanced  by  association  with  symptoms  and  the  knowledge  of 
pathological  laws.  The  results  of  physical  exploration  alone  frequently 
leave  room  for  doubt  and  liability  to  error,  when  a  due  appreciation  of 
vital  phenomena  and  of  facts  embraced  in  the  natural  history  of  dis- 
eases insures  accuracy  and  positiveness.  An  overweening  confidence  in 
the  former  is  to  be  deprecated,  as  well  as  exclusive  reliance  on  the  latter. 
And,  since  the  practical  discrimination  of  intrathoracic  affections  is 
always  to  be  based  on  the  combined  evidence  afforded  b}-  these  three 
sources  of  information,  in  treating  of  the  subject  it  is  desirable  that  the 
attention  shall  not  be  limited  to  one  source  to  the  exclusion  of  the  others." 

We  are  largely  indebted  to  the  French  pathologists  for  pointing  out 
the  necessity  of  comparison  of  all  symptoms  of  -pulmonary  disease  and 
of  connecting  this  comparison  with  their  succession  in  order.  Tliis  phase 
of  the  subject  was  especially  dealt  with  by  Andral,  and  more  particularly 
by  Louis  in  the  promulgation  of  his  numerical  theory. 

Gerhard  also  emphasized  the  great  importance  of  the  comparison  of 
the  general  symptoms  and  physical  signs.  As  he  points  out,  the  earlier 
writers  on  physical  diagnosis,  especially  Laennec,  were  rather  disposed 
to  separate  plwsical  from  symptomatic  diagnosis.  And,  although  this 
error  depended  on  the  novelty  of  the  art  and  the  overstrained  efforts  to 
extend  its  application,  it  still  persists,  although  possibly  to  a  less  extent 
than  formerly.  Not  only  are  we  to  avoid  exclusive  reliance  on  the  pres- 
ence or  absence  of  physical  signs,  but  it  is  also  to  be  borne  in  mind  that 
physical  signs,  while  often  indicating  the  extent  and  degree  of  pulmonary 
damage,  convey  no  dhect  information  as  to  the  pathological  nature  of 
those  changes. 

As  to  whether  one  shall  take  a  radical  or  a  conservative  view  in  cases 
of  a  doubtful  nature,  there  does  not  seem  to  be,  in  the  writer's  opinion, 
any  room  for  argument.  A  doubtful  case  is  at  best  still  doubtful,  and 
such  being  the  case,  one  should  exercise  every  precaution  to  exclude  the 
presence  of  tuberculosis,  always  bearing  in  mind  that  the  disease  in  its 
very  earliest  stages  is,  as  a  rule,  extremely  amenable  to  treatment.  On 
the  other  hand,  the  more  marked  the  physical  signs,  the  greater  the 
damage  to  the  lung  and  the  more  uncertainty  as  to  whether  the  disease 
can  be  arrested. 

Inspection. — This  method  of  physical  examination  is  too  frequently 
omitted,  or  made  so  hastily  and  cursorily  that  little  or  no  information 
is  obtained.  As  a  matter  of  fact,  inspection  properly  done  yields  more 
valuable  information  than  any  other  procedure  at  our  disposal,  next  to 
auscultation.  And  furthermore,  it  has  this  to  commend  it,  namely,  that 
no  special  training  is  requii-ed  and  the  beginner,  pro%'iding  he  uses  his 
eyes,  is  as  capable  of  seeing  defects  as  the  trained  observer.  This  is  in 
marked  contrast  to  the  training  necessary  to  educate  the  ear  to  differen- 
tiate sounds,  particularly  those  produced  b}-  percussion,  the  latter  often 
taking  years  of  practice.  One  who  has  been  taught  to  make  a  proper 
inspection  can  in  the  majority  of  cases  of  tuberculosis,  from  this  method 

DISEASES    OF    THE    LL'XGS  343 

alone,  determine  the  side  affected,  and  approximately  the  extent  of  the 
lesion.  As  this  method  takes  no  special  training,  it  is  especially  valuable 
to  the  student  and  to  those  who  see  chest  cases  incidentally,  and  not 

In  order  that  inspection  should  }deld  the  best  results  it  is  absolutely 
essential  that  the  patient  be  stripped  to  the  waist,  and  so  placed  that 
the  parts  under  inspection  are  equally  exposed  to  the  light,  as  an  error 
may  occur  if  one-half  of  the  chest  is  less  well  hghted  than  its  fellow. 

Before  directing  special  attention  to  the  chest  itseh  it  is  important 
to  look  for  abnormalities  in  other  regions,  although  the  earher  the  chsease, 
the  less  frequently  do  we  find  am-thing  of  moment.  In  a  large  number 
of  cases  the  pupils  are  unequal  in  size,  the  dilated  pupil  being  on  the 
affected  side.  Flushing  of  the  cheek  on  the  afi'ected  side  may  be  present 
as  an  early  manifestation,  but  is  more  frequently  encountered  later. 
The  mouth  should  be  examined  at  this  time,  as  a  matter  of  routine,  and 
any  abnormalities  of  the  teeth,  tonsils  or  upper  resph'atory  tract  rioted. 
Information  of  this  sort,  however,  is  of  value  from  the  standpoint  of 
treatment  rather  than  diagnosis. 

The  thyroid  gloAicl  is  often  enlarged,  although  this  may  be  more 
apparent  than  real  owing  to  emaciation.  Among  2122  patients  seen  at 
the  Phipps  Institute  enlargement  of  the  th^Toid  gland  was  noted  in  135 
(6.69  per  cent.) .  In  many  of  these  cases  the  eye  phenomena,  so  commonly 
seen  in  exophthalmic  goitre,  are  also  present.  "Whether  hyperth^Toidism 
exists  or  not  in  these  cases  can  be  determined  by  the  injection  of  73-^ 
minims  of  adrenahn.  If  such  is  the  case  the  blood  pressure  is  raised  and 
the  phenomena  usualh^  associated  with  this  condition  are  accentuated,  if 
shghtly  present,  or  are  brought  to  Hght  if  unsuspected.  The  test  is  of 
service  in  determining  whether  extensive  constitutional  symptoms  are 
due  in  part  or  entirely  to  hypersecretion  of  the  thyroid  gland. 

Inspection  of  the  hands  often  gives  most  valuable  information.  The 
nails  especially  should  be  carefully  examined.  The  most  common  change 
encountered  in  the  nails  is  a  tendency  to  curving,  without  any  associated 
clubbing.  The  nails  not  onh^  curve  over  the  end  of  the  finger  slightly, 
but  they  are  narrower  from  side  to  side  than  normally.  The  color 
may  be  normal,  or  it  may  be  an  exaggeration  of  the  normal,  whitish- 
pink  color.  "While  violet  or  bluish-colored  nails  are  of  frequent  occur- 
rence in  the  advanced  stages  of  the  disease,  thej^  are  not  usual  in  the  early 
stages;  when  present  at  this  time  they  are  extremely  ominous.  Their 
presence,  in  the  early  stages  of  tuberculosis,  should  cause  one  to  be  very 
guarded  in  predicting  the  outcome,  no  matter  how  slight  the  involvement 
may  seem  from  the  physical  signs,  as  they  usually  indicate  an  especially 
severe  form  of  infection. 

Clubbing  of  the  fingers,  although  usuaUj'  stated  to  be  commonly 
associated  with  pulmonary  tuberculosis,  is  as  a  matter  of  fact,  not  fre- 
quent, and  even  when  present,  not  marked.  The  extreme  grades  of 
clubbing  of  the  fingers  occur  for  the  most  part  in  non-tuberculous  affec- 
tions, notably  empyema,  bronchiectasis  and  congenital  heart  disease. 

In  the  early  stages  the  shin  may  present  a  mottled  appearance  indica- 
tive of  a  poor  vasomotor  tone.  Profuse  sweating  either  at  night  or 
after  exertion  is  not  common  at  the  onset  of  the  disease,  but  axillary 
sweating,  often  noted  during  the  examination,  is  sufficiently  frequent  in 
these  cases  to  be  worth v  of  note. 


Taking  up  the  chest  proper,  it  is  usually  best  to  note,  when  visible, 
the  position  of  the  apex  beat  of  the  heart,  as  in  addition  to  disease  of  the 
heart  itself,  the  apex  may  be  displaced  out  of  its  normal  position  as  the 
result  of  disease  of  the  lungs  or  pleura.  An  effusion  displaces  the  heart 
toward  the  opposite  side  while  fibroid  changes  in  the  lung  draw  the 
lung  toward  the  affected  side. 

Coming  now  to  inspection  of  the  chest  with  a  view  of  detecting  pleura] 
or  pulmonary  mischief,  it  must  be  borne  in  mind  that  we  are  dealing  with 
comparisons.  In  regard  to  the  shape  of  the  chest,  no  information  of 
importance  is  obtained  in  the  incipient  stage.  The  majority  of  patients 
at  the  onset  of  the  disease  present  well-shaped  chests,  which  do  not 
present  any  marked  abnormality.  Thus  Pope  and  Brown  found  83 
per  cent,  of  well-formed  chests  in  193  incipient  cases.     The  so-called 

Fig.  251. — Shows  drooping  of  the  right  shoulder  and  the  long  line  from  the  neck  to  the 

point  of  the  shoulder. 

paralytic  thorax,  which  is  sometimes  seen,  is  not  uncommonly  noted  in 
individuals  with  a  marked  hereditary  taint  and  antedates  the  tubercu- 
losis rather  than  being  caused  by  it.  The  paralytic  thorax  is  long  and 
narrow  and  apparently  flattened  in  the  antero-posterior  diameter,  the 
clavicles  and  scapulae  are  prominent,  the  latter  being  tilted  outward  from 
the  chest  and  away  from  the  spine.  The  ribs  are  oblique,  forming  an 
acute  angle  with  the  sternum.     (See  Figs.  13,  24,  31,  35.) 

The  following  points  should  be  noted:  (a)  Whether  the  shoulders 
are  on  a  level ;  a  very  early  sign  is  drooping  of  the  shoulder  on  the  affected 
side.  In  this  connection,  however,  it  must  be  recalled  that  certain  occu- 
pations, such  as  clerks,  predispose  to  a  faulty  sitting  posture,  which  will 
raise  or  lower  one  shoulder. 

(6)  The  line  from  the  neck  to  the  point  of  the  shoulder.  This  line 
is  normally  slightly  convex,  but  with  beginning  disease  at  one  apex,  it 
tends  to  become  straight  and  also  longer  than  its  fellow,  the  latter  defect 
being  brought  about  by  the  drooping  of  the  shoulder  (Fig.  251). 

DISEASES    OP    THE    LUNGS  345 

(c)  The  degree  of  prominence  of  the  clavicles.  In  most  well-nourished 
women  the  clavicles  are  scarcely,  if  at  all,  visible;  in  men,  on  the  other 
hand,  unless  unusually  fat,  the  clavicles  are  more  or  less  prominent. 

Associated  with  undue  prominence  of  the  clavicle  is  an  exaggeration 
of  the  supraclavicular  fossa.  A  noticeable  amount  of  flattening  may  be 
noted  also  beneath  the  clavicle. 

(d)  Expansion. — ^Deficient  expansion  of  the  chest  wall  overlying  the 
apex  of  the  lung  is  one  of  the  most  valuable  signs  of  early  tuberculosis 
which  we  possess.  It  is  especially  to  be  looked  for  toward  the  outer 
border  of  the  lung,  just  beneath  the  clavicle.  In  this  situation  the 
chest  wall  normally  balloons  out  quite  markedly.  If,  however,  there 
exists  an  infiltration  of  tubercles  at  or  near  the  apex,  the  underlying  lung 
does  not  expand  as  fully  as  its  fellow,  or  if  the  expansion  is  equal  on  both 
sides  the  affected  side  tends  to  lag  behind  slightly,  especially  at  the 
beginning  of  the  inspiratory  period. 

Inspection  of  the  apices  for  the  purpose  of  determining  the  degree 
of  expansion  yields  the  best  results,  if  but  one  apex  is  involved.  If 
there  exists  disease  at  the  summit  of  both  lungs  the  value  of  comparison 
is  thus  lost,  and  one  may  be  unable  to  come  to  any  definite  conclusion 
from  this  method  alone.  Two  other  methods  of  determining  slight 
amounts  of  retraction  on  the  affected  side  are  available,  namely,  palpation 
and  mensuration,  both  of  which  will  be  described  in  detail  later. 

Inspection  of  the  chest  posteriorly.  In  the  early  stages  of  tubercu- 
losis the  amount  of  information  gained  from  the  posterior  view  of  the 
chest  is  slight  compared  to  what  can  be  learned  from  the  anterior  view. 
A  very  common  occurrence  in  tuberculous  subjects  is  the  presence  of 
fine  venules  in  the  region  of  the  nape  of  the  neck.  These  small  veins 
may  be  bluish  or  purplish  in  color.  They  have  been  cited  as  an  evidence 
of  the  existence  of  pulmonary  tuberculosis,  but  are  so  frequently 
encountered  as  to  be  of  little  value  as  a  diagnostic  sign. 

Owing  to  the  interposition  of  the  scapular  muscles  and  the  ribs  little 
can  be  noted  as  to  expansion  in  the  upper  part  of  the  chest.  At  the  bases, 
however,  expansion  can  be  determined  in  the  same  manner  as  over  the 
apices  anteriorly.  The  most  noticeable  finding  is  the  presence  of  varying 
degrees  of  atrophy  of  the  muscles  in  the  supraspinous  fossa.  If  the  arms 
are  allowed  to  hang  naturally  at  the  sides,  the  angle  of  the  scapula  on  the 
affected  side  may  tip  backward  slightly  more  than  its  fellow.  This 
tendency  to  "winged  scapulae"  becomes  much  more  marked  as  the 
disease  progresses. 

Slight  degrees  of  scoliosis  may  be  present.  Litten's  sign  may  be 
present  (see  Part  I,  p.  29).  The  sign  is  not  often  employed  as  there  is 
another  and  easier  method  of  determining  the  mobility  of  the  lower  part 
of  the  lung,  namely,  by  percussing  the  lower  border  of  the  lung  during 
forced  expiration  and  inspiration.  The  fluoroscope  may  be  employed 

Palpation. — Tactile  fremitus  is  a  sign  of  comparatively  little  value  in 
incipient  tuberculosis,  as  the  amount  of  infiltration  in  the  underlying 
lung  is  usually  too  slight  to  produce  much  exaggeration  over  the  normal. 
The  normal  discrepancy  between  the  two  apices  has  already  been  alluded 
to  (see  p.  74). 

Pottenger  has  called  attention  to  rigidity  of  the  muscles  over  the 
affected  area.     Recently  Galecki^  reports  on  finding  this  sign  present  in 

^  Beiirdge  Zur  Klin.  d.  Tuberculose,  1914,  xxx,  No.  3. 


93  per  cent,  of  recent  cases  and  not  at  all  in  cases  with  a  healed  lesion. 
The  sign  is  elicited  by  light  touch  palpation.  This  sign  is  not  to  be  con- 
fused with  myoidenia.  The  latter  term  is  applied  to  a  local  contraction 
of  the  muscle,  produced  by  chrect  percussion,  and  causing  a  nodular  swell- 
ing, which  arises  immediately  after  percussion,  lasts  a  second  or  two, 
and  then  gradually  disappears.  It  may  be  produced  two  or  three  times 
and  then  cease  to  appear.  It  is  best  seen  in  the  pectoralis  major  muscle. 
Although  this  phenomenon  is  commonh'  encountered  in?  tuberculosis, 
it  is  not  peculiar  to  the  disease. 

Palpation,  however,  is  an  invaluable  method,  for  determining  the 
amount  of  expansioyi  at  the  apices  in  those  instances  where  the  difference 
between  the  two  sides  is  slight  and  one  is  in  doubt  from  inspection  alone. 
In  determining  the  degree  of  expansion  over  the  apices  anteriorly  by 
means  of  palpation,  one  of  two  procedures  may  be  followed.  The 
examiner  sits  squareh'  in  front  of  the  patient  and  places  one  hand  in  the 
same  relative  position  beneath  each  clavicle;  he  should  then  close  his 
eyes,  or  turn  his  head  aside.  In  this  wa}'-  even  the  very  slightest  variation 
may  be  noted.  Or  the  examiner  can  watch  his  two  hands  and  determine 
which  moves  the  most.  The  former  is  by  far  the  more  delicate  method. 
The  value  of  the  sign  is  enhanced  by  the  reacUness  with  which  it  is 
elicited.  Students  with  but  a  ruchmentary  knowledge  of  physical  diag- 
nosis can  readily  detect  a  slight  difference  between  the  two  apices  when 
the  other  signs,  indicative  of  a  lesion,  are  too  vague  to  be  appreciated  by 
an  untrained  observer.  In  the  incipient  stage  palpation  is  not  apt  to 
reveal  abnormalities  in  portions  of  the  chest  other  than  one  or  the  other 

Mensuration  is  the  least  used  of  the  various  procedures  of  phj'sical 
diagnosis.  At  one  time  a  great  deal  of  stress  was  laid  on  the  degree  of 
expansion  of  the  chest,  good  expansive  power  being  looked  upon  as  in- 
dicating freedom  from  thoracic  disease;  insurance  companies  still  in- 
sist on  a  record  of  the  cUiference  between  expiration  and  deep  inspira- 
tion. In  the  absence  of  more  convincing  signs  it  is  doubtful  whether 
any  importance  can  be  attached  to  a  degree  of  expansion  below  the 
normal  (approximately  23^^^  inches) ,  if  this  is  the  only  evidence  obtainable. 

A  more  useful  method  of  employing  mensuration  is  by  means  of  the 
lead  tape  cyrtometer.  This  method  is  too  little  used.  While  it  is  valuable 
for  diagnostic  purposes,  its  greatest  usefulness  is  in  depicting  the  changes 
in  the  contour  of  the  chest  as  the  disease  progresses,  either  to  a  favorable 
or  an  unfavorable  termination.  The  technique  of  the  method  is  readily 
acquired  with  a  little  practice.  The  lead  cyrtometer  consists  of  a  piece 
of  sheet  lead,  ^g  inch  thick,  ^^  inch  wide  and  26  inches  long.  It  should 
be  covered  with  thin  calfskin.  In  addition  there  is  required  a  pair  of 
obstetrical  calipers  capable  of  opening  at  least  12  inches.  The  first  step 
is  to  obtain  the  antero-posterior  diameter  of  the  chest.  Minor  recom- 
mends for  the  two  fixed  points,  the  middle  of  the  sternum  at  the  level  of 
the  fourth  costal  cartilage  in  front,  and  the  eighth  dorsal  spine  posteriorly. 
The  latter  is  a  little  below  the  level  of  the  inferior  angles  of  the  scapulae. 
Having,  with  the  calipers,  ascertained  the  depth  of  the  chest  between 
the  above-mentioned  points  the  distance  is  marked  on  a  sheet  of  paper, 
capable  of  receiving  the  tracing  of  a  chest  12  inches  in  its  antero-posterior 
diameter  and  16  inches  in  its  lateral  diameter. 

Each  half  of  the  chest  is  taken  separately'.     With  the  eighth  dorsal 


spine  as  the  fixed  point,  one  end  of  tlie  tape  is  firmly  held  so  that  it  will 
not  slip  and  is  then  brought  around  to  the  anterior  fixed  point.  The  tape 
should  be  firmly  applied  so  that  it  fits  snugly.  In  crossing  the  axillary 
space  care  must  be  taken  to  mould  the  tape  to  the  chest  wall,  otherwise 
this  space  is  apt  to  be  bridged.     The  anterior  point  can  be  marked  by 


Fig.  252. — Slight  retraction  of  right  side.     Lesion  at  right  apex 


Fig.  253. — Slight  retraction  of  left  side.     Lesion  at  left  apex. 


Fig.   254. — Advanced  bilateral  disease.      Marked  retraction  of  right  side. 

indenting  the  leather  with  the  finger  nail.  The  tape  is  then  carefully 
removed  and  the  two  ends  placed  over  the  marks  indicated  on  the  paper 
by  the  calipers.  By  means  of  a  pencil  the  perimeter  is  then  traced  on  the 
paper.     The  left  side  is  similarly  taken  (Figs.  252,  253  and  254). 

By  using  different  colored  pencils  at  each  subsequent  tracing,  one 
obtains  an  excellent  picture  of  the  contour  of  the  chest.     Even  in  very 


early  cases  there  is  a  slight  amount  of  shrinkage  on  the  affected  side,  and 
the  greater  the  amount  of  disease  present  the  greater,  as  a  rule,  is  the 
degree  of  retraction.  As  the  case  progresses  toward  recovery  the 
affected  side  tends  to  fill  out  so  that  eventually  discrepancies  between  the 
two  sides  disappear.  In  some  early  cases  with  a  marked  degree  of 
shrinkage,  the  reexpansion  is  quite  rapid.  On  the  other  hand,  if  the 
disease  advances,  the  affected  side  shows  an  increased  amount  of  re- 
traction, and  with  involvement  of  the  sound  side  evidences  of  shrinkage 
will  likewise  appear.  Minor  states  that  the  increase  of  the  perimeter 
takes  place  on  the  unaffected  side  first  as  a  result  of  the  compensatory 
action  of  the  sound  lung,  and  that  the  increase  of  the  affected  side  gener- 
ally follows  the  increase  of  the  unaffected  side.  The  increase  can  be  in 
breadth  or  depth;  the  latter  is  of  more  significance,  however,  as  the  trac- 
ing of  the  former  may  be  affected  by  an  increase  in  the  amount  of  fat 
and  muscle,  while  the  latter  being  measured  between  two  bony  points  is 
not  so  affected.  Thus  it  can  be  seen  that  the  method  is  a  valuable  diag- 
nostic, as  well  as  a  prognostic  aid.  One  precaution  should  be  kept  in 
mind,  nameh',  as  to  whether  the  individual  is  right-handed  or  left-handed. 
Percussion. — Before  undertaking  to  describe  the  percussion  changes 
in  early  tuberculosis,  it  is  necessary  to  emphasize  several  important  facts. 

1.  There  is  a  normal  discrepancy  between  the  percussion  notes  of 
the  two  apices.  This  has  been  recognized  for  many  years,  but  advantage 
is  not  always  taken  of  the  knowledge.  The  note  on  the  right  side  is 
normally  a  little  higher  in  pitch  and  a  little  less  resonant  than  the  note  on 
the  left  side.  Flint  described  the  note  on  the  right  side  as  vesiculo- 
tympanitic without,  however,  advancing  anj^  reason  for  the  change. 
Recently  Fetterolf  and  Norris  have  given  a  satisfactory  explanation  of 
the  difference.  Then-  stud}-,  from  both  the  clinical  and  anatomical  stand- 
points, shows  quite  clearly  that  the  right  apex  is  smaller  than  the  left 
(see  Figs.  62,  63,  64,  76  and  77)  and  that  furthermore  the  position  of  the 
blood-vessels  on  the  right  side  tend  to  diminish  the  resonance.  The  close 
approximation  of  the  right  apex  to  the  trachea  (see  Figs.  49,  75,  95  and 
104),  the  latter  giving  a  tympanitic  note,  thus  tends  to  raise  the  pitch 
of  the  percussion  note;  the  left  apex,  being  larger  and  having  large  blood- 
vessels and  areolar  tissue  interposed  between  it  and  the  trachea,  gives  a 
pure  resonant  note. 

2.  One  of  the  difficulties  the  beginner  has  in  percussing  the  apices  is 
that  to  his  ear  the  note  is  frequently  impaired.  The  real  difficulty, 
however,  is  that  the  note  is  less  intense  in  this  region  owing  to  the  small 
amount  of  lung  tissue  at  the  apex  as  compared  to  the  base,  and  also  be- 
cause of  the  distance  of  the  lung  from  the  surface  over  which  the  per- 
cussion is  being  applied.  These  differences  apply  to  the  posterior  aspect 
of  the  apex,  and  to  a  less  extent,  the  area  above  the  clavicle.  Anteriorly 
beneath  the  clavicle  the  pulmonary  tissue  lies  immediately  beneath  the 
chest  wall  so  that  the  note  is  usually  intense,  and  on  the  left  side  tvpically 
resonant  (see  Figs.  260,  261,  and  262). 

3.  Keeping  in  mind  this  normal  difference,  it  must  be  remembered 
again  that  we  are  dealing  with  comparisons,  and  inasmuch  as  the  changes 
are  at  best  slight,  each  side  must  be  compared  carefully  with  the  other. 
If  slight  changes  exist  at  the  summit  of  both  lungs  it  is  probable  that  very 
little  definite  information  will  be  forthcoming  from  percussion. 

Percussion  of  the  apices  in  a  case  of  suspected  incipient  tuberculosis 



is  a  procedure  that  requires  a  well-trained  ear,  and  not  a  little  experience. 
The  change  from  the  normal  is  usually  so  shght  that  for  the  beginner  the 
method  is  the  least  fruitful  of  results;  and  even  the  experienced  observer 
is,  in  doubtful  cases,  apt  to  be  influenced  in  his  interpretation  by  the 
presence  or  absence  of  symptoms,  or  other  associated  physical  signs. 
The  detection  of  slight  changes  at  the  apex  is  facihtated  by  marking  with 
a  skin  pencil  the  borders  of  what  is  known  as  "  Kronig's  isthmus."  This 
is  a  band  of  resonance  which  crosses  the  shoulder  (Figs.  255  and  256). 
Its  narrowest  point  is  at  the  top  of  the  shoulder,  and  in  both  front 
and  back  it  widens  out  to  meet  the  extended  areas  of  resonance  beneath 
the  clavicle  and  supraspinous  fossa.  The  value  of  this  sign  arises  because 
of  the  well-known  tendency  of  the  lung  wdth  a  developing  tuberculous 
focus  to  shrink,  either  as  the  result  of  fibrosis,  or  of  lessened  functional 

In  mapping  out  the  "isthmus"  it  is  well  to  begin  the  percussion  well 
up  the  side  of  the  neck  and  gradually  come  downward  until  a  change 


Xormal  anterior  view 

Fig.  256. — Kronig's  isthmus. 
Normal  posterior  view. 

from  non-resonance  to  resonance  is  noted.  This  point  is  marked  with 
the  pencil  and  by  working  either  forward  or  backward  the  inner  line  is 
traced  out.  The  outer  line  is  mapped  out  similarly  bj^  approaching  the 
resonant  area  from  the  point  of  the  shoulder.  The  inner  line,  except  at 
the  inner  anterior  extremity,  is  concave  and  runs  downward  and  for- 
ward, ending  just  a  little  outside  the  sterno-clavicular  joint.  Posterior^ 
the  inner  line  inclines  toward  the  spinal  column ;  at  the  level  of  the  second 
dorsal  vertebra  it  continues  parallel  with  the  spinal  column,  at  a  distance 
of  about  )-^  inch. 

The  outer  line,  anteriorly,  runs  downward  and  outward,  ending 
at  the  junction  of  the  outer  and  middle  third  of  the  clavicle.  Posteriorh' 
it  runs  downw^ard  to  about  the  middle  of  the  spine  of  the  scapula. 

The  value  of  this  procedure  lies  in  the  fact  that  while  one  may  be  in 
doubt  as  to  the  quality  of  the  note,  if  percussion  is  made  directly  over 
the  situation  of  normal  resonance,  one  is  less  likely  to  err  if  the  normal 
area  is  approached  from  non-resonant  parts,  such  as  the  neck  or  shoul- 
der.    One  quickly  learns  to  appreciate  what  the  normal  width  of  the 


isthmus  should  be,  and  if  this  becomes  narrower  it  is  an  indication  of 
trouble  in  the  underlying  apex.  If  but  one  side  is  diseased,  the  affected 
side  will  show  a  much  narrower  "isthmus"  than  the  healthy  side  (Figs. 
257  and  258).  As  the  disease  becomes  more  extensive  at  the  apex  the 
two  Hnes  of  the  "isthmus"  tend  to  become  closer  and  closer  until 
finally  in  the  advanced  case  no  semblance  of  resonance  remains. 

Some  observers  have  laid  stress  on  direct  percussion  of  the  clavicles 
without  the  intervention  of  a  pleximeter,  the  claim  being  made  that  at  times, 
a  small  area  of  impairment  can  be  detected  that  would  otherwise  escape 
detection.  Such  instances  may  occur,  but  they  are  far  from  being 

Having  outlined  the  apices  the  percussion  should  be  continued  down- 
ward until  the  base  of  the  lung  is  reached.     Even  in  incipient  cases  it 

Fig.  257. — Kronig's  isthmus.  Normal 
on  left  side.  Narrowed  on  right  side  due 
to  tuberculosis  of  right  apex. 

Fig.   258.— Kronig's  isthmus.     Both  sides 
narrow  due  to  bilateral  tuberculosis. 

will  usually  be  found  that  the  resonance  does  not  extend  quite  so  low  on 
the  affected  as  on  the  unaffected  side  after  deep  inspiration  (see  Fig.  259). 
It  will  be  recalled  that  mensuration  shows  some  diminution  in  the  size 
of  the  affected  side.  Furthermore,  it  has  been  shown  by  fluoroscopic 
examinations  that  the  descent  of  the  diaphragm  on  the  affected  side  is 
usually  diminished.  This  is  known  as  Williams'  early  diaphragmatic 
sign  (see  p.  646).  These  observations  indicate  that  the  lung,  even  when 
the  seat  of  a  small  amount  of  disease,  functionates  less  freely  than  the 
unaffected  lung,  or  that  the  unaffected  lung  is  functionating  more  than 
the  diseased  one.  Whichever  is  the  correct  explanation,  the  fact  remains 
that  the  resonant  note  is  apt  to  stop  at  a  higher  level  on  the  affected, 
than  the  unaffected  side. 

With  ordinary  quiet  breathing  the  bases  of  the  lungs  extend  to  the 
level  of  the  tenth  dorsal  vertebra;  the  complementary  space  of  the  pleural 
cavity,  however,  extends  to  the  level  of  the  twelfth  dorsal  vertebra. 
On  deep  inspiration  the  lung  can  be  made  to  expand  for  an  inch  or  more 
below  the  level  of  the  tenth  dorsal  vertebra,  providing  it  or  the  pleura 

DISEASES    OF    THE    LUNGS  351 

is  free  from  disease.  If,  however,  the  lung  is  much  diseased,  or  the 
pleural  cavity  is  obliterated,  or  the  diaphragm  is  immobile,  the  base 
line  on  the  affected  side  remains  stationary. 

Having  marked  out  the  borders  of  the  lung,  the  heart  and  viscera 
in  relationship  to  the  lungs  should  be  outlined. 

Auscultation. — The  fact  that  there  normally  exists  a  difference  be- 
tween the  right  and  left  apex  has  already  been  alluded  to  (see  p.  74). 
Nothing  further  need  be  said  except  to  emphasize  the  importance  of 
bearing  this  in  mind.  One  other  fact  should  be  mentioned,  namely,  the 
relative  importance  of  the  different  steps  taken  to  determine  whether  one 
or  the  other  apex  is  the  seat  of  tuberculous  disease.  That  auscultation 
is  the  most  important  means  at  our  disposal  for  the  detection  of  intra- 
thoracic disease,  there  can  be  no  doubt.     On  the  other  hand,  it  is  equally 

Fig.  259. — Restriction  of  inotion  at  base  of  left  lung.     Lesion  at  left  apex. 

true  that  in  those  instances  in  which  the  pulmonary  damage  is  slight  aus- 
cultation alone,  valuable  as  it  is,  will  frequently  fail.  The  recognition  of 
true  incipient  tuberculosis  cannot  be  accomplished  except  by  a  careful  con- 
sideration of  the  facts  revealed  in  the  history,  and  a  proper  estimation  of 
the  slight  deviation  from  normal  as  revealed  by  inspection,  palpation,  men- 
suration and  percussion.  Even  a  skilled  auscultator  would  often  be  in 
doubt  as  to  the  presence  of  a  slight  tuberculous  deposit  if  he  relied  on  aus- 
cultation alone.  The  question  as  to  whether  suspicious  breath  sounds 
may  be  considered  normal  or  abnormal  not  infrequently  hinges  on  the 
character  of  the  information  obtained  in  the  history  and  by  the  other 
methods  of  physical  exploration.     This  digression  has  seemed  necessary 


because  of  the  absolute  reliance  so  manj'  physicians  place  on  auscultation 

Granular  Breathing. — This  type  of  breathing,  which  owes  its  impor- 
tance as  an  early  diagnostic  sign  to  Grancher,  and  in  this  country'  to 
Minor,  is  now  regarded  as  the  earliest  manifestation  of  the  auscultatory 
changes  in  pulmonarj-  tuberculosis.  While  readily  recognized  after 
one  has  heard  it  a  few  times,  it  is  a  sound  not  easily  described  bj''  words. 
Granular  breathing  is  a  rough  or  sputtering  type  of  breathing.  Turban 
has  likened  this  type  of  breathing  to  the  rapid  succession  of  minute 
explosions;  !Minor  to  "a  succession  of  very  short  sounds,  as  though  small, 
soft  granules  of  fine,  wet  sago  were  being  rolled  over  each  other."  Per- 
haps the  clearest  description  is  that  it  suggests  the  coexistence  of  rales, 
and  yet,  just  as  the  listener  fully  expects  to  hear  fine  rales  at  the  end  of 
inspiration,  the  inspiratory  phase  ceases.  This  type  of  breathing  has 
been  described  as  being  due  to  slight  narrowing  or  uneven  surface  of  the 
bronchioles,  or  to  a  rapid  interruption  of  the  air  entering  the  alveoli 
about  the  tuberculous  deposit.  The  following  seems  to  us  a  more 
plausible  explanation.  It  should  be  recalled  that  in  the  early  stages  of 
pulmonary  tuberculosis  there  is  a  considerable  amount  of  relaxation  and 
collapse,  or  partial  collapse  of  the  vesicles  immediately  around  the  tuber- 
cles. As  the  air  forces  its  way  into  these  partially  collapsed  vesicles  they 
expand  independently  instead  of  synchronously.  This  imparts  to  the 
inspirator}'  murmur  a  jerky  sound  and  also  gives  the  impression  of  crepi- 
tation due  to  the  separation  of  the  slightly  moistened  walls  of  the  air 

Feeble  Breathing. — Next  in  importance  to  granular  breathing  is 
slight  enfeeblement  of  the  respiratory  murmur.  This  type  needs  no 
special  description.  If  on  comparing  the  two  apices  the  breath  sounds 
are  less  intense  on  one  side  than  the  other,  the  fact  is  significant.  It 
is  usually  taught  that  enfeebled  breathing  to  be  of  significance  as  an  earlj^ 
sign  in  tuberculosis  must  be  limited  to  the  apex.  It  has  been  our  experi- 
ence, however,  that  the  breath  sounds  all  OA'er  the  affected  lung,  even 
with  very  slight  apical  signs,  are  not  infrequently  less  intense  than  over 
the  affected  side.  This  is  after  all  not  surprising,  when  we  recall  that 
mensuration  shows  a  diminution  of  the  affected  side  and  the  fluoroscope 
a  heightened  diaphragm. 

Prolonged  Expiration. — Prolonged  expiration,  although  not  the  earli- 
est change  from  the  normal  in  the  breath  sounds,  is  the  most  usual  find- 
ing, as  the  two  earlier  changes  described  above  often  escape  detection. 
The  respiratory  murmur  in  this  type  of  breathing  may  be  harsh  or 
slighth'  suppressed,  but  in  either  instance  the  characteristic  feature  is 
the  prolonged,  high-pitched,  bronchial  quality  of  the  expiration.  Heard 
at  the  left  apex,  one  is  rareh'in  doubt  as  to  its  significance;  when  con- 
fined to  the  right  side,  there  is  apt  to  be  a  certain  amount  of  question 
as  to  whether  we  are  dealing  with  normal  or  pathological  broncho-vesi- 
cular breathing.  AMiile  in  everj-  normal  chest  there  is  more  or  less 
marked  broncho-vesicular  breathing  at  the  right  apex,  there  is  no  definite 
standard  and  the  question  of  whether  it  is  pathological  or  not  is  usually 
settled  by  the  presence  or  absence  of  collateral  evidence.  In  children 
especially'  there  is  a  strong  tendency  towards  exaggeration  of  the  normal 
signs  at  the  right  apex,  and  not  infrequently  children  are  said  to  be  tuber- 
culous, because  of  the  strong  transmission  of  both  the  spoken  and  whis- 
pered voice  and  the  prolonged  blowing  character  of  expiration. 

DISEASES    OF    THE    LUNGS  353 

Cog-wheel  or  Wavy  Breathing. — Cog-wheel  or  wavy  breathing  has  been 
described  as  an  evidence  of  incipient  tuberculosis,  but  the  best  authorities 
now  are  agreed  that  it  can  no  longer  be  considered  of  importance  as  an 
early  sign.  As  the  name  indicates  it  is  an  interrupted  type  of  breathing. 
The  inspiratory  phase  is  the  one  commonly  subject  to  the  interruptions; 
rarely  the  expiratory.  It  may  occur  in  a  patient  suffering  from  the  pain 
of  acute  pleurisy,  or  in  nervous  or  chillj^  individuals.  In  tuberculous 
subjects  it  is  usuallj^  heard  over  areas  which  divide  healthy  from  diseased 
tissue.  Cog-wheel  breathing  is  not  to  be  confounded  wdth  the  carcho- 
inspiratory  murmur  of  which  we  will  speak  presently. 

Vocal  Resonance. — The  alterations  in  the  voice  sounds  are  not  of  great 
value  in  early  tuberculosis,  as  the  deviation  from  the  normal  may  not  be 
sufficient  to  be  appreciated.  The  whispered  voice  is  normall}^  heard  with 
distinctness  over  the  second  costal  cartilage  on  the  right  side,  and  poste- 
riorly in  the  interscapular  regions.  In  many  chests  it  is  indistinctly 
heard  also  over  the  extreme  right  apex  anteriorly  and  posteriorly.  In- 
distinct whispering  pectoriloquy  in  the  latter  situation  is  of  no  significance 
without  collateral  evidence.  As  an  indication  of  infiltration  the  whis- 
pered voice  is  subject  to  the  same  rule  as  the  spoken  voice. 

Rales.- — I  have  already  pointed  out  that  in  the  earliest  change  of  the 
breath  sounds  (that  is  the  ''granular  breathing")  one  gets  the  impression 
that  rales  are  about  to  be  heard,  but  as  a  matter  of  fact  are  not.  In  true 
incipient  tuberculosis,  no  matter  what  the  type  of  breathing  may  be,  rales 
are  not  heard  with  ordinary  quiet  breathing.  If,  however,  a  deep  in- 
spiration is  taken,  fine,  dry  crackles  may  be  elicited  above  or  just  below 
the  clavicle,  or  above  the  spine  of  the  scapula,  posteriorly  on  the  affected 

An  invaluable  procedure  for  bringing  out  these  rales  is  after  auscultat- 
ing the  chest,  while  the  patient  is  breathing  quietly  through  the  mouth, 
to  have  him  give  a  short  cough,  followed  hj  a  moderately  deep  inspiration. 
This  is  repeated  first  on  one  side,  then  the  other  until  the  entire  chest  has 
been  gone  over.  In  this  way  small,  localized  areas  containing  these  fine 
rales  are  detected  which  would  otherwise  escape  observation.  If  crackles 
are  confined  to  an  apex  and  do  not  disappear  after  deep  breathing  or 
coughing,  they  are  the  strongest  kind  of  evidence  of  the  existence  of  a 
pulmonary  tuberculosis.  In  other  situations  thej^  are  of  less  importance 
as  a  diagnostic  sign  of  tuberculosis. 

Rales  that  are  heard  with  ordinarj^  quiet  breathing  are  somewhat 
coarser,  and  in  addition  give  the  impression  of  moisture.  Rales  heard 
under  these  circumstances  are  not  evidence  of  incipiency,  but  indicate 
that  the  disease  has  probably  passed  that  stage.  This  is  true  also  of  the 
larger  moist  rales  (the  so-called  mucous  click,  etc.)  even  though  limited 
to  one  apex. 

Cardiac  Phenomena  Occurring  in  Tuberculosis. — Most  of  the  abnormal 
signs  of  cardiac  origin  in  tube^-culosis  manifest  themselves  in  the  second 
and  third  stages  of  the  disease. 

The  heart  sounds  are  at  times  unduly  transmitted  toward  the  affected 
apex,  even  in  the  incipient  stage,  and  the  denser  the  infiltration  the  more 
intense  do  the  heart  sounds  become. 

Cardio-respiratory  murmurs  are  common  in  tuberculous  subjects,  and 
while  they  have  lost  much  of  the  diagnostic  significance  attached  to  them 
by  the  older  clinicians,  it  is  surprising  how  frequently  they  are  encountered 



in  tuberculous  patients.  They  are  as  a  rule  associated  with  a  rapid 
cardiac  action  (see  p.  254). 

While  the  cardio-respiratory  nuu'mur  may  be  heard  in  the  incipient 
stage,  it  is  more  commonly  encountered  in  the  moderately  advanced 
stages  of  the  disease.  It  is  also  encountered  in  individuals  with  an  old 
healed  lesion  at  one  or  the  other  apex.  In  the  same  category  may  be 
placed  sys!olic  munmors  heard  in  the  subclavian  arteries. 

The  frequency  of  the  heart's  action  is  not  greatly  accelerated  in  the 
early  stages;  if  so,  it  is  an  incUcation  of  marked  toxemia.  A  single 
office  observation  as  to  the  frequency  of  the  heart's  action  is  untrust- 
worthy because  of  the  nervousness  and  excitement  often  incident  to  the 
examination.  To  be  of  value  the  pulse  rate  must  be  observed  with  the 
patient  at  rest  for  a  number  of  days.  As  the  disease  progresses  the 
heart's  action  almost  invariabl}'  increases  in  frequency.  With  the  de- 
velopment of  tachycarcUa,  even  moderately  severe,  reduplication  of  the 
heart  sounds  is  frequent,  particularly  the  second  pulmonic;  less  fre- 
quently the  fu'st  sound  at  the  apex.  With  extensive  disease  of  the  left 
lung,  retraction  of  its  anterior  border  is  common.  This  results  in  visible 
pulsation  of  the  heart  in  the  region  of  the  second  costal  cartilage  on  the 
left  side. 

At  one  time  it  was  current^  believed  that  an  individual  who  suf- 
fered from  organic  heart  disease  was  not  apt  to  become  tuberculous. 
As  Xorris  pointed  out  some  years  ago,  there  is  no  support  for  this  theory, 
and  one  is  apt  to  encounter  an  associated  organic  lesion  of  the  heart  as 
frequently  in  tuberculosis  as  in  any  other  disease.  In  addition  to  organic 
murmurs,  accidental  murmurs  of  unknown  origin  are  frequent,  particu- 
larly in  the  latter  stages  of  the  disease.  Functional  murmurs,  systolic 
in  time,  are  of  not  infrequent  occurrence  at  the  apex,  but  by  far  the  most 
frequent  murmur  of  this  type  is  a  systolic  murmur  heard  at  the  base 
of  the  heart,  at  or  near  the  second  pulmonic  area. 

Physical  Signs  in  the  Second  or  Moderately  Advanced  Stage. — In- 
spection.— When  the  disease  has  progressed  sufficiently  to  be  designated 
moderately  advanced,  the  general  health  of  the  patient  begins  to  show 
impairment  (see  Fig.  230) .  The  loss  of  weight  is  'apt  to  be  noticeable 
and  the  muscles  present  a  flabby  condition.  Slight  flushing  of  the  cheek 
on  the  affected  side  is  frequently  noted  and  this  is  in  striking  contrast 
to  the  anemia. 

Skin  eruptions  which  are  not  uncommon  in  the  third  or  advanced 
stage  may  make  their  appearance  during  the  second  stage.  The  com- 
monest of  these  eruptions  is  pityriasis  versicolor  caused  by  the  micro- 
sporon  furfur. 

As  to  the  chest  itself  the  affected  side  shows  more  marked  evidence 
of  shrinkage.  The  clavicle  is  more  prominent;  the  fossa  above  the 
clavicle  is  deeper  and  flattening  beneath  the  clavicle  more  noticeable. 
Diminution  of  expansion  which,  in  the  incipient  stage,  is  not  always 
apparent  on  inspection,  becomes  readily  so  in  this  stage. 

Some  atrophy  of  the  muscles  overlying  the  affected  apex  is  apt  to 
make  its  appearance  at  this  time.  Including  all  types  of  cases  atrophy 
of  the  muscles  was  noted  at  the  Phipps  Institute  in  1325  cases  out  of  4343 
— 931  on  the  right  side  and  394  on  the  left.  In  women  the  breast  on  the 
affected  side  may  be  distinctly  smaller  than  that  on  the  opposite  side. 

Varying  degrees  of  spinal  curvature  are  also  of  frequent  occurrence 
and  the  more  extensive  the  disease  the  more  marked  does  this  tendency 


become.  Spinal  curvature  was  recorded  as  having  been  present  in  968 
out  of  3436  cases  of  all  types  at  the  Phipps  Institute. 

The  heart  is  not  apt  to  be  noticeably  displaced  at  this  time. 

Palpation. — This  confirms  the  diminished  respiratory  movement 
over  the  affected  area  already  noted  on  inspection.  The  tactile  fremitus 
is  usually  exaggerated  but  may  show  no  appreciable  change. 

Percussion. — While  in  the  incipient  stage  one  is  often  in  doubt  as  to 
whether  the  percussion  note  deviates  from  the  normal ;  this  is  rarely  so 
when  the  infiltration  has  become  more  dense  and  more  tissue  is  involved. 
In  the  majority  of  instances  the  percussion  note  is  not  entirely  devoid  of 
resonance  because  the  tuberculous  infiltration  is  rarely  massive.  Patches 
of  air-bearing  tissue  still  exist  about  the  tubercles  and  for  this  reason 
varying  degrees  of  pulmonary  resonance  persist.  In  some  cases  a  tym- 
panitic note  is  obtained  as  the  result  of  cavity  formation.  This,  however, 
is  usually  a  manifestation  of  advanced  disease,  the  signs  of  which  will  be 
considered  in  detail  later. 

Kronig's  isthmus  becomes  narrower  in  the  second  stage  and  the  im- 
paired percussion  note  may  extend  as  low  as  the  third  or  fourth  rib  (see 
Fig.  258).  By  the  time  the  infiltration  has  become  marked  at  the  apex 
and  shrinkage  of  the  affected  side  is  apparent  the  percussion  note  at  the 
base  will  be  found  to  be  on  a  higher  level  than  the  sound  side.  With  the 
disease  advanced  to  the  second  stage  at  one  apex  there  may  be  signs 
indicative  of  the  first  stage  in  the  opposite  apex. 

Mensuration. — If  a  cyrtometer  tracing  has  been  made  during  the  first 
stage  a  second  tracing  made  after  the  disease  has  advanced  to  the  second 
stage  shows  more  shrinkage  and  if,  in  the  meantime,  the  opposite  apex 
has  become  involved,  that  side  will  also  show  some  diminution  in  size. 

Auscultation.- — The  breath  sounds  in  the  second  stage  of  the  disease 
are,  as  a  rule,  sharply  differentiated  from  those  heard  over  the  healthy 
lung  and  from  those  heard  in  the  first  or  incipient  stage.  The  granular, 
or  slightly  enfeebled  or  doubtful  broncho-vesicular  breathing  becomes 
definitely  broncho-vesicular;  the  latter  may  be  slightly  suppressed  or  may 
closely  approach  true  bronchial  breathing.  Bronchial  breathing  such 
as  is  heard  in  croupous  pneumonia,  when  the  lung  is  completely  solidified, 
is  not  common  in  tuberculosis.  This  is  because  the  infiltration  rarely 
becomes  massive,  as  a  rule  remnants  of  healthy  tissue  remain  between  the 
caseous  areas  and  thus  impart  a  vesicular  quality  to  the  respiratory 
murmur.  The  broncho-vesicular  breathing  may  therefore  be  slightly 
bronchial  in  character  or  very  markedly  so,  depending  on  the  density  of 
the  infiltration.  When  the  infiltration  has  destroyed  most  of  the  pul- 
monary tissue  in  a  given  area,  the  chief  characteristic  of  the  breath  sounds 
is  that  they  are  greatly  suppressed.  At  times  they  may  be  almost 
inaudible,  especially  if  rales  are  present. 

While  in  a  few  cases  broncho-vesicular  breathing  may  gradually  pass 
into  the  pure  bronchial  type  it  far  more  frequently  happens  that  caver- 
nous or  amphoric  breathing  appears  as  the  result  of  cavity  formation. 
At  the  lower  border  of  the  infiltrated  area,  cog-wheel  breathing  is 
frequently  heard. 

Vocal  resonance  is  a  sign  of  relatively  little  value.  It  is  usually  ex- 
aggerated and  the  increase  corresponds  closely  to  the  percussion  changes. 

Rales. — ^As  there  is  usually  an  associated  bronchitis  and  some  soften- 
ing of  the  caseous  areas  medium-sized  rales  are  common.     They  may  be 


very  numerous  or  one  may  hear  only  a  few  isolated  rales;  the  latter  may 
be  constantly  present  or  may  be  heard  only  during  every  second  or 
third  inspiration  or  expiration.  Veiy  often  when  but  one  rale  is  heard 
it  has  a  peculiar  sticky  quality;  it  is  often  referred  to  as  a  mucous  click. 
By  some  it  is  considered  almost  pathognomonic  of  tuberculous  infiltra- 
tion. While  not  absolute,  one  is  safe  in  saying  that  the  more  numerous 
the  rales  the  greater  is  the  probability  of  softening  and  hence  the  more 
serious  the  outlook.  If  the  rales  have  a  metallic  quality,  a  cavity  may 
be  suspected  even  if  other  signs  of  excavation  are  absent.  Some  crepi- 
tating rales  are  commonly  present  in  this  stage  but  in  some  instances 
they  are  not  heard  while  the  patient  is  breathing  naturally.  Having  the 
patient  cough  and  then  take  a  deep  breath,  or  breath  out  and  then 
cough,  will  often  bring  out  a  shower  of  fine  rales;  sometimes  deep 
breathing  will  accomplish  the  same  result. 

Accordingly  as  the  rales  diminish  or  increase  or  change  in  character 
one  is  often  able  to  foretell  the  probable  outcome  of  the  disease.  If  the 
rales  diminish  it  is  an  indication  that  the  associated  bronchitis  is  dis- 
appearing and  that  the  softening  of  the  caseous  areas  is  ceasing.  On 
the  other  hand,  if  the  rales  gradually  become  more  numerous  breaking 
down  of  the  lung  tissue  is  probably  taking  place. 

With  arrest  of  the  disease  the  rales,  particularly  the  medium-sized 
ones,  may  entirely  disappear.  The  crepitating  rales,  on  the  other  hand, 
may  persist  for  years  even  when  the  patient  is  entirely  free  from 

Pleuritic  friction  sounds  are  frequently  heard  during  this  stage.  The 
friction  rub  may  occur  on  the  affected  side  or  it  may  be  heard  on  the  op- 
posite side.  It  is  often  difficult  to  distinguish  between  crepitating  rales 
located  in  the  lung  and  fine  pleural  crepitations.  At  times  these  fine 
crepitations  may  be  heard  over  both  the  upper  and  the  lower  portion  of 
one  lung.  While  it  is  not  always  possible  from  the  character  of  the  sound 
alone,  to  differentiate  them,  one  can  usually  judge  whether  the  rales  are 
entirely  due  to  infiltration  of  the  pulmonary  tissue  or  whether  those 
heard  over  the  lower  portion  of  the  lung  are  due  to  pleurisy,  by  the  char- 
acter of  the  symptoms.  If  the  entire  lung  is  infiltrated  the  patient  is 
almost  certain  to  have  serious  symptoms;  on  the  other  hand,  if  the  symp- 
toms are  mild  and  the  patient  in  good  condition  the  lower  portion  of  the 
lung  is  presumably  free  from  disease  and  the  rales  are  pleuritic. 

The  Heart. — In  many  instances  the  heart  presents  no  abnormalities. 
On  the  other  hand,  there  may  be  noted  in  this  stage  an  increase  in  the 
number  of  heart  beats  per  minute.  A  cardio-respiratory  murmur  is 
quite  frequently  encountered. 

The  nearer  the  disease  approaches  the  third  or  advanced  stage  the 
more  frequently  does  one  hear  abnormal  heart  sounds.  The  first  sound 
may  be  reduplicated  and  reduplication  and  accentuation  of  the  second 
pulmonic  sound  are  commonly  heard.  Accidental  murmurs  may  also  be 
heard  particularly  at  the  pulmonic  area.  As  a  rule  the  systolic  blood- 
pressure  is  low. 

Physical  Signs  in  the  Third  or  Advanced  Stage. — In  taking  up  a  con- 
sideration of  the  physical  signs  encountered  in  the  advanced  stage  of 
pulmonaiy  tuberculosis  the  task  is  at  once  very  easy  and  at  the  same 
time  very  difficult.  It  is  easy  because  inspection  alone  will  frequently 
indicate  that  serious  mischief  has  been  wrought  by  the  disease;  it  is  often 

DISEASES    OF    THE    LUNGS  357 

difficult,  however,  to  indicate  the  exact  nature  of  the  damage  because  of 
the  extremely  varied  pathological  changes  which  are  present.  In  one 
and  the  same  lung  there  may  be  cavity  formation,  consolidation  and 
varjdng  degrees  of  infiltration;  and  in  addition  there  may  be  present  an 
effusion,  a  partial  pneumothorax,  or  involvement  of  the  pleura,  which 
further  complicates  the  picture. 

With  reasonable  care  in  the  examination  of  the  chest  the  examiner 
should  be  able  to  determine  the  approximate  amount  of  damage  present. " 
The  more  experienced  the  physical  diagnostician  the  more  clearl^^  will 
the  phj'sical  signs  he  elicits  correspond  to  the  actual  pathological  changes. 

Inspection. — When  the  disease  has  progressed  to  this  stage  the  vast 
majority  of  incUviduals  present  the  appearance  so  faixdliar  to  all.  The 
most  dominant  feature  of  the  picture  is  the  extreme  emaciation,  a  fact 
that  gave  the  disease  its  first  name,  phthisis  or  the  wasting  disease.  The 
hair  presents  a  lanky,  lusterless  appearance,  the  temples  and  cheeks  are 
sunken  and  the  eyes  look  unnaturally  bright  and  feverish.  The  so-called 
hectic  flush  is  usually  present  and  is  more  marked  on  the  side  most  dis- 
eased; the  bright  color  of  the  cheeks  is  in  marked  contrast  to  the  blanched, 
waxy  appearance  of  the  surrounding  skin.  Flushing  of  the  cheeks  usu- 
ally occurs  synchronously  with  the  afternoon  rise  in  the  temperature 
but  maj^  be  noted  before  the  thermometer  shows  the  presence  of  fever. 

The  skin  is  usually  di'y  and  very  often  scaly.  Pityriasis  versicolor 
is  frequently  noted,  especiallj^  among  those  who  are  not  cleanly  in  their 

Inspection  of  the  mouth  at  this  time  may  show  a  tuberculous  ulcera- 
tion of  the  tongue,  the  buccal  surface  of  the  cheeks,  the  tonsils  or  the 

The  hands  in  many  cases  are  noticeably  altered.  In  the  vast  majority 
of  advanced  cases  the  finger  nails  present  a  slightly  bluish  color.  The 
nails  themselves  are  often  curved,  usually  from  side  to  side  but  ihej  may 
also  curve  over  the  end  of  the  finger.  Clubbing  of  the  fingers  is  not  so 
frequently"  encountered  in  tuberculosis  as  usually  is  taught  and  when 
present  is  rarely  of  the  extreme  grade  seen  in  bronchiectasis,  congenital 
heart  disease,  or  empyema.  Clubbing  of  the  fingers  and  extreme  curv- 
ing of  the  nails,  when  at  all  marked  in  pulmonary  tuberculosis,  are  usually 
evidences  that  the  disease  has  been  of  long  standing  and  that  there  is 
considerable  fibrosis  and  bronchial  dilatation  present  in  the  lungs. 
Clubbing  of  the  fingers  was  noted  at  the  Phipps  Institute  in  21.7  per 
cent.,  and  curving  of  the  nails  in  38.9  per  cent,  of  3551  cases. 

In  the  terminal  stages  of  the  disease  edema  of  the  lower  extremities 
is  not  infrequent.  A  small  percentage  of  cases  towards  the  end.  show  a 
purpuric  eruption  usually  over  the  legs  and  thighs. 

Inasmuch  as  individuals  wdth  anj^  type  of  chest  may  acquire  the  dis- 
ease the  only  striking  features  in  mam^  instances  are  the  emaciation,  the 
sunken  interspaces  and  evidences  of  retraction  on  one  side  or  the  other. 

Inspection  will  usually  show  marked  flattening  at  both  apices  and 
retraction  and  lack  of  motion  at  one  base.  As  a  rule  the  motion  is  good 
at  the  base  of  the  lung  least  diseased. 

The  Heart.- — More  or  less  displacement  of  the  heart  is  extremely'  com- 
mon, being  present  in  about  two-thirds  of  advanced  cases.  This  often 
can  be  detected  hy  inspection  but  in  many  instances  the  position  of  the 


heart  can  be  determined  only  after  percussion  and  auscultation,  or  an 
X-ray  examination. 

The  displacement  is  always  toward  the  affected  side  or  the  side  most 
diseased  and  is  caused  to  some  extent  by  traction.  In  some  instances  a 
contributing  factor  in  the  displacement  is  a  vicariously  hypertrophied 
lung  which  tends  to  crowd  the  heart  toward  the  affected  side.  Dis- 
placement toward  the  left  is  far  more  common  than  toward  the  right 
side  except  in  the  far-advanced  cases  when  the  two  sides  are  about  equally 
involved.  As  a  rule  the  displacement  to  the  left  is  more  pronounced 
than  toward  the  right  partly  because  of  the  anatomical  position  of  the 
heart  and  partly  because  of  the  attachment  of  the  mediastinum  to  the 
central  tendon  of  the  diaphragm.  When  the  heart  is  drawn  toward  the 
left  it  is  also  apt  to  be  pulled  upward  toward  the  axilla. 

At  times  the  right-sided  displacement  may  be  so  marked  as  to  consti- 
tute a  dextro-cardia.  It  is  to  be  borne  in  mind  that  when  the  impulse 
is  noted  on  the  right  side  in  acquired  dextro-cardia,  it  is  caused  by  the 
right  ventricle. 

While  some  displacement  of  the  heart  unquestionably  takes  place, 
it  is  more  apparent  than  real.  This  is  due  to  the  retraction  of  the  chest 
wall  and  the  consequent  diminution  of  the  capacity  of  the  thorax  which 
naturally  alters  the  landmarks  with  reference  to  the  apex  beat. 

When  the  left  lung  is  extensively  diseased  and  retraction  takes  place 
there  is  often  a  marked  pulsation  in  the  second  and  third  interspaces  on 
the  left.  This  is  caused  by  the  exposure  of  the  right  auricle  which  in 
health  is  covered  by  pulmonary  tissue. 

Palpation  serves  to  confirm  the  lack  of  expansion  noted  on  inspection 
and  it  may  also  serve  to  locate  the  apex  beat. 

The  tactile  fremitus  will  vary:  at  the  apex  over  a  cavity  it  may  be 
increased  or  diminished.  In  other  portions  of  the  chest  it  will  be  in- 
creased or  not  according  to  the  amount  of  underlying  infiltration.  A 
rhonchal  fremitus  may  be  felt  at  times. 

Percussion. — Assuming  that  there  is  a  cavity  the  size  of  an  orange 
in  the  upper  part  of  the  upper  lobe  with  dense  infiltration  below  it  which 
gradually  thins  out  as  the  base  of  the  lower  lobe  is  reached,  the  following 
percussion  changes  will  be  present :  Over  the  cavity  the  note  will  be  tym- 
panitic. It  is  high-pitched  and  may  have  an  amphoric  or  cracked-pot 
quality.  The  amphoric  note  is  similar  to  that  produced  by  percussing 
the  cheek  with  the  mouth  open;  the  cracked-pot  sound  can  be  reproduced 
by  striking  the  clasped  and  concave  hands  on  the  knee. 

Wintrich's  and  Gerhardt's  changes  of  note  are  always  referred  to  as 
aids  in  recognizing  a  cavity.  The  information  furnished  by  these  signs 
is  uncertain  and  of  little  value  when  present.  Personally  I  cannot  recall 
having  looked  for  them  for  years. 

Below  the  cavity  over  the  dense  infiltration  the  note  is  dull  or  nearly 
so;  as  the  base  is  approached  the  note  becomes  more  and  more  resonant. 
If  the  tubercles  are  widely  separated  in  the  inferior  portion  of  the  lung 
the  percussion  note  may  show  no  abnormality. 

Over  the  opposite  lung  the  disease  is  apt  to  be  less  extensive  and  the 
percussion  changes  correspondingly  less  marked.  A  cavity  may  be  pres- 
ent i