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RC941 .N791920 Diseases of the ches

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DISEASES OF THE CHEST

AND THE PRINCIPLES OF

P^^mfiM^acPJ^M^J^osis

COLUMBIA UNiVERSITY
I 437 W. 59th Street,
11;^. NEW YORJ^^ITY.
GEORGE WILLIAM NORRIS, A. B., M. D

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

AND

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

ELECTROCARDIOGRAPH IN HEART DISEASE

EDWARD B. KRUMBHAAR, Ph.D., M. D.

Assistant Professor of Research Medicine in the University of Pennsylvania

SECOND EDITION, REVISED

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1920

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

Printed in America.

DEDICATED TO
OUR FRIEND

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

ASSISTANT PBOFESSOB OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA

TO WHOM "WE ARE INDEBTED FOR MOST OF OTJR ANATOMIC SECTIONS

WITHOUT WHOSE CO-OPERATION, CORDIAL AND SELF-EFFACING,

OUR BOOK WOULD LACK WHAT IS PROBABLY ITS

MOST CHARACTERISTIC FEATURE.

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in 2010 with funding from

Open Knowledge Commons

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PREFACE TO THE SECOND EDITION

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

PREFACE

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
others.

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

CONTENTS

PART I

THE EXAMINATION OF THE LUNGS

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

CHAPTER I

Page

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.

CHAPTER II

Palpatiox 43

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

CHAPTER III

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.

CHAPTER IV

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.

CHAPTER V
Anatomic Coxsideratioxs 74

CHAPTER VI

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.

12 CONTENTS

CHAPTER VII

Page

Normal Variations of Pulmoxart Percussion Souxds 95

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

CHAPTER VIII

ArSCULTATIOX 106

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

CIL\PTER IX

Normal axd .\bxormal Breath Souxds 115

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

CHAPTER X

Advextitious Breath Souxd.s 124

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

CHAPTER XI

Voice Sounds 132

Vocal resonance, 132; Bronchophony, 134; Pectoriloquy, 134; Egophony,
137.

CHAPTER XII

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.

PART II

THE EXAMINATION OF THE CIRCULATORY SYSTEM

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

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.

CHAPTER XIV

IXSTRUMEXTAL METHODS 163

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

CONTENTS 13

CHAPTER XV

Page

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.

CHAPTER XVI

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

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

CHAPTER XVII
Palpation 199

Cardiac impulse, 199; Thrills, 204.

CHAPTER XVIII

Percussion of the Heart 206

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

CHAPTER XIX

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.

CHAPTER XX
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.

PART III

DISEASES OF THE BRONCHI, LUNGS, PLEURA,
AND DIAPHRAGM

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

CHAPTER XXI

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.

14 CONTEXTS

CHAPTER XXII

Page

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.

CHAPTER XXIII

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,
617.

CHAPTER XXIV

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.

PART IV

DISEASES OF THE PERICARDIUM, HEART, AND AORTA
By H. R. M. Laxdis, A. B., M. D.

CHAPTER XXV

Diseases of the Pericardium 653

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

CONTENTS 15

CHAPTER XXVI

Page

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.

CHAPTER XXVII

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.

CHAPTER XXVIII

Congenital Heart Disease 756

CHAPTER XXIX

Angina Pectoris 766

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

CHAPTER XXX

Diseases op the Aorta 774

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

CHAPTER XXXI

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

PART I

THE EXAMINATION OF THE LUNGS

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

CHAPTER I

PHYSICAL DIAGNOSIS

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.

INSPECTION

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

THE EXAMINATION OF THE LUNGS

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
latter."

INSPECTION

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

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 INSPECTION

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

20 THE EXAMINATION CF TI'E 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.

INSPECTION OF THE CHEST

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
constantly.

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

INSPECTION

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
patient.

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

THE EXAMINATION OF THE LUNGS

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
examiner.

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

INSPECTION

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-

THE EXAMINATION OF THE LUNGS

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
Barth.)

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).

INSPECTIOX

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.)

Apex

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-

THE EXAMINATION OF THE LUNGS

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-
cardium.

INSPECTION 27

THE VITAL CAPACITY OF THE LUNGS

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 EXAMINATION OF THE LUNOS

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 ]

years

Pulse rate..

122
30

114
26

103
25

89
24

Respiratory

rate.

T. 98°

102

0 / Respiratory

1 Pulse

141

135

128

117

106

10.5

0 / Respiratory

50 ,

\ Pulse

149 1

161

136

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

INSPECTION

(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

THE EXAMINATION OF THE LUNGS

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^
Henry.)

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

IXSPECTIOX

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.) '- ° * ■

THE EXAMINATION OF THE LUNGS

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.)

INSPECTION

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.

ABNORMAL THORACIC CONFORMATION

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
shape.

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

THE EXAMINATION OF THE LUNGS

Fig. 21.— The rachitic
chest.

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.)

IXSPECTIOX

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.

The

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

THE EXAMINATION OF THE LUNGS

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

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.)

IXSPECTION

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).

TITE EXAMINATION OF THE LUNGS

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.)

IXSPECTION" 39

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
distended.

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).

40 THE EXAMINATION OF THE LUNGS

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.)

ABNORMAL RESPIRATION

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.

INSPECTION

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

UlllUlllUllllllUlilUilllU

iiiiiiiiiiiiiiiiHiiiiHiiiiin

illlllllllllljllillj^^

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.

THE EXAMINATION OF THE LUNGS

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.

VISIBLE CHANGES IN RESPIRATORY RHYTHM

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

l,^,ll,lH^»^^l»)l^■l("f^"n^M.')ll»»ln■^l^l7'>||Ml)|»)<)l^>>)(w'/lW'l■y'''')'/^ll)>rnlV"/'///j>l;l>ll<|^|)l|//!lfJ)/)l/

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.

CHAPTER II

PALPATION

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.

44 THE EXAMINATION OF THE LITNGS

ZONES OF CUTANEOUS HYPERESTHESIA (HEAD'S AREAS), AND REFLEX

PAIN

" 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
body.

" 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.

PALPATION

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.^

PLEURAL 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.

THE EXAMINATION OF THE LUNGS

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.

TACTILE OR VOCAL FREMITUS

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

PALPATIOX

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
rapid.

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-

THE EXAMINATION OF THE LUNGS

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-

PALPATION

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).

{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
wall.

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

THE EXAMINATION OF THE LUNGS

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

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

COLUMBIA UNIVERSITY
. 437 W. 59tH Street.

UtW YORK CITY.

PALPATION

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
expansibility.

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
absent.

THE EXAMINATION OF THE LUNGS

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).

(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

PALPATION 53

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.

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.

CHAPTER III
ACOUSTICS IN PHYSICAL DIAGNOSIS

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
rate

ACOUSTICS IN PHYSICAL DIAGNOSIS

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

THE EXAMINATION OF THE LUNGS

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.

[JT717T7T]TTTTI7T71

./\/\/\/\/\A/WV

Anww,

Rhythmic vibrations

Unrhythmic vibrations

Very unrhj-thmic vibrations

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

uuuuuuuuuuu

Loud sound

(large wave amplitude)

Feeble sound

(small wave amplitude)

fiiiiiiii

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-

ACOUSTICS IN PHYSICAL DIAGNOSIS

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

VOCAL CORDS

,rUNOAMENTA.L

RESOANANCe CAPACITY OF THE NASAL OAV 1
IS OBTAINED WITH THE RESULT THAT ALL

.mg^^^m^emm^ ■3Kj> overtone

Fundamental

, VOCAL CORPS

WHEN THE SOFT PALATE CLOSES THE NASAL CAVITY THE
MOUTH ALONE ACTS AS A RESONATOR *ITH THE RESULT
THAT THE VOLUME IS MARKEDLY REOUCEO. THE FUNDA-
MENTAL TONE IS *EAK AND SOME OF THE OVERTONES MAY
BE SUPPRESSED.

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
American.)

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-

58 THE EXAMINATION OF THE LUNGS

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

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.

ACOUSTICS IN PHYSICAL DIAGNOSIS 59

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
short.

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.

60 THE EXAMINATION OF THE LUNGS

THE ORIGIN OF SOUNDS HEARD OVER THE CHEST

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.

ACOUSTICS IN PHYSICAL DIAGNOSIS

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.

Diaphragm.'

^i Trachea

I. 1

Bronchus

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.

Pulmonary
surface

/ /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.

62 THE EXAMINATION OF THE LUNGS

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
effusion.

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.

ACOUSTICS IX PHYSICAL DIAGNOSIS 63

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.

CHAPTER IV
THE HISTORY AND THE THEORY OF PERCUSSION ^

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."

PERCUSSION SOUNDS

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.

THE HISTOKY AND THE THEORY OF PERCUSSION 65

(.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
percussion.

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.

66 THE EXAMINATION OF THE LUNGS

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-
panitic).

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
(Flint).

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,

THE HISTORY AND THE THEORY OF PERCUSSION 67

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 EXAMIXATIOX OF THE LUNGS

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.

THE HISTORY AND THE THEORY OF PERCUSSION 69

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. ,

MODIFIED TYMPANY

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,
1378.

70 THE EXAMINATION OF THE LUNGS

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
walls."

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
metallic.

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

THE HISTORY AND THE THEORY OF PERCUSSION 71

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

sounds.
Markedly unrhythmic vibrations produce metallic
sounds.

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

THE EXAMINATION OF THE LUNGS

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

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
illustrated.

THE HISTOEY AXD THE THEORY OF PERCUSSION 73

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
far.

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.

SPECIAL PERCUSSION SIGNS

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
effusion.

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. \

CHAPTER V
ANATOMIC CONSIDERATIONS

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.

SURFACE LANDMARKS, ETC.

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,
vertebra.

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.)

ANATOMIC CONSIDERATIONS

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.

THE EXAMINATION OF THE LUNGS

SG-

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.)

ANATOMIC CONSIDERATIONS

Fig.

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.

THE EXAMINATION OF THE LUNGS

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,
vertebrae.

ANATOMIC CONSIDERATIONS

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.

CHAPTER VI
METHODS AND RESULTS OF PERCUSSION

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.

METHODS AND RESULTS OF PERCUSSION

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.
6

82 THE EX^VMIXATIOX OF THE LUNGS

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
noise.

THE RESULTS OF PERCUSSION

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
penetration.

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

METHODS AND RESULTS OF PERCUSSION

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.

1.
a'Pb'.
2.
3.
4.

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

84 THE EXAMINATION OF THE LUNGS

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
axis.

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-
filtration.

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
required.

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

METHODS AND RESULTS OF PERCUSSION

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

THE EXAMINATION OF THE LUNGS

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.

METHODS AND EESULTS OF PERCTSSIOX 87

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.

THE PURPOSE OF PERCUSSION

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,
etc.

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

THE EXAMINATION OF THE LUNGS

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

Resonant

Slight dulness

Flat (absolute
dulness)

Tympany

High-pitched
tympany

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

METHODS AND RESULTS OF PERCUSSION 89

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 TECHNIC OF PERCUSSION

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 EXAMINATION OF THE LUNGS

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.

SPECIAL VARIETIES OF PERCUSSION

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).

METHODS AND RESULTS OF PERCUSSION

, 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.

THE EXAMINATION OF THE LUNGS

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.

METHODS AND RESULTS OF PERCUSSION

CONDITIONS MODIFYING PERCUSSION SOUNDS

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.

94 THE EXAMINATION OF THE LUNGS

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.

CHAPTER VII

NORMAL VARIATIONS OF THE PULMONARY PERCUSSION

SOUNDS

INDIVIDUAL VARIATIONS

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.)

REGIONAL VARIATIONS

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

THE EXAMINATION OF THE LUNGS

— 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
percussion.

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

VARIATIONS OF PULMOXARY PERCUSSIOX SOUNDS 97

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 EXAMINATIOX OF THE LL'NGS

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
noted:

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

VARIATIONS OF PULMONARY PERCUSSION SOUNDS 99

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

VARIATIONS OF PULMONARY PERCUSSION SOUNDS

101

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
arch.

* 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

102 THE EXAMINATION OF THE LUNGS

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

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.)

OTHER VARIATIONS

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 DIAPHRAGM

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

VARIATIONS OF PULMONARY PERCUSSION SOUNDS 103

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
emphysema).

SOME PHYSIOLOGIC CONSIDERATIONS

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

104 THE EXAMINATION OF THE LUNGS

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.

VAEIATIONS OF PULMONARY PERCUSSION SOUNDS 105

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

CHAPTER VIII

AUSCULTATION

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.

THE METHOD

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
possible.

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

106

AUSCULTATION

107

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

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.

L.M.A

D.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
nerve.

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

108 THE EXAMINATION OF THE LUNGS

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 INFLUENCE OF POSTURE ON THE PHYSICAL SIGNS

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
(resonators).

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.

AUSCULTATION 109

THE STETHOSCOPE

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

110 THE EXAMINATION' OF THE LUNGS

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
sounds.

"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
spent.

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.

A.USCULTATION 1 1 1

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 BREATH SOUNDS

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
advantage."

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

112 THE EXAMINATION OF THE LUNGS

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
sounds.

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

AUSCULTATION 1 13

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.

114 THE EXAMINATIOX OF THE LUXGS

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.

CHAPTER IX
NORMAL AND ABNORMAL BREATH SOUNDS

THE NORMAL VESICULAR SOUND

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.

ABNORMAL BREATH SOUNDS

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.

THE CLASSIFICATION OF ABNORMAL BREATH SOUNDS

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

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

115

116

THE EXAMINATION OF THE LUNGS

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
emphysema.

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).

NORMAL AND ABNORMAL BREATH SOUNDS 117

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

118

THE EXAMINATION OF THE LUNGS

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.)

NORMAL AND ABNORMAL BREATH SOUNDS

119

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

Broncho-
vesicular
(incomplete
consolida-
tion)

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."

120

THE EXAMINATION OF THE LUNGS

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

NORMAL AND ABNORMAL BREATH SOUNDS 121

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.

122

THE EXAMINATION OF THE LUNGS

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.

XORMAL AXD ABNORMAL BREATH SOUNDS 123

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.

CHANGES IN RESPIRATORY RHYTHM

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.

CHAPTER X
ADVENTITIOUS BREATH SOUNDS

RALES AND FRICTIONS

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.
High-pitched.

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.

124

ADVENTITIOUS BREATH SOUNDS

125

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.

jopij^g

-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.

126

THE EXAMINATION OF THE LUNGS

No phrenic
wave.

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."

ADVENTITIOUS BREATH SOUNDS 127

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,

creaking.

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

pressure,

(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.

bronchi.
(/) 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.

128

THE EXAMINATION OF THE LUNGS

Expansion
— . V. frem-
itus O- V
resonance
O. tympany
+ , Breatli
sounds,
O, metallic |
tinkle +,
succusion
splash +,
bell tym-
pany + ,
[nterspaces
full. Ex-
panison — ,
Phrenic
wave 'O. V.
fremitus O-
V. reso-
[nance O-
Movable
dulness +
-t-. Breath
sounds O,
Metallic
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.

ADVENTITIOUS BREATH SOUNDS

129

Expansion
— . Vocal
fremitus
+ . Vocal
resonance
+ . Percus-
sion: high
pitched
tympany,
Breath
sounds :,
broncho-
vesicular

Expansion
— . Inter-
spaces full.
Vocal
fremitus O-
Vocal reso-
nance O- ,
percussion |
dulness '
+ + +.
Breath
sounds O-
Phrenic
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.)

130

THE EXAMINATION OF THE LUNGS

SUCCUSSION SPLASH

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

ADVENTITIOUS BREATH SOUNDS 131

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).

METALLIC TINKLE

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.

CHAPTER XI
THE VOICE SOUNDS

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
quality.

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.

VOCAL RESONANCE

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-

132

THE VOICE SOUNDS 133

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
opposed.

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

134 THE EXAMINATION OF THE LUNGS

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).

BRONCHOPHONY

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

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.

THE VOICE SOUNDS

135

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.

136

THE EXAMINATION OF THE LUNG5

RUL

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
Gitlings.)

THE VOICE SOUNDS 137

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

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.

CHAPTER XII
THE PHYSICAL FINDINGS IN INFANTS AND YOUNG CHILDREN^

NORMAL CONDITIONS

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
former.

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.

138

PHYSICAL FINDINGS IN INFANTS AND YOUNG CHILDREN 139

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

140 THE EXAMINATION OF THE LUNGS

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

PHYSICAL FINDINGS IN INFANTS AND YOUNG CHILDREN

141

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.

-RL

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.

142

THE EXAMINATION OF THE LUNGS

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

PHYSICAL FINDINGS IN INFANTS AND YOUNG CHILDREN

143

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.

PATHOLOGIC CONDITIONS

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

144

THE EXAMINATION OF THE LUNGS

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.

PHYSICAL FINDINGS IN INFANTS AND YOUNG CHILDREN 145

l«-

^'1
1_.

rIS

I^^HH '

'^^^B

lHMB^>^f|&M

g^aaifatiA^JiAMi

^5v>*4.j3k

'yr*i

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.
10

146 THE EXAMINATION OF THE LUNGS

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
procedure.

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.^

.^ PRACTICAL CONSIDERATIONS

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.

PHYSICAL FINDINGS IN INFANTS AND YOUNG CHILDREN

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

Tympar.y:

Hyper- re 30 nance;

Noraal Breathing:

Vfeai breatiiing:

Exaggerated 'breathing:

Bronoiio-vssicular breathing:

Bronchial breathing:
CavernouB breathing:

Cog-wheel breathing:

Friction:

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
clinicians.

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

148

THE EXAMINATION OF THE LUNGS

Resonance

Heart and Abdominai,

Vw-Cvvvovvvc. 'i. i-

-Wtt tv<X^ , S H^^ti'^C

Indicfitt—

Slight dulness

Moderate **

Marked "

■III

Flataess

Pectoriloquy outlined
Tympany
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.

PHYSICAL FINDINGS IN INFANTS AND YOUNG CHILDREN

149

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

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.

PART II

THE EXAMINATION OF THE CIRCULATORY SYSTEM
By George W. Norris, A. B., M. D

CHAPTER XIII
THE CIRCULATORY SYSTEM

INSPECTION

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

151

152

THE EXAMINATION OF CIRCULATORY SYSTEM

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.

Pulmon

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 CIRCULATORY SYSTEM

153

THE HEART— ANATOMICAL CONSIDERATIONS

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

'--r-jf^^

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.

154

THE EXAMINATION' OF CIRCULATORY SYSTEM

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.

THE CIRCULATORY SYSTEM

155

Left innom-
inate vein

Right auricle

Papillary -^

muscle

Right ventricle

Right pulmo-
nary artery
Descending
aorta
Left bronchus

Aortic leaflets

Left lunc

Fig. 12G.

156

.THE EXAMINATION OF CIRCULATORY SYSTEM

Right pul. artery

Left super, pul. vein ..

L.auricular appendix s ^

L. infer, pul. vein

Left auricle

Mitral valve ante- "

rior leaflet v>.

Aorta

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.

THE CIRCULATORY SYSTEM 157

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).

PALPATION OF THE PULSE

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
diminished.

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.

158 THE EXAMINATION OF CIRCULATORY SYSTEM

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-

THE CIRCULATORY SYSTEM 159

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.^

NORMAL AND ABNORMAL TYPES OF THE ARTERIAL PULSE

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
filling.

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).

160 THE EXAMINATION OF CIRCULATORY SYSTEM

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
(Hewlett).

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
rib.)

1 Lewis, T.: Brit. Med. Jour., April 20, 1907.

THE CIRCULATORY SYSTEM

161

The bigeminal pulse (digitalis effect in auricular fibrillation

ion).

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.

162 THE EXAMINATION OF CIRCULATORY SYSTEM

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.

CHAPTER XIV

INSTRUMENTAL METHODS, BLOOD-PRESSURE ESTIMATION

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.

TECHNIC

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

163

164 THE EXAMINATION OF CIRCULATORY SYSTEM

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.

NORMAL BLOOD-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.

THE SIGNIFICANCE OF BLOOD-PRESSURE ABNORMALITIES

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.

INSTRUMENTAL METHODS, BLOOD-PRESS.URE ESTIMATION 165

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.

166 THE EXAMINATION OF CIRCULATORY SYSTEM

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.

VENOUS BLOOD-PRESSURE

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
fails.

THE VENOUS PULSE

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.

IXSTRUMEXTAL METHODS, BLOOD-PRESSURE ESTIMATION 167

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).

SPHYGMOGRAPHS

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

168

THE EXAMINATION OF CIRCULATORY SYSTEM

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

Right

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-

INSTRUMENTAL METHODS, BLOOD-PRESSURE ESTIMATION 169

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.

THE INTERPRETATION OF PULSE TRACINGS

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
obtained.

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.

CHAPTER XV

CARDIAC ARRHYTHMIA

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.

NORMAL RHYTHM

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
cava."

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

170

CARDIAC AREHYTHMIA 171

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).

TACTILE DIAGNOSIS OF THE ARRHYTHMIAS

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
fibrillation."

172 THE EXAMINATION OF CIRCULATORY SYSTEM

" 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
wrist."

"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-
block."

"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). ^

SINUS ARRHYTHMIA

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.)

CARDIAC ARRHYTHMIA

173

sounds remain unaltered during sinus arrhythmia, only diastole being
affected.

HEART BLOCK

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, , ^

'«i|k4«ya«kc.

*^sJi^vC.twV^/-

^-sUuV.

Oyvswlo.V.

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

BRACHIAL.

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

174

THE EXAMINATION OF CIRCULATORY SYSTEM

(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.)

EXTRASYSTOLE

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

CARDIAC ARRHYTHMIA

175

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^^

Ov^uVaor

V^^^W-w

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-

Cardiogram

Phlebogram

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-

176 THE EXAMINATION OF CIRCULATORY SYSTEM

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.

PAROXYSMAL TACHYCARDIA

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

Auricular flutter is a not uncommon form of arrhythmia which occurs
chiefly in elderly subjects. It is characterized by an extremely rapid

CARDIAC ARRHYTHMIA 177

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).!

AURICULAR FIBRILLATION

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.

178

THE EXAMINATION OF CIRCULATORY SYSTEM

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.'"

ui.ut.muLUtiitnt

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

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

CARDIAC ARRHYTHMIA 179

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"
(Gordinier).

Pulsus alternans is met with in cases of nephritis and myocarditis,
generally during failing compensation. It may be complicated by
extrasystoles.

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.

180

THE EXAMIXATIOX OF CIRCULATORY SYSTEM

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."^

.Jic^

WWWW^^■NWv~MM

® 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.

TH.E EFFORT SYNDROME

("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.

CARDIAC ARRHYTHMIA 181

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
leukocytosis.

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.

182 THE EXAMINATION OF CIRCULATORY SYSTEM

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.

THE ESTIMATION OF VASOMOTOR EFFICIENCY

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
integrity.

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.

CAEDIAC AERHYTHMIA

183

PERCENTAGE SCALE
Vasomotor Toste

Blood-pressure

Heart-rate

Increase

Decrease

increase

+ 10

+ 8

+ 6

+ 4

+ 2 1

-2

- 4

- 6

- 8

- 10

0 to 4

100

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.

CHAPTER XVI

THE ELECTROCARDIOGRAPH

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

;184

THE ELECTROCARDIOGRAPH 185

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

186

THE EXAMINATION OF CIRCULATORY SYSTEM

(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

THE ELECTROCARDIOGRAPH 187

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
understood.

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

188

THE EXAMINATION OF CIRCULATORY SYSTEM

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

THE ELECTROCARDIOGRAPH

189

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.

SfnC

I^W:*^

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-

190

THE EXAMINATION OF CIRCULATORY SYSTEM

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.)

THE CARDIAC ARRHYTHMIAS

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.

-: — *-

-H*-

15:

-^Rr^

-U-

^'iLw^''^*>>^>*WV^

( %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

THE ELECTROCARDIOGRAPH

191

^=^1<A.J&-M=i.^

___ S-

i4-.-^#^3~

~^-Sgc:

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
interpolated.

;JtoRiK^?BS^^-ted"^C£r:

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.

192

THE EXAMINATION OF CIRCULATORY SYSTEM

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

•'• "•' 1

:-Z~:zzk:

i.S^

_ ^ -R.

if%l yLjJ

iBf?F*l

1 -. A. i \ , ,„ >, > \ ^

■ ' ' " '

BKHMHf

^■^

^^^

rERMCPfATE

Ve/VTR/Cv/MI?

jtM^:

J.( ivc-.

",ir,:X^

___ __

— — ■—

ijc:

____ .

""""*"'""'

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.

THE ELECTROCARDIOGRAPH

193

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
observed.

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

194

THE EXAMINATION OF CIRCULATORY SYSTEM

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.

•EAD

% 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.

THE ELECTROCARDIOGRAPH

195

196

THE EXAMINATION OF CIRCULATORY SYSTEM

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,

THE ELECTROCARDIOGRAPH

197

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

ligJilL^-

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,

iO«99i

■JF'^

'/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.

19S THE EXAMINATION OF CIRCULATORY SYSTEM

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).

CONCLUSION

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
physician.

CHAPTER XVll
PALPATION

THE CARDIAC IMPULSE

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

199

200

THE EXAMINATION OF CIRCULATORY SYSTEM

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

Right

•auricular

appendage

Diaphragm

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-
trophied.

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

PALPATION 201

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

202 THE EXAMINATION OF CIRCULATORY SYSTEM

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).

FALPATION

203

(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.

Trachea

Right bronchus

Branch, left pul-
monary artery'

Left superior'pu 1-
monary vein

Left inferior pul-
monary vein

Left auricle

Thoracic aotra

Right kidney

Stomach

Spleen

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-.

204 THE EXAMINATION OF CIRCULATORY SYSTEM

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.

THRILLS

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
exertion.

iNoRRis, G. W.: "Studies in Cardiac Pathology," 1911, 123.

PALPATION

205

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-

L.I.\

R.A.A

R.\

L.B.

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
obstruction.

CHAPTER XVIII
PERCUSSION OF THE HEART

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

206

PERCUSSION or THE HEART

207

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.)

208

THE EXAMINATION OF CIRCULATORY SYSTEM

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
nerve

Right

: 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

PERCUSSION OF THE HEART

209

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

210 THE EXAMINATION OF CIRCULATORY SYSTEM

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 SIGNIFICANCE OF CARDIAC DULNESS

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.)

PEKCUSSION OF THE HEART

211

Aortic insufficiency.

Aortic obstruction.

Mitral obstruction.

Mitral insufficiency.

Mitral obstruction and
insufficiency.

Aortic obstruction and
mitral insufficiency.

Chronic myocarditis.
Fig. 172.

212

THE EXAMINATION OF CIRCULATORY SYSTEM

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
inspiration.

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.

Wt^*

^<^^

QQ\JiUB^^

...ViB

SHY

PERCUSSION OF THE HE

213

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). |

214

THE EXAMINATION OF CIRCULATORY SYSTEM

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

Men

Women

r"-. Feet and
^™- inches

MR
Cm.

ML
Cm.

L
Cm.

Cm.

Cardiac! %r7}
area, ^^
Q Cm. ^™-

ML \ L Q
Cm. J Cm. Cm.

Cardiac
area,
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

3.5

4.1
4.2
4.4

7.9

8.7
8.8
9.1

12.5

13.8
14.1
14.8

9.7

9.9

10.3

10.7

95 3.5
109 1 3.5
116 1 3.8
127

8.1
8.4
8.5

12.7
13.2
13.4

9.4
9.7
9.9

Q3^

■ ioi

105

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.

PERCUSSION OF THE HEART

215

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.

CHAPTER XIX
AUSCULTATION

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 ORIGIN AND CHARACTER OF THE HEART SOUNDS

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

216

AUSCULTATION

217

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,

218

THE EXAMINATION OF CIRCULATORY SYSTEM

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

Rle.itro-'phonoat'Ci'p}!/

Se/^onis

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.)

THE ACOUSTICS OF HEART SOUNDS

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."

AUSCULTATIOX 219

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
two.

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

220

THE EXAMIXATIOX OF CIRCULATORY SYSTEM

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
(Geigel).

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.

THE INDIVIDUAL VARIATION OF HEART SOUNDS

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.

AUSCULTATION 221

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
audibility.

DISPROPORTIONATE INTENSITY OF THE HEART SOUNDS

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.

222

THE EXAMINATION OF CIRCL'LATORY SYSTEM

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-

AUSCULTATION 223

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.

CHANGES IN THE PITCH OF HEART SOUNDS

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.

THE REDUPLICATION OF HEART SOUNDS

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-
lupp.

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

224

THE EXAMINATION OF CIRCULATORY SYSTEM

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
TVessyre.

VolvL-me of
Vent-r-icles

lVesijitoli,c Gillop
Split |irst sounj.
SfUt sewfil souvi
TTotoiiistolic

TT-LUB DUB

lil

LUB DUB DA

kJI

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.

CHANGES IN THE RHYTHM OF THE HEART SOUNDS

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

AUSCULTATION

225

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.

CHAPTER XX
HEART MURMURS

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.

226

HEART MURMURS

227

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

^^^\5_

riC'Vy ■= — -

Fig. 185.

Fig. 184.

^^^^^s

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,
etc.

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.)

228 THE EXAMINATION OF CIRCULATORY SYSTEM

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).

THE TECHNIQUE OF CARDIAC AUSCULTATION

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
reliable.

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).

VARIATIONS IN THE INTENSITY OF HEART SOUNDS

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

HEART MURMURS

229

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
itself.

ENDOCARDIAL MURMURS

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

Insufficiency

Mitral
Tricuspid

Aorta
Pulmonary artery

Aorta '

Pulmonary artery
(Presystolic)
Mitral
Tricuspid

Obstruction

230 THE EXAMINATION OF CIRCULATORY SYSTEM

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

HEART MURMURS

231

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

I'llilMili,

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
sound.

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
gradually.

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.

232 THE EXAMINATION OF CIRCULATORY SYSTEM

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
reestablished.

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.)

INDIVIDUAL VALVULAR MURMURS

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

HEART MURMURS

233

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.

234 THE EXAMINATION OF CIRCULATORY SYSTEM

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.

HEART MURMURS

235

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

236

THE EXAMINATION OF CIRCULATORY SYSTEM

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

HEART MURMURS

237

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

238 THE EXAMINATION OF CIRCULATORY SYSTEM

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

HEART MURMURS 239

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

240

THE EXAMINATION OF CIRCULATORY SYSTEM

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

HEART MURMURS 241

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-

242 THE EXAMIXATION OF CIRCULATORY SYSTEM

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.

HEART MURMURS

243

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.

r<^

Fig. 204. — Illustrating the direction of blood flow in mitral obstruction.

244

THE EXAMINATION OF CIRCULATORY SYSTEM

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

V.A.M.

R.P.A.

B.L.N.

L.A.

I.V.C.

s.v.c.

R.A.A.

R.A.

A.T.

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.

HEART MURMURS

245

Pleural
cavity
filled with
serous exu-
date

Com-
pressed
lung (part
of right
lower lobe)

f Rt. internal

■', ugular
vein

Diaphragm

(comple-
mental
space)

Inferior
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
artery.

246 THE EXAMINATION OF CIRCULATORY SYSTEM

FUNCTIONAL MURMURS

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.

HEART MURMURS

247

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

248 THE EXAMINATION OF CIRCULATORY SYSTEM

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. ^

THE EFFECT OF RESPIRATION ON ENDOCARDIAL MURMURS

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.

HEART MURMURS

249

SPECIAL VARIETIES OF MURMURS

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.

250

THE EXAMINATION OF CIRCULATORY SYSTEM

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.

Flatness

Pulsating liver tender-
ness.

Bulging flanks, succus
sion wave.

Pulmonic second sound

loud.

Apex impulse displaced,

downward and outward

arrhythmia.

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.

HEART MURMURS

251

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).

252 THE EXAMINATION OF CIRCULATORY SYSTEM

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).

EXOCARDIAL MURMURS

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.

HEART MURMURS 253

ARTERIAL SOUNDS AND MURMURS

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 MURMURS

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,
873.

254 THE EXAMINATION OF CIRCULATORY SYSTEM

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 -RESPIRATORY MURMURS

(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.

HEART MURMURS

255

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-
cardia.

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-
pericardium.

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.

PERICARDIAL FRICTION SOUNDS

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-

256 THE EXAMINATION OF CIRCULATORY SYSTEM

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

HEART MURMURS

257

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.

258

THE EXAMINATION OF CIRCULATORY SYSTEM

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
lung.

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

rales

Muffled breath
sounds, distant bron-
cho-vesicular

breathing

small pleural

effusion)

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 MURMURS

259

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
value.

Fig. 217. — Precordial bulging as a result of (rheuraatir-) pericardial effusion in a lad of 13

years.

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
cases.

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

260 THE EXAMINATION OF CIKCULATORY SYSTEM

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-
ology.")

PRACTICAL CONSIDERATIONS

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.

HEART MURMURS 261

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- .
struction.

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
murmurs.

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

262 THE EXAMIXATIOX OF CIRCULATORY SYSTEM

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
Balfour.

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

HEART MURMURS 263

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.

PART III

DISEASES OF THE BRONCHI, LUNGS, PLEURA,
AND DIAPHRAGM

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

CHAPTER XXI
DISEASES OF THE BRONCHI

ACUTE BRONCHITIS

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
broncho-pneumonia.

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

265

266 DISEASES OF THE BRONCHI. LUNGS, PLEURA, AND DIAPHRAGM

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
pneumococcus.

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
clinically.

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.)

DISEASES OF THE BRONCHI 267

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.

CHRONIC BRONCHITIS

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

268 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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

DISEASES OF THE BRONCHI 269

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
present.

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.

FIBRINOUS BRONCHITIS

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.

270 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

DISEASES OF THE BRONCHI

271

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-
develops.

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

272 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
(IVIcPhcdran).

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
bronchitis.

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
develops.

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

DISEASES OF THE BRONCHI 273

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.

SPIROCHETAL BRONCHITIS

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.
18

274 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

BRONCHIOLITIS FIBROSA OBLITERANS

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.

DISEASES OF THE BRONCHI 275

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.

276 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

WHOOPING COUGH (PERTUSSIS)

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.

DISEASES OF THE BRONCHI 277

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.

278 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
decline.

Complications may arise, however, during the paroxysmal stage.

1 "Clinical Lectures, "~vol. i, New Sj'denham Soc, p. 664.

DISEASES OF THE BRONCHI 279

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.

BRONCHIAL ASTHMA

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
disorder.

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
Salter^:

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.

280 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
anaphylactic.

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.

DISEASES OF THE BEOXCHI 281

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.

282 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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

DISEASES OF THE BRONCHI 283

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

284 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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

DISEASES OF THE BROXCHI 285

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.

286 DISEASES OF THE BROXCHI, LUNGS, PLErRA, AND DIAPHRAGM

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
acidosis.

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

DISEASES OF THE BROXCHI 287

careful study should be made of the patient's environment; especially
as regards dust exposure and also his cHetary habits.

BRONCHIECTASIS

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.

288 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

DISEASES OF THE BRONCHI

289

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.

290 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

DISEASES OF THE BRONCHI 291

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).

292 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
224).

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.)

DISEASES OF THE BROXCHI 293

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
lobes.

294 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

In the bilateral cases, the chest shows no discrepancy between the
two sides; it may be normal in appearance or of the emphysematous

typp-

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
side.

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
dilatation.

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

DISEASES OF THE BRONCHI 295

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.

296 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

Bronchiolectasis

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.

DISEASES OF THE BRONCHI 297

flammation, patches of broncho-pneumonia and some compensatory
emphysema.

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
104°F.

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.

FOREIGN BODIES IN THE AIR PASSAGES

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.

298 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

DISEASES OF THE BRONCHI

299

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
Museum.)

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.

300 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DL\PHRAGM

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

DISEASES OF THE BRONXHI 301

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
intervene.

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

302 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

CHAPTER XXII
DISEASES OF THE LUNGS

TUBERCULOSIS OF THE LUNGS

"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 TUBERCULOSIS OF THE LUNGS

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.

303

304 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

(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.

306 DISEASES OP THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
udder.

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
life.

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.

308 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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."

DISEASES OF THE LUNGS

309

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

3O.39U0.49'50-59!GO.69i7O.79!8O.89,9O.99|

DEATHS FROM t'ub'eRCUiIos'iS |

EVERY HUNDRED DEATHS |

.e;

same!

DECADE

\/r\

, ! 1 Ai \

)

■s

—

\ \

1/'

! 1

DEATHS I^ROM

TUBERCULOSIS

LIVIN'G PER'SONS

1 v

]

PERCENTAGE OF ALl' DEATHS

FROM TUBERCULOSIS

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.

310 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
uncommon.

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. .

DISEASES OF THE LUNGS 311

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
children.

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.

312 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
scattered.

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-

DISEASES OF THE LUNGS

313

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
disease.

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.

314 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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

DISEASES OF THE LUNGS

315

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
tissue.

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

316 DISEASES OF THE BRONCHI, LUXGS, PLErRA, AND DIAPHRAGM

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.)

DISEASES OF THE LUNGS

317

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.

318 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

DISEASES OF THE LUNGS

319

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
shoulder.

■"'^^WTfiP'***.*'

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.

320 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

21;

322 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
cases.

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.

DISEASES OF THE LUNGS 323

also concerned in metabolism. Amyloid changes in the liver are not
uncommon.

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

TUBERCULOSIS fl^^lHH^^Hll^HHHHHHIHHHBa^Hl 848

TRAUMA ■§ n

PNEUMONIA ■ 1

HEART DISEASE I 5

BRONCHIECTASIS I 4

INFLUENZA | 3

SYPHILIS I %

ABSCESS AND GAN-)
GRENE OF TH E - I 5

LUNG i

HYDATID CYST OFl
THE LUNG /

IRRITATING FUMES \ ^

INHALED i"

Fig. 23S — Causes of hemoptysis in Pm^an soJdiers. {Cabot, "Differential Diagnosis,'^

after F. Strieker.)

■■^^^■^^■■■■i^HH^H^HH^H 1723

MITRAL DISEASE l^^^l^l^HIH^BII^HHB 1177

UNSPECIFIED CAUSE B^^^H 183

PULMONARY THROM- i ^^^^
BOSIS OR EMBOLISM )' ^^^™

PULMONARY ABSCESS-) ^^
OR GANGRENE / ^^

BRONCHIECTASIS ^H 58'

PNEUMONIA Bi 52

ANEURYSM ■ 22

TRAUMA ■ 17

NEOPLASM I 6

Fig. 239. — Causes of hemoptysis, ^lassaehusetts General Hospital, (Cahot, "Differential

Diagnosis")

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.

326 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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.

DISEASES OP THE LUNGS 327

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
lungs.

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

328 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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-

DISEASES OF THE LUNGS

329

normal temperatures are also present in cases witli advanced disease
XXis temporarily cpiescent. In such instances the vitality is usually
poor.

102° :

101°

100°

1
1
1
1

t 1

rf=

-i-+

•■

1 — •■ —

— ^ —

1
—

1
1

99°

98°
97°

1 ,
J—

— Lj*-

ZZ£Z

—■ —

- 1
— 1—

--r
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^-^

— ^

— H(-

1
1

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j i 1 1

1 —

T — '

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-t-T-

-i-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.

100^

99°

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.

330 DISEASES OF THE BRONCHI, LLNGS, PLEURA, AND DIAPHRAGM

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

A.M.

J-

P.M

It*

•/•

H-

V-

■

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Fig. 243. — Afebrile case. Rise in temperature due to an acute cold.

i ■ 1

102

lOl °

7^~

r:^

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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

DISEASES OF THE LL'XGS

331

M E

M| E

MJE

M E

MjE

M|E

M E

MiE

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M; E

\'/'E

:v;;e

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y \ E

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Fig. 245. — Active disease progressing.

104°
103°
102°
101°

M E M E M

1
1

Te M E m[

1 1

r
— r

—

mTe
— ]

-— t—
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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*^! "-^

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/\ j ■: ::\A

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I : I

Fig. 247. — Rapidly advancing process of bronchopneumonic type. Also shows inverted

temperature.

332 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

(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-

A.M.

tt\

M 1^

P.M

cy.

-V

}±

_k M H

±,

""""

f —

1 —

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Fig. 248. — Rapidly advancing type of disease. Also shows inverted temperature.

103° -T~

102° — }-;>

ioi°

m|e|m|e|m|e|m

e|m|e m

M
7A

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5

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98° r

1 1 I

1—

—

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-

DISEASES OF THE LUNGS

333

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
lobe.

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.

A.HI.

?-! h\ ?l '^

^: i^l k

S:i

1 —

"?i

"^1

P.M

it| H >! ^ '-^1 ^^

Lii

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i 1

' 1 ' ( ' i

—

1 ! i

' I ■ i : 1

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' 1 ■

;

r'l '

, , 1 '

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1 1 \ ' ' ' ' '1 1 '

/ '

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iM /li III ,'\l .

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7 t i ' \ ' .

III' M /

/ M' ' \ ^'

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1 V / ■ 1 i ' ' 1 '

n i

\ » Is WW

1 1\

/ W •

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/ 1

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7 \ / :\ ,

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1 «ft

\ ■ ' .

/ ' \ / \ /

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* i j

; /

\ 1 IW i\/'

1 !

\ ./

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f ' • 1

^1 r il

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^ 1

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iOKUAl

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LINE

;

[

i W:

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/ \ j

1 ^

/ '

;

1 i

1 '

/ 1

i 11/

;

M ■

n- -H-^--

.1 il '

■

|L *

1 ^

1 1 j

1 '

;

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i 1

— .

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rt<-

;

; 1

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— \ — ■ — ■ —

■ 1

-^-

-i-

—

-J

h-^

—

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r-H

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

334 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
disease.

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

336 DISEASES OF THE BROXCHI, LUXGS, PLEURA, AXD DIAPHRAGM

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
attack.

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
abdomen.

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
appearance.

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
glycosuria.

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-

338 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
meningitis.

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
bronchiectasis.

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

DISEASES OF THE LUNGS 339

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.

340 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
tuberculin.

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.

DISEASES OF THE LUNGS 341

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

342 DISEASES OF THE BROXCHI, LLXGS, PLEURA, AND DIAPHRAGM

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
constantly.

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.

344 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
also.

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.

346 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
apex.

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

DISEASES OF THE LUNGS 347

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

348 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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

DISEASES OF THE LUNGS

349

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
activity.

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

Fig

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

350 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
common.

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

352 DISEASES OF THE BROXCHI, LUXGS, PLEURA, AXD DIAPHRAGM

because of the absolute reliance so manj' physicians place on auscultation
alone.

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
vesicles.

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
side.

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

354 DISEASES OF THE BRONCHI, LrXGS, PLEURA, AND DIAPHRAGM

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

DISEASES OF THE LUNGS 355

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

356 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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
symptoms.

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
habits.

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
pharynx.

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

358 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM

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

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Full text of "Diseases of the chest and the principles of physical diagnosis"

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