The Young Stethoscopist or The Student's Aid To Auscultation

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THE
YOUNG STETHOSCOPIST,
STUDENT'S AID
AUSCULTATION
BY HENRY
I,
gj)WDITCH, M. D.
NEW YORK:
J.
& H
G.
LANGLEY,
No. 8AstorHouse.
WILLIAM
BOSTON:
D. TICKNOR &
1846.
CO.
WBB
Entered, according to act of Congress, in the year 1846,
BY
HENRY
in the Clerk's Office
Fi7m
I.
B.
I.
BOWDITCH,
of the District Court of the District of

Massachusetts.
BUTTS, PBINTEE.
no.
fO-f
TO
JAMES JACKSON,
Whom,
in the earliest
was
my
to
my Medical
Good Fortune
FATHER
And
hours of
M. D.
Life, it
to call
MEDICINE,
IN
of my Professional
my Happiness to look as
whom, during the years
Practice,
it
has "been
COUNSELLOR AND FRIEND,

THIS LITTLE
WORK
M2$
at
IS
35
GRATEFULLY
TO THE
STUDENT OF AUSCULTATION
For you have

nosis.
In
its
cise, yet clear

its
object
I prepared this
book on physical diag-
preparation I have endeavored to be con-
and comprehensive.
viz.
Its
to give you, in a
name
indicates
compact form, a
complete view of what are technically called the physical signs.
But I have had another, and perhaps
ly important end in view, viz.
to
make you
equal-
feel that
the time, the place, the circumstances in which you
meet with these morbid
signs,
may
and the relations which
they bear to the rational signs, are of as
much impor-
tance as the physical signs themselves.
There have
been, I think, too
many minute
distinctions in regard
to the particular sounds, a diffuseness of detail that has
served to discourage rather than to allure you onward

in the study of the interesting art of auscultation.
PREFACE.
VI
But
this
book
is
not intended to supersede
more elaborate character.
ers of a
as a pocket companion merely
summary
a kind of
many oth-
have prepared
the essentials of auscultation, the details of which

will find
more fully displayed
Among
these last, there are
The immortal
debted.
fountains
on the
ers, 1
in other
many
labors
whence have flowed
To
subject.
which
in-
subsequent writings
the numberless host of his follow-
have endeavored
to give
due
whenever I
credit,
Nevertheless,
the greater part of the book, at least so far as

to the thorax, is a transcript of
its
am
Laennec are the
have borrowed any ideas from them.
formed
you
and higher works.

to
of
all
it
of
my own
it
relates
mind, as
it
has
opinions during the experience of several
To Hope,
years' practice.
owe much on
ney and Smith
auscultation
Bouillaud and Pennock I
diseases of the heart

is
to Fisher,
Whit-
due almost all I have given on cephalic
from Drs.
Cammann and Clark's
publica-
tions has arisen the article on auscultatory percussion
on obstetric auscultation,
invaluable
work of Dr. Kennedy
tings of Youatt and Percival, I have
meagre though they may
and from the wri-
drawn
this subject to
friend, Louis.
It
was
my accounts,
be, of veterinary auscultation.
I cannot forbear stating in this connection
owe on
have consulted freely the
my
how much
former preceptor and kind
in his
wards, at
La
Pitie, that
PREFACE.
I first
Vll
caught a love for physical and rational diag-
nosis, as a
means of cultivating the higher
faculties
of
the mind, which I trust I shall ever carry with me.
In conclusion, while presenting this

the physical signs, let
me
disclaim
all
little
work on
intention of pla-
cing them higher than they really deserve.
Fifteen
many
persons.
years ago, they were sneered at by
Now,
very few would be foolish enough
the tendency
is
niceties of our physical examinations
The
neglect the rational signs.

scoffs at either
to
truth
must necessarily be a
nosis of not a few diseases
we
is,
do so, and
Amidst the
strong to overrate them.
are apt to
that he
who
child in the diag-
and he who cultivates both
with the clear, keen-sighted eye of a true observer,
and then notes

physician.
in its
own
their
mutual
relations, is the truly
Both categories of signs are

sphere
wise
useful, each
and neither should be allowed to
predominate; neither should be neglected.
H.
Boston, 1846.
I.
B.
THE
YOUNG
STETHOSCGPIST.
PRELIMINARIES ABSOLUTELY ESSENTIAL TO AN ACCURATE EXAMINATION OF THE PHYSICAL SIGNS OF

DISEASES OF THE CHEST
AND WITHOUT STRICT
ATTENTION TO WHICH, NO ONE CAN BECOME AN
;
ACCURATE AUSCULTATOR.
\Lihi patient must have the

chest wholly uncovered, or
be clothed with a thin, single dress.
him
<C~ b
inasmuch
If possible, let
or stand
but
be impracticable,
lie
back
sit
perfectly flat
as a pillow, supporting
der and not the other,
may change
if this
let
on
him
his
one shoul-
the character
of the sound produced by percussion, and also
murmur. If we cannot attend to

we must be cautious of our inferences
from any examination, however accurately we
may apparently make it.
the respiratory
these rules,
THE YOUNG STETHOSCOPIST.
1.
for
The
following Plates show the best positions
examining the
front, back,
chest.
Fie.
1.
and sides of the
POSITIONS FOR AUSCULTATION.
Fiff. 2.

Fig.
3.
POSITIONS FOR AUSCULTATION.
Fig.
This position
1.
the best for the front
is
and the tops of the shoulders.
Let the arms
by the sides of the body, and
easily
let the
fall
body
be erect and firmly poised.
Fig.
In this position, (which
2.
assumed when the back
to be
is
is
that to be
examined) the
drawn forward, making the whole

back tense, and more resonant than in figure 1.
Let the arms be clasped firmly in front, and the
scapulae are
head and neck be bent forward, so that a regular

curve is formed by the dorsal and cervical vertebra?.
Fig.
in the
3.
This position
rarely needed, except
is
examination of the
axillse.
Let the palms
of the hands rest lightly on the vertex.
2.
In the acts of auscultation and percussion,
always compare one lung with the other, and one

part of the lung with the corresponding part of
the other.
3.
N. B. The above
and, in order to follow
with
my
median
is
it
most important rule;
accurately, I measure
eye equal distances laterally from the
lines of the sternum,
processes of the vertebras
and of the spinous

and vertically from
the clavicles, the tops of the shoulders, the spines
of the scapulae, &c.

4.
Examples.
Strike upon the sternal end of
one clavicle and on the acromial end of the other,

and observe the difference.
Again
try the differ-
ence between the sound on percussion over the

lower angle of one scapula, and that heard on a
spot an inch or two below the
same angle of the
Similar examples might be cited
other scapula.
with reference to the respiration and the voice.

5.
This rule
where there
is
is
especially necessary in cases
only a difference of note, and no real
dullness on percussion, a fact which occurs not
unfrequently in the earlier stages of phthisis.
INSPECTION.
inspection,
;=s
as a
method of examination,
moment but it is of very

little use when compared with other
more marked signs that may be present.
The two sides of the chest are rarely
is
of some
symmetrical, even in the most healthy persons
the right, according to some writers, being larger
than the
left,
the heart not
by half an inch.
The
uncommonly causes
nence over the precordial region.

lateral curvature
of the spine will
pulsation of
a slight
promi-
The slightest
make one side
INSPECTION.
more prominent, and one shoulder higher than

the other.
This last cause of want of symmetry
is
almost universal, and
To
is
perceptible at a glance.
examine, by inspection, thoroughly, the chest
must be naked.
7.
Diseases cause great changes in the results of
inspection.
8.
An
Examples of Dilatation.
old man,
long affected with asthma, usually has more or less

general emphysema, or dilatation of the air-vesicles.
In him
we
find,
rounded than usual

with, or
commonly, the chest more
the intercostal spaces, even
perhaps projecting beyond the ribs
clavicles scarcely to be seen,
owing
the
to the promi-
Usually these
nence of the adjacent soft parts.
appearances are more manifest over one lung than
the other.
Acute
sions cause
dilatations.
pleuritic
and pericardial
The
the whole of one side of the chest

course,
is
effu-
former may enlarge

the latter, of
limited to the left breast.
Malignant
tumors, causing enlargement of the thorax, are

very rare.
Aneurism of the
aorta
may
press out
through the sternum, or behind between the vertebrae
and scapulas.
(See Aneurism, Fig. Si.)
Examples of Contraction. An old pleurisy

with thick membranes will contract a whole side,
so that the shoulder will fall, the scapula become
9.
more prominent and lower, and the
intercostal
spaces concave.
Phthisis, with partial pleurisy
covering the apex of either lung, causes contraction about the
the latter stands
clavicle, so that
out more prominent than usual.

10.
To observe the motions
of the chest
very necessary, especially in children.
is
Great mo-
abdomen, either
tion of the muscles of the neck, or
with or without increased motion of the respira-
symptom.
tory muscles, is always a serious
occurs in severe, acute
It
inflammations of the
larynx, bronchi, or substance of the lung, in se-
vere attacks of asthma, and in pneumothorax.
labored
breath
is
observed
in
Absence of motion of the chest

on the diseased side in
erally
pleuritic effusion
acute phthisis.
is
observed gen-
pneumothorax,
and locally in chronic phthisis.
permanently distended condition, without mo-
tion, of the parietes, is seen in
emphysema, with
forcible compression of the intercostal spaces
expiration.
may
in
pulsation, perceptible in a part,
indicate enlarged heart, or aneurism, &,c.
11.
croup
Examples.
In laryngitis of adults, and
in children, the
most violent motions of the
cervical respiratory muscles are observed.
object
is
which
is
Their
to open, as far as possible, the passage
gradually closing.
A severe
pneumonia,
or a pleuritic effusion, or pneumothorax, of

side, will
one
cause active motions of the muscles of
INSPECTION.
the other, and, for similar reasons to those just
mentioned,
viz.
the other
obliged to labor harder in order to
is
perform the
one lung being put out of use,
Sometimes
respiratory function.
the abdominal muscles only perform the respiratory movements.
tom,
for
it
This
usually a serious symp-
is
indicates that there
severe acute
is
The labored
disease on both sides of the thorax.
breath of acute phthisis
is
owing
to the
sudden
development of miliary granulations throughout

both lungs, and
marked by panting and
is
fre-
quent motion of the chest, rather than by any very

distressed movements, such as are observed in
pneumothorax, double pneumonia, &x.

12. N. B. This breathlessness of acute phthisis
one of the most marked signs of the disease
and, if combined with a very rapid pulse in an
is
obscure febrile disease,

of the affection.
the parietes of the
is
almost pathognomonic
left
breast
hypertrophy of the heart.
shows
itself
and a lifting-up of
pulsation
is
by slight pulsations
the sternum.
Rarely do we
very
common
in
Aneurism generally
at the
find the
upper part of
same amount
when the disease protrudes behind.

Examples of Diminished Motion. Chro-
of motion
13.
nic phthisis, by the adhesions consequent there-
upon, causes a diminution of motion of the upper

ribs of the diseased side.
Pneumothorax, and great
10
pleuritic
same
effusion,
effect
would, of course, cause the
throughout the whole of a diseased
Effusion into the pericardium destroys the
side.
usually perceptible impulse of the heart.
PALPATION.
alpation of the chest
tion
parietes, for the
the applica-
purpose of recog-
nizing the health or disease of the
<&AB
may
is
of the hand or finger to the
thoracic viscera.
be felt in health, at
all
slight
tremor
by any one,
times,
if
he applies his hand to the chest while speaking

This is modified by disease. It is
or coughing.
augmented by the hepatization of pneumonia, by

a tuberculous cavity communicating with the
bronchi
it
is
diminished by pleurisy, with
sion of fluid, and by tumors.
The
effu-
sonorous and
crackling rales and the rubbing sounds are some-
times
felt
by the physician, and very frequently
by the patient.
peculiar
thrill,
called fremisse-
mcnt calaire by the French, similar to that perceived on placing the ends of the fingers upon
PALPATION.
when she
the chest of a cat
is
11
purring,
felt at
is
times over aneurisms, and in some affections of

the heart, that cause obstruction to the passage of
The
the blood.
impulse of the heart
likewise
is
perceived by the hand, but more distinctly by

the ear and head, and
ear,
varied by diseases.
be
more
still
armed with a stethoscope.
felt in
Fluctuation
by the
distinctly
This likewise
may
is
very rarely
the case of a fluid in the cavity of the
pleura, and in this case the natural tremor on
speaking
little
is
diminished,
if
not wholly destroyed.
N. B. This method of exploration
15.
importance
it
conveys so
little real
is
of so
knowl-
edge, except, perhaps, with reference to the operation of paracentesis thoracis, that very
made of it.
The
thrill
little
rubbing sound, the purring sensation,
most
distinct
lightly
on the
one cause,
viz.
to
is
&c,
are
the ends of the fingers, placed
part.
:
use
of the voice, the rales, the
They
are
all
dependent on
the passage of air or fluid under-
neath, and the vibrations consequent thereupon.
MENSURATION.
ffss
ensuration,
is
name
as the
merely the
denotes,
admeasurement of
the different parts of the chest, but

usually
and
this
it
does not indicate
much
more than the eye readily perceives,

latter discovers what admeasurements
never would.
It is
used
effusion, hydrothorax,
in
pleurisy, with recent
emphysema,
phthisis,
pneu-
monia, disease of the heart, pneumothorax, &c.
The
dimensions of one side of the thorax
may
be compared with the other, by means of a tape

passed around the chest at different distances
from the apex of the lungs.
We
must notice the
position of the nipples in reFie. 4.
ference to the middle of the
sternum, the clavicles and the

spinous processes of
The
ilia.
position of the scapula with re-
gard to the vertebra) and
ilia,
and the thickness of the two

lungs from front to back should
be observed.
poses some use callipers.
17.
Fig.
For these pur4.
Examples. Hydrothorax, and pleurisy with
effusion of fluid, enlarge the diseased side
some"
AUSCULTATION.
times more than an inch.
13
Frequently, however,
inspection discovers a great difference,
tape does not give so

this
same
much
when
real enlargement.
the
In
case, the nipple of the diseased side is
raised towards the clavicle and thrown out from
the sternum; whereas, in chronic pleurisy, with
contraction of the side, exactly the reverse takes
The
place.
scapula, in
chronic pleurisy,
The
towards the vertebrae.
falls
contraction over the
apex of a tuberculous lung may be recognized by

the instrument.
Inspection does the same, per-
One late French writer

made of steel, to measure the
haps, nearly as well.
proposes a spring
arc of the circle formed by the prominence from

a diseased heart.
AUSCULTATION.
uscultation may be mediate,
means of
a stethoscope
it
or by
may be
immediate, or by means of the ear

applied directly to the chest.
nec thought the whole

on the stethoscope.
All tyros in auscultation
discuss the relative merits of the

oscopes.
for in
Laen-
art rested
numerous
steth-
Adepts do not discard the instrument,
some cases they
find
it
useful, but in the
14
vast majority of instances of
disease, the ear
I find a stethoscope
sufficient.
needed
is
most
in
diseases of the heart, when I am desirous of

making an accurate diagnosis; in obstetric auscultation, and finally in deciding the relative con-
dition of
two small spaces of one or both lungs.
All I seek in a stethoscope are lightness, small-
and a good-sized ear-piece.
ness,
The following figures

common forms of the
19.
of the
is
give an idea of
some
Fig. 5
instrument.
copied from the stethoscope originally used by
Laennec.
"
parts,
It
shortening
a
plug
is
it
at its
divided
if
into
two
l
purpose of
for the
(Jig. 6)
'
necessary, and has
jjjj
which
yj
lower extremity
was thought necessary
for the
'
exam-
ination of the heart and the sound
of the
The
voice;
wholly obsolete,
instrument
being
is
altogether
too heavy and unwieldy.
20. Figs. 7, 8, 9,
Fig.
7.
&
10, contain Piorry's stetho-
Fig. 7 shows
scope.
for auscultation.
resent
its
it
prepared Fig.
Figs. 8 &, 9 rep-
various parts separated
8 being the shaft of the instrument; Jig. 9, a, being an ivory
Jig.
ear-piece, pierced with a
screw
to
J>
fasten
it
to the
upper part of the
8.
15
STETHOSCOPES.
shaft
b, a
plessimeter, (see plessimeters) which
can be screwed to the bottom of the same

the plug to be used as in
jY<r. 9,
nec's
{)
in a portable form, the
it
ear-piece being screwed upon the
^.^
b
c,
Fig. 10 rep-
instrument.
resents
Laen-j^
bottom of the plessimeter.
This
a convenient form, but the ivory
is
edge
at
the bottom of the shaft
apt to hurt the person
is
The
ausculted.
plug likewise
is
who
is
found to be un-
necessary.
21. Figs. 11, 12,
&
13 present a very conve-
nient form proposed by

BicreJ Dr.
b
.... *\/
Fig. II.,
_.
Fig. 13.
.
low,
of
this
city.
Fig.
11
*^
shows
^=5)
,
the instrument.
so that
its
It
is
wholly of
The ear-piece is broad,
softwood.
side
may
be pressed on
the chest and used as a plessi-
Fig. 12
meter.
is
a worsted ball,
covered with velvet, through which

Fie. 12.
Oa
slender but firm handle of ebo-
ony passes.
This
is
used as a
percussor, instead of the tip of the finger,

in
order to avoid the click of the nails,
which sometimes causes a confusion of

sounds.
Fig. 13 represents the instru-
ment
its
in
portable condition.
This
16
stethoscope
is
very convenient for auscultation.
As an instrument
for percussion, I
use
it,
at times,
behind the clavicle, but even there I prefer a

piece of caoutchouc, and
22. Fig. 14
my own
fore-finger.
the flexible stethoscope used by
is
Dr. Pennock, of Philadelphia, for the sounds of

Fig. 14.
the heart.
It
an elegant instru-
is
ment, about two feet long.

not used
rule
is
it
much
but
if
of importance, viz., that, while
we ought to have
ausculting the heart,
one hand upon the pulse,
it
evidently be impossible to use

it
have
Dr. Hope's
would
it,
for
requires the use of both hands of
the auscultator.
similar
one
is
used by Dr.
Golding Bird, of London.

Fig. 15.
23. Figs. 15
&
16.
intended to represent
scopes used by Drs.
These
the
plates are
Cammann
and Clark,
They
(see Auscultatory Percussion.)
made of
soft
wood.
stetho-
solid
Fig. 15
is
are
a cylin-
^\T"i6.der, about six inches by three-quarters of
an inch
the other, (fg. 16)
is
like a
same dimensions, made

wedge-like, in order that the narrow part
may be placed on the soft parts between
cylinder of the
the ribs.
[Appendix, A.)
RESPIRATORY MURMUR.
17
AUSCULTATION OF THE RESPIRATION.
n
K'Vrh
espiratory murmur.
breezy
delicate,
This
is
a very
which
sound,
is
heard, on application of the ear to
ê
tion
cnes *
very
25. This sound
chiefly during
'
little
influenced
is
inspira-
in expiration.
by age
it
is
loud in childhood, hence called puerile; more

indistinct in adult and old age.
26.
By
position
example, a constrained
for
posture, causing contraction of the muscles of the

chest, of course prevents a full expansion of the
lungs, and diminishes the sound.

27.
heard
By temperament
frequently
in a full sized healthy
it
is
man, while
scarcely
it is
very
one who breathes more quickly, and

of a more active temperament.
distinct in
28.
By
diseases
cause puerile
one lung when diseased may
murmur
in the other;
for
example,
pneumonia, pleurisy, pneumothorax, tumors,

that prevent
is
&c,
one lung from acting, stimulate the
other to the puerile respiration.
one part of a lung
is
filled
So, likewise,
with tubercles, or
if
is
otherwise obstructed, those parts that are healthy,

usually have puerile respiration; any cause, in fact,
THE YOUNG STETHOSCOPJST.
18
which puts suddenly out of use a large part of

sound in
either lung, will diminish or destroy the
one
part,
and increase
diminishes
By
29.
it
(178)
may destroy
the part of the chest
murmur
Emphysema
in another.
it
pleurisy
which
is
it
(132).
examined
generally stronger
the
vesicular
the
lower portions than above, and frequently
is
is
at
very distinct throughout the whole of the back
when
it is
heard with difficulty in front
versa; yet the person
and there
will
may be
and
vice
entirely healthy,
be no sufficient explanation of the
In such cases we must remember to com-
fact.
pare, with great accuracy, corresponding parts of
the two lungs, and the natural differences that

exist
between them.
30.
(2, 38.)
By emotions of
frightened and cries,
vented
in
the
all
mind
sound
if
child be
for a time
some nervous females,
it is
is
pre-
sometimes
impossible to hear any sound.

31. By rapidity
murmur becoming
of breathing
the respiratory
louder with increase of
fre-
quency.
By the action of the heart agitation of

mind or organic disease may cause such loud
32.
the
sounds of the heart as to obscure the respiratorv
murmur.
33.
By any
injury
whereby the muscles of the
chest are prevented from
acting freely
for
ex-
INSPIRATION AND EXPIRATION.
ample,
19
saw a man whose arm had been torn
off
by machinery, and the cicatrix had contracted so
much
dilate;
tion
that that
thorax could not
of the
side
and a diminution of the sound of respira-
was the consequence.
34.
Though
usually the expiration
except as described (38),
it
is
is
slight,
equally important
with inspiration as a means of diagnosis.

35.
The
ratio of the length of inspiration to
that of expiration should be carefully studied,
being
30.
a
in the healthy
Any disease
change
in
that condenses the lung causes
this ratio
for
example, pneumonia
or tubercles, with condensation of the lungs.
inspiratory
it
lung as ten to two (46).
murmur
is
usually
first
The
changed and
rather diminished in length, while the expiration

is
soon prolonged.
When
perfect hepatization
from pneumonia occurs, the sounds are frequently
of the same length and of the same character.
(41, 40, 122.)
In dilated bronchi likewise,
we
frequently find the expiration prolonged.
The annexed
ferred to,
figures will
be occasionally re-
and therefore are introduced here.
20
Fig. 17.
Fig. 18.
21
DIVISIONS OF THE THORAX.
The
figures 1, 2, &c.,to 10,
mark
arbitrary divisions
of the thorax.
1.
Post clavicular space.
2.
From
clavicle to
3.
"2d rib
4.
"
&
to
2d
rib.
4th
"
4th " to base of breast.
6 divide the sides into two equal parts, below
axilla.
7.
8.
9.
10.
Top of shoulder.
From top to spine of scapula.
From spine of scapula to lower angle of do.
From lower angle of do. to bottom of back
of
chest.
Projection of the outlines of the lung L.
T.
Trachea, over which
is
heard in health, tracheal
or cavernous respiration with pectoriloquy.
B.
Large bronchial tubes, over which are heard
in health, bronchial respiration

r r.
and bronchophony.
Points upon the superficies of the lung, and
remote from
vesicular respiration
is
heard there,
with the natural, slight resonance of the voice.
37.
Remarks.
Nos.
1, 2,
&
7, are very
portant, in cases of suspected phthisis
im-
& 4, on
the left side, in suspected disease of pericardium
and heart
&
10, in cases of pleurisy, and
generally of pneumonia. (143,
most
17, 128,258.)
There is naturally a prolonged expiration

some persons, at the top of the right lung in
38.
in
1
& 2, in front, and
in
corresponding parts be-
22
hind,
owing
bronchus
is
right primary
that the
to the fact
larger and shorter than the
left.
The
adjacent figure shows the reason

for this increased length of the
Fi-. 19.
left
primary bronchus.
crosses
The
it
and consequently the lung

farther
aorta
just as the arch turns,
The
off.
is
put
plate represents
the posterior view of the various
But when
parts.
expiration
is
always morbid, and
is
prolonged
heard elsewhere,
it
an important indication
is
of disease.
39.
spiration
natural bronchial or tubal sound of reis found in health at the union of the
The
regions marked 2 in front and 8 behind.
seems passing through

40.
N. B.
Study
more
a,
this
sound thoroughly on
upon
children, and thin adults,
whom
heard more distinctly than on others.

will
be prepared
which
It is
it
for
recognizing
may be heard
in
air
or less distant, tube.
it
can be
Thus you
in diseases in
it
any part of the chest.
heard more distinctly behind than in front.
41. Bronchial respiration

disease which affords a
than the
soft air-cells are
of the bronchial tubes.
is
produced by any
medium
better capable
of transmitting the sound

It
then becomes the
Bronchial respiration of Laennec.
It is
most
MORBID RESPIRATORY MURMURS.
23
pneumonia;
less so,
perfect in hepatization from

in effusion
of fluid into the pleura; in tubercular
condensation,
dilatation of the
bronchial tubes,
gangrene of the lung, tumors, either of the lung

or arteries: as, for example, schirrus of the lung,
or aneurism of the aorta, or of
its
an increase of the bronchial, and

limited than this
in
great branches.
is
only
usually
more
Cavernous or tracheal respiration
42.
It
last.
is
is
heard over cavities
the lung communicating with the bronchial
tubes
tubercular cavities, for example
also over
those arising from gangrene, from pneumonia, or
from dilatated
On
air tubes.
the healthy body,
lis-
ten to the air entering the trachea, and you will
hear natural cavernous or tracheal respiration.

43.
Rude
respiration
cular and bronchial
is
it is
a mingling of the vesiless
expansive and per-
haps rougher than the former, while
more expiration
which marks
It
it
as
usually heard
is
but
it
is
different
it
has usually
not distinctly tubal,
from the bronchial.
over a part of the lung in
which there are some tubercles interspersed with

healthy lung.
We hear it in the earlier and later
stages of pneumonia, before and
tion
make
in
the
fact,
after
hepatiza-
under any circumstances which
lungs a better conductor of sound,
while at the same time the

the cells. (118, 151.)
air is still able to
enter
24

44.
Amphoric respiration
is
merely a peculiar
species of the cavernous, heard over a cavity with

thin tense walls.
It
most distinctly heard
is
in
some cases of pneumothorax, where the bronchi

communicate with the pleural sac. Also in tubercular and other cavities.
ring,
It
has a peculiar
which may be imitated by getting an
assist-
some force into one extremity

of a common glass lamp chimney, while the other
is pressed against the palm of your hand, the back
ant to breathe with
of which rests upon your ear. (158, 164.)

45.
ly
Wavy
ox jerking respiration.
This usual-
does not indicate very much, save some slight
obstruction to the passage of air into the lung,
whereby the respiratory murmur becomes apparently broken, instead of being
pansion.
In one case
tance, and almost
when
it
it
nary disease
in
viz.
at
the
while throughout the remainder of

is
heard.
(110, 149.)
adjoined diagram shows, in a general
manner, the
relative
the inspiration
ease.
impor-
chronic case of pulmo-
the lung no morbid sound
The
infinite
the only physical sign,
heard in a very limited spot
is
apex of either lung
46.
one continuous ex-
may be of
differences that
and expiration
The diagram
is
appear in
in health
and
dis-
divided into three com-
partments, by three vertical lines, marked by

2, 3,
1,
and each of these into ten smaller divisions,
'
INSPIRATION AND EXPIRATION.
25
Fig. 20.
No.
No.
1.
2 %\
Ak-
IU
i|\
_J<
a V
',
|
ii
No.
2.
ft
l-V
l\
3.
-1/
\/
>
\'
1
by lines
1, 2, 3,
at
IE
right angles to the latter,
&c,
to
marked by
Compartment No.
10.
shows
the natural vesicular respiration, in the healthy

lung, in which the inspiration
slight,
is
more or
less perfect, solidification of the
lung, from tubercles, pneumonia,

points, resting
to the expiration
Compartment No. 2 shows some
as ten to two.
on
&c. The arrow-
the various lines, indicate the
all
various changes that occur in either parts of the

respiratory act.
No
definite
decision can be ar-
rived at from these changes, but of course the
more
become obstructed,
the vesicles
will the inspiratory
becomes manifest.
sound be heard,
the less
until the tubal
Compartment No. 3
indicates
complete solidification from pneumonia, or from a

cavity, in both of
which the two
acts are nearly
identical in length and in their tubal character.
26
AUSCULTATION OF THE VOICE.

tudy
sults
the re-
carefully, in every case,
obtained from the examination
of the voice
for
signs peculiarly
it
its
tain cases, brings
affords not
own,
out to distinctness
a bronchial or tubal sound, which
during the respiratory
merely
but, in cer-
is
not heard
For example
act.
in
some cases of pneumonia, and tubercular condensation, the bronchial respiration

perceptible during the
but
it
common
becomes very evident,
is
wholly im-
act of respiration,
in the
form of a slight
blowing, after each slowly-spoken word.
As in
we hear
the
auscultation of the respiration, so
certain sounds of the voice
perfectly normal, while confined

situations, but
elsewhere.
which are
to their proper
which indicate disease when heard

T would cite bronchophony
In proof:
and pectoriloquy, both of which may be natural

This will become more evident by
or diseased.
the perusal of the following.

47.
oquy.
Over the trachea we hear natural

It
pectoril-
corresponds, in place, to the natural tra-
cheal respiration.
Fig. 17, at page 20, (42.)
BRONCHOPHONY AND PECTORILOQUY.

48.
At
chophony.
It
49. In health there
the
it
The
may be
very
;
that
murmur.
natu-
resonance
little
18;
Jigs. 17,
in
vesicular
styled.
may modify
(25,
Bronchophony
51.
2,
Figs. 17, 18.
resonance of the voice
same causes
spiratory
(39.)
is
other parts of the chest
resonance
in place, to the
corresponds,
bronchial respiration.
50.
marked by
the union of the regions
and by 8, behind, we hear natural bron-
in front,
ral
ii
is
is
affected by
the healthy re-
&c
heard in any disease which
causes condensation of the
air-cells,
but allows
the sound from the tubes to be transmitted.

intensity varies
being either so slight that
Its
can
it
be discovered only by the minutest comparison
between the sounds produced by both lungs or

It is heard
it may almost equal pectoriloquy.
;
most purely
in hepatization
from pneumonia, in
lated bronchi, sometimes in pleurisy

ly in phthisis,
52. Pectoriloquy, or
may be heard
cause
gangrene, tumors, &c.

the
highest
di-
less distinct-
(122, 158.)
resonance,
over a cavity in the lung from any
tubercular disease, pneumonia, gangrene,
or dilated bronchial tubes.
53. It
is
(125, 158, 172, 188.)
not always equally perceptible, hence
the division into perfect, imperfect, and doubtful.
Too much mucus may
obstruct a bronchus, and
cause these variations. (158.)
28
Tl&gophony or goat-like resonance, occurs

some cases of pleurisy, when a thin layer only
54.
in
of fluid
between the ear and the surface of the
is
Hence
lung.
thought to be an important
it is
sign in pleurisy.
It
indicates,
when heard
per-
fectly in the earlier stages, that there is little fluid
When
effused.
occurs after a severe attack,
it
and during which the sound was absent,

that there
is
By compressing
of tone.
shows
sharpness
Its peculiar characteristic is
effused.*
it
diminution of the amount of fluid
the nostrils and speak-
ing quickly in a high key, you will get sometimes

very perfect hnsgophony, especially
your voice
if
somewhat treble in its tones. This

is the mode whereby Punch produces his peculiar
voice, and Laennec compares this sound to his
incline to be
tones.
5">.
(135.)
Pure hiegophony
is
rarely heard
but
some
modification of the voice, between hscgophony and
bronchophony,
this I
is
always heard in pleurisy; and
conceive to be more important than the
haegophonic character
makes hasgophony
itself.
Another
less valuable is this
* This in general
is
true
fact
:
it is
which
heard
but I have obtained a
of the voice, resembling haegophony or

bronchophony, in some cases in which the pleura
modification
was
filled
with
fluid.
VOICE
at
times
when
there
is
merely a membrane cover-
&c.
ing the pleura,
56. Diminished resonance of the voice
common
less
than some modification of
or increase of
with
it
in
still
it
is
much
tone,
have met
emphy-
(152, 119.)
of no importance for the
whether he hears bronchophony
on
is
its
himself to decide, definitely,
the various kinds of pectoriloquy

that,
early cases of phthisis,
trouble
to
resonance
may be remembered.
It
57. Finally
pupil
its
some
sema, &c.
29
DIFFERENTIAL DIAGNOSIS.
hccgophony
or
It is sufficient
comparison between the lungs, he finds
an increased or diminished natural resonance in

any
part.
toms,
ly,
The
other physical and rational symp-
when combined with even
these, apparent-
doubtful signs, will enable him to arrive at a
correct diagnosis.
mind
He
must,
however, bear in
the different sizes and shapes of the two
primary bronchi (Jig- 19); which facts usually

cause a little more vocal resonance at the top of
the right lung, than at the top of the left lung.
58.
tient
General Remarks.
for
In examining a pa-
we
must, in
remember
the rules
the respiration or voice,
order to be very accurate,
above given.
(1, 2, 25, &-c.)
30
RALES, OR RHONCHI.
uring
inspiration,
and more rarely
during expiration, are heard, in seviUWi
sounds; called
eral diseases, certain
[2]
rales, rhonchi, or rattles.
They
various in
and they
are
\]j/J
their qualities,
may be heard in all parts of the chest some are

more or less permanent, while others are very
At times, some of them are brought to
volatile.
:
existence only by coughing, or by

tion
other
in
cases,
ease, destroyed by the
indicate disease
they
same
may
acts.
but this disease
to the ulceration
with equal
They always
may vary from
the slightest swelling of a bronchial
up
long inspira-
be,
membrane,
and destruction of an entire
lobe of one lung.

59. This class of
health
60.
it
There
are
sounds produced
cavities
phenomena never occurs
in
always indicates disease.
two great divisions:
1st,
those
in the bronchial tubes, or in the
connected with them
2d, those
con-
nected with the pleurae, and unconnected with the

tubes.
61.
The
first
of these divisions
may be
sub-
divided into (a) canorous or musical tones, and

into (b) crackling rales, rattles, or rhonchi.
RALES
SIBTLANT, SONOROUS.
31
62. In (a) are the sibilant and sonorous rales.
They
indicate a condition of the lung whereby
the air
not prevented from entering the most
is
minute parts, though
They occur
in
swelling of the
it
enters with
typhoid
tubes,
They
are most evident during an
ma, and
bronchitis,
this case
in
is
mucous membrane of
chial
in
difficulty.
asthma, where there
usually
the bron-
&c.
fever,
attack of asth-
they are usually heard
all
over the chest, and they vary from the sound pro-
duced by
tles,
a violent gale
down
deep tones of the

03.
ing
which blows
until
it
The
bass-viol.
(106, 180.)
sibilant closely resembles the
sound sometimes heard
wheez-
the nostrils, in
in
cases of inflammation, and of congestion

as this
whis-
to the soft cooings of the dove, or the
wheezing frequently runs into
and
a kind of
whistle or snore, so the sibilant in the chest joins
and alternates with the sonorous.

64.
gree,
the
Both of these sounds may, to a certain debe imitated by inhaling strongly through
lips, that
time are
is
are partially closed, and at the
flexible, in
By contracting
heard.
them more tense

is
produced.
the latter,
perhaps
which case
the lips, and by
in expiration, a
The
making
kind of whistle
former resembles the sibilant,
the sonorous rale.
will
same
a slight, soft hiss
This experiment
explain the philosophy of the two
32
sounds.
In slight attacks of bronchitis
we hear
we
the sibilant, but in violent attacks of asthma
have the sonorous most manifest.

fugitive,
being heard one
They
moment and
are very
disappear-
ing the next, owing to the removal of the obstruc-
mucus perhaps, from the bronchial tube.

coughing may produce or destroy
them. They are most permanent in asthma, when
tion,
single act of
they occasionally last several days, and a sibilant

condition of the respiration sometimes continues
for
months, owing to a chronic thickening, and
congestion of the mucous membrane. (106, 180.)

65.
Not
unfrequently, a
whistle or sonorous rale

cle,
is
sound like a single

heard under the clavi-
while in the remainder of the chest there
a healthy
vesicular
murmur.
is
This indicates
strongly the existence of tubercular disease, if

the patient be suffering from a chronic affection
especially, if
it
be connected with any other,
tinctly morbid, physical or rational sign.
66. Metallic tinkling
is
dis-
(153.)
sound resemblincr
produced by some wire toys, and can be produced very readily by the following experiment.
that
Into a bladder half

theter,
and
let
full
of water, introduce a ca-
an assistant blow into
it
while you
have your ear upon the outside, and as the bladder becomes more tense, the sound of the bursting
bubbles becomes more metallic, until,
at length,
33
CRACKLING RALES.
pure metallic tinkling
the
is
This sound occurs
is
whenever
in diseases
On
produced.
shaking the bladder the same sound
heard.
a bron-
tube communicates with a cavity, having
chial
thin and tense walls, either in the pleura, or in the
In pneumothorax
substance of the lung.
most
perfect, but
it is,
at times,
it
is
very distinct over
a tuberculous cavity. (164.)
67. Metallic Echo, a ringing respiration, with-
out tinkling, and
it
occurs under similar circum-
stances.
68. In the second subdivision (b), are found the
crackling rales,
viz.,
the crepitous, sub-crepitous,
mucous and muco-crepitous and gurgling.

69. These produce the sensation as of bursting
of bubbles, and there
a regular, gradual, in-
is
crease in their size and in their other qualities,
from the most minute crepitous rale up to the

loudest gurgling.
Notwithstanding the marked
difference between the crepitous rale and gurgling,
the intermediate degrees are often difficult to be
distinguished; and these differences are of no real
importance, because they will be connected with

other signs, which will aid the diagnosis.
70.
The
crepitous rale
is a
duced, by the crackling of

the
ear,
fire,
sound like that pro-
salt,
when thrown upon
or by the rubbing of the hair, near the
between the finger and thumb.

s
It
may
also
34
be
THE YOUNG STETHOSCOP1ST.

artificially
produced by pressing
sponge
a dry
upon a thin book or pamphlet previously placed
upon your
ear.
It
may be heard by placing your
ear upon the lung of

ant inflates
upon
it;
some animal, while an
or, still better,
These
a hair pillow.
produce an explosion,
as
last
it
assist-
by pressing the ear
two experiments
were, of myriads of
very minute bubbles, and apparently of a uniform

size,
When
such as we often hear during inspiration.

this sign is
heard in the
commonly
indicates either the
monia, or
its
human
first
tion,
followed
heard
for
period of resolution, or oedema of
by
fatal
phthisis,
a very rare cause
pneumonia.)
71.
this
rale
was
weeks, limited to one spot, where the
tubercles were most developed at

is
it
In two cases of distinct tuberculiza-
the lung.
This
chest,
stage of pneu-
the autopsy.
of the sound.
(See
(120, 155, 195.)
The mucous
rale
is
a louder, moister,
irregular rale, with not nearly so
more
many bubbles
as the crepitous.
72. It
is
heard most often in acute bronchitis,
with copious expectoration
and towards the base
of the lung. (107.)

73.
The
muco-crepitous, sub-crepitous, and sub-
mucous, are merely intermediate steps to suit the

fancy of auscultators, according
as
the sound
approaches more nearly the mucous or crepitous.
35
gurgling; mucous rale.
These, with the mucous, indicate mucus in the

bronchi, or cavities.
similar rale
is
not unfre-
quently heard in phthisis, at the upper part of

the lung (15G); and in
in dilated bronchi
Gurgling
74.
bubbling, and
is
pneumonia (124), and
190), usually at the lower part.
the largest and most irregular
indicates
it
single bubble
is
a cavity in
sometimes
the lungs.
sufficient to
mark
combined most commonly with cavernous respiration. (42). At times a cough will proit;
for
it is
when simple respiration fails. By closing

we are gargling the throat, we
may hear a sound somewhat similar.
T5. Examples.
A tubercular patient has this
under the clavicle, when there is a cavity; and
duce
it,
the mouth, while
in this
case
it is
may be heard
in
the most distinct (158)
but
it
cases of gangrene of the lung
(171), or of pneumonia,
when an abscess is formed,
and there
is
a loss of a part of the substance of the
lung, and
if
the cavity formed communicates with
the bronchi. (125.)

76.
N. B.
Irregular cracklings, (mucous,
mu-
co-crepitous, or gurgling) at the top of either lung,
while the rest of the organs are free from any
morbid sound, indicate strongly,

the existence of phthisis;
the lungs,
anywhere,
they
in
mark
when
in a chronic case,
at the
bronchitis;
bottom of
when heard
an acute disease, and combined with
36
a dullness on percussion, or an alteration in the

sound of the voice, and in the vesicular respiration, they indicate
pneumonia.
77. In the second division
sound,
viz.,
ment).
It
we have only one
the rubbing sound (bruit de frotte-
occurs in
consequence of the two
layers of the pleura being rough, so that during

the respiration the lung, being in motion, pro-
duces a rubbing sound.
It
usually caused by
is
Any
pleurisy.
organic change, however, which

gives a roughness to the parts, such as emphyse-
ma
of the lungs, and cancerous and other diseases
of the pleura,
may cause
divisions, according
viz
as
it.
is
it
It
has various sub-
more or
less harsh,
the slight rub (bruit de frolement), and the

grating sound (raclement) but there is no differ,
ence, except in degree. (128, 135.)

78. Examples.
The simplest form of this
occurs from a slight dryness of the membrane, and
on the
earliest
effusion
of lymph in pleurisy.
(128.) In the later stages, after a copious effusion

and a subsequent absorption of a fluid, it is
rough-
er.
(141.)
It is
but rare that
it is
heard in any
other disease.
79.
A modification of this sound has lately
been noticed, under the name of the pulmonary
crumpling sound, as pathognomonic of the early
stages of phthisis.
As
the
name
indicates,
it
REMARKS ON THE RALES.

seems
as if
37
one heard, directly under the
sound like the
have heard
it
slight
ear,
crumpling of parchment.
twice in apparently early stages of
was connected with no
tubercular disease.
It
other physical sign,
and occurred
at the
end of
Both patients had had hcemoptysis
inspiration.
both apparently regained their health.
QJ * Remember
5
80.
trouble yourself so
sound;
Do
Rule.
this
much about
not
nice distinctions
but observe accurately,
first,
of
where the
sounds arc heard; second, where the focus of them

is, supposing that they exist everywhere in both
lungs; and third, their combinations with other
physical and rational signs.
N. B.
81.
lung
is
of
very small sign at the apex of the
much more
serious import, than very
loud, and extensive rales,

for the
one points
in
every other part;
to phthisis; the other to bron-
chitis, dilated bronchi, &,c.
Remember,
therefore,
always to compare the signs in the upper part of

the lung, with those in the lower
the rales are very general,
if
you
and, in case
find
only an
inch even of the lower part of the lung free,

while the rest
is
affected
with rales, you
sure of having to deal with something
mere
bronchitis.
will find the
Generally,
in
may be
more than
this case,
you
evidences of disease to augment as
you approach the apex.
38
PERCUSSION.
ercussion
form
is
more
difficult
delicately than
Like the
latter,
either imme-
is
it
to per-
auscultation.
diate or mediate.
83.
By
the former,
striking of the chest with the
its
results
the
now
rarely
are inaccurate, in
com-
out any intermediate substance.

used, because
we mean
hand merely, withIt is
parison with those from mediate percussion.

84. Mediate percussion needs
I usually find
the fore-finger of
sufficient for this purpose.
simeter
is
to
The
a plessimeter.
my
hand
left
compress gently but firmly the
parts, so as to
is
object of a plessoft
form a dense vibrating surface over
the part of the lung that
is
examined.
After this
compression, we strike upon the plessimeter, in-
we do in immewhen using your

finger as plessimeter, not to put the back of it upon
one portion of the chest and the inside of it upon
Try the experiment upon a table, and
another.
stead of
upon the chest
diate percussion.
you
will see
Be
itself,
as
careful
the reason for this remark.
different effect
is
produced
in the
two
A wholly
cases.
The
39
PLESS1METERS.
must be more
rules given in (1,2)
strictly attend-
ed to in percussion than in auscultation.

85. Various plessimeters are used by different
Among
practitioners.
Fig. 21.
these, the following are
the most important.
is
chouc.
large
Fig. 21
a simple cubic block of caoutIt
should be of a size
enough
to be easily held
between the thumb and
but to be capable of lying

as, for instance,
flat
finger,
space;
in a small
behind the clavicle.
22 shows the stethoscope-plessimeter
86. Fig.
and percussor used by Pro-
Fig: 22.
fessor Bigelow. It
useful
is
chiefly
when examining
be-
hind the clavicles; because
by
it
we
are enabled, better
perhaps than with any other

plessimeter, to
make
equal
degrees of pressure behind
both clavicles, and

angles.
23
87. Fig.
ivory.
It
is
Fi-. 23.
is a
piece of very thin smooth
Raciborski's instrument.
is
at like
(21.)
similar, and
is
to his stethoscope.
ments give
Piorry's
usually fastened
These
instru-
a very clear resonance,
but the sound has the tone of the
40
ivory,
and therefore
is
not so pleasant to
me
as
the finger, or the India-rubber.

88. Fig. 24
Cammann
is
the instrument proposed by Drs.
and Clark.
It
a very delicate
is
made
Fig. 24. beautiful apparatus,
In the plate, a
ished steel.
and
chiefly of pol-
of ivory, riveted to the steel
a handle
is
;
b,
a small
thumb to rest upon

of steel, upon which is
plate of ivory for the
an oval plate
c,
fitted
a piece of caoutchouc, to prevent
any noise from the striking of the finger
upon the bare metal.

structed as this
for
it
is
is,
suspect
it
Beautifully con-
will
be rarely used
too bulky for every day practice,
moreover
and
not absolutely necessary, even for
is
auscultatory percussion. (386.)

89.
The
sounds on percussion of the chest
are either natural, augmented, diminished, changed

in note or character, or absent.
90.
there
The
is
natural resonance
is
greatest
where
the least muscular substance covering
the chest; hence the axilla, the side, the lower

part of the breast and below the scapula, give
more, resonance than the other parts.
91.
give so
These places
little
sound
the shoulders
glected by some
importance.
vary in
as, for
Some
instance, the tops of
that they are
most unwisely ne-
auscultators, as giving
no
definite
41
VARIETIES OF NATURAL SOUNDS.
results.
them
In
as the
all
cases of chronic cough
most
regard
important, for they are the first
affected in the earliest stages of phthisis. (143.)
92.
following plates will give, in a rough
The
manner, the various shades of differences of sound

chest.
on percussion of various portions of the
have endeavored to represent the different degrees of sonorousness by the lighter and deeper
shadings; the darker points being the more dull
on percussion.
25 presents a view of the front of the

Above the clavicles, especially towards
93. Fig.
thorax.
the top and outside of the shoulders,

is
obtained.
sion,
but
phthisis.
This
is
a place
sound
little
of percus-
difficult
infinite importance in suspected

Below, we find a difference of note,
of
between the two

angular space,
breasts,
from
Fig. 25.
the
over a somewhat
third
second or
downward
sixth.
the
to
This
is
tri-
rib,
owing
to the heart, the aorta,
and the great ves-
sels
lying under the
sternum,
and on
level with the

rib,
second
and thence ex-
tending
downward.
About the
fifth
rib,
42
over the cardiac ventricles,
and which sometimes
is
is
quite
flat,
duller
space,
for the extent
of about two inches in circumference.
The
sides of the breast of course
owing
are dull,
The mammae,
the pectoral muscles.
women, cause flatness.

94. Fig. 26 shows that
less
clear
outto
likewise, in
sounds can
generally be obtained from the back than from
the front.
For instance
the tops of the shoul-
ders, the scapulas, especially towards their exterior
column are
Below the angles of scapsounds; fully equal, and
edges, and each side of the vertebral
very dull, almost

ulas,
we get very
flat.
clear
sometimes superior,
front of the chest.
to
The
those
on the
obtained
tops of the shoulders,
though the darkest on the diagrams, as being

Fig. 26.
capable of producing
but
little
sound, are
however very important
when compared
The
together (2,5).
slightest difference
note
with
of
(99), combined
other
physical
and
rational
signs,
will
perhaps
decide
your
diagnosis.
In
order to percuss well
VARIETIES OF NATURAL SOUNDS.

in these parts, the scaleni muscles
43
must be com-
pressed very firmly.

96. Fig.
breast,
27 presents
and a
front
back and
profiles of the
view of the most resonant
Fig. 27.
portion
viz.
of
chest,
the
the axilla and the
This
parts below.
part,
though the most resonim-
ant, is of the least
portance
because a
dis-
ease rarely shows itself

there, until
has
it
made
very severe and evident

ravages, either in front
or behind.
96.
The sound
is
aug-
mented by strong inhalation,
emphysema (177),
pneumothorax
&/C.
( 166 ),
by any thing that increases the quantity of air
Sometimes
in the chest.
also I
have recognized
hepatization of the posterior part of a lung from
an extraordinary resonance in front.
(123.)
have observed an increase of resonance in some

cases of early phthisis.
97.
est
Examples.
sound
there
is
Pneumothorax gives the loudAt times
next comes emphysema.
great
resonance in phthisis, owing, I
44
think, to the fact, that the vesicles near tubercular
deposits are frequently emphysematous.

98. It
out the
is
diminished by any thing that drives
An
air.
effusion of fluid in the pleura,
(130), pneumonia (122), tubercular (146, &c),
and other organic changes in the lungs; an unua constrained position of the
sual quantity of fat;
body
or pain
on motion of the
ribs
may produce
the same effect. (102.)

99.
of note between two corres-
difference
ponding parts
is
not
uncommon, when
real flatness in either (154).

in
which the lung
to
air.
is
Sometimes
It
there
is
no
occurs in cases
not by any means impervious

in the early stages
(140), of pneumonia (123), in
its
of phthisis
early or latest
stages.
100.
There
is
a peculiar
sound produced
at
imes when percussing over a cavity with thin

walls,
much more
or sometimes, but
rarely, in
hepatization of the upper lobe of the lung.
It is
called the cracked-pot sound, (bruit de pot fele,)
and
its
name
explains
itself.
In itself
it is
not of
Sometimes, when there
great importance.
is
slight jar about the clavicle, or the percussion is
badly performed, a sound similar to this
duced.
101.
Hence caution
At
is
times, the sound
mill or absent, as
if
is
pro-
needed.
seems to be
as entirely
the thigh were struck.
This
CRACKED-POT SOUND
SOUNDS ABSENT.
45
degree of dullness of sound indicates most serious

disease.
Usually
into the chest;
owing
it is
to an effusion of fluid
with a greater or less compres-
More
sion of one lung.
rarely, the dullness
is
as
great in very extensive and severe hepatization
from pneumonia, gangrene, &c.

aneurismal tumors
may cause
dullness, but, in these cases,

102.
Examples.
Malignant and
a similar degree of
it is
local.
Fluid in the pleura
will,
of
course, push aside the lung, and cause the greatest
degree of dullness
pneumonia
is
cause perfect
the want of sound from
Tubercles rarely
rarely so perfect.
On the
flatness.
contrary
of the lungs very commonly does.

an ivory plessimeter
is
good
to
In
gangrene
fat
people,
compress the
position of the body
is
of
vital
amining differences of note,
importance
adi-
The
pose matter, and to bring out a good sound.
in ex-
in the earlier stages of
phthisis; a slight deviation from
symmetry
in the
position of the two sides of the thorax, being fatal

to accuracy.
Pain sometimes
the ingress of
air,
hence
in pleurisy
prevents
arises a difference of note
between the affected side and the other.

Percussion
is
of great importance in
cardiac and cardiac diseases. (24S.)
all
peri-
4G
PHYSICAL SIGNS OF LARYNGEAL DISEASES.

1st,
the
laryngeal respiration,"
2d,
arth and Roger mention,
"harsh
)\p)
the " sibilant," 3d, the " sonorous,"

4th, the " cavernous and gurgling,"
^C
is))
and 5th, the " flapping rales
;"
as
indicative of laryngeal affections.
The
1st attends acute
and chronic laryngitis;
tumors compressing the trachea
Spasms
2d.
or
oedema of the
croup.
glottis
stridulous
laryngitis; foreign bodies in the trachea; com-
pression of the trachea.

3d.
Laryngeal
ulceration,
and
vegetations
croup.
4th.
Hoemoptysis; laryngeal ulcerations
eign bodies in the trachea

5th.
I
Membranous
nosis
It
;
may, however,
but
for-
croup.
have rarely used auscultation
tions.
death-rattle.
aid
you
in
these affec-
in
their diag-
have usually found the rational and
other local signs
much more
important.
ACUTE BRONCHITIS, SIGNS
47
OF.
PHYSICAL SIGNS OF BRONCHITIS.

two kinds of bronchitis,
s there are
viz
acute and chronic, so their phy-
sical signs are different.
105. O^r* In certain cases, of both
may
kinds, you
Example.
105.
in the larger
no physical
bronchial tubes, and have but

In such
expectoration.
to
get
signs.
Let an individual be affected
there
a case,
produce physical signs, because there
is
is
little
nothing
nothing
which seriously obstructs the passage of the

in its circulation
through the bronchi.
sence of signs
very
is
common
air
This ab-
in chronic cases.
SIGNS OF ACUTE BRONCHITIS.

106. In the earliest period of the disease, a sonorous, or sibilant rale, (62,) or both combined, are
heard
in various parts
of the chest
chiefly,
how-
ever, at the middle and lower parts of the back.
If they be found
more
ally,
all
over the chest, they are, usu-
distinct at the lower than at the upper
They are owing chiefly to a thickening of

mucous membrane of the air tubes.
part.
the
107.
tion
As
the disease augments, and expectora-
begins, the crackling rales
commence, and
48
these likewise are usually, heard most distinctly at
the bottom of the lung.
There may be mucous
(71), submucous, muco-crcpitous, or sub-crepitous
may be mingled with
All these
(73).
the sono-
rous and sibilant; but, usually, in this stage of

the affection, the sonorous
and sibilant are
less
constant than in the previous stage, owing to their
being caused more by obstruction, from the mu-
cous secretions remaining in the air-tubes, than
from a thickening of the mucous membrane of

the bronchi.
108.
As
the disease subsides, and the expecto-
ration diminishes, because the

is less,
heard
these various rales
last in the
109.
all
mucous
secretion
diminish, and are
lower parts of the lungs.
Finally, nothing manifestly abnormal
is
observed, except a few crackling rales, during an

access of coughing either in the morning or eve-
ning; but during the remainder of the day, nothing
is
perceptible, except a slight waviness and a
little less
expansiveness than usual in the respira-
tion (45).
110. Especially
coughing.
is this
have met
waviness manifest
it
a few times.
after
call
mucous respiration, in contradistinction to muIt seems as if there were a little moiscous rale.
it
ture in the minute bronchi, and only a
were needed
to
produce pure mucous
little
rale.
more
This
ACUTE BRONCHITIS.
49
increase of secretion actually occurs, with the pro-
duction of mucous rales, about the time of the usual

fit
of coughing
the
membrane
alone
is
but
is
portions of the day
at other
drier,
and the mucous respiration
heard.
111. N. B.
3
fl^r
Hence
the importance of ex-
amining such doubtful cases during the period of

the usual access of cough, whether that period
occurs early in the morning before rising in bed,

or late at night.
112.
for the
Example.
A. B. called
Infirmary
at the
He
Diseases of the Lungs.
had chronic
cough, which he suspected to be " consumptive"

in its tendencies.
found no physical signs to
confirm this view;
but, instead, I heard
respiration at the bottom of both backs.

that he had, usually, his most
coughing early
delayed
my
in the
diagnosis.
mucous
I learned
severe periods of
morning.
Visiting
Accordingly, I
him
at
six the
next morning, I found him in bed, according
appointment, having made no
had no cough.
The
effort,
to
and having
exertion needed in the ex-
amination produced a cough, and distinct mucous

rales
were heard
at the
bottom of both backs,
in other words, at the precise spots
respiration
day.
was heard
at
or,
where mucous
noon of the preceding
Thus I was confirmed
in
two views,
viz.
1st,
that mucous respiration indicated a smaller
de-
50
gree of secretion from the bronchi than that necessary to the production of rales; and 2d, that
the case was one of bronchitis and not phthisis.
(116, 143.)
113.
The
respiratory
murmur, except
sometimes obscured by the

lost
owing
to
mucus
rales, or
in
being
temporarily
in the tubes, the
resonance
of the voice, and the results of percussion, are

natural in acute bronchitis.
SIGNS OF CHRONIC BRONCHITIS.
They may be wholly absent where there

no mucous secretion. The sonorous rale (62)
114.
is
is
rarely heard,
acute form.
and
ally in various parts
the base,
is
is
never so constant as in the
mucous
rale (71)
heard occasion-
of the chest, but chiefly at
the most striking
The
phenomenon.
place in which this rale appears will generally enable you to distinguish bronchitis from phthisis.
(81, 143.)
115.
The
respiratory
roughened or obscured,
(1 13.)
The
murmur may be
as in acute
a little
bronchitis.
resonance of the voice, and the results
of percussion, are normal in chronic bronchitis.

116.
Examples.
A man
symptoms; and perhaps

in the nostrils,
will
is
seized with febrile
have some wheezing
which, in one or two days,
extend to the lungs.
At
and sonorous rales are heard
may
period, the sibilant
this
;
indicating conges-
CHRONIC BRONCHITIS.
tion
51
and thickening of the mucous membrane.
This stage
usually, less than a week, and,
lasts,
gradually, runs into that in
which the crackling
These are owing to a secretion

from the bronchial mucous membrane; and with
it comes, usually, some relief to the active conrales will appear.
They may
gestion.
last
In a se-
indefinitely.
vere case, they rarely wholly disappear before the

lapse of three or four
weeks
ble persons, they continue as
and, in
are heard at the bottom of the lungs
with the wavy
ternate
some
fee-
many months. They
mucous
or they
respiration,
al-
de-
all the rales may

may remain; owing to a
thickening and an irritation of the membrane in
scribed above (112).
Finally;
disappear, yet the cough
the larger bronchi.
During
no
serious
It
may be
may be wholly absent for

of mucus obstructing
a time,
these periods, there
all
change in the respiratory

obscured, or
owing
but a
There
it
to a portion
full
is
breath, or
no change
in the
it.
sounds of the voice,

;
and
if,
perchance,
a case of suspected bronchitis, you perceive
any modification of either, you
you are wrong
in
are dealing with

it
a tube,
a cough, will reproduce
or in the results of percussion

in
is
murmur.
may be
may be
sure that
your diagnosis, and that you
some
disease
probably
much more
either
with
serious,
pneumonia
(122), pleurisy (135), or phthisis (153, 154.)
52
PHYSICAL SIGNS OF PNEUMONIA.

his disease
in any part of
may occur
and you must examine
the lung,
more carefully than in bronchitis.

Most frequently, however, it commences in the lower lobe (Jig- 18),
?.
and thence extends, involving the whole of that

lobe, or the greater part of 9, 6, and 5, and perhaps 4
118.
sometimes the whole lung.
The
first
signs are, either a diminution
(28), or an increase ( 28 ), of the natural reI have seen a case of the forspiratory murmur.
mer with a case of the latter I have not met.
;
is
a rudeness or roughness oi
the respiration (43).
Ordinarily, however, these
Sometimes there
abnormal sounds are rarely observed,

this stage lasts
flammation begins
thence extends
in the
we hear an
may
of the lung.
last for
some
part,
in
In this
days.
increased respiratory
around an inflamed
rale
centre of the organ, and
to the surface
case the diminution

times,
because
but & few hours, unless the in-
At
murmur
which a crepitous
and a bronchial respiration are the most
prominent signs of inflammation.

the probability
is,
that
you
will
In such a case,
hear crepitation
in that part, within twenty-four hours.
;;
PNEUMONIA
Example.
119.
53
CREPITUS.
have had a case, in which
there were marks of severe febrile action in the
system, and pain in the right side of the thorax
but no physical signs, except an obscurity in the

respiration about the right scapular region; until,
after the lapse of three or four
itous
rale
came
days, a fine crep-
up, apparently from the deep
seated parts, to the surface of the lung
and a
pneumonia then became evident.

In this case, I presume that there was some internal pneumonia which extended outward.
plain case of
120.
The
second sign, and what
heard by the physician,
is
usually
first
a crackling in the in-
This may be coarse, but usually
flamed portion.
it is
is
minute crepitation (70). When you

last, you may be sure that the first stage
a very
hear this
of pneumonia, or congestion of the lung, has
The
commenced.
voice
may be
slightly altered,
and the percussion may give a change of note

but they
121.
only
for
may be both
3
fl^r
(99.)
is
heard
at the first inspiration, after the patient rises
examination
at others,
inspiration, or both
it.
entirely normal.
Sometimes, the crepitus
When
a cough, or a long
combined,
pure and most
will alone
distinct,
it
produce
resembles an
explosion of myriads of very minute, regular, and
dry bubbles, and

122.
The
is
heard during inspiration. (70.)
third sign,
and
marking, what
is
54
THE VOUNG STETHOSCOPIST.
usually called, the second stage of pneumonia, or
red hepatization,
With
you
this
is
will
bronchial respiration (41).
have bronchophony (51), and
dullness on percussion (98).
The type of morbid bronchial respi(39,40,41) may be heard in this stage
123. {/=
ration,
Sometimes, however,
of pneumonia.
it
is
scarce-
except during the act of speaking
ly heard,
hardly at
all,
bronchophony (48,51), likewise varies;

sometimes
while,
at
slight
others,
(47, 52).
The
it
modification of
is
almost like
and
The
during that of respiration.
being
voice;
the
pectoriloquy
dullness on percussion
is
rarely so great, as that found in pleurisy.
very
(101.)
Hence, merely a change of note (99) is of consein the diagnosis of pneumonia.

Twice
quence
I
have observed a very curious phenomenon in
this stage of
of a lung;
pneumonia, of the posterior portions

an almost tympanitic state of
viz.:
the breast. (96.)

124. If the patient begins to recover, you will
hear
crackling
70,) as the lung
(" returning crepitous
becomes
enters the minute cells.
but in a few days

73).
The
it
softer,
This
and the
is,
air
at first,
rale"
again
minute;
becomes larger (sub-crepitous,
voice becomes
more
natural.
But
the results of percussion are, at times, apparently

unfavorable, for the dullness augments as the other
PNEUMONIA
GURGLING.
signs improve.
presume
oedema of the lung, similar

on
this
is
to that
owing
55
to an
which conies
an external inflammation; whereby the
after
parts
IN CHILDREN.
become more swollen than they were during
the acute stage.

125. But
if
the lung suppurates, you will hear
a large, irregular crackling
and gurgling.
The
pure bronchial respiration, and the bronchophony,

disappear; and instead of these, you will hear a
rude, indistinctly tubal, sound (43), and a less
resonance of the voice; unless, indeed, a
clear
cavity forms; in
which case, you
will
probably
hear gurgling (74), an obscure cavernous respiration (42), and perhaps pectoriloquy (52).
12(5.
Q^3 The
description given above, strictly
speaking, applies only to adults

the
same phenomena may occur
in these latter
fine,
and
is
persons, the rale
heard,
more
for,
although
in children, still,
is,
usually, less
generally, over the lung;
and the bronchial respiration, and bronchophony,

It is rare, moreover, that
be wholly absent.
may
the results of percussion are so manifest in chil-
dren as in adults.
If,
in a child
affected with a
great febrile excitement, owing to a severe pul-
monary
trouble, I find rales to exist everywhere
in the lungs; especially, if they are minute,
lfear
that the case will prove serious; probably pneu-
monia.
If,
with these circumstances, a dullness
56
of sound
one side
is
heard on percussion
duller than the other
is
pneumonia
that
127.
exists.
Example.
particularly if
certain
feel
(2, 3.)
A man
rusty, viscid sputa, fever,
seized with cough,
is
&c.
and
ed within forty-eight hours, you
if
you are
call-
the
ma-
will, in
jority of cases, hear a crepitation, with a
in the tone of the voice (5G, 57),
of note (99) on percussion
change
and a difference
or, in other
words,
signs of a partial hepatization of a portion of one
of the lungs.
The
disease augments; and the
crepitous rale disappears, in part, at least, usually

in twelve
bronchial
The
or twenty-four hours, leaving a pure
respiration
(41),
and
bronchophony.
percussion, which previously has not given
very marked
results,
modification of note,
(98.)
probably nothing
now
but
gives a dull sound.
This stage continues longer than the
usually from three or four days to a
week
first,
but
of this time, a returning
crepitous rale (70) begins to be heard on coughing, or on any active effort to inspire deeply.
towards the
latter part
From the end of the fifth to the tenth or twelfth

day, the bronchial respiration begins to diminish,
and becomes daily
ling
dull
less
and
less clear
the crack-
becomes louder and more irregular. The

sound on percussion, on the contrary, often
continues to augment.
Finally
by the sixteenth
pleurisy; rubbing sound.
57
or seventeenth day, the bronchial respiration will
have wholly disappeared
but the rales
may
main, in a slight degree, with some dullness,
weeks
refor
after full convalescence.
PHYSICAL SIGNS OF PLEURISY.

you are fortunate, you may hear,
^=\ f
as
the earliest sign, a diminished respiration
s I
f^-J
the chest.
doing
is
on the affected
The
to the
pain prevents him from
But, generally, the
so.
a rubbing sound,
of the pleura; and

the lung
owing
side,
unwillingness of the patient to expand
?>.
it
moves most,
(77),
will
first
owing
sound heard
to the dryness
be most manifest where
either in
4,
6 or
10, (Jigs.
17 and 18).
129. Explanation.
tion, the
health,
two
move
the other.
With each
pleurae, lubricated
noiselessly
act of respiraas they are in
up and down one upon
In pleurisy, they become dry, or have
a thin deposite of
lymph on each surface and,

is produced when they are
of course, some sound
rubbed together.
58

130.
Among
the
symptoms
first
is
dullness on
percussion (101) in 10, owing to a fluid effused,
and the gravitation of
toward the lower part of
it
You may mark
the chest.
the height of the liquid
by the dullness, and no disease of the chest so

destroys
all
sound as
Of
pleuritic effusion.
course, the extent of the flatness increases with

the quantity of fluid, and, as
great as to
fill
sometimes
it
the whole of one pleura,
so
is
you
will
In
perceive absence of sound throughout. (28.)
lung
this case, the
is
wholly compressed against
the spine.
131.
may
be,
When
where
in
doubt about the dullness, as you
a small quantity of fluid
effused,
is
change the posture of your patient and see
if
the
most depending portions of the chest become

flat,
while the
uppermost.
produce
same
parts
Nothing but
this effect.
are
resonant
when
a pleuritic effusion
can
have met with one or two
rare cases in which a change of posture produced
no difference;
in
consequence,
presume, of old
adhesions preventing any motion of the

132.
As an
effusion of fluid causes, as
fluid.
we have
seen (130), a partial or total compression of the

lung, the respiratory
it
may be
murmur
entirely absent;
find a puerile or increased
is
and
diminished, or
in
murmur
this
in the
case
we
healthy
parts (25, 28), and throughout the other lung.
pleurisy;
Some speak
133.
murmur.
It
seems
hcegohony, etc.
of a hoegophonic respiratory
to be a mingling of the bron-
and the vesicular, or
chial
59
an
is
it
indistinct
bronchial respiratory murmur. (80.)
At
134.
times, however,
respiration (41)
pleuritic effusion
but this
bronchial
distinct
when
heard, even
is
rare.
is
there
is
have met
with two cases, in which that sound was as distinctly bronchial as I ever heard
it
pneumonia.
in
between
Nevertheless, the differential diagnosis
pneumonia and
inasmuch as, in
pleurisy
is
usually not difficult;
pleurisy, there are usually
none
of the rales of pneumonia, and the dullness on

percussion
is
greater in pleurisy than in pneu-
monia.
The
135.
times
is
is
it
voice
is
always modified
very small or very great.
only
is
chest,
(55)
at
simply diminished, when the effusion
When
thin layer
between the lung and the outside of the
we
get hoegophony. (54.)
Hoegophony
favorable after extensive effusion, because

a diminution of the fluid, and
if it
it
is
marks
be followed
by the rubbing sound (77), your patient
is
usually
cured.
136.
OJ^ This
nec, and
of
late,
may
it is
is
the old
statement by Laen-
followed generally by writers; but,
not a few have found that hoegophony
exist
when
there
is
a great effusion.
have
60
heard
it,
found so
one case, in which the chest was
in
of fluid that the lung was almost
full
wholly compressed.
137.
When
amount, there
side,
there
is
is
an effusion to a great
an enlargement of the diseased
and when the patient
is
cured there remains
permanently a contraction of the same, drawing
down
the shoulder, and causing an apparent pro-
jection of the lower angle of the scapula. (16, 17.)
In some cases, I have
138. N. B.
falling
known
this
back of the scapula to be a serious annoy-
ance to the patient
by causing the arm of that
side to swing towards the spine, rather than in a
plane parallel to the side of the body
whereby
a difficulty in walking was produced (142.)

139. Immobility of the thorax
upon
a large effusion,
hand placed upon a healthy chest

the same.
of
is
and the slight

is
consequent
thrill
to the
destroyed by
Neither of these signs, however, are
much importance when compared
with others.
(10, 14.)
140.
When
cent organs
the effusion
are
liable
to
is
great,
all
the adja-
displacement.
The
may be pushed wholly to the right side, the

liver may be thrust down below the cartilages of
the ribs, &c.
So, likewise, when contraction
heart
ensues, after absorption of the fluid, these
organs
may be drawn
out of their places.
same
PLEURISY, EXAMPLE OF,
Example.
141.
First.
61
man may have no
rational signs, and then the physical signs detail-
ed above become of
ease
is,
ally;
vital
after
some
fever
and pain
a slight and difficult cough,

tion
we
The
importance.
witbin the
find,
first
dis-
Usu-
in fact, wholly latent without them.
with
in the side,
without expectora-
two days
either a
rubbing sound, (77) from the layers of inflamed

pleura, or a diminished respiratory murmur, owing
(28) to the pain in the side preventing the
pansion of the lung.
on
Second.
The
full
ex-
disease goes
and, within a week, a dullness, (101) of a most
marked character, but over
a small extent,
is
ob-
served in the lower two or three inches of either

back.
With
this
of the respiratory
comes
murmur
still
greater diminution
in the
same
parts
al-
though owing
to the subsidence of the acute pain
in the side,
may have augmented
the
lung.
it
slight modification
generally in
of the voice
(55) frequently appears at this period.
of posture will begin to be of use.
lean backward from the side of a chair

assistant support his shoulders, while
on the back.
Change
Let the patient

;
let
an
you strike
Keeping your finger upon the highback that becomes dull in this
est point in the
posture, let the patient stand up and lean over so

that the trunk shall be again horizontal, but the
breasts, being the
most depending
parts, will
be
G2

while the back, previously
flat,
tity
emit a
will
flat,
In this manner, a very small quan-
clear sound.
The
Third.
of fluid will be discovered.
ef-
fusion augments, hoegophony (54) appears;
and
perhaps half the chest
flat-
is filled
with fluid
the
ness rises higher; the respiration becomes null
(28) or
The
but very slight in the same parts.
is
begin to be enlarged (8)

the intercostal
spaces to swell out.
Fourth. The greatest degree
sides
of effusion
may occur, and
compressed
the
the whole lung
become
parietes then are immovable,
(10), enlarged, perfectly
flat
even up underneath
the clavicle and on the top of the shoulder (130);

the respiration
null (28)
is
usually disappears.
heart,
&c,
and hoegophony (54)
At this period
the organs, liver,
state of things,
under bad cirumstances, may oc-
cur within a fortnight from the attack

last for
months; and,
cases,
may
it
This
are displaced as described (140).
finally, as
and
happens
it
in a
may
few
point and discharge externally, or the
patient die from exhaustion, unless the chest be
tapped, and the fluid removed.
may commence
sorption
Fifth.
The
ab-
and the dullness on percussion diminishes from above downward; the

;
respiration returns at the top and thence proceeds
towards the base

(54)
scapula?
the hoegophony soon reappears
lower edge of the pectoral muscle or

the ribs begin to move, and to contract,
at the
PLEURISY, EXAMPLE OF,
63
and the coarse rubbing sound begins (77). Sixth.

The absorption is complete the respiration, how;
ever, remains for months, if not for years, diminish-
ed throughout the whole lung
may remain
for
the rubbing sound
sometime, and be perceptible to

has become im-
the patient a long while after
it
perceptible to the auscultator.
The side contracts,
the scapula and arm

the shoulder
Fig. 28.
is
fall
toward the vertebrae, and
depressed. (138, 142.)
The accompanying Fig.
142.
28 shows the appearance of

tient after recovery
a pa-
from severe
The
pleurisy of the right side.
right shoulder and elbow are lower than the left;
and the whole
of that side of the chest
vertebrae, and
angle
left.
It
in
downward
so that
lower than that of the
is
ward the
arm,
con*
backward, toward the
la to fall
its
is
This causes the scapu-
tracted.
is
likewise
farther to-
vertebrae, so that
the
walking, moves with less
ease than usual (13S.)
64
PHYSICAL SIGNS OF PHTHISIS.

ince tubercles are developed in adults
at the
apex of the lung
Div. 1,)
and
Divisions 2, 7, 8,
we must
in the
Fig.
17,
upper parts of
at the
(Fig.
17,
18,
look in these places, and not
lower parts, 10, for the
first
signs of phthisis
(37, 117.)
144.
As
pleuritic adhesions are not
uncommon
we
over a spot of the lung containing tubercles,
usually find a contraction of the soft parts behind
and below the clavicles
causing thereby an ap-
parent prominence of the clavicles (9.)

145.
Hence;
if,
on inspection, we perceive a
depression about one clavicle, that
is
not seen
about the other, we have an indication of some

importance. (9).
N. B.
To judge
fairly
on
this point, the patient
should be standing perfectly erect, (1 and Fig.
1).
146. Dullness on percussion (93) in the post-clavicular space, or at the tops of the shoulder,
another very important sign.
It
may be
in
the former, or in one of the latter places
times
if the
it is
observed in both. Should
it
rational signs of phthisis exist,
is
one of
some-
be in either
we may be
PHTHISIS, PERCUSSION IN.
65
justly led to suspect a small deposit of tubercles.
Generally the same remark holds good with refer-
ence
to a simple difference of note. (99)

If connected with any change in the respiratory mur-
mur, or resonance of the voice, this change of resonance becomes of still greater importance.
147.
As
the
number of tubercles
increases, the
diminution of the sound on percussion extends

lower; and may,
lobe,
at last, occupy the whole of one

which perhaps becomes distinctly flat.
148. In certain cases, there
is
an augmentation
of the natural sounds on percussion (96) even

when there are many tubercles. This may occur
;
where there are merely crude tubercles; and it is

owing then, I am disposed to think, to the fact,
that the vesicles around these tubercles are very
much
dilated
occurrence.
a fact
which
The same may
a softening of the tubercles,
admission of more
come
air
is
uncommon
not of
occur when there
and, finally,
it
very manifest over a large cavity
exist with that sound,
named
is
and consequently an
may
be-
and co-
the craclccd-pot sound,
(bruit de pot fele, Fr.) (100).

149.
liest
The respiratory murmur
sound, but what
is
alters.
pulmonary crumpling sound (79).
It
is
the
indicates
number of tubercles.
more tubercles may almost wholly obscure
the deposit of a very small
A kw
The ear-
of rare occurrence,
66
the sound of inspiration and expiration (46)
may make
seems
it
air
to force itself into the structure of the organ,
by jerks, (45,) as
before
is
the inspiration jerking so that the
it
if it
could enter
had
at
to
overcome obstacles
times, too, the expiration
prolonged, while the inspiration
much
is
shorter
than usual (36).
QJ^ Hence
150.
either of these alterations, or,
any difference between the sounds of the
in fact,
becomes a
respiration, as heard in the
two
very significant sign (80).
A natural exception to
this has
been mentioned
As
151.
the tubercles
size, the differences
we may
apices,
in (38).
augment
number and
in
above-mentioned increase, and
get a rude respiration, (43,) indicating a
enough
partial solidification of the lung, but not
to
produce pure bronchial,
wholly the vesicular
murmur
(41), or to destroy
(24.)
152. In this stage, the voice, which previously
has not been altered materially,

resonant.
may become more
have seen cases where
ished in resonance (56)
and
it
was dimin-
consider this as
important a sign as the increase of
it
for
it
indi-
of homogeneousness in the lung,
cates
a want
owing
to the fact that
groups of tubercles are
in-
termixed with the healthy lung.

153.
When
the lung
is
in this condition, if
cause the patient to cough, you will hear,
at
you
times
RUDE RESPIRATION
MURMDR ABSENT.
67
a single click or a single sonorous rale or whistle of

the most delicate and distant character.
Either of
these sounds, heard ever so slightly, just below the
shoulder, (while in
clavicle, or at the top of the
the remainder of the lung

ratory
is
heard healthy respi-
murmur), may be considered
as a very un-
combined with any change

in the inspiration or expiration, they become still
more momentous ( Fig. 20, No. 2.)
154. If with the above signs there be a change on
favorable sign (65).
percussion
If
especially,
trivial, rational
united with, the most
if
symptoms of phthisis, you may be
almost morally certain that tubercles have been

developed.
155. In two cases of undoubted phthisis, and
in neither of
sis
whom was
I heard, for
there copious hcemopty-
many weeks
fine crepitus (70).
When
in succession, a very
heard
I first
it
I sup-
posed the case was one of acute pneumonia, and

used remedies
for that disease
but the rale con-
tinued unchanged for weeks, and,

cular cavity was formed.
fore, that a tubercular deposit
as
minute and
as copious
tion as the acutest
me
a tuber-
may,
at times,
cause
an explosion of crepita-
pneumonia. Dr. Fisher informs
that he observed the
auscultating a patient,
have hcemoptysis.
finally,
have no doubt, there-
same phenomenon, while
who immediately began
to
68

156.
When
one or several tubercles soften and
open into the bronchi, you

distinctly, a crackling,
will hear,
more
or less
mucous or sub-mucous rale
(71, 73); generally most clearly during inspiration,

or,
still
better, after
coughing and along with
re-
This, in a chronic disease, attended
spiration.
with cough, {figs. 17, 18,) and entirely confined

7 or 8, is almost pathognomo-
to either Nos. 1, 2,
nic of phthisis. Connected with crackling you

get changes in the respiratory
rally is
somewhat tubal
murmur.
).
may
gene-
or bronchial but never as
distinctly so as in hepatization
(39, 41
It
from pneumonia,
The percussion likewise gives more deci-
ded alterations from the normal sound.

157.
As
the disease
still
advances and cavities
form, you will hear gurgling, (74,) produced either
common inspiration or coughing.

The voice, in the earlier stages, rarely alters so much as in pneumonia, because portions
by
158.
of healthy lung are mixed with the tubercles, and
consequently the sound

ly.
When
cavities
is
not transmitted so readi-
form you
will
have pectorilo-
quy (53) divided into several kinds, according as

the voice seems to resound more or less.
It is, of
course, more evident after expectoration than when
the cavity
ly
is full
of fluid. In fact, you will frequent-
hear gurgling before expectoration, but after-
wards cavernous or amphoric respiration, pectoriloquy and the cracked-pot sound (74,42,52, 100.)
PHTHISIS
The cough
159.
and
is,
CREPITOUS KALE
is
69
IN.
quite resonant as the voice
frequently produces signs, crackling,
it
&c, when
simple respiration will not
becomes important
as a sign in
itself
hence
it
and as a
cause of others (112, 121, 153, 156.)

160. Mensuration and Palpation, though noticed
by some writers, seem to be of
little
importance in
comparison with others much more striking (See
Mensuration and Palpation.) (16, 10.)

161. Sometimes the sounds of the heart
help you,
by a
for, as
solidified part
you may
than by a soft yielding lung,
infer that a part is
more
solid than usual
by the greater transmission of sound.
ample
the
left
will
they are transmitted more readily
For ex-
these sounds are usually heard better under

clavicle than
verse takes place
under the
we may
right.
If the re-
suspect disease of the
right.
162.
Example of chronic
phthisis.
As
it
is
impossible to give any definite period, at which

the peculiar signs occur; I will briefly give you
an idea of
my method
of examining any case of
chronic cough, in which I suspect phthisis.

the
first
In
place, I spend from twenty minutes to
half an hour in learning the exact condition of the

patient; his previous health from early age; his
hereditary tendencies
been subject
to
the various diseases he has
during his
life
his profession
and
70
the influences of that
upon
Having
his health.
learned these and considered their bearing as pre-
disposing causes of phthisis,
exact
commencement
discover whether
it
showed
eral state of
itself, first
the
and to
by symptoms
phases of the disease and gen-
the functions up to the
all
fix
After fixing those dates,
in the chest or elsewhere.

I trace the different
endeavor to
of his actual disease,
moment
Finally; I examine the cerebral,
of examination.
thoracic and abdominal functions in their actual

condition.
In doing
commencement of
months, or even years.

cal signs.
our views,
cough
for
In order that
let
proceed then
us suppose that a
to the physi-
has emaciated somewhat
definite in
man
has had
that he has or has not
that he has or has not
had trouble
Let us suppose that he
in his digestive functions.
still
date back the
we may be more
some months
had haemoptysis
may
all this, I
the actual disease for weeks,
has lost strength, but
able to attend to his work.
is
Let us imagine,
moreover, that occasionally he has had slight

" rheumatic pains," as they are called, about either
of his sides or shoulders.
In a word
let a
man
be affected with any rational symptoms that could
be referred to tubercular disease of the lungs.

then strip the chest wholly bare, and
patient
sit
or
stand very
hanging by the side
make
the
erect with the hands
{fig. 1).
If the clavicles are
PHTHISIS,
prominent
ed
sis,
if
if
METHOD OF EXAMINING.
the intercostal spaces are contract-
the chest
is
flattened in front, I
nent than the other,
fear phthi-
much more promi-
If I see one clavicle
(9).
71
I fear still
more
that, in the
apex corresponding to the most prominent clavicle, (9,) I shall find tubercles
I anticipate this result, if the
more
especially,
do
"rheumatic pains,"
mentioned above, have generally been seated
in
In regard to the movements, constrain-
that part.
ed or otherwise, of the parietes of the upper part

of the chest, I pay but
may
at
times
whether one shoulder

whether the ribs have
scapula to
fall
the nipple
is
attention though they
little
be of service,
is
(10).
observe
higher than the other
fallen in behind,
causing the
towards the vertebra, and whether
depressed,
all
of which are the signs
of old general pleurisy, (9, 138). Having inspected

sufficiently, I
proceed to percussion.
examine,
with especial care, the clavicles, in order to dis-
cover the slightest difference of sound between
corresponding parts of each clavicle,
(4).
Any
degree of dullness, even the slightest difference
of note (99), if confined to the upper part of the

chest, between two portions equidistant from the
spine or sternum augments
existence of tubercles.
my
suspicion of the
care not whether that
dullness be found on a part of the clavicle, or a
spot only an inch square, at the top of the shoul-
72

muscles
der, over the scaleni
ded difference, on repeated

mentioned.
If there
is
if
there be a deci-
my
trials,
faith is, as
great dullness, for two or
three inches from the top, while elsewhere per-
cussion gives a clear sound, I

is
tubercular disease.
dullness extends
if
all
am
almost sure there
on the contrary, the
If,
am
over one lung, I
be not the result of former pleurisy.
it
dullness
part
is
ease
is
adult.
is
If the
at the base of the lungs, and the upper
clear, I
am
morally certain that the dis-
not tuberculous
If
doubtful
it
i.
the patient
e. if
be a child, there
is
is
some doubt,
an
be-
cause tuberculous disease sometimes attacks the

youth, while the upper
lower part of the lungs
in
portions are healthy.
Having noted thoroughly
all
these results of percussion, even in their mi-
nutest shades,
respiratory
proceed to the auscultation of the
My
murmur.
object
is
to
examine the
inspiration and expiration, to observe whether their

ratio
is
normal (36)
it ought
longer than
spiration
is
full
whether one
to
be (46)
is
shorter or
whether the
in-
and expansive, corresponding in
duration to the movements of the chest, or whether

it is
shortened, so that theparietes are
and
to
felt to rise
expand considerably under the ear before
the vesicular sound
is
heard
whether there be
any prolongation of the expiration (38)
whether
either of these acts are jerking (45,), as from
some
METHOD OF EXAMINING A
PHTHISIS,
CASE.
73
obstruction to the passage of air; whether there

is
the slightest rale, of any kind, with either
if there be,
whether
of the chest.
it is
and,
limited to the upper parts
If either of these conditions occur,
and the results of auscultation and percussion

agree, even in the slightest degree, ray suspicions
For example
are confirmed.
simple case.
Suppose
the right lung, at
than the
left
if,
its
us take the most
let
I find a difference
of note
apex, resounding less well
in the
same
spot, I find the in-
where the rational
spiration shortened, in a case
signs point to phthisis, I feel certain of the exist-
ence of tubercles.
If,
however, the rational signs
do not indicate the existence
phthisis, I shall
of
have doubts about the diagnosis
but I shall have,
nevertheless, very great fears that there are a few
tubercles deposited near the part.
But, suppose
I find
absolute dullness and evident crackling;
then I
am
sure of tubercles being there in a soft-
ened state; the forerunners of a cavity with gurgling and pectoriloquy.
In these examinations, I auscult during the
common measured
is
accustomed
to.
breathing which the patient

Having thus examined the whole
chest, I try the effect of long breaths, at stated intervals,
upon
ined.
Thus,
all
examsome of
parts that I have previously
I frequently
the differences in the
am
murmur,
able to find
or
some of the
rales,
74
mentioned above, when nothing marked can be

In making the
discovered in common breathing.
patient do this I
careful that the sound from
am
the mouth, simulating bronchial respiration,
Many
transmitted.
glect
I
on
Having
this point.
is
not
gross errors arise from netried long inspirations,
the patient cough and immediately inhale
make
deeply, and listen to that and the rales which
Through
sometimes produces (159).
marks
have supposed that I
am examining
doubtful early case of phthisis.

signs
may be
very manifest
fever, emaciation,
&c,
is
owing
hosmoptysis, hectic
being present.
may then
to the equal
may
decide unfavorably
rude, or coarse,
under the ear,
is
or
if
development of the disease in
still
patient, for, very likely, the respiration
become
not any manifest difference on percussion,
both lungs, I
there
But the rational
obtain greater differences on percussion

there
it
these re-
ease than of healthy

that the lung
is
(43,)
for
my
may have
which indicates
much more of tubercular dislung.

In others I may find
greatly solidified, causing an ab-
sence or great diminution of the respiratory mur-
mur
bal
(28)
or, possibly, a distinct
bronchial or tu-
sound may be heard, indicating
with possibly condensation about

ly, I
may
comes
to
find a
me
it
a small cavity,
(41).
Final-
cavernous sound, (42), which be-
an indication of a large excavation
METHOD OF EXAMINING A
PHTHISIS,
CASE.
75
with thin parietes.
Connected with these variamurmur, are the rales I frequently
tions in the
For example.
hear.
slight sibilant or sono-
rous rale, or a single click (65)

the rude respiration (43)
and
often heard in
is
it is
then indicative
of condensation without excavation; a crackling

(73) with the simple tubal (39 to 41), indicating
softened tubercles, and finally gurgling (74) with
the tracheal or cavernous, (42), indicating large

ulceration.
remember
are produced only by
Hence
that frequently these rales
full
breath, or a cough.
cause the patient to cough, and generally
perceive the importance of the act, as I have
ready stated elsewhere.
al-
In addition to the pro-
duction of rales the cough
is
useful in itself as a
means of testing the resonance I therefore notice

the amount of that resonance in the same manner
;
as I notice the resonance of the voice.

If,
in
any
phthisical case, 1 find
marked
reso-
nance of the voice or any manifest difference between the two apices, except, perhaps,
resonance
at the top
(38, Jig. 19)
a little
my prognosis
is
what
is
more common,
left
very unfavorable, for
avery general condensation by tubercles

ted, or
more
of the right than of the
is
indica-
a cavity, either larger
or smaller, in the portion of the lung under the ear.

(57.)
THE X0UNG STETHOSCOPIST
76
ACUTE PHTHISIS, AND PHTHISIS IN CHILDREN.
162
The
a.
physical signs of these diseases are
In
very inferior to the rational signs.
former has none
fact,
the
that can be called peculiar, or,
in the least, characteristic of the disease.
(12.)
the same
presents
children rarely
manifest and regularly ordered signs as are found
Phthisis in
in adults
chiefly
and for the diagnosis
on the rational
we must depend
signs.
PHYSICAL SIGNS OF PNEUMOTHORAX.
neumothoras causes
a sudden en-
largement, immobility, either partial

or general, and a
permanent
disten-
tion of the walls of that side of the
chest which
There
164.
is
is
diseased.
absence or a very great feebleness
of the respiratory murmur, or, perhaps,

is a free
there
is
if
there
communicatiorirwith the bronchial tubes,
amphoric (44) respiration
echo (67), or tinkling (16),

mingled with the air, and it
if a
is
a metallic
little
fluid
be
produced either
by inspiration, or by shaking the patient, or by

the act of swallowing.
PNEUMOTHORAX.
165.
The
voice, usually,
is
but sometimes, when there
not
is
77
much
modified
am-
a very clear
phoric respiration, you will hear an increased
resonance
and, in this case, usually, there
is
diminution of the vibration of the parietes of the

chest (37, 14.)
166. Finally, there
is
great resonance on per-
cussion, tympanitis of the diseased side, especially

in the earliest period of the disease.
great resonance usually does occur.

less I
have met with cases
pended
entirely
167.
The surrounding
&c,
Neverthe-
which, had I de-
on the resonance,
upon any of the physical

been deceived.
spleen, stomach,
in
N. B. This
signs,
or,
in
fact,
might have
organs, the liver, heart,
are pressed out of place by
the quantity of air distending the pleura.

168.
The most common
Example.
pneumothorax
is
a rupture
cause of
of a portion of the
lung into the pleura, from the bursting of a
tu-
bercle, or of a small
gangrenous eschar on the
surface of the lung.
In either case the pleura
becomes
filled
with
air.
Great orthopnoea, cold
sweats, almost total loss of voice, usually severe
pain in the side, great prostration, and lividity of

lips
all
the signs, in fact, proving that
a large
portion of a lung has been suddenly prevented
from the performance of
its
functions
these
78
symptoms, suddenly appearing,
are,
of themselves,
The
almost sufficient grounds of diagnosis.
per-
manent distention (10), the augmentation of the

resonance (96) on percussion, are always present;
the metallic tinkling (66)
amphoric
most usually heard;
is
respiration (44) rarely, unless a large
aperture communicates between the bronchi and

pleura.
Phthisis most frequently produces this
but gangrene of the lung has done
it.
The
other
causes of pneumothorax are of a more chronic

nature, and have similar though less severe symp-
toms.
PHYSICAL SIGNS OF GANGRENE OF THE LUNG.

efore the disease reaches the surface
of the lung, and the physical signs
may
appear, you
ence from the

the disease
is
suspect
foetid
its exist-
sputa; but
if
extensive, and reach
the surface of the lung, you will have, in the

earlier stages, a total flatness (101)
seated, and healthy lung above
merely a slight difference
in
it,
and
if
deep
you may obtain
tone (99)
between
When
a cavity
the diseased and healthy parts.
GANGRENE, FLATNESS, RESPIRATION, RALES. 79

may,
forms, you
if
it
be superficial, get the
cracked-pot sound. (100.)
The
170.
respiratory
roughened, and
murmur
is
lessened, or
as a cavity forms, you will obtain
cavernous respiration (42), which, however, is

apt to appear distant, and sometimes is heard only
during the act of coughing.
171.
There
irregular
various
are
the parts begin to soften the
when
crackling
As soon
rales heard during the disease (68).
common mucous
a cavity appears, gurgling (74)
is
as
(71)
heard with
the cavernous respiration (42.)
The
172.
either
voice
afterwards
resonance
is
(57) or diminished (56) before
augmented
the abscess forms
Its
altered.
is
it
becomes pectoriloquial (52)

after months
which gradually subsides
of convalescence.
173. N. B.
The
physical signs are not nearly
so diagnostic as the rational.
Example.
174.
and
if
there
is
man
until after a time varying
months.
It
is
seized with cough,
any expectoration,
it is
not peculiar
from a week to several
then becomes somewhat offensive to the
smell, very nauseous to the taste.
This augments
and the expectoration becomes dark, more fluid

and very offensive, so that sometimes the apartment and it may be a whole house is scented with
it.
This
state of things
may come on suddenly
80
from a sudden communication of the gangrenous

mass with the bronchi, or be slowly superinduced,
but the gangrenous odour
of gangrene.
is
the only certain sign
Usually in such a case you will get
marked dullness on percussion, (101), crackling,

gurgling, (68), cavernous respiration and great
resonance of the voice, (42, 52).
As
the patient
recovers, the rales diminish, and finally are heard
only on coughing, or deep breathing
nance of the voice subsides
mur
the reso-
the respiratory mur-
gradually comes again, but very slowly, and
frequently by a
full
ous sound, or rale
breath a deep seated cavern-
is
brought out
where
in a spot
on quiet breath the respiration seems only

ly less than
it is
eighteen months
the other lung.
in
is
moderate time
to recover in, after having
slight-
year or
for a
person
had a large portion of
the lung slough, such as occurs not unfrequently in
cases of gangrene.
Sometimes, cases of gangrene
have been mistaken
for phthisis.
Of
course, the
spot in which the diseased sounds are heard,
may
possibly assist you in your diagnosis, for if you

find the chief signs towards the
middle or base of
the lung, you will be almost sure that
case of phthisis (143).
it is
not a
Should the signs occur
at the top the diagnosis will
be more
difficult
and
the rational signs would have to be depended on.
In one case that I saw, the percussion, giving a

very
flat
sound, made us suspect gangrene.
EMPHYSEMA
RESPIRATION
81
RALES.
PHYSICAL SIGNS OF EMPHYSEMA OF LUNG.

anifest enlargement
76.
in the intercos-
phthisis causes de-
behind the clavicles, so
pression
As
spaces.
tal
emphysema produces a fullness in

the same part (8, 144).
The parietes of the chest move with much
effort, as if
from permanent distention, during the
respiratory act (10).
177.
On
percussion there
is
an extraordinary
resonance of the chest (97).
The
178.
respiratory
minished very much;
At times
ing (28).
than natural and
it
at
murmur
times
it
is
usually di-
wholly want-
is
the expiration
is
much
becomes, as
it
were, a con-
longer
stant, slight, sibilant rale.
179.
or
is
The
is
as in health,
diminished (56).
180.
The
sometimes
is
sibilant rale
is
frequent (62), and
mistaken for the respiratory murmur,
and during a severe attack of asthma (which

disease gives rise to) you will have
above described,
6
viz.
all
this
the sounds
sonorous, mucous, sub-cre-
82
&c.
pitous,
in
all
(62, 72, 73).
They
are usually heard
parts of the chest.
The sounds
181.
of the heart are transmitted
less clearly.
182.
is
In
tics.
to
Example.
This disease,
found almost exclusively
some
fact,
old asthma-
emphysema and asthma according
writers,
tient rarely
in its severity,
among
are cause and effect.
The
pa-
shows any physical signs of importance,
except during an acute attack of bronchitis, to
which emphysematous people are peculiarly liable.

after such an attack you will find him wheez-
Soon
ing,
and with a dry cough, and
tion.
there
On inspection, you
is
will
difficult
expectora-
perceive that although
labor in breathing there
is
tion of the parietes of the chest (10)
not
;
much mo-
the muscles
of the neck, however, are strained and often hypertrophied.
On
applying your ear to the chest,
the wheezing becomes
still
more manifest,
haps obscuring the natural respiration

ally the
sonorous rale
is
heard (62).
per-
occasion-
This
state
of things continues, perhaps, for a week or more,

unless remedies of an expectorant nature are used
under the influence of which a secretion of mucus takes place, the crackling rales (68) come on
all over the chest and some relief is obtained from
the severe dyspnoea,
&c.
If no relapse takes place,
the patient recovers from the acute attack in a
PULMONARY APOPLEXY. DULLNESS

week
RALES. 83
But the habitual
or fortnight longer.
to dyspnoea remains, with a
liability
rounded swollen aspect
of the chest (8), and increased resonance on percussion, (96) and
somewhat diminished
respiration.
PHYSICAL SIGNS OF PULMONARY APOPLEXY.

of the lung, commonly,
disease
since the times of Laennec, called
pulmonary apoplexy, from

sisting of a
its
con-
deep congestion with ex.
travasation of blood into the cellular structure
When
of the lungs,
severe,
184.
murmur
it
is
a very rare disease.
causes dullness on percussion.
Absence or roughness of the respiratory

in the part (28).
185. Crackling around the edges of the diseased

part (68).
There may be
186.
a slight alteration
in the
resonance of the voice, when compared with the
sound
in the healthy
187.
lung (80).
Haemoptysis happening in a
which you are
case,
is
Example.
satisfied is not tuberculous,
the only sure sign of apoplexy of the lungs.
The
physical signs will give you the extent of the
As an idiopathic
we meet with.
disease.
rarest
disease
it is
one of the
84
PHYSICAL SIGNS OF DILATED BRONCHI.

dilatation of the bronchi, the voice
becomes more resonant

even pectoriloquy
tube be very
A bronchial
189.
cavernous respiration
190.
constant
much
(41), or perhaps
heard (42).
is
mucous
make one
191. Percussion
all
altered,
192.
it
is
usually
Example.
ry, I
not materially altered

is
slightly
in early
monary symptoms, but
ill,
if at
my room
into
until five
haemoptysis.
life
diminished (98).
A youth walked
when he had
found that
base and
at the
suspect the disease (76).
and said he had been quite well

previously,
some months,
rale for
in a person not very
posterior part of a lung,

to
one
if
enlarged.
always heard in one particular spot
is sufficient
(51, 52) and
caused,
is
minutes
On
inqui-
he had severe pul-
that since that he
had been
usually in good health, though liable at times to

a cough.
ed
As
the haemoptysis was slight, I expect-
to find little or
no physical
signs.
was
sur-
prised to find that he had cavernous (42) and
bronchial (41) respiration, with pectoriloquy (52)
and bronchophony (51) throughout the whole of

left luncr.
This side had a contraction as from
the
old pleurisy (142).
BO
EXAMPLE.
DILATED BRONCHI.
I inferred that these signs of
the respiration and voice were of a chronic nature
and not
at all
Otherwise,
connected with his acute attack.

should have been obliged to suppose
hepatization and cavities to have come on in the

young man without previous sign. The contrac-
my
tion of the chest confirmed
er, the
My
suspicions.
explanation was, that in former times,
when young-
lung had been compressed, and upon re-
covery from the pleurisy, the pulmonary parenchy-
ma
not being able to expand
lymph over and
in
it,
itself,
owing
to firm
the bronchi had yielded to
the pressure of the external atmosphere, and had
become
dilated in proportion to the absorption of
Three months afterwards

young man died of tubercles developed in the
other lung, and the bronchi, enormously dilated,
filled up the major part of the lung over which we
the fluid in the pleura.
the
had heard the tubal sounds, &c.

193. Dilated bronchi
you
may
to think that the case
deceive you and lead

is
one of
should have been deceived, had
man above-mentioned
haemoptysis occurred.
phthisis.
not examined the
within five minutes after the

If I
had seen him a week
or fortnight afterwards, I might have imagined a
condensed lung, or even that cavities had been

formed.
error.
There
is
no sure defence against
You must examine
accurately
all
this
the ra-
86
tional
symptoms and compare them very
carefully
with the physical, and usually you will be able to

However, a dilatation such as
decide correctly.
I have never met
making up your mind
rarely occurs.
the above very
In
with another case.
you must have reference to the spot in which the

If heard in the lower portions
rales are heard.
of the lungs, where they are heard usually in dilatation of the bronchi, you will of course have less
fear of phthisis.
may
If at the apex, the physical signs
absolutely deceive instead of helping you
(143, 162,80,81).
PHYSICAL SIGNS OF (EDEMA OF THE LUNG.
=^x
arely do cases of oedema of the lung

produce any change of sound on
percussion, or
if at all
but slightly diminished.

i/v~/
195.
The
there
is
altered
merely a change of
vesicular respiration
is
it is
At times
note.
usually obscu-
red by a minute crackling (70) heard in 10 (fig.

18), most distinctly, because that is the posterior
and lower part of the organ.

196.
The
is
normal.
87
(EDEMA OF THE LUNG.
Example.
197.
Pulmonary oedema,
as a idi-
opathic disease, I have never seen, and do not beIt is usually a
lieve in its existence.
consequence
of some malady that causes dropsical effusions
elsewhere
&c.
fine (70),
usually
such as a disease of the heart, tumors,
You
will generally
such as
it is
hear a crackling that
louder and the bubbles seem larger,
and
more moist (sub-crepitous,
signs
may
may
is
observed in pneumonia, but
is
last
73).
an indefinite period of time
These
;
they
cease, under remedies, producing absorption,
and subsequently reappear.
COUGHS, HAVING NO PHYSICAL SIGNS.

,hese cases are different from bronchitis
(
105
or
).
phthisis,
without signs,
But they have frequently
made me anxious about a patient, because they made me suspect phthisis

and I have no doubt they will trouble you. I
have met this symptom, commonly, in females
below the middle age. Usually the throat has been
and on examination the fauces have
The cough has been loud and
appeared red.
complained
of,
88
Warm
"barking."
commonly
has
weather or a change of
relieved
it,
but
it
air
has always been
most inveterate and intractable under the use of

remedies.
It
has been connected with no other
severe symptom.
patients; viz.
these cases, I have

lent
cough
There
is still
another class of
In one of
the distinctly nervous.
known aphonia and
to last for
most
vio-
months, and then suddenly
disappear.
199.
is
The diagnosis in
sometimes
difficult.
these two classes of cases
Yet,
if
we
are accurate in
the investigation of the rational and physical signs,
we
shall generally
mer
be able to decide.
class, the fact that the
cough
In the
symptom, or with nothing connected with
some wandering pains about the

of coughing
and
for-
exists as a single
it
save
chest, after a
fit
in the latter category, the ner-
vous, hysterical, character of the patient, and the
absence of
all
physical signs about the lungs in
both, are generally sufficient indications to an ac-
curate diagnosis.
PHYSICAL SIGNS
RELATING TO THE
CIRCULATORY ORGANS
CIRCULATORY ORGANS.
LMOST
all
the physical
signs of diseases of the heart
are less
sure
indications
of the kind and degree of

disease of that organ, than
the physical signs found in
diseases of the lungs
are
indications of the characters
and degrees of disease
in
them.
If you keep
this remark in mind while reading the following

rules, and carry it into your subsequent practice,
you
will save yourself
from many a hasty and
er-
roneous diagnosis.
201.
The
rules in regard to the position,
of the patient
),
&c.
apply to the examination of car-
diac diseases, as well as to that of pulmonary

complaints.
92
made with the padownward

about an inch lower than it is when he is lying
Hence
on the back; it is also tilted forward.
202. If the examination
is
tient in a sitting posture, the heart falls
arise differences
on percussion, auscultation,
&c,
the signs being lower in the erect than in the hori-
There
zontal posture.
will
likewise be greater
dullness on percussion in the erect than in the
horizontal position.
203. In examining the heart, mediate
is
usually
better than immediate auscultation (IS), for wiih
the
stethoscope
you can examine small
spots,
without being confused by the sounds from the adjacent parts.
much
greater
This point,
moment in
as
we
shall see, is of
auscultation of the heart,
than in our examination of the lungs.
nock recommends very strongly the

oscope.
have never found
it
Dr. Pen-
flexible steth-
necessary (22).
In our examination of the circulatory organs we
make
use of inspection, palpation, mensuration,
auscultation, percussion, and finally, if
auscultatory percussion.
need be,
CARDIAC DISEASES.
93
PALPATION.
INSPECTION.
^=\ nspection commonly shows a very
motion of the heart, that
about the sixth rib
but in a case of
hypertrophy,
or
heart, or of
aneurism
of dilatation of
sation
may become much more
neck
also
diseases
slight
perceptible
is
10
),
the
the pul-
manifest.
The
should be observed, because various
of the heart
produce a great pulsa-
tion of the carotids, or of the jugular veins, in
which there
is
usually
manifest to the sight

ly, a
but
tumor forms either
little
At
10).
if
any motion
times, though rare-
in the
back or
front, in
consequence of an aneurism pressing through the

ribs (8).
In pericarditis, with effusion, there
prominence of the
is
somewhat
left breast,
raised (8).
strikes a little outside

it
left
is
nipple
In hypertrophy the apex
and higher up than the spot
usually appears in (275).
may form over
and the
Sometimes,
tumor
a great vessel and cause a pulsa-
tion to be perceptible.
In such a case, nice diag-
nostic powers will sometimes be needed.
94
PALPATION.
alpation should be attended
to in
all
or
no
diseases of the heart.
205. In health, there
impulse
when
felt
is little
the fingers are
placed over the apex of the heart,
between the
fifth
and sixth ribs on the
left breast.
In diseases, hypertrophy and dilatation, especially

the former, you
may
get a very strong impulse,
even through the clothing.

observable over a
whole of the
with effusion
is
is
It
some
is
so.
or chronic disease
of the aorta
In pericarditis
destroyed (260).
It
low type (215).
fevers of a
sometimes intermitting.
always
may, moreover, be
larger space, even the
breast (275).
impulse
all
very feeble in
It is
it
left
much
In some old persons
Great irregularity in an acute

is
Aneurism
always a bad sign.
may cause
a pulsation through the
sternum about the second or third rib (336).

behind the clavicle we may find
it
in
Or
aneurism of
the subclavian (347), and near the lower part of

the back in disease of the descending aorta (346).
206. Palpation gives the peculiar
frcmisscmcnt cataire.
thrill
It is so called
called
because
it
produces to the end of the finger, gently applied to

apart, a sensation similar to that
of a cat that
is
purring.
It is
felt
on the chest
most distinctly per-
CARDIAC diseases;
mensuration.
95
ceived over some aneurisms of the arch of the

aorta.
It
may however be
diseases of the heart.
felt in
various valvular
It usually indicates serious
obstruction of the blood in
its
passage through the
heart (14.)
MENSURATION.
ome use mensuration, but
in compari-
son with inspection, auscultation and

percussion,
it is
writer,
done
much
use in
An
named
has,
instrument,
however,
rarely of
diseases of the heart (19, 17).
cyrtometer,
been recently invented by a French
to
with
mark more
the
over a heart that
eye,
is
accurately than can be
the various
prominences
diseased (262).
AUSCULTATION OF THE HEART.

elicate changes
in the
sounds and
impulse of the heart are the chief

elements in cardiac auscultation.
209.
The sounds
ral, diminished,
are either natu-
augmented, absent,
increased in number, irregular, changed into or
accompanied by abnormal characteristics.
96
The
210.
dull
natural sounds are two
and hard, and most distinct below
about the
fifth rib
the second
is
the
left
first is
nipple,
sharp and quick,
and most evident about the median line and between the second and third ribs. * The first sound
depends upon many conditions, the most important
of which
is
the muscular contraction of the ven-
But besides
tricles.
this are the
motion of the
mitral and tricuspid valves, the impulse
of the
heart against the walls of the chest, contraction of
the auricles, the rush of the blood from the ventricles, all
owing
having an influence.
The
second
is
to the regurgitation of the blood in the aorta
and pulmonary artery against the semilunar valves

in those vessels.
The sounds in health take place in reguFrom the commencement of the first
211.
lar order.
sound
time
to its return, a little
occupied.
is
by the
first
and the
rest.
Of
less than a
this,
one half
is
second of
occupied
sound, the next quarter by the second
last quarter
by a period of almost entire
Dr. Pennock states that the sounds over the
right cavities are of a "
more
acter than those over the
clear flapping " char-
left.
* Dr. Williams represents them by the words " Lubb

tup." I should prefer " Lubb tuk." Pronounce these
and apply your ear
to a healthy heart,
derstand this description.
and you will un-
CARDIAC AUSCULTATION.
The sounds
212.
97
SOUNDS.
are of course heard most dis-
where they
tinctly over the spots
originate.
Thence
they radiate, being generally heard less distinctly
over the right breast than over the

back,
they are perceived
course of the aorta,
at the left
umn, and generally more

left
than the right back.
left.
On
the
somewhat along the

of the vertebral col-
clearly throughout the
At
the top of the right
back, they are scarcely perceptible.
We
may
add that the second sounds, whether healthy or

diseased, are transmitted along the aorta and pul-
monary
213.
artery
The
more
readily than elsewhere.
following diagram, taken from a larger
drawing, made under the direction of Dr. Pennock

of Philadelphia, will serve to show the position of
the heart, and of
sternum and
distended.
diagram
its
It will
valves.
during
life,
when
fully
be well to study carefully this
in order to get a definite idea of the va-
rious parts in which

to hear
valves with reference to the
to the ribs,
we should
auscult in order
most clearly the sounds from the different
98

Fig. 29.
a Vena cava descendens.

b Pulmonary artery valves, lying midway between
the second and third ribs, half an inch from the left edge
of the sternum.
c
Left auricle, only a small portion of
above the third
it
visible
rib.
d Aortic valves, lying under the median line of the

sternum, and on a level with the lower edge of the third
rib.
the
e Mitral valve, represented by
, lying between
point of union of the third rib with its cartilage, and the
upper edge of the junction of the fourth cartilage with
the sternum.
m Tricuspid valve, represented by

> extending
under the sternum from a little below the level of the
third rib of the left side, to the lower edge of the fifth
rib of the right side.
n Right
ventricle.
o Left ventricle, almost concealed by the right
p Right, auricle, distended and fully seen.
CARDIAC AUSCULTATION.
The
214.
following diagram
of the ac-
motions of the heart, shows the times
tual
the different sounds are
curs
astole
tole,
made and
at
which
the impulse oc-
their relation to the periods of systole, di-
and rest; the relation of the systole, dias-
and
rest, to
each other and to the impulse
The
externally.
active dilatation
rest
felt
converging straight lines indi-
cate active contraction;
of
drawn from the
Hope and Pennock
descriptions by Drs.
99
DIAGRAM.
the diverging indicate
the 'parallels point out a state
the waving, converging and diverging
lines indicate passive contraction
Supposing the pulse
and dilatation.
to be at sixty per
minute
one
half a second will be occupied by the ventricular

systole,
and
of a second
this
causes the impulse; one quarter
will
be occupied by the diastole, and
the same time by the state of rest.

Fie. 30.
/
Systole.
Active
>
First sound.
Impulse.
l
Diastole.
2d sound.
/
1
CL
Rest.
CO
Dilatation.
f.
Diastole.
c:
VENTR
\
\(
zn
m
Co
\
Collapse
from blood
falling into
ventricle.
[Dilatation
with venous blood.
<\>niract'n.
100
INFERENCES FROM THE ABOVE.
214
a.
ventricles are con-
While the
First.
tracting, the auricles are dilating.
214
b.
Second.
While the
ventricles are dila-
ting, the auricles passively collapse, and allow their
blood to flow into the ventricles, during about two

thirds of the period of the diastole,
veins begin again to
214
c.
Third.
fill
gradually distending
becoming swollen
finally,
contract with a sudden jerk
more blood
filled
the
During the period of ventricu-
lar rest, the auricles are

til,
when
the auricles.
un-
to their utmost, they
This throws
a little
into the ventricles, previously nearly
by the blood that had fallen into them from
the auricles, and they are again
stimulated to
active systole.
THE SOUNDS OF THE HEART.

215.
when
They
are diminished in cases of debility,
the heart
is
soft or flaccid (205), as in fe-
some cases of hypertrophy, (275),

when the heart moves with difficulty, as from
vers
also, in
congestion
(260).
also,
in pericarditis
with effusion
Simple diminution of the sound
is
not,
however, sufficient to enable us to decide upon the

existence of disease, or upon the nature of
it.
THE CARDIAC SOUNDS.
They
(216)
are
101
augmented after exercise,
in in-
flammatory excitements of the system, mental emotion,
&c.
in
some nervous patients they
sometimes
at a
the patient
are heard
distance of two or three feet from
Andral).
Formerly a loud sound was
considered an evidence of dilatation of the heart,

but
now
it is
considered to
mean nothing
of itself
(277).
known an individual, a chlorotic

whom, frequently, the first sound was
217. I have
patient, in
wholly absent, and returned only after some hours.
This patient was able
to work,
and had no very
evident signs of organic disease.
sound was probably owing
The
absence of
to the sluggish
con-
tractions of the ventricles.
218.
four
The sounds sometimes
in number,
mony between
are three
owing probably
to a
the two sides of the heart
course there must be four sounds

parts contracting at the
are heard
and even
want of har-
of
same moment only two

owing to unequal
laud says, that this change in the

is
for
or perhaps they are
repetitions of the ventricular contractions.
heard,
but similar
Bouil-
number of sounds
indicative of serious disease of the heart
or pericardium.
219. Irregularity of the sounds and motions of

the heart
itself,
may
exist without organic disease.
therefore, especially if not permanent,
By
it is
102
little importance, but it becomes a more serious

symptom when combined with other signs such
of
dullness on percussion, and the va-
as increased
rious types of bellows
Many
murmur, &c. (223).
have this irregularity as a constant
old persons
symptom, while
what seems
in health, and,
at first
sight very peculiar, they have regular pulsations
only
when
affected with
some acute
disease.
ABNORMAL SOUNDS OF THE HEART.

220.
Among
the abnormal sounds
striking as the bdloivs
murmur.
It
without serious organic disease.
cause
it
times in patients enfeebled by any
it is
very frequent in chlorosis and after
severe haemorrhage.
It
may be
caused, in peculiar
constitutions, by any over-exertion by
respiration
up
be present
For example
at
heard
is
none are so
may
is
which the
accelerated, such as running, going
stairs, coitus,
&c.
In general,
it
may be
said to
be, at times, produced by any functional or organic
change which, without absolutely causing disease

of the heart,
221.
What
may
I
yet obstruct
its
motions (315).
have stated above applies almost
exclusively to the mildest
form of the bellows
murmur.
222. There are several degrees to this sound,
which, although they are called by different names,

as they
may run
into each other,
and may
all
be
SOUNDS
BELLOWS, FILING, SAWING.
103
caused by the same disease, I prefer to consider

as one sound, varying in
its
greater or less degree
of harshness.
223. In
its
mildest form,
it is
slight, short
and
breezy, the slightest prolongation of either sound
of the heart (311 bruit de
comes the pure
ciently indicates
The
fiet, Fr.).
indicating
also
we
its
Then
name suffi-
Fr.).
its
characteristics (bruit de souf-
filing sound (bruit de rape, Fr).
its
the decided
gives
souffle,
bellows sound, and
nature by
its
appellation,
roughness (289).
first
Finally,
hear the loudest and roughest of the whole,

the sawing sound (bruit de
The
Fr).
viz
last
two, rarely exist as constant symptoms, un-
less they are
scie,
caused by some organic disease of
the heart (297).
224. Occasionally
sical note,
which
is
these sounds have a
all
mu-
resembling the cry of a young bird,
sometimes heard some inches from the
chest.
225.
The
causes of this sound are, according
to Andral, 1st, any difficulty in the passage of the
blood through one of the orifices; 2d,

the
same through the
cation in the play of the
tumor compressing
it;
of
3d,
ural contraction of the muscular
heart; 5th, increase
a reflux
some modifivalves; 4th, some unnat-
orifices
of
its
7th,
fibres
of the
impulse; 6th, some

obstruction by adhe-
104

two layers of the pericardium
sion of the
chlorosis,
will
&c. various
add to the above, that I have met
clavicle in
has heard
some
it
early cases of phthisis.
in
it
8th,
diseases of the system.
pneumonia.
Dr. Graves
presume these
cases may, however, be referred to the
mentioned by Andral.
under the
first
cause
most formidable num-
ber of causes truly for a young auscultator to decipher

will,
Be of good courage
The
mystery
generally, be easily unravelled if you truly
study a case
off than
or, if
it is
not,
you
will not
be worse
your elders (312 to 3 15).
226. These sounds,
when
constant, usually in-
dicate a disease of the valves of the heart of such

a character, as to cause a disturbance in the cur-
rent of the blood
and
as
such diseases may either
of a regurgitation of the curbecomes necessary to study the morbid
obstruct or allow
rent,
it
sounds arising therefrom with reference not only,

1st, to the spots
where they are heard,
the time at which they occur

during, or subsequent
but, 2d, to
whether before,
the action of the parts
to,
that cause the healthy sound.
227.
The following diagram serves to illustrate

we have been speaking of. This plate
the places
represents the outlines of an auricle and ventricle
with the aorta and

ventricle;
its
branches.
aortic orifice
A. auricle, V.
b auriculo-ventricular
DIAGRAM FOR PLACES OF MORBID SOUND. 105

Fig. 31.
The
orifice.
direc-
tion of the arrows rep-
resents the currents
hence
aortic
evident
is
it
obstruction
of the
would
orifice
be heard more up the

aorta than in the ventricle (297), while an
insufficiency of
it
and
consequently regurg-
2 would
itation
slighter
be
and rather more down in the ventricle,
though by no means absent along the course of

Obstruction 3 of the mitral valve
the aorta (302).
would produce
a very slight sound,
heard chiefly over the

but slightly,
left
if at all,
Insufficiency 4 of the
would be
focus and
same would be louder
tinct, or, perhaps, absent
and much
less dis-
along the carotids (289).
Similar statements might be

tricuspid
it
its
along the carotids (283).
but over the ventricle chiefly
the
and
ventricle as
made
in regard to
and the pulmonary artery valves
(294, 296, 307 309).
227.
tfcf"
N. B. All these remarks must be taken

for, in actual life, we can rarely
with limitations
analyze the sounds so clearly.

in the hospital at
strong bellows
have seen a case
Boston, in which there was a
murmur for some
time, but no dis-
106
ease of the valves was found at the autopsy
simple
hypertrophy of the heart and obstruction of the

blood in the lungs, were the marked conditions.
But the most remarkable case,

that given by Dr. Graves,* in
ease of the aorta with bellows

ventricles,
will be well to
caution,
murmur
and none over the aorta.
for definiteness
as a
which there was
is
dis-
over the
Nevertheless,
of purpose, as an auscultator,
it
study the diagram and the remarks
thereupon.
228.
The
following diagram
is
intended to pre-
sent an idea of the times, at which these sounds
occur with reference to the various movements,

the sounds and the impulse of the healthy heart.
It
is,
in
fact,
the
same
as Jig. 30,
(214), and
represents exactly what that did, but, in addition,

gives the times of the morbid valvular murmurs.
Fig. 32.
From
From
obstruction
insvfficiency
of semilunar
of auriculoventricular
valves.
valves.
VENTR
AURI
From
insufficiency
of semilunars; sounds
lasting
times
this
ai
thro'
period.
rn
(A
\z/
r^
From
obstruction
of the
auric, vent,
valves.
* Clinical Medicine, page 922, Dublin, 1843.
DIAGRAM FOR VALVULAR MURMURS.
228
a.
From
this
diagram we perceive,
107
first,
morbid murmurs, from obstruction of the
that
se-
milunar valves, occur during the ventricular systole,
and near the time of the impulse of the heart
that
murmurs from
insufficiency of the
same valves
immediately succeed the systole and impulse, and

that, if the disease is severe, the
sounds may con-
tinue until the next systole, thus causing a contin-
uous bellows sound.

229. Second. That murmurs, from obstruction
of the semilunar valves of the aorta and of the pul-
monary artery, occur at the same time with murmurs from insufficiency of the mitral and tricuspid
valves. How then are we to decide between them ?
By
observing the places
at
which the healthy
sounds are most distinct (fig- 29), for those spots

are the foci of the morbid sounds, and, moreover,
by remembering that the aortic and pulmonary

artery sounds are, generally speaking, transmitted
up along
their respective canals, fig.
whereas the
auriculo-ventricular
31 (227),
murmurs
are
chiefly limited to the ventricles (290, 297).
230.
Third.
We
see that sounds, arising from
obstruction of the semilunar valves, or insufficien-
cy of the auricido-ventricular valves, will generally be louder
than others, because produced by
the strong contractions of the muscular ventricles.
231. Fourth.
We can understand
how
a sound,
108
from insufficiency of the semilunar valves of the

aorta especially, may be continued through not
merely the diastole, but the period of rest of the

ventricle.
From
232. Fifth.
left for
it
the slight spaces of time
the feeble contractions of the thin auricles,
becomes
evident
that
only
all
consid-
is
This actually oc-
erable disease of the valves.

curs, and
mur-
slight
mur can be produced, even where there
morbid sounds are sometimes imper-
ceptible, even
when
there
is
a very great obstruc-
tion of the auriculo-ventricular orifices.
233. Sixth.
It is
plain that a
murmur from
may
obstruction of the auriculo-ventricular valves
occur
the same time with the second sound, or
at
just before the
is
to
said to occur
A priori,
however,
it
234. Aortic sounds

said by Dr.
may occur at both periodsfrom obstruction have been
Hope (297)
to
resemble the whispered
or "r," and to be very superficial.
sounds,
one
think so from the fact, that
then an active contraction of the auricle.
I believe,
"*"
it is
at the latter time.
would be induced
there
By some,
first.
most commonly
from
word " awe."
Aortic
insufficiency of valves, resemble the
Murmurs from
obstruction of au-
riculo-ventricular valves resemble "
who"
those
from insufficiency of the same valves have the
same
tone, but they are
much
louder,
frequently heard (302, 294, 289).
and more
PERICARDIAC SOUNDS.
235.
French writer speaks of
late
ment-like character
which, though
109
to the
difficult
tinct to his ear,
a parch-
sounds of the valves,
of description,
is
very dis-
and indicates an hypertrophy and
thickening of the valves
not, however, in so great

degree as to cause any real obstruction to the
passage of the blood not enough to prevent these
;
valves from fully performing their functions.
am
not aware of having ever heard
PERICARDIAC
235
In
some appear
a.
it.
SOUNDS.
health there are none.
In disease
that are of infinite importance in en-
abling us to form a correct diagnosis.
236.
Sound of new leather (bruit de
This sound
cair neufj.
heard in the earliest * stages of

pericarditis (258). It is not very common
thereis
fore
hear
you must not be surprised

it.
It is like
if
the creaking of
you do not
new
leather
;
and
heard when the two layers of the pericardium are rough and stiff from inflammation.
It
it is
disappears
when an
effusion of fluid takes place
into the pericardial sack
because, of course, the
two layers are then separated.

* Dr. Graves (Clinical Med., 910, Dublin,
1843),
in which a distinct musical murmur
mentions a case
preceded the creaking sound.
110
237. Pericardial rubbing sound, called by
and fro sound, occurs

(259) with effusion of lymph, or
writers to
some
in pericarditis
in
any disease
of the heart that causes a roughness of the pericardial layers.
In pericarditis,
it
may be heard
beginning of the disease, and follow the
at the
leather sound; but

disease,
when
it
usually appears later in the
the absorption of a quantity of liquid
previously effused, allows the two layers to

in
contact (2G3).
It
resembles in
come
characters
its
the rubbing sound heard in pleurisy (128); and

it
is
very superficial.
It
may be
distinguished
from pleuritic sounds by causing the patient to

hold the breath, and then the sound will evidently
be perceived to occur during the action of the
Occurring
heart.
carditis,
it is,
in
effusion in peri-
after a large
some degree,
a favorable sign
though some writers doubt whether any adhesion

of the pericardium, of which this sound
is
the fore-
runner, can be otherwise than unfavorable.
238. Sometimes in case of an effusion of fluid

into the pericardial cavity there
is
churning sound heard (2G1
It is of little
b).
washing or
im-
portance, and rarely heard.
239. All these pericardiac sounds are said to be
*more
superficial,
and are more subject to changes
than the valvular murmurs.
think that such
the case.
* Graves' Clinical Medicine.
is,
Hi
IMPULSE OF THE HEART.
THE IMPULSE OF THE HEART.

other element used in auscultation
The
240.
of the heart
is
It is
slight.
This
the impulse.
is
usually very
synchronous with the contraction of
the ventricles, and almost synchronous with the

radial pulse.
and
felt
In health,
it is
scarcely perceptible,
in a very limited space between the fourth
and sixth
ribs,
on the
left
breast (2C5).
241. Like the sounds of the heart,
it
may be
natural, diminished, absent, quickened, augmented

in force, or irregular.
242.
It is
diminished in various diseases, as
ening of the organ
in fever
soft-
by pericardial effu-
sions (2G0); and usually by dilatation of the heart

projecting
(277), and an emphysematous lung,
may produce this effect.

sometimes absent, under similar, but
over the heart,

243.
more
It is
severe, circumstances; for instance, peri-
carditis (201 a) with effusion
and hydro-pericarthat it cannot
dium may push the heart away so

reach the parietes.
244.
by
all
It is
quickened, by emotions of the mind;
acute febrile diseases
by great haemorrhage
by the approach of death, &.c.

con24.3. It is augmented in. force by those
impulse.
and
sounds
the
ditions that quicken
But
it is
most strikingly increased by hypertrophy
112
THE YOUNG TETHOSCOPIST.
(275)
a
much
and, in this case,
frequently extends over
it
larger space than usual, and
may be
strong as to jar the bed on which the patient
246. Irregularity
is,
is
sometimes natural; that
persons are subject to
years, and
it is
so
lies.
it
from their
earliest
not then a serious symptom.
curious circumstance in these cases
is
that usually
during an attack of disease the pulse becomes reg-
Old persons are peculiarly liable to this.

Under other circumstances, when combined with
other rational and physical signs of disease, it may
ular.
be of great moment as indicative of valvular

ease (258, 292).
to
I think
it
meet with idiosyncrasies
irregularity
sign
for
is
not very
whom
in children in
occurs in any disease.
dis-
uncommon
If no other
present, in these cases, I care but
little
it.
PERCUSSION OVER THE HEART.

difference of note (99)
is
usually
perceptible, in healthy persons, be-
tween the two
breasts, the left being
rather duller than the right.
space, in which this difference

ceptible (93), begins
on
a level with
The
is
per-
the second
PERCUSSION OVER THE HEART.
and about a
rib
finger's breadth
from the
113
left
sternum, and gradually widening on the sixth
may be
viz.:
in
rib,
it
there two and a half or three inches broad
from the right side of the sternum over
one inch of a line
This space
is,
from the
let fall
at times,
but generally there
a small spot, at
is
about the junction of the
left ribs
some
carditis or hypertrophy, exists, if
extensive (275).
The
considerable influence,
mented when
forward
in
with their car-
left
flat-
nipple (260),
and you may be sure either that there

the heart or that
dull
lower part,
In health, this
ness never extends outside of the
ment of
nipple.
left
its
to with-
no where completely
tilages, that is evidently flat.
ards
of the
is
displace-
disease, as peri-
you
find
more
it
position of the patient has
the
dullness being aug-
an erect posture or when leaning
and, of course, the flatness extends tow-
either side that the patient
may be
lying
upon.
248. Various diseases of the lung modify
Emphysema
tends to
make more resonance
it.
over
Pneumothorax does
more marked degree, and at the
the cardiac region (177).

the
same
in a
same time usually presses the heart out of

place (166).
its
wise tends to thrust the heart from
its
usual place
(130), and augments the cardiac dullness.
tended stomach
8
usual
Pleurisy, with large effusion, like-
will
A dis-
sometimes encroach upon the
114
cardiac space, and cause increased clearness, or

dullness, according as
The
liver,
when
it is
filled
with
air or food.
enlarged, also encroaches in the
same way, always, of course, augmenting the
dull-
ness (See Auscultatory Percussion, 389).
248
Its
a.
own
diseases modify the sound on
Pericarditis, with effusion of fluid,
percussion.
(260), and rupture of the heart with an effusion of
blood into the pericardium, hypertrophy (275) and
augment the space of dullness.

by some to produce the
Atrophy
of the organ will of
(271).
dilatation (277)
Endo-carditis
same
effect
all
is
course diminish
dium.
It
said
it.
Some
has never been
talk of air in pericar-
my
fortune to meet
it.
ARTERIES.
INSPECTION OF ARTERIES.
nspection
in diseases of the heart (275,
292) very frequently affords a visible

increased pulsation of both carotids.
similar local pulsation in any part
may
lead to the suspicion of aneurism (335).
115
PALPATION OF ARTERIES.
250.
tumor over the artery may, however,
cause a similar pulsation
hence
arises a neces-
Chlorosis
sity for a cautious diagnosis.
is
apt to
produce local pulsations, in the carotid or cceliac
example (280).
arteries, for
PALPATION OF ARTERIES.
imple increased throbbing in a part
.;
dicates merely increased action
eurism
((>)
^W
sat
'
may give,
in
on tne peculiar
in-
an an-
addition to a pul-
thrill called
>
purring
sensation (fremissement cataire) (14,
206)
this,
however,
is
not constant.
ination of the radial pulse
portance
at times,
in
in all diseases
by
its
is
The exam-
of the greatest im-
of the heart.
It
irregularity, either organic
suggests
changes
chronic diseases, or an inflammatory condition
in acute attacks (246).
A full pulse, in
any chronic
trouble of the circulation, points at hypertrophy,
and usually without great obstruction of the aortic

valves
(275).
small,
irregular,
or dicrotic
pulse indicates a disease of the mitral valve, pre-
venting the free passage of the blood from the auricle into the ventricle,
beat
is
liable to
and consequently
occur (292.)
double
116
MENSURATION OF ARTERIES.
ensuration
is
never used save
in
the case of a great prominence of
some aneurism,
the
as of the arch of
aorta (344),
the
abdominal
aorta, or of the popliteal artery.
AUSCULTATION OF ARTERIES.
Tfrir^N y auscultation we always obtain a
very slight sound, and an impulse
over the various arteries of the body.
These indicate nothing of importance; but,

strong local sound (340)
(336)
felt in
the part,
in cases
if it
of aneurism, a
heard and an impulse
is
is
cause any prominence of
A tumor, over a
the external skin (344, fig. 34).
healthy artery, may produce the same effects (343).
A bellows murmur not unfrequently

aneurism.
This sound used
attends a local
to be considered
very important as indicating aneurism.

ent,
it
has
At
pres-
much less value, except when connected
with other signs of the same disease.
117
Chlorosis (220), prolonged haemorrhage,
254.
and anhaemia or any undue pressure of the stethoscope frequently produce bellows
arteries
(220)
drawn from
may be
its
hence, be
this
murmur
murmur
in the
wary of inferences
merely, however rough
character.
VEINS.
INSPECTION OF VEINS.
ulsation of the jugular veins
is
not
unfrequently the result of any severe

disease of the heart, causing patency
of the tricuspid valves,
and conse-
quently a regurgitation into the auri-
and veins (296).
cles
phenomenon
similar
is
observed in some peculiar cases in which the capillaries of the
body seem to allow the force of
the heart's action to be continued directly through
them
into the veins.
ed by the
blood
course
is,
;
The two may
fact that the

in the
be distinguish-
course of the current of
former case, contrary to
while in the latter
it is
its
usual
only the natural
current augmented by slight pulsations.
118
PALPATION OP VEINS.
disease of the veins
is
never recog-
nised by palpation alone, but this

affords generally similar re-
method
sults to those given in the last section.
AUSCULTATION OF VEINS.
arely
is
there any sound produced
in the veins; but in certain cases,
example, in chlorotic females
for
in
hemorrhagic, and
patients; in
all,
in
in fact,
any cause, have less fibrine than usual
anhaemic
who, from
in the blood,
a sound called bruit de Diable or Devil's noise,
heard (311).
It
was named by Bouillaud and
sembles the sound produced by a toy.

lar to the bellows
that
it is
murmur of
continuous.
cases, musical in
its
It
is
re-
It is simi-
the arteries, except
becomes,
in very
marked
character, reminding one of
119
VEINS.
the whistling of a violent wind.

ble,
It is
very varia-
and depends much upon the degree, and pe-
culiarity
of pressure, exerted by the stethoscope
Under too great
on the vein.
ceases.
a pressure
think I have observed
it
wholly
it
most distinctly
when only one edge of the instrument has
rested
on one half of the right external jugular.
It is
augmented when the vein
and
sterno-mastoid
muscle are made tense, by turning the head strong-
which you are ex-
ly to the side opposite to that,
amining.
It is
right jugular.
may appear
most commonly heard only
in the
In severe cases of hsemorrhage
in other parts.
nomonic of no serious
This sound
is
it
pathog-
disease.
PHYSICAL SIGNS OF PERICARDITIS.

uring the
that
is,
first stages of the disease
before any effusion of fluid
has taken place, a musical
murmur
has been heard by Dr. Graves* (236).

I never
heard
it
but
* Clinical Medicine, Dublin, 1843,
when
the two
page 910.
120
move
layers of the pericardium are dry, and

freely than usual
upon each
other,
owing
Iofs
to their
congestion, the sound like the creaking of new

leather (bruit de cuir ncuf),
where
in the
there will be
may be heard any
cardiac region * (230).
some
Probably,
irregularity in the motions
and
sounds of the heart, and perhaps, though rarely,

a slight prolongation of the
first
sound (223), ow-
ing to the difficulty that the ventricles have in con-
may be
absent, or they
tracting.
All these signs
may be of
so short a duration, that
have any signs but those of a

259. Second.
we may
not
later date.
rubbing or
to
and fro sound
(237), similar to that heard in inflammation of the
pleura (128), occurs
when lymph has been thrown

have been made
This sound is much more
out, and the pericardial layers
very
rough thereby.
frequently heard than the signs already described.
When
is
any
difficulty arises as to
whether the sound
caused by the heart or by the pleura,
if
you
re-
quest the patient to hold his breath, you will be usually able to decide, for if
the sound will continue.

varieties observed
it
be caused by the heart

It is liable to the
in pleural
same
and other rubbing
* This will vary in character, from a gentle sound,

like the rustling of silk, to a rasping, grating, or croak-
ing.
(Hope on Diseases of the Heart,
nock's Edition.)
p.
175, Pen-
121
Some say that in this stage a bellows

murmur (223) is, at times, heard. It may be so
but were I to hear a distinct bellows murmur
(77)
sounds.*
I should suspect endo-carditis (269.)
Third. These sounds will
2G0.
and instead of them you
will
all
disappear,
have (in consequence
of an effusion of fluid taking place into the pericardial sack), an indistinctness
of the sounds of the
heart and a great diminution,
if
not an entire ab-
The latter happens when the

great.
The space usually dull
sence ofthe impulse.

effusion
is
very
(248 a) becomes two, three, or four times larger

than usual.
ple,
If you find dullness outside ofthe nip-
you may be sure that considerable effusion ex-
Sometimes
ists.
a vibratory tremor is felt in this
case.t
The respiratory murmur
261. Fourth.
much obscured
the lung
is
or if there
pushed aside to
is
very
and
a great extent, there is

I
have known
want ofthe respiratory murmur
to be observ-
an entire absence of the sound.

this
is
a large effusion,
A man died a short time since
General Hospital in
this city, over
at the
Massachusetts
whose
liver
was
felt
and heard a rubbing sound resembling the creak of new

At
It occurred on any motion of the parts.
leather.
membrane was found covwas not rough, and scarcely explained the phenomenon.
the autopsy a very delicate

ering the liver.
It
f C. J. B. Williams's Lectures.
122
able from the second rib to the base of the chest,
and from beyond the right edge of the sternum to

the outside of the
201
will
a.
With
left
this
nipple.
diminished respiration there
be a diminution of the sounds and of the im-
The
pulse of the heart.
wholly
latter,
the pericardium
lost, if
is
may be
much dis-
in fact,
very
tended (215, 242, 243).
261
At
b.
period likewise
this
is
sometimes
heard a washing or churning sound, caused by the
motions of the heart in a
You
262. Fifth.
of the
and
left
breast,
fluid (238).
will perceive a
prominence
when compared with
the right,
pressing out of the intercostal spaces in the

cardiac region (204). *
a
As
263. Sixth.
valescence from
all
the effusion subsides, and con-
these signs will begin to disappear
when
the layers of the pericardium
contact,
we may
commences,
the acute disease

:
and, finally,
come again
in
hear as in pleurisy (128, 237)
* It has been proposed to use a
" cyrtometer "
to
measure the prominence caused by any disease of the

heart and its membranes.
(Manuel de diagnostic des
maladies du cceur precedes de recherchescliniques pour
servir a
Andry )
to
me
1
.
etude de ces affections, par

I
le
Docteur Felix
have never seen the instrument, but
it
seems
that inspection will generally afford us all the in-
formation that
is
really necessary.

the rubbing sound again, and
as
it
it is
123
favorable so far
indicates diminution of the effusion (237).
This rubbing sound may begin
in
one
spot, for
instance, near the junction of the third rib with
the sternum, and extend thence over the whole car-
diac space, or
it
may be
limited to a small spot.
when convalescence is
may disappear, and
all the operations of the heart may become perIrregularity of motion, &c. may
fectly normal.
however remain, and gradually hypertrophy of the
264. Seventh.
fully established,
Finally,
the signs
all
heart will probably ensue, with
all
its
train of se-
vere physical and general symptoms (275, 6).
265. At times, after an effusion and the conse-
quent contraction of the adjacent parts,

that there
at
is
drawing
it is
said
in of the intercostal spaces
each movement of the heart.

266. Example.
Nothing
is
more
indefinite
than the rational signs of pericarditis.

possible to be sure of
its
existence, unless
recourse to the physical signs.

case
is
as follows.
healthy, or,
A man
is
most
It is
common
seized, either
more commonly, when
im-
we have
when
affected with
rheumatism, with a pain, either very severe or

very slight, about the cardiac region.
is
it
more common
This
is
At times, however, there

no pain. Dyspnoea may come on, and, though
is usually slight, it may become orthopncea.
the
case.
124
With
these
may come
other,
more or
signs of trouble in the circulation

ness,
oedema of the
legs,
&c.
but
less
marked,
such as dizziall
these symp-
toms may be absent, and the disease would be

wholly latent
if
to inform us of
we did not have the physical
its
If you
existence.
the patient quite early, you
may
signs
happen to see
obtain only signs
of some obscure disease about the circulatory sys-
tem; but of what character you may be doubtful.
Any
alteration either of the sounds or of the im-
may
lead
to suspect pericarditis or endo-carditis. If
any
pulse, any irregularity of the rhythm, &-c.
you
physical sign be combined with any local rational

sign, such as a pain in the region of the heart, or
palpitation,
mented.
&c,
your suspicions would be aug-
in
connection with these signs, or
If,
without them, you hear a superficial creak like the
sound of new leather (236), you may be certain of

your diagnosis, and decide that it is a case of pericarditis.
and
if
it
Yet
it is
quite rare to hear this sign;
be absent you must not necessarily infer
that pericarditis does not exist.

will, in
If
you hear
it,
you
your mind's eye, see the two layers of the
pericardial sack, congested and drier than usual,
and hence moving with
less ease
than ordinary
yet not sufficiently obstructed to present the next
phenomena; viz.: rubbing sound (237), which

may come on within forty-eight hours from the
125
the third
it
Hearing
attack.
first
and fourth
would be most
rally,
over
all
either locally,
this,
rib,
about
near the sternum, where
likely to
commence,
the cardiac space, you
or,
gene-
may be moral-
you have pericarditis to deal with

and that the opposing layers of the pericardium
are even then covered with a tolerably dense, and
ly certain that
moist membrane, the motions of which, upon each
This
other, produce the sound in question.

last
moment
is
for active, efficient treatment, if
have not used
it
before.
At
this period
the
you
you may
perceive some obscurity in the movements of the

heart (205)
little
percussion (248 a).
no increased dullness on
or
be not checked, an effusion of
and
if
the disease
fluid will
take place
In a few hours,
will separate the layers,
push back the heart,
destroy the rubbing sound, and you will have ingreat
stead,
diminution in the strength of the
sounds of the heart (215); absence of impulse

(243) perhaps a sort of churning or washing
;
sound (238),
fluid
in
consequence of the dashing of the
against the
walls of the distended sack
dullness on percussion, which
may extend from
the
second rib to the cartilages, and from the junction

of the cartilage and right ribs to beyond the nipple
of the
left
side (248 a)
and, finally, an absence of
respiration over a large part of the
left
breast (ow-
ing to the pushing aside of the lung), with pronii-
126
nence of the same point
204
These are
).
the most perfect and undoubted physical signs
of pericarditis.
If the disease
is
prepared to yield,
these signs will diminish, the prominence will
all
disappear, the dullness on percussion will

ish
perhaps the rubbing sound
heard, and then
it
will
dimin-
be again
will
be very favorable, as
indicate an absorption of the fluid (237).

usually
commence near
and pulmonary
artery,
will
may
extend thence over
last for
weeks
impulse and the sounds of the heart will be
heard more distinctly, and gradually

will disappear.
But
this is not the
for palpitation usually
will
the origins of the aorta
and
the cajdiac space, and
it
It will
remains
all
the
and
symptoms
common
for
felt
course,
some time, and
not unfrequently will this symptom go on augmenting until the patient will finally sink under the
signs of confirmed hypertrophy of the heart (275).
267. Chronic Pericarditis presents very
much
the same signs as those described for the acute

it is useless to speak of them.
Moreover, they are frequently connected with hy-
disease, therefore
pertrophy.
PHYSICAL SIGNS OF CARDITIS.
127
PHYSICAL SIGNS OF CARDITIS.
^nhe
present state of science
that I doubt
dare
make
is
such
whether any one would
a differential diagnosis so
acute, as the recognition of carditis,
uncombined
endo-carditis.
firm
my
And
as
with
pericarditis
or
Laennec and Hope con-
view, I shall pass on.
PHYSICAL SIGNS OF ENDO-CARDITIS.
eldom can we be
entirely satisfied of
the accuracy of our diagnosis of this

disease, for there
is
no
perfectly, un-
doubted, physical sign of endo-cardi-
But we can make an approxima-
tis.
tion thereto.
The
chief sign
(220), either with the

the heart.
This
is
first
is
a bellows
murmur
or second sounds of
usually dependent
upon ob-
128
some of the orifices of the

heart.
This bellows murmur, in an acute attack,
may vary. Usually it is soft, but it may be very
struction, by lymph, of
rough, and, generally, unless the affection

lieved,
it is
and then
murmur
it
re-
(223).
270. In addition to
larity
is
when the disease becomes chronic,

may pass through all the phases of this
so
this,
we may have an
irregu-
and an increase of the impulse (245), ow-
ing to the irritation of the organ.
271. According to Bouillaud, you should find
an enlargement of the ordinary dull space
in the
cardiac region, owing to a swelling of the heart

as in inflammation of any other part (248 a).
271
a.
Finally
unless the disease
is
checked,
permanent obstruction or regurgitatory murmurs

(226) may appear, with signs of hypertrophy (2*5).
272. Example.
ly the result
lining
This disease
membrane of
during
this
most frequent-
is
of a rheumatic inflammation of the
Not uncommonly,
the heart.
disease, the pains will
leave the ex-
more
tremities, and a dull aching sensation, and,

rarely, a severe pain, will
cardiac region.
It
be
may be
felt
in or
near the
so slight, that, fre-
quently, the patient will neglect to speak of

will
it,
and
think himself wholly recovered, so freely
he able to move.
cessary
and,
if
Thus
daily auscultation
endo-carditis
is
is
is
ne-
commencing, you
PHYSICAL SIGNS OF ENDO-CARDIT1S.

will probably hear
129
some prolongation of the
first
sound (223). This may, perhaps, be very slight,

but more important, from that very fact; because,
at this time,
you
tively speaking,
there
will
have the disease, compara-
under your own hand.
Generally,
not a very marked increase of the impulse
is
of the heart (240, &-c), and rarely an enlargement

of the dull space on percussion (248 a).
This
may be checked and your patient may get

well
the bellows murmur may either subside entirely, or may remain, as a mere trifle, not sufficient
to impair the health.
This period you may overlook, or you may be unable to check it, and your
stage
patient, in a few weeks, will probably complain of
palpitation and of
murmur
The
some dyspnoea.
bellows
then will have become more rough (223)
and the impulse stronger (245).
Remedies may
relieve, but they rarely cure in this stage of the
disease
&c,
for the
will
lymph deposited on the
valves,
have too firmly obstructed the valvular
The disease may continue for months,
apparatus.
and the patient may have the same physical signs

and no great deterioration of health or he may,
from inattention to the rules of health, become
;
more
ill,
and be
finally affected
with hypertrophy of
the heart (275) and the symptoms usually follow-
ing
in the train
of this combination.
This may be
given as an example of an acute attack, but the

9
130
more quietly and tiie

For the peculiar sounds,
majority of cases progress

signs are less distinct.
and the results produced by endocarditis,
affect-
ing the various valves, see from 294 to 316.
DIAGNOSIS OF ENDO-CARDITIS, ETC.

uring most of these acute diseases,
it is
no importance whether you make

an exact diagnosis, or remain satis-
of
fied
with the general idea of an in-
flammation of one or more of the textures of the heart.
If you have decided that your
patient has an acute inflammatory attack of either
the covering
(pericarditis), the substance
(car-
membrane of the heart (endo-cardo not stop to make an accurate diagno-
ditis), or lining
ditis),
sis,
most speedy and

diseases
carditis
is,
Let them be
but use your remedies instantly.
of the most active character.
may
is
efficient
worker,
God
speed the
for either
entail a lifetime of misery.
of these
Endo-
the most formidable; but pericarditis
generally speaking, of no small moment.
nally, I suspect that they are generally
combined; and then you may have
more or
Filess
their various
DIAGNOSIS
signs
want
ENDO-CARDITIS, PERICARDITIS. 131
combined together
to
make
more
the following table

carditis
But
in the case.
if
you
refined analysis of the signs,
may
help you.
I shall unite
and endo-carditis under one head.

ENDO-CARDITIS
PHYSICAL SIGNS.
AND
CARDITIS.
PERICARDITIS.
Tenderness
pressure of cardiac
Usually none.
space.
Prominence of
Sometimes.
Decidedly, after
effusion.
the chest.
Impulse of the
Strong, usually
irregular, and
heart.
may
give a purring sensation.
Not strong
first,
usually
at
null
when effusion has

taken place; irregularity, not marked rarely if ever
purring sensation.
;
Sounds of
the
heart.
Rarely bellows
Bellows mur
mur; deep-seated; murmur, especialheard more gene ly of a rough
rally
and a
over
the character
chest.
sound of creaking
leather or washing
;
sound,
perficial
ally
Results of percussion.
quite
su-
and usu-
more
limited.
Dullness rarely Dullness may be

so extensive as in very extensive and
usually it is great,
pericarditis.
and if it be not so,
is
disease
the
slight.
132
SIGNS OF HYPERTROPHY OF THE HEART.
ure hypertrophy rarely exists without

some lesion of the valves. Its signs
are
an increased, heaving impulse
(245), moving the whole of the
left
times,
breast, and perceptible at

through the clothing; * more dullness on percus-
sion (248 a)
upward and outward of
a throwing
the apex of the heart, and the chief point of impulse
nearer the nipple than in health (204)
is
lar action, not necessarily but frequently,
severe cases you will
find at
irregu-
and in
times a diastolic
or back stroke; diminution of the sounds of the
heart (215), and often asoufflet with them (223).

If there be hypertrophy of the
left
ventricle
be
felt at
&c. (251).
the carotids,
If the
and
may
the aortic orifices be free, a strong impulse
same
case occur with the right ventricle, a pulsation of
the jugulars
vere cases,
is
frequently
there
is
the lungs being pushed
* This
is
it
was
In
se-
owing
to
met with a case of hyperowing to an obstruction
slight,
in the motions of the heart.
(255).
away (261), with promi-
usual, but I have
trophy in which
felt
respiration
less
HYPERTROPHY OF THE HEART.
133
nence of the left breast (207). The diagnosis of the

varieties of hypertrophy, given by authors under
names,
different
(viz.
diminished cavity
cavity normal
augmented
is
first,
hypertrophy with a
hypertrophy with
third,
in size), is
as treatment
second, hypertrophy with the
of
In a word,
concerned.
said that, by percussion,
you
will usually
recognise the difference between the

for
cavity
importance so
little
first
it
far
may be
be able to
and third,
the dullness will be over a larger space than
normal
in the third, but of
normal size
in the
first.
When
call-
EXAMPLE OF HYPERTROPHY.
may occur
276. This
at
any age.
ed to your patient, you will probably find that he

has been suffering more or less with trouble about
the heart.
scure
Sometimes the symptoms are very ob-
perhaps, merely a sense of fullness about
the breast;
a tendency
to palpitation;
but the
may all go on very

and the countenance may appear even more
than usual.
In this case, you may have no
general functions of the body

well,
fresh
physical signs save a stronger impulse to the ear
(245), and even that
may sometimes be mistaken

mind. As the dis-
for the result of agitation of
ease goes on, a greater extent of dullness on percussion
becomes perceptible
pressed away
the lung
seems
the action of the heart becomes
134
stronger;
its
apex does not strike between the
and sixth ribs as usual (204), but higher up

and farther from the sternum, or over a larger
fifth
The symptoms
space than usual.

the dyspnoea
health
is
is
more marked
good.
less
Finally,
the distinct signs given above
over a large space (205)
cussion (247)
(215)
vere rational
dropsy,
you
will
have
all
a heaving impulse
great dullness on per-
some
and, generally,
murmur
are greater;
and the general
diminished sounds of heart usually
movements (219)
lows
irregularity in the
and sometimes a strong
With
(223).
these
bel-
come more
se-
ruined health, orthopncea,
signs,
&c.
SIGNS OF DILATATION OF THE HEART.
r^HERE
is
dullness over a larger space
than usual
(248
a).
The sounds
are sharp and clear so that they are
very
much
impulse
and much
alike
in character
the
than in health (242),

less than in hypertrophy (275).
The
respiratory
murmur
is
is
less
likewise diminished or ab-
DILATATION OF THE HEART.
135
Such
sent over a larger space than usual (28).

the signs given by authors.
But
doubt
if
can always make an accurate diagnosis of

affection.
The
fact
is, it is
it
in cases
this
rarely seen except as
connected with hypertrophy.
remember
are
any one
Still
is
it
well to
where the sounds are clearer
than usual, and both are very
much
alike,
when,
according to Williams, they resemble the words
"Lup tup"
instead of
"Lubbtup"
(210); for
these signs, in any disease of the heart,
bined with a
slight, soft impulse,
when com-
and an augment-
ed dullness on percussion, should lead you
to sus-
pect dilatation (242, 248 a).
278.
The
following case illustrates
somewhat
the effects of dilatation of the heart without serious

lesion of the valves, also the effects
gulars
upon the
ju-
from hypertrophy of the right ventricle.
A. B. aged 49, mariner, entered Massachusetts

General Hospital, Dec. 31, 1841.
He
a great sufferer from rheumatism,
and had had
dyspnoea, palpitation, oedema,
&c,
had been
occasionally
Nine months previous to his entrance, his symptoms had increased, so that he
lost the power of laboring, and dropsy had ensued.
At his entrance he was evidently suffering from sefor four years.
rious difficulty in the circulation.
The
physical
signs noted on the day after his entrance were, im-
pulse of heart, generally, rather feeble with an occa-
136
THE YOUNG STETHOSCOriST.
sional, very forcible
and double stroke (246).
Neither sound was prolonged (223), the second
was
than usual.
less abrupt
Percussion not dull
over a great extent in the cardiac region (247).
On
the next day, great irregularity of motion (246) and
was observed (242).
feeble impulse
slight
Finally
pulsation of the jugulars was perceived,
especially in the right side of neck (255).

tient died sixteen days after entrance,
The pa-
and
at the
autopsy the heart was found nearly twice as large

as
usual.
The
parietes of the right side were
twice as thick as usual.
Those of
slightly hypertrophied, but the
sides
were enlarged.
The
the
cavities
valves were
left
were
of both
all
well.
SIGNS OF ATROPHY OF THE HEART.

tjthors speak of this, but I have never
seen
it
it
so as to be able to recognise
before death
that
it
will ever
nor do I believe
cause such serious
trouble as to need your attention.
NERVOUS DISEASES OF THE HEART.
137
NERVOUS AFFECTIONS OF THE HEART.

use
this
word, nervous, for want of a
You
better.
know what
will
you have been
after
time.
means
important that you
very
It is
it
in practice a short
should recognise these affections and
them from organic
distinguish
diseases.
The
physical signs are, a normal sound on percussion
increased impulse with a fluttering, disagreeable to

the patient (244)
mur
dency
mur
at
times a variable bellows mur-
(223), usually with the

to a bruit
in the veins
first
sound and
a ten-
dediable (257) and bellows mur-
and arteries
and not unfrequent-
ly a pulsation in the latter (251).
281. Example.
chlorotic female, or a ner-
vous or debilitated man,

toms.
life a
The
may
present these symp-
palpitations are so severe as to render
burthen, but rarely are the severer symptoms
You
may produce all of them by bad treatment. I
knew a female who had been bled every fortnight
dyspnoea and orthopncea, or cEdema found.
for nearly
two years,
for,
what was supposed
severe disease of the heart.
anhaemia.
The
She was
to be,
in a state
of
throbbing of the heart and rapidi-
ty of its fluttering
were extraordinary, and during
138
her attacks she suffered extremely.

a bellows
murmur, sometimes of
character,
is
was not
felt
In such a case
a very
rough
heard, but the impulse, in this case,
over a large space, nor was the dull-
The
ness greater than usual.
patient held her
hand over her heart, as if to restrain its motions.

She died and no disease of the organ was found.
The symptoms are always eventually aggravated
by the depleting treatment, and the improvement
under the tonic course
is
one of the most impor-
tant diagnostic signs.
SIGNS OF VALVULAR DISEASE.
any times
there
is
thickening mere-
with slight obstruction of the
ly,
movements of the valves, but not

enough to produce valvular murmurs.
recognises what
is
I have not heard
In these cases Bouillaud*
called a parchment-like sound.
it;
possible to recognise
but I can conceive

it.
As
it
it
to be
however does not
indicate any very severe lesion of the valves,
it is
of minor importance (235).
Maladies du
cceur,
&c, parle Docteur Andry
(262).
139
OBSTRUCTION OF THE MITRAL VALVE.
OBSTRUCTION OF THE MITRAL YALYE.

ecollecting
ventricle,
to the
^w
yja^V
is
force,
traction,
we
might, a priori, suppose
really
does occur, viz.:
any sound, caused by obstruction of this

usually imperceptible, and
it is
find evidence that there
orifice, is
times very
at all
Consequently, you may,
slight.
owing
generally slight,
is
with
projected into the
weakness of the auricular con-
happen which
that to
the
that
which the blood
an autopsy,
at
must have been serious
obstruction to the blood passing from the auricle
when there has been no
into the ventricle,
mark
before
tl
would be most manifest just
rst or dull
sound (233), and would be
life.
very likely to be continuous with
diagram (Jig- 32, 228) you
to
latter part
sign to
It
during
it
it.
By
referring
will see that at the
of the period of ventricular rest, the
auricle contracts smartly and dilates the ventricle,
which
there
At
is
latter
is
immediately begins
its systole.
But
another period manifested by the diagram.
the end of the ventricular systole, the auricle
most
dilated.
Suddenly an active dilatation or
diastole of the ventricle takes place, and the blood
from the distended auricle
falls
into
it
hence
this
140
obstruction-sound
after the first
may occur
just before or just
sound, and, in the
last case, it
would
be identical with the second sound, which occurs,

of course, at the
284.
mur
is
The
moment
the diastole begins.
point of greatest sound for this mur-
over the
left ventricle,
between the third and fourth
i.
e.
ribs,
{Jig. 29, p.
96)
and two inches
from the sternum.

2S5. Impulse oj the heart.
is
Irregular beating
almost always an accompaniment of an obstruc-
tion of the mitral valve,
owing
to the blood being
unable to pass rapidly enough into the ventricle

to
distend
Hence
it,
before
the ventricle
the
commences.
more small spas-
systole
makes two
or
modic contractions, and consequently impulses

one firm one, which occurs occasionally when the ventricle becomes full.
This irregularity is usually perceptible at the radial
to the auscultator's ear, to
pulse, but
sometimes not
so,
and the pulse seems
very slow, corresponding to the

heart, and not irregular.
full
beats of the
The amount
of irregu-
and inequality of force depends on the
larity
amount of disease (246, 251).

286.
It is
but right to state, however, that ac-
cording to Hope,* the same kind of pulse
may be
found, in softening of the heart, great pericardial

*
Hope on
Diseases of the Heart, page 360.
OBSTRUCTION OF THE MITRAL VALVE.
But
and polypi from endocarditis.
effusion
these cases there
is,
usually,
141
in
no valvular murmur,
and there are other signs diagnostic of each.

287.
give
mensuration and palpation
Inspection,
little
results of importance,
more than those
revealed by auscultation.
288.
The
following case illustrates what has
I have obtained it from Dr. Hope.*

" Dilatation and softening of all the cavities :
been
stated.
hypertrophy of the right ventricle

the left
of
fatal polypus.
Mrs. L
She had
27, 1829.
attenuation
great contraction of the mitral valve
red on the cheeks
n consulted
livid lips
me Dec.
a defined purplish
complexion elsewhere sallow
dyspno3a and palpitation, excited even by walking

across a room, and to excess by ascending a flight
of
frequent cough, preventing sleep
stairs;
con-
stant copious expectoration of frothy, viscous
mu-
cus, the temporary suppression of which, by sleep
or opiates, caused paroxysms of excessive dyspnoea
and orthopnoea; chilliness, particularly of the extremities
universal and extreme anasarca
cata-
menia regular; bowels open; pulse small, weak,

unequal, and intermittent
urine scanty and high
colored; thirst; anorexia.
Hope on
page 518.
Diseases of the Heart, Pennock's edition
THE XOUNG STETHOSCOPIST.
142
Complaint commenced ten years before
and was attributed
her,
saw
to difficult parturition.
The symptoms were always
greatly aggravated by
which she was particularly liable. She

frequently had slight oedema pedum, which subAlways felt best in a warm,
sided spontaneously.
" colds,"
to
humid atmosphere.
Auscultation.
Both were
Impulse imperceptible. Sounds.
short,
right clavicle.
of the heart.
flat,
and audible so
far as the
They were weaker on the left side

Murmur was not noticed. By the
usual diuretics and aperients, the dropsy was completely

little
removed
in six
weeks, the strength being
impaired and the appetite good.
She was
then suddenly seized with oppressed palpitation,

suffocative orthopncea, constant nausea, and overexhaustion, anxiety and jactitation.
The
dropsy
began to re-accumulate, the sense of suffocation
became agonizing, the pulse
failed entirely for
twenty-four hours before death, and she sank a
week
after the relapse.
Pulmonary apoplexy and engorgHeart double the natural size, and very
Right dilated to
Ventricles.
flaccid and pale.
double; its parietes were not attenuated, and the
column carneae were hypertrophous. The left
Autopsy.
ment.
was
less dilated,
and
its
walls were reduced to one-
third of an inch in thickness.
Auricles.
Right,
INSUFFICIENCY OF THE MITRAL VALVE. 143
dilated
parietes thin and diaphanous.
its
greatly
dilated,
most completely
firmly to
slightly
membrane.
cartilaginous,
Valves.
Aortic,
but unimpeded.
Mitral,
contracted by cartilage into a

mitted a writing
slit
which only ad-
Liver slightly enlarged,
quill.
granular, and of yellowish
Remarks.
This case
is
brown
color.
remarkable as present-
ing a degree of valvular contraction seldom
exceeded,
al-
with a polypus adhering
filled
lining
its
Left,
considerably thickened, and
if
ever
and as showing with how great an
amount of disease
may be prolonged for
life
a series
of years."
REGURGITATION THROUGH THE MITRAL VALVES.

289.
Auscultation.
The most
striking phe-
nomenon in this disease is a bellows murmur,

which may vary from the slightest breezy character up to the saw-mill
sound, according to the
kind of disease of the valve and to the amount of

that disease.
very rugged and at the
time permanently open orifice
is
supposed
same
to pro-
duce usually a rougher sound than when the valve

is
smoother but equally open (226).
of
it
290. This
the
Hope speaks
as resembling a distant whispered
first
murmur
is,
sound, because
who (234).
of course, connected with

it
must occur during the
144
systole of the ventricle
{Jig. 32, 228).
may
It
be so loud and long as to obscure the second
sound; but
tinctly
this is not usual.
It is
heard most dis-
between the third and sixth ribs
over the
left ventricle.
corresponding to the valve, and
is
Hence
slightly along the carotid.
{fig.
29)
from the spot
It radiates
heard
arises a
only
means
of diagnosis between this and disease of the aortic

valves, the
sounds from the
passing along
latter
the carotids and aorta, so that they are heard over a

larger space than these of which
ing (227).
we
are
now
treat-
This sound may be caused by anything
that causes any degree of patency of the valve, for
example, anything that contracts the chordae tendineae
by atrophy of the valves
by adhesions of
do.; by their dilatation in consequence of dilatation of ventricle
finally,
mental excitement
may
cause undue action of the organ, and a momentary regurgitation
may occur
(220, 225).
291. Percussion gives no characteristic signs.

292. Inspection, palpation and mensuration
ford
no certain signs of
this disease,
af-
though pal-
pation indicates at times an increased impulse of

the heart, from hypertrophy, which frequently,
though not necessarily, accompanies the disease.
An
irregular or dicrotic impulse at the heart, at
the carotid and radial arteries (251); with the
INSUFFICIENCY OF THE MITRAL VALVE.
purring tremor in the cardiac region (206)

wise very
293.
145
is like-
common.
The
following case illustrates the above
remarks.
T. aged 13, of a feeble constitution, and having suffered with chronic disease of the heart, entered the Mass. General Hospital, April 1, 1845.
He
was delirious and had been so
He
more.
for a
week
or
died six days after entrance, of tuber-
cular meningitis.
The
physical signs relating to
the heart, were a strong impulse over the ventri-
with a bellows
cles,
connected with the
murmur
first
over the same, and
sound, while the second
sound was normal. At the autopsy, the aortic and

pulmonary artery valves were normal, and held
water most perfectly.
through the mitral
The
valve. It
water passed freely
was thickened, opaque,
hardened, and contracted, as were likewise the

chordae tendineae and columnae carneae attached to
it.
In other words, there was exactly enough of
disease to seriously
valve,
into the
The
obstruct
the action of the
and allow the blood to be thrown back

auricle with each ventricular
heart was normal.
10
systole.
146
OBSTRUCTION OF TRICUSPID VALYE.

same physical conditions
s the
mitral valve,
you may refer
description of that (283).
must bear
First,
it is
in
to the
But you
mind these
facts
very rare that disease of the tricuspid
exists alone.
do not remember of ever seeing
but one case, and, in

slight.
exist in
case as in obstruction of the
this
that,' the
disease was very
Second, owing to there being usually very
slight disease, the valves are rarely obstructed in
Their murmurs resemble the
their operation.*
"who"
of the mitral valve (289).
295. For the spot at which the morbid sounds

resulting from
it
will
you may
refer to
see that
will
and
it
fifth
be heard most distinctly,
diagram
(Jig. 29, p.
96) and
be about the junction of the fourth
ribs with the right of the sternum,
and
extending up diagonally along the sternum.
REGURGITATION THROUGH THE TRICUSPID VALVE.

296. This, as a morbid change,
found (Hope).t
*
Hope on Diseases
f Ibid., p. 105.
not unfrequently.
is
almost never
refer to the last article for the
of the Heart, page 104.
Pennock, however, says
it is
heard
147
OBSTRUCTION OF THE AORTIC VALVES.

parts at which you shall auscult
and also to the
on regurgitation through the mitral valve,
article
for the principles
duced (289).
on which the sounds are proproduce a pulsation
It is liable to
of the jugulars, owing to the blood from the ventricles
being thrown back into the veins with each
contraction of the ventricles (255).
OBSTRUCTION OF THE AORTIC VALVES.

AUSCULTATION.
ome obstruction of these valves is very

common, and a bellows murmur of any
variety may be heard in consequence
It may simply prolong the
thereof.
first sound (223), or it may mask it by
a
sawing or rasping character (223).
It is
usually
heard most distinctly over the aortic valves, and

thence radiates, being less distinct as you go
farther
strongly
down
from the valve.

along the
the back,
It
carotids,
is
transmitted very
and
less
along the aorta (229).
one diagnostic sign between

the mitral valve (227).
It
this
distinctly
Hence
and diseases of
occurs during the sys-
148
tole of the ventricle.
The
to
It is generally
and sounds like a whispered
ficial,
impulse
is
very super-
"r"
or " s."
usually augmented (245),
owing
hypertrophy of the ventricle (275) from the
obstruction to the proper performance of
its
duty
of sending the blood over the body.
monly there
is
an irregularity in
to the vpntricle being obliged to
Very comthe beats, owing
make one or more
contractions to overcome that obstruction (246).

298. Palpation.
At times, there is a thrill
(206), as the purring sensation, but this
pen
in
may
hap-
any disease of the heart where there
The
great obstruction.
be small
if
there
is
is
pulse, at the wrist, will
great obstruction, though the
impulse at the cardiac region be very strong.

299.
Percussion.
larger space
hypertrophy.
owing
Generally dullness over a
to a distention of the heart or
This, of course,
poses a chronic disease.
ordinarily
There may
exist
sup-
no
ab-
normal dullness.
300. Inspection gives no results.
301. For an example of this combined with regurgitation or diastolic sounds, see (306).
REGURGITATION THROUGH THE AORTIC VALVE.

302. Auscultation.
The blood, not being retain-
ed by the semilunar valves, returns during the diastole of the ventricle.
Of
course
it
immediately
REGURGITATION THROUGH AORTIC VALVES. 149
follows after the second sound.
murmur
slight musical
or bellows sound would be thus produced,
either immediately following or
ond sound.
masking the
sec-
It would be heard over the aortic
valves {Jig. 29), less,
down along the
ventricle.
It
generally slighter than the sound from obstruction, and sounds like a whispered " awe " (234).
is
303. Inspection teaches but
The
trophy exists.
little
unless hyper-
may be somewhat
impulse
irregular, and, at times, a back-stroke
and the pulse
is
is
perceived,
jerking (246, 275).
304. Percussion and mensuration reveal nothing.
305. Palpation
may
Hope
give a
The
306. Example.
206).
thrill (14,
following taken
from
* will afford examples of the sounds usually
heard in the three conditions of the valves com-
monly found
causing,
in diseases of the heart, viz.
first,
regurgitation
disease
through the mitral
valve (289);
second, obstruction of the aortic
valve (297)
and,
the
third,
regurgitation
through
same (302).
V. aged 50, had a weak, irregular, unequal and

small pulse.
winded.
phy),
For three years he had been short
Impulse, natural (showing no hypertro-
(205).
musical note, loud, sounding
Hope on Diseases
150
close under the ear, an inch helow,
the sternal
the
first
and a
(The position,
sound of the heart (289).
viz.: over the mitral valve; the time, viz.
the systole, or with
first
sound, and finally
nution on ascending the ventricle;

cated the mitral valve to be
orifice
was
higher, a musical note,
became again
with the
still
audible, and
became
tinct over the aortic valves (297)
along the aorta where
it
cal note
was mixed with
ascending
first
superficial
This musi-
common murmur, which

Both sounds were
very indistinct along the pulmonary artery.

still
sound,
then two inches
seemed more
also heard along the aorta.
musical note
dimi-
perfectly dis-
than at the valves themselves (334).
was
during
its
and that the
On
insufficiently closed).
these indi-
all
seat,
its
little to
accompanied
side of the left nipple,
accompanying the
first
(The
sound,
and heard over the aorta, indicated obstruction of

the semilunar valves of the aorta, while the sound
becoming more
superficial,
above the aorta, might
lead to the suspicion that there was
some roughness
The second sound
of that vessel).
over the aortic
valves was tailed by a feeble though distinct blow-
ing like a whispered
creased on going
prolonged
(The
to
down
the
time, viz.
"awe"
(234), which de-
over the ventricle, and was
ensuing
ventricular
that of the
immediately connected with
it,
systole.
second sound, and

the place at which
OBSTRUCTION OF THE PULMONARY ARTERY. 151
this
was heard,
viz.
over the aorta, indicated re-
gurgitation, during the whole period of the rest
of the heart, through the semilunar valves of the

aorta) (302, 231).
OBSTRUCTION OF PULMONARY ARTERY VALVE.

isease of
this valve is a very rare cir-
cumstance.
Consequently, a mark-
ed sound connected with
uncommon.
In
fact, I
it
have suspicion of any disease
exist-
some
affec-
ing in the pulmonary artery without

tion of the aorta,
for
most never seen.
There
such a state of things

are
is
con-
do not absolutely deny the existence of
disease of this artery solely, but I

it is
is al-
some malformations
of this part, but in these cases, the trouble

genital.
very
is
should rarely
mean
to say that
very rare and that I have never seen a case.
308.
Still
therefore
it
the rules laid

orifice,
may be some disease of it, and

know that, by following
down for auscultation of the aortic
there
is
proper to
but changing your place of examination
to the left breast, off
from the sternum instead of
152
on
it,
you may generally come to some conclusion
{Jig. 29, 213).
mind.
in
Another
Usually
the
fact should
clapping
be borne
sound of the
healthy pulmonary artery valves will be heard,
when
even
there
serious aortic disease, with
is
loud and very marked sounds consequent there-
upon.
If,
therefore, in a case of serious disease
of the heart, with very morbid sounds, you

cover that this second sound
is
wanting, you
dis-
may
suspect disease of that valve.
But you must not
be sure of it,
murmur
for a
ularity of the
loud bellows
or irreg-
sounds and motion of the heart may
obscure the sound of the healthy pulmonary
arte-
ry valve.
REGURGITATION THROUGH THE PULMONARY ARTERY.

309. This likewise
The
seen a case.
less
than over the
is
very rare.
I have never
sounds, of course, would be

aorta and to the left
of
it
{Jig. 29, 213).
EXAMPLE OF DISEASE OF THE PULMONARY ARTERY.

310.
The
following case
is
very interesting and
quote from Pennock's edition of

Dr. Hope's work. *
instructive.
Hope on Diseases
EXAMPLE OF DISEASE OF PULMONARY ARTERY. 153
W.
S.
winded
aged 36, yellowish complexion
for ten years,
short
owing, she thinks, to
ing the chest against a post.
strik-
Dyspnoea on en-
trance; pain in scrobiculus cordis; ascites, oede-
ma. Pulse seventy, large,
full,
rather tense.
Great
dullness over the heart, prominence, pulsation and
purring sensation between the cartilages of the
second and third
left ribs.
(The
point was
last
immediately over the place of the pulmonary

tery).
Impulse of the heart,
ar-
much more extensive
and considerably stronger than natural,

ularly in the left precordial region.
partic-
Pulsation,
Sounds of the heart. The

was an extremely loud, harsh and superficial
sawing sound, extensively audible, and most so
in epigastrium.
felt
first
over the prominence of the second and third
(The place of
ribs.
the sounds indicated the pulmon-
ary artery as the most probable seat of disease).
Diagnosis by Dr. Hope.
more
side.
Hypertrophy and
dilatation of the heart, greatest
on the
still
left
Dilatation of the origin of the aorta, proba-
bly forming an aneurismal
At the autopsy the
facts
pouch towards the
were as follows
left.
Hyper-
trophy and dilatation of the heart, aorta contract-
ed
pulmonary artery
of four inches and a
dilated to a circumference
half.
154
PALPITATIONS IN DYSPEPSIA, ETCalpitation
tom
dents.
ally
is
a very
common symp-
in old dyspeptics,
and
in stu-
In these cases there are usu-
no severe
rational signs;
the
dyspnoea and palpitations being the

only marked ones.
There are no physical signs,
or they are but a slight prolongation of the sound
;
and sometimes
increased impulse,
at the first
part of the examination, which subsides in a short

time.
These negative signs may,
come of
great importance.
Not
at times, be-
unfrequently, in
purely dyspeptic cases, especially in females, you

may hear in the jugulars the bruit dcdiable (257).
I should consider this a favorable
it is
very rarely,
if ever,
omen
because
heard in organic diseases
of the heart or large vessels.
REMARKS ON VALVULAR DISEASES.
155
GENERAL REMARKS ON VALVULAR DISEASES.
REMARKS AND CAUTIONS ON VALVULAR DIAGNOSIS.
y considering what we now know of

diseases of the heart, and the comparative accuracy of our diagnoses
in all
these complaints, with what
the medical profession
Laennec
arose, the difference
mense.
The following
are
knew
before
seen to be im-
is
some of the important
advantages gained by auscultation.

First. Pericarditis
nised before death.
was never
definitely recog-
Since Laennec, Louis, Bouil-
laud, and others have written,
easy thing to recognise
it
even
it
has become an
in its earlieststages
(258).
Second.
The common
rational signs only of dis-
eases of the substance of the organ were
known
of course, therefore, none but the most general
and
indefinite results could be obtained.
must be evident even
This
to the greatest sceptic in re-
gard to the usefulness of auscultation.

Third. Formerly, the recognition of the
differ-
156
ences between organic and functional diseases was

at
times very
difficult, if
not impossible.
Fourth. Scarcely a quarter of a century has

elapsed since the time
when the
slightest
approach
to a decision of the particular valve that
eased was never thought

lowers of Laennec
liams,
Thanks
of.
dis-
Bouillaud, Hope, Louis, Wil-
Graves, Stokes and others
attempt to solve
was
to the fol-
we now can
these problems, and, in the
all
majority of cases, may, with a due degree of care
and by carefully weighing the
relative value of the
various physical and rational signs,
come
to an
accurate decision.
Then why should we complain, if, in some

we cannot determine the peculiar structural
disease that may exist ?
That such is the fact,
that mistakes are not unfrequently made by the
best auscultators, I know from having seen these
313.
cases,
errors committed, and from the writings of others.*
314.
Still
times, even
further
ought we to complain
good auscultators decide that
one of organic disease, when,

# Messrs.
lished
at
is
in fact, the heart
is
Graves and Stokes, a few years ago, pub-
their manifesto of unbelief in the
some of the
if,
a case
accuracy of
rules of diagnosis, from the physical signs
alone in diseases of the heart.
See Hope's case (310).
CAUTIONS ON CARDIAC DIAGNOSIS.

perfectly healthy, but interrupted in
157
action by
its
the influence of adjacent organs? *
315.
would, therefore,
make
the following
remarks, as warnings to the young auscultator.
Be
First.
careful about inferring too
much from
physical signs alone.
Second.
Do
not risk your reputation by too nice
a diagnosis.
Third.
If you
make an
error, comfort your-
self with the belief, that, perhaps, part of the dif-
and not wholly
ficulty lies inherent in the subject,
in your blundering ear
and judgment.
make many errors, still be hopehow much more clear-sighted you

are than those who have gone before you. Believe
that auscultation teaches very much although it
may be imperfect. Learn humility; but do not
Fourth. If you
ful, at
thinking
despair of becoming
Fifth.
Above
more accurate
all,
in future.
do not, from the physical
signs alone, imagine that you have found out a se-
vere organic disease of the heart,
when
perhaps,
nothing but a functional derangement really

that will
* See
mock your
New York
fatal
exists,
prognosis.
Journal of Medicine and Surgery
by Dr. Sweet, in -which notice is taken of a severe form of bellows murmur, in consequence of the
heart being pushed out of place by an abdominal tumor.
article
158
Example of my method of examining
316.
man who
appears, on inquiry, to have the symp-
toms of chronic disease of the heart,

tation, dyspnoea,
If possible, I
viz.: palpi-
perhaps orthopncea, dropsy, &c.
examine the patient
and recumbent posture.
remember
the erect
in
particularly
the rules already given (1, 202).

Inspection. I
remove
all
the clothing from the
chest and neck, and I observe
if
there
any
is
evi-
dent pulsation about the cardiac region, and,

there be any, whether
(245)
er
whether
it is
it is
it
and irregular
rolling
out of the right place, between the
sixth left ribs (205)
whether there
pulsation over the aorta
if
over a large space
is
wheth-
fifth
and
any local
is
or any unusual prominence over the heart (262) (remembering, however, on this last point, that a slight prominence
may exist, without any disease of the heart ow;
ing to a want of symmetry in the two sides of the

thorax
).
Passing
serve whether there
is
my
eye upwards,
or prominent distention of
there
is
rally.
them (255) whether

any unusual fulness about the neck geneIf any one of these signs exist I suspect or-
ganic disease.
If
all
certain of that fact.

as
it is
I ob-
any pulsation of the jugulars

;
of them occur
The
am
nearly
differential diagnosis,
called, of the particular disease, I refer to a
later stage of the
examination.
then proceed
to,
METHOD OF EXAMINING
317 Palpation.
pulse (205)
If I find a full heaving im-
especially, if
nected with the purring
of the auscultator
the heart,
if
IN CARDIAC DISEASE. 159
be irregular, or con(206)
is
a back-stroke (275), or an
irregular jogging motion (246)
of them are
felt,
my
if
these or any
suspicions are confirmed that

If there
serious disease of the heart exists.

thrill
the head
if
raised with every action of
is
there
it
thrill
is
over the aorta (251), I should fear disease
there as well as in the heart.
318. Mensuration
may be of importance
in giv-
ing exactly the arc of the prominence of the chest,
but
never
ter for
me
make
use of
319. Percussion.
by
it
it.
Inspection
is far
bet-
(262).
I rely very
much on
learn the size of the heart.
this, for
If there
is
greater dullness than usual over the heart, especially if
it
extend outside of the nipple and beyond
the right side of the sternum, I fear hypertrophy
(275), dilatation (277) or pericarditis (260); the

first
usually, in a chronic disease,
and
decide
between these diseases by the examination of the

other signs.
320.
Finally;
I auscult,
first,
my
with
ear
to get a general idea of the sounds; but, in order

to distinctly localize the various sounds, the steth-
oscope
is
absolutely necessary.
Dr.
Hope
advises
us always during auscultation, to keep the hand
ICO
on the
do
I frequently find
pulse.
it
important to
so.
321.
If,
under these circumstances, with
in-
spection, palpation, and percussion favoring the
idea of
first
severe
of the heart, I
disease
a modification of the first
a simple soft prolongation of
rasping sound (223)
second,
hear
sound, whether as
it,
or the severest
if,
moreover, this
most distinct over the sternum about the

second rib, and it extends up the carotids, and is
sound
is
less distinct
third, if this
below over the ventricles of the heart

occur
at the
time of a strong systole,
I infer that the aorta is obstructed (297),
probably the heart
is
and that
larger than usual.
on the contrary, the same modification

of sound be heard after the second sound as a tail
to it, as it were, I should think, that the heart was
322.
If,
enlarged and diseased with aortic insufficiency
and regurgitation (302).

323. Again suppose the sound
;
down and towards

tinctly heard, or
carotids
the
left
perhaps not
suppose
it still
is
heard lower
nipple, and not so disat all
exists
heard alongthe
during the systole
of the ventricle and with the radial pulse, I should

infer that the mitral valve allowed the blood to
thrown back into the
left
auricle,
or,
be
in other
words, there was insufficiency of the mitral valves
MODE OF EXAMINING CARDIAC

324. Finally,
in
the
if
the sound
same place,
if
it
is
DISEASES. 161
very slight and
precede
immediately
either the systole or diastole, I should suppose
obstruction to the mitral valve (283)
case, the auricular contractions, at the
period of
rest,
would cause a
tempting to force
its
the systole of this
325.
slight
some
for, in that
end of the
murmur on
at-
blood into the ventricle before
last.
similar sound might be heard
when
the
flood falls from the highly distended auricle into
the ventricle at the beginning of the diastole of this

last (233).
fer to
To make
this
more evident
let
us re-
our diagram already used {Jig. 30, 214
and Jig. 32, 228).

Fig. 33.
It is evident, I think, that at the points
B, a fluid
auricle
is
into the ventricle,
sound must be produced.

11
of time,
rushing with impetuosity from the

and, of course,
This sound,
in
some
both
162
cases,
is
tible
it is
always slight
it is
sometimes impercep-
strongest at B, because there the auri-
cle contracts
and forces the
in the other case
it is
fluid
onward, whereas
simply a falling of the
fluid
from the auricle into the ventricle

(233).
325 a. Similar remarks might be made in regard to the pulmonary artery and tricuspid valves.
The
places, in which the sounds would be heard,

would be changed. Those of the former would
be transmitted up the carotids less than murmurs
from the aorta; and sounds from the tricuspid
would be perceived strongest under the sternum

{fig. 29, 213).
326. If instead of only one of these sounds I

hear several, as for instance, the sounds of mitral
regurgitation and of aortic obstruction and regurgitation, the
only inference
make
is,
that both of
these valves are diseased instead of one.
be confessed that sometimes

distinctly localize the sounds.
it is
It
must
impossible to
In such a case
think
it
do
inasmuch as I can at least be certain that I

have to deal with serious valvular disease,
so,
shall
and
scarcely worth the trouble to attempt to
in this case I settle
by percussion, or auscul-
tatory percussion (389) the exact size of the heart.
327. But, finally, supposing that the rational

signs have led
me
to
organic disease, and
believe in the existence of
I find
on inspection and
pal-
MALFORMATIONS OF THE HEART.
163
some abnormal impulse, but no increased

no morbid sound on
of course the physical signs become
auscultation
pation
dullness on percussion, and

;
the sheet-anchor of faith for myself and
and
may
tell
say I
him he has no
may be
risk of being so
ble
my
in
true, but the
small, whereas if I
make him
misera-
am satisfied
that the
patient I
and do myself no good.
number of cases
Very
deceived.
is infinitely
express a doubt to
my patient,
Some
severe disease.
which such a declaration would
be correct are not a few.
MALFORMATIONS OF THE HEART.

S^=\ f you
remember that these
are congenital
and that no hope can be entertained of

doing any good by treatment, you see
that
it is
of
little
practical importance
to attend to the physical signs.
vary in every possible manner.
lows sound
in the
is
the most
common, with
rhythm (223, 219).
They
Usually the belirregularity
164
SIGNS OF MALPOSITION OF THE HEART.

alpositions of the heart may be
congenital, or the result of disease.
The
congenital are those in which
most of the organs of the body are

exactly reversed in their position.
The
the
is
left
heart lies in the right chest, the liver in
hypochondrium
given off to the
left,
the arteria innominata
&c.
Inspection shows the apex of the heart beating

to the right of the sternum.
Palpation may give the same.

Auscultation and percussion prove the same
the sounds being heard at the right side of the
sternum, perfectly normal, and the percussion gives
;
dull
sounds on the right breast, while the
left is
clear.
MALPOSITION FROM DISEASE.

330. Pleurisy, pneumothorax, organic diseases
of the lung or abdomen

ly out
of
its
may
usual position
thrust the heart wholeither far
up towards
the clavicle, as in distention of the abdomen, or to
OF THE HEART.
POI/VPI
165
the right side, as in case of pleurisy of the
So, too, pleurisy,
side.
&c. of the
push the organ to the
Pneumothorax
left
right side,
left
may
beyond the nipple.
do the same, &x. (167, 140).

331. Inspection, palpation and percussion will
will
easily indicate this change, but
332. Auscultation
may
mislead you.
The
ob-
struction caused to the heart by thus being thrust
out of place, produces, at times, a bellows mur-
mur which may, by
its
rasping character, similate
Be
severe valvular disease.
careful of inferring
anything from these sounds when there
is
any
great change from the normal position of the heart

(314).
SIGNS OF POLYPI OF THE HEART.
^hat we can
sometimes suspect the ex-
istence of polypi or coagula in the

(S
am
heart, I
to
deny
can make
not disposed absolutely
but the cases in which

this diagnosis,
we
generally
occur when patients are in articulo mortis, or so
166
near death that
we can do nothing for
The symptoms
are an obscurity of the sounds of
the heart, and a bellows
some
irregularity of
murmur
their relief.
and usually
motion (223, 219).
DISEASES OF THE ARTERIES.
ROUGHNESS OP THE ARCH OF AORTA.

oughness, simply, without other
se-
rious lesion of the aorta, I do not
consider an affection worth
much
In connection with various
notice.
diseases of the heart
some importance, from
its
quite superficial bellows
it
becomes of
producing a roughened,
murmur, just at the upper

This sound, it is dif-
part of the sternum (223).

ficult to distinguish
from an obstruction-sound of
the aortic valves (297).
It is
but just, however, to
say that one able writer (Dr. Graves) has given the
report of a case in which there was great rough-
ness of the aorta, but no morbid sound was heard
along the aorta, but, on the contrary, a loud sound
appeared over the ventricle (227).
168
SIGNS OF ANEURISM OF ARCH OF AORTA.
efore the arch is so dilated as to cause

some absorption of the upper part of
the sternum and some prominence
When
nothing.
is
superficial perhaps,
tumor appears,
may
it
though distinctly seen to be
pulsating by the eye of the observer.

it
teaches
simple inspection
thereof,
Gradually,
project three or four inches from the level
of the sternum (Jig. 34, 344), and in this case the

pulsations
become
still
more evident (249).
Not unfrequently we can
336. Palpation.
an impulse and likewise a purring
tumor
is
thrill
is
not a proof of aneurism, be-
may be a tumor pressing on

may be normal (250, 251).
cause there
which
last
337. Mensuration
spection
Simple
very manifest to the eyesight.
impulse, however,
is
much
feel
before the
is
of
little
the aorta,
importance, for in-
better and supersedes
it.
It
may
be sometimes needed (252, 344).
Sometimes you may hear

338. Auscultation.
no sound or have no sign from auscultation.
For example.
very small aneurism of the
SIGNS OF ANEURISM OF ARCH OF AORTA. 169

arch,
which does not compress any important
may remain
part,
latent to auscultation.
339. But suppose
it is
size, but so situated as to
mary bronchi.
larger, or of the
same
compress one of the
pri-
In this case you may, with ob-
scure rational signs of disease of the circulatory

organs, find decided diminution of vesicular mur-
mur throughout the whole of one lung. One primary air-tube may be compressed and will then
allow, perhaps, only half
to enter.
some bellows murmur

340.
its
usual quantity of air
In this case, likewise, you
As
may hear
(28, 223).
the disease augments, a simple, clear
sound, or, more commonly, a bellows murmur,
sometimes very
distinct, like a saw-mill sound,
may
be heard towards the upper part of the sternum,

or behind, along the vertebrae, on a level with the
spine of the scapula (253).
This may become
very rough in
Formerly,
its
character.
was considered patlwgnotnonic of the

of blood through an aneurism.
It
Still further
if
buzz
merely sug-
gests an aneurism, but can never prove
341.
this
swift rushing
it.
the disease form a tumor
so large as to compress and push aside a portion
of the lung, there will

respiratory
murmur
to
bean entire absence of the

some extent on both sides
of the median line of the

Generally,
sternum
(28, 41).
however, this phenomenon does not
170
occur unless other signs, such as prominence of

the part (204), the purring
it
Of itself,
(206).
it
thrill,
&c. accompany
would not be pathognomonic
of aneurism, for though
it
should certainly lead us
to suspect aneurism of the arch of the aorta,

it
still
might be produced by any tumor lying directly
over the aorta (348 a).
342. Finally,
when
the disease projects as in
the profile plate given below (Jig. 34, 344),
tumor has the
thrilling feel (14,
pulsates (251)
and
is flat
206, 251)
if
;
the
if it
on percussion (101)
especially, if, com-
if the circulation is troubled,
bined with these,
we
find the
that there
343.
is
pulse in one wrist
we may
/ess than in the other,
feel
very certain
aortic aneurism (348 a).
Percussion.
Of
nothing until the tumor
is
course this indicates

of some size, and
then merely corroborative of other signs.
it is
When
the tumor augments so as to compress the parts
underneath, even
sternum, you
part (99).
if it
may
When
does not wholly reach the
get a change of note over the

it is
very large, especially
cause any prominence, you

ness (101).
The
will find
if it
complete dull-
diagnosis between this and a
malignant or other tumor over the arch may possibly be gained by auscultatory percussion
but I have no experience in that matter.
(390),
case of aneurism of arch of aorta. 171
Example of aneurism of the aorta.
344.
A. M., porter
The
follows
a patient of Dr.
account he gave of himself was as
Health, in early
Diseases of the
for
He was
Lungs, Nov. 20, 1839.

Perry's.
warehouse,
in a large wholesale
aged 44, entered the Infirmary
life,
good
seven years
before consulting us he had had dyspnoea and
cough without expectoration, and with these symptoms he had occasionally suffered from that period.
At
his entrance, there
was soreness
region and pain shooting to the
in the cardiac
left
shoulder and
arm hoarseness constant dyspnoea, and the

cough was increased with some expectoration.
The other functions were well. On examination
by inspection, a tumor (249) was seen, bounded
left
above by the clavicle and the upper part of the
sternum
at the left,
by a line
clavicle an inch from the
let
sternum
fall
from the
below, by the
cartilages of the third rib, and at the right, by a

line
The
drawn from the middle of the sternum.
tumor was circular and raised one quarter of an

inch above the surrounding parts.
On percussion,
the sound was normal every where on the chest
except over the tumor where
On palpation,
it
a purring sensation
over the tumor (251).
On
was
flat
auscultation, the res-
piration was well every where, except that
more
distinct
(101).
was perceived
it
on the right back than on the
was
left
172
(339), and that over the tumor

nearly tracheal (41).
were heard
it
was bronchial or
The sounds
of the heart
slightly over the cardiac region (215),
but on ascending the tumor they became, espe-
much more manifest. No belSome sonorous rales

(223, 253).
were heard on the back (02). The tumor contin-
ically the
ued
second,
murmur
lows
to
augment
till
the patient died.
The
invest-
ing skin became very thin, so that for months
seemed
it
as if
it
it
In November, 1841,
would break.
projected as represented in the plate (Jig. 34)
beyond the
line of the chin.
wore a metallic shield over
made
It
tumor and interfered with

and was so liable to be injured,
ble a
so formida-
his labor so
much,
that, for a time,

It
it.
he
was nine and a
half inches in circumference and projected about
one and
The
and
a halfinches
all
the muscles of the neck were very
developed.
his
above the level of the sternum,
sterno-mastoid muscles were raised upon
The accompanying
appearance
at that time.
it,
much
plate represents
1 is the tip of the
tumor, very thin and somewhat discolored, dark.
2, are the sterno-mastoid
the tumor.
muscles raised upon
CASE OF ANEURISM OF AORTA.
173
Fig. 34.
The
time he visited the Infirmary (June
last
22, 1842),
its
apex was three inches beyond the
level of the sternum,
and had a purplish aspect,
and the pulsation could be seen

from him.
stool
and the aneurism burst.
ways of
at a
great distance
In August, 1842, he went to the close-
Having been
his handkerchief into the aperture,
mained
al-
most cool temperament, he firmly thrust
until
where
he died, three days afterwards.
it
re-
At
174
the autopsy, an
immense aneurism of the arch of
the aorta was found pressing forward and causing
absorption of the sternum, and likewise backwards,
producing absorption of the bodies of several of

the dorsal vertebras.
ANEURISM OF OTHER PARTS OF AORTA.

igns like those mentioned
ceding section,
may be
in the pre-
present in an-
eurisms of the thoracic aorta.

physical
signs,
more manifest
at
however,
The
would be
the posterior part of
the chest than they would be in front.
There
is
diminution of the respiration on one side of the

vertebrae (339), and
prominence of the
ribs at their
junction with the same (335), the aneurismal buzz

(340), dullness on percussion (343).
346.
In
abdominal aneurism there may be
prominence, &c.
in
the loins.
with rational symptoms,

sis,
but
front,
we must
may
This, combined
lead us to a diagno-
be very careful in auscultincr in
through the parietes of the abdomen, not to
175
ANEURISM OF THE ABDOMINAL AORTA.
much stress upon any amount of bellows murmur that may be heard, for the pressure of the
lay
stethoscope on the aorta
apt to produce
is
For
it.
the signs, see those of aortic aneurism (335 to
343).
ANEURISM OF THE SUBCLAVIAN.

347. For the signs you
may have
the pulsation (251), the purring
bellows
murmur
as
(223),
in
(335 to 343), but the prominence
the tumor,
thrill
(14), the
aortic
aneurism
less
and about
is
the clavicle.
ANEURISM OF OTHER ARTERIES OF THE BODY.

348. For signs, see aneurism of the arch of the
aorta (335 to 343).
The tumor
will,
of course,
be in the part corresponding to the diseased

ry.
arte-
In the extremities, palpation will be of more
But this comes under

more than of medicine.
service than anything else.
the province of surgery
TUMORS OVER ARTERIES, SIMULATING ANEURISMS.

348
a.
At
subject, for
times, you
you may
hear a bellows
percussion,
ly,
may be
feel a
murmur
&c. (101),
in
doubt upon
this
pulsating tumor (251),
(223), and find flatness on

as in aneurism.
the diagnosis will not be difficult,
if
Ordinari-
we compare
176
the rational signs with the physical, and these
much
The
each other.
ter with
lat-
pulse will assist very
aneurisms; as aneurism of this
in aortic
tube frequently interferes with the arteria innominata or the left subclavian, and, consequently,
with one or both of the radials,

it
&c,
according as
encroaches upon and checks the current of blood
sent towards the origin of the former vessels.
348
6.
For instance, aneurism of the aorta
fre-
quently causes a difference in the pulse in the two

radials or carotids.
on the femoral
likely to
It
might have
arteries.
produce
a similar effect
tumor would be
course of the carotids, brachial or femoral
also present difficulties.
gland
will, at times,
appear
to pulsate,
we
will
tumor of the thyroid
protrude to one side, and will
giving the appearance of disease
of the carotid underneath.

swallow,
less
Aneurism along the
this effect.
By making the patient
see these tumors rise and
each act of deglutition, showing
it
fall
with
to be evidently
a disease attached to the trachea, and not an an-
eurism of the carotids.
tumors
will be
found
In like manner, pulsating
in the legs.
Frequently,
can, by deep pressure, separate the tumor from
bed and
raise
it
a little
and the pulsation

all
is
difficult,
Notwithstanding
relieved.
and requires
experienced surgeon.
its
from the subjacent artery,
these remarks the diagnosis
what
we
all
is at
times some-
the tact of the most
OBSTETRIC AUSCULTATION.
12
OBSTETRIC AUSCULTATION
dN
the course of
my
midwifery practice I
have frequently ausculted
labor,
will
and have heard
all
women when
in
the sounds that
be hereafter mentioned.
have made
use of them to satisf ymyself of the death

or
I
life,
and the position of the fetus.
have rarely ausculted
pregnancy.
I shall
make
So
in
that
in the
earlier
But
months of
most of the remarks that
regard to
these periods I shall
quote from others.*

350.
You may
use your ear or a stethoscope,
according as you may be accustomed to use one

* Cyclopaedia of Practical
Pregnancy," by
W.
Medicine,
vations on Obstetric Auscultation,
New
1837.
York, 1843
" Signs of
F. Montgomery, M. D.
Obser-
by Evory Kennedy,
Andral's Edition of Laennec, Paris,
180
or the other in examinations of the chest.
You
hear better with your ear, but you would do
may
well to auscult, at times, with the stethoscope, as

in
some cases you may need it. You must have

more so than in pectoral ex-
the room very quiet,

aminations.
men,
your
You
will press
firmly, but not in
own powers
your ear on the abdo-
such a manner as to disturb
Let the patient be
of hearing.
lying on her back in bed, and with a single cover-
ing
not that this position
ry, but
it is
is
absolutely necessa-
the best one (19, 1).
351. There are two auscultatory
which are of service

viz.
the placental
phenomena
in the practice of midwifery,
murmur
and the sounds of the
(bruit placentaire)
foetal heart.
PLACENTAL MURMURS.
s early as the fourth
month, or per-
haps earlier (see below), that

fore quickening,
rus
is
is,
be-
and when the ute-
just rising out of the pelvis,
you may perceive,
if you
have
a sharp
sense of hearing, a sound resembling the bellows
PLACENTAL MURMUR
WHEN AND WHERE HEARD. 181
murmur of Laennec.
Now
this varies, as in the
murmur up to the
sawing sound (223). At times, like
chest, from the slightest breezy
most violent
that of the chest,
it
becomes
softly cooing,
dron-
ing, or musical (224).
353 It is not constant; that is, either from

change of posture of the womb, or from its contraction, as during labor, and perhaps from other
causes,
it
sometimes ceases to be heard.
354. But
when
heard,
it is
always in the same
place, unless indeed during the intervals
the two examinations, the
355.
Some
womb
between
has enlarged.
say that this sound
owing
is
to the
passage of blood in the uterine vessels connected

with the placenta, and of course ceases
356.
is
It usually
thrown
off.
It
ceases the
moment
short time afterwards,
little
womb
the placenta
may, however, continue a very
owing apparently
vessels of the uterine placenta being
and the
when
have ceased to be pervious.
these vessels
uncontracted.
It
still
to the
pervious,
may continue
while after the death of the fetus.
It alter-
nates and corresponds with the mother's pulse.

corresIt is heard most distinctly over the spot
ponding
to the
attachment of the placenta, most
frequently on the right side.*
* Dr.
Montgomery, Cyclopaedia of Practical Medicine
182
357.
liest
Some doubt
appears to exist as to the earDrs.
period at which this sound can be heard.
Kennedy and Irvine record cases in which as early

as the tenth week after conception, they suspected
pregnancy, (and would not declare the patients to
be
in the contrary condition,
which, under the
cir-
cumstances, was a very desirable object), simply
from repeatedly hearing, on two or three successive days, a souffle just over the pubes.
gomery has never heard
it
Dr. Mont-
until the fourth
month
has been completed, although he has frequently
endeavored
covers
it
to hear
it
earlier.
Dr.
Kennedy
dis-
before any uterine tumor can be observed.
SOUNDS OF THE F(ETAL HEART.
=^v
uring labor, the sounds of the foetal

Vjm heart can be heard usually without
difficulty.
[j
The sounds remind one
JwJJ
of the distant ticking of a watch, and

it is
good practice
for
you to en-
close a patent lever watch in a handkerchief, and
hold it at such a distance from the ear that you

can just perceive the ticking. Imagine that tick-
SOUNDS OF THE FCETAL HEART.
183
ing to be twice as quick as the adult pulse, so

as to be
one hundred and twenty or
thirty in-
stead of sixty or seventy times per minute, and
you
will
have a very
fair
idea of the
foetal
pulsa-
tion.
359. Usually, this frequency distinguishes the

foetal
may
heart from the mother's circulation.
be very
much
altered,
Yet
&c. by the various conditions of the
ed,
it
quickened or weakenparent.
Mental emotions, joy or sorrow, haemorrhage, &c.

produce changes, though no general rule can be
laid
down
amount or character of
But they may become of vital im-
in regard to the
these changes.
portance to the child under certain circumstances,

and it is well for you to study the pulsations in
The
every case with reference to this point.
fol-
lowing case shows the excellent results of a wise

auscultation.
360. Example.
on
woman
physician was in attendance
in labor.
heart several times, and
He had
heard the
foetal
seemed perfectly normal.

Suddenly, the patient began to appear somewhat languid, and showed other, though indistinct
it
signs of depression of strength, and on auscultation he
to beat.
found that the heart of the
He
inferred that there
foetus
was
had ceased
internal haem-
orrhage, and that the child was dying or dead

in
consequence thereof.
He
immediately turned
184
and delivered by the

born
nal
feet.
The
child
haemorrhage, as he anticipated,
By
place.
child
was
still-
the placenta was found detached, and inter-
the use of artificial
was restored.
probably have died,
had taken
respiration the
In this case, the foetus would

if
the physician had not been
acquainted with obstetric auscultation.

361. Sometimes, the sounds have a metallic
character like the metallic tinkling in pneumotho-
From
rax.
iliac region,
believe, that
being heard always in the right
its
Dr. Kennedy suggests, with truth, as I
owing
it is
to the transmission of the
sound through a distended cavity with thin walls

like the
362.
ccecum (66).
The
extent over
fetal sounds varies

cide, however,
of course,
is
which you
much.
You
on the spot whence
will
hear the
can always deit
radiates.
heard low down on the abdomen,
It,
at
the earliest period at which the sound can be heard,

viz.
about the fourth month or somewhat
later.
Immediately over Poupart's ligament, on either

side, you will perceive it in its greatest distinct-
As
ness.
little
the uterus augments,
higher, but
it
is
it
will
be heard a
rarely if ever heard most
distinctly above the line of the
umbilicus.
In
breech presentations the sounds are higher up than

in presentations
363.
The
of the head.
earliest time at
which the fetal heart
WHEN HEARD
FCETAL HEART,
is
heard
city has
somewhat
is
heard
it
doubtful.
FIRST.
Dr. Fisher of this
about the fourth month or a
Dr. Kennedy, likewise, has heard
later.
commonly
sixteenth week,* but
185
it
little
at
the
four and a half
or five months, or after quickening, has been the
When
earliest period (352).

ly
we need
After the
a delicate ear and
fifth
month
it
ausculting thus ear-
much
perseverance.
continues to become more
and more evident.

364. Is absence of sound a proof of no pregNo; because the child may be dead, or
nancy?
the position
365.
may be
Among
altered for a time.
the obstacles to obstetric ausculta-
may be mentioned borborygmi, which some-
tion
times are so loud and constant that they confuse
young
auscultators.
nervous female
may have
such spasmodic movements of the abdominal pari-
Tumay cause
etes as to interfere sadly with the operation.
mors lying on the aorta or

a bellows
murmur
is
said, the respiratory
should
murmur
of the moth-
attended with sonorous rales (62),
obscures delicate
we
A change of posture may re-
and remove the sound. At times,
lieve the pressure
er, especially if
branches,
that simulating the placental
souffle will confuse us.
it
its
make
foetal
sounds.
In these cases
the patient cease breathing for a
* Obstetric Auscultation,
page
61.
186
The auscultatory head if not placed caremay deceive him, by allowing the pulsations
from his own temporal arteries to be transmitted.
time.
fully
In cases of hydatids a sound like chirping or gurgling
times heard, in consequence of the mo-
is at
tion of the hydatids
upon each other.*
USE OF AUSCULTATION IN LABOR.

y auscultation we may possibly have
one more means for deciding the
position of the
fetus.
The
fetal
heart, being heard, for instance,
ligament,
presents to the pubes, and
we might
low
down towards the right of Poupart's

we may suspect that the back of the head
suspect
it
to
if
heard towards the back
be an opposite position, with
the face to the pubes.
If heard high up,
we might,
on the contrary, suspect a breech presentation.

But this is of little importance, because the results
are
much
* I
am
less definite
than in some other cases.
indebted to Mr. Kennedy, Obstetric Auscul-
tation, p. 346, for
most of the remarks
in this section.
AUSCULTATION IN TIME OF LABOR.

367. Suppose the question
is
on the application
of the forceps or the perforator.
If the child
dead we need not fear the perforator
we might not
death
is
try
Now,
it.
absence of the
Again, sometimes, a
heart.
foetal
woman
feels certain that the child is dead.
has
no motion
felt
tator
the
may
for
many
The
hours.
assure her of her mistake,
foetal heart,
and new hope
into the sufferer's heart.
is
if otherwise,
the only sure sign of
a constant, long continued,
sound of the
187
if
She
auscul-
he hears
thereby instilled
is
Hence
it
becomes right
for every practitioner to auscult his patient several
times during labor, and any one
this fails in the
performance of
who
neglects
his obvious duty.
For an exceedingly interesting case
illustrating
the use of obstetric auscultation, see above (360).
DIAGNOSIS OF PREGNANCY FROM TUMORS, ETC.

ô)TWirfrS^
HE diagnosis, by means of auscultation,
of pregnancy from dropsy of ad-
domen
or tumors of the uterus,
will, I
trust,
&c.
hereafter prevent any
practitioner from plunging a trocar
188
into a pregnant
woman, on
the vain supposition of
her being affected with ascites
may make women
Tympanitis, too,
suspect themselves to be preg-
nant, and though the stethoscope
hopes of the patient,
still
may
destroy the
your stern duty as an
auscultator will require the destruction of
all
such
That such cases do
oc-
cur the following will prove.*

of a full habit, desired
(368 a). " Mrs.
me
fanciful maternal hopes.
to give her
my
opinion whether she was pregnant.
She has been married for two years, but has had no
family.
Her abdomen has been gradually increasing in size for the last nine months, and appears
now
sufficiently distended for a
irregular,
is
tense.
ago,
and the breasts
States, that she
when she
fainted,
woman
at the full
Her menstrual discharge
period of pregnancy.
much
swollen and
quickened some months
and shortly afterwards ob-
served the motions of a child, which she has

quently
felt
since
fre-
has even experienced consid-
erable uneasiness, particularly at night, from them.
Some weeks
cal
since, she had the opinion of a medi-
gentleman of some eminence, who, on her ex-
pressing doubts of her being pregnant, told her,
Madam, you are just as surely pregnant

am not.' Since then, she consulted Dr.
'
Kennedy on
Obstetric Auscultation,
as that I
Collins,
page 182.
DIAGNOSIS OF PREGNANCY, TUMORS, ETC. 189
who
expressed a very contrary opinion, and gave
her to understand, that her swelling and other appearances of pregnancy depended upon wind.
With
these conflicting opinions pressing on her
me to pronounce
same time informing me,
that whatever opinion might be expressed, no human being could convince her that there was not
something alive and moving within her. On examining the abdomen most attentively, it was immind, she subsequently called on
as to her state
at the
possible to say, from the extreme distention of

walls,
whether
its
did or did not contain an enlarg-
The
ed uterus.
more
it
vaginal examination was
satisfactory, as I could scarcely
feel
little
the os
uteri with the extremity of the finger, there
such a depth of the parts, and she was so
under examination.
Recourse was had
tation and percussion
was
irritable
to auscul-
by the assistance of the
former, nought but a diffused intestinal murmur,
with the puffing and borborygmus, could be distinguished
while on percussion, so decidedly a
tympantic sound was emitted, as to leave no room

to
doubt of the cause of the swelling and other
symptoms.
The
oil
and turpentine draught was
ordered for her, but she was prohibited by her hus-
band from taking
it
for
some
time, lest, as she
stated, the child should be injured.
did eventually
However, she
and the consequence was, that
190
the bowels were freely acted on, flatus and faeces
considerable
expelled in
quantity,
and
all
the
symptoms of pregnancy vanished."

36S
b.
Some tumors give rise to
In these cases look out for the
a souffle (352).
fcetal
Tumors never produce sounds
heart (358).
like those of the
foetal heart.
AUSCULTATION IN MEDICO-LEGAL QUESTIONS.

ince
common law
does not allow the
death-punishment to be inflicted on
a
woman quick
with child, the im-
portnnceof accurate auscultation to

decide whether a
woman
be pregnant,
becomes manifest (Appendix B). So,

to me, that in our State where a woman
it
seems
is
allow-
ed to swear the paternity of a child upon any one,

the law ought to allow at least of a stethoscopic
examination.
Not unfrequently
are
we consulted
by young women, some wishing to deceive

others asking to
dition as to
know
us,
and
the truth about their con-
pregnancy or
not.
In these cases aus-
cultation will be of great use, and the skilful auscultator has vastly the
mus
(357, 3D3).
advantage of the ignora-
CEPHALIC AUSCULTATION.
CEPHALIC AUSCULTATION.
July, 1832,* Dr. Fisher
was examining
a case of chronic hydrocephalus, and upon
applying his ear over the open and pulsating anterior fontanelle, " he heard a bel-
lows sound accompanying each pulsatory
Czrg) movement of the fontanelle, and synchronous with the pulsations of the heart."
was the origin of cephalic auscultation.

continued his researches in persons of
This
Dr. F.
all
ages,
and gives as his results the following.

*
This section
have obtained chiefly from the wri-
tings of J. D. Fisher,
M. D.,
published by S. S. Whitney,
in the
of Boston, as given in his
Laennec, Boston, 1838
edition of
from the
article,
M. D., of Newton, Mass.
American Journal of the Medical Sciences,

and, finally, from a review of a
in
work on
Hydrocephalus, published by Thomas Smith, M. D., in
Oct. 1843
the Medico-Chirurgical
13
Review, Oct. 1845.
194
371. Mediate or immediate auscultation
be used
but the
as the ear
latter is preferable to the
may
former,
The
can be easily applied to the head.
person ausculted should be in a horizontal posture,
and the head should be covered with a napkin,

and supported by a pillow. If it be a child the
auscultation should be performed while the patient
sleeps.
372.
The
culting a
first
young
sound that will strike you
infant, is the noisy
ration heard in the nasal fossae,
in aus-
sound of respi-
&c.
It is called
by Dr. F. the cephalic sound of respiration.

of course,
is
derian membrane, and by tumors,

373.
The second sound seems
distance.
This,
modified by any swelling of the schnei-
It is the
&c.
come from
to
sound of the heart, and
is
called
the cephalic sound of the heart.

These are the
only sounds heard while the patient is at rest.
If
the child cries or speaks, the sound is transmitted
generally sharply, and
from the cranium.
of the
voice.
it
appears to arise directly
It is called the cephalic
It varies
somewhat
sound
in its tones
and
apparent proximity to the ear in different parts of

the head.
374.
as
The sound of deglutition
we hear it frequently
Dr. F. calls
is
it
is
likewise heard
in auscultation
the cephalic
of the chest.
sound of deglutition.
perceived best while the child
is
nursino-.
It
CEPHALIC SOUND OF
All these sounds I have heard
375.
They
heart especially
more
distant,
many
times.
are modified by growth and the den
of the cranium and brain.
sity
195
VOICE, ETC.
The sounds
become harsher and
by age.
Dr. Fisher,
of the
coarser, but
at the
time of
had discovered that the cardiac
his publication,
sound was changed in various diseases into a
bel-
lows sound (223), hence called the cephalic
bel-
lows
murmur.
376.
The sound
diseases,
of the heart, also, in certain
becomes impulsive instead of being
soft,
near and almost under the ear instead of distant.
The
impulsiveness Dr. F. considers the greatest
peculiarity.
It
seems
as if the brain
were moved
en masse against the interior of the cranium.
377. Subsequently to Dr. Fisher's publication,
came
the able paper by Dr. Whitney confirming
Dr. F.'s results, except in regard to the " impulsive " sound, which Dr. W. says he had never
all
heard, though one of his

the reverse.*
the
Dr.
W.
own
cases seems to prove
has, moreover, extended
domain of cephalic auscultation by the addi-
tion of three
new
signs, viz.
the cephalic haigoph-
ony, the purring thrill or frcmissement cataire,
and the cooing or musical sound.

*
The
subject
American Journal of Medical Sciences, Oct. 1843,
page 310.
196
has been somewhat noticed by European writers,

but they do not seem to have carried
Dr. Smith appears to have studied
attention than any
377
a.
one
have given
else.
new, and
is
to your notice, as I
am
of your attention.
I cannot,
much
is
open
signs
you
satisfied that
it is
it is
it
worthy
promise
true,
new
field
to study upon, and, moreover, the
may sometimes
afford useful hints relative
to the nature of a class of diseases

as
account,
wish to bring
of a practical character, but a
for
forward.
it
with closer
this brief historical
because the subject
very
it
which now are
dark as any we have to deal with.
The
378.
following
is
the present state of the

First.
The
This may occur
in ce-
knowledge of the morbid sounds.

Cephalic Bellows sound.
any source.
rebral congestion from
Dentition,
hooping-cough, for example, are very apt to cause

it.
It is
mation
heard likewise in acute cerebral inflam-
hydrocephalus ; compression of the brain

scirrhous induration with softening, abscesses of
;
and scrum
the brain,
tion
of the
ease.
It
can be of
is
arteries,
little
When
pret other
the hydrencephaloid dis-
evident that, of
itself,
(223, 225),
it
service in the present state of our
knowledge, save that

able.
in its membranes, ossifica-
and
it is
its
absence, at least,
symptoms
is
favor-
may
serve to inter-
or those other
symptoms may
present,
it
THE CEPHALIC BELLOWS SOUND.

interpret that.
197
never occurs in children before
It
dentition, unless in actual disease of the brain.
The impulsive sound of the heart.
379. Second.
Dr. Fisher mentions, what he calls an impulsive

sound, by which he
means a sensation
as if the
whole mass of the brain rose and struck the cra-
nium with each sound from the

heard
it
in six cases
he thinks
it
may be
that disease.
Smith does not mention

that he has never heard
self,
to be with difficulty per-
Dr. F. says that such
ceived.
has
accompaniment of
a constant
seems
It
He
arteries.
of cerebral apoplexy, so that
it,
it.
the case.
Dr.
and Dr. Whitney
states
is
He
contradicts him-
however, for he quotes a case which had
it
That case was one of carcinoma and not
(377).
apoplexy.
hregophony
ter either in or
distinctly says
ter
to
was
it
sound (54).
381. Fourth.
in a case of
Dr. Whitney
about the brain.
he has never heard
in
The name
some
This
depends on wa-
in the chest,
it
when
the wa-
Dr. Smith seems
in the ventricles alone.
have heard
cles.
The cerebral hagophony.
Third.
380.
like the
largely distended ventri-
indicates the character of the
The purring
thrill
was
aneurism of the basilar artery.
felt
once
There
was a continuous sort of bruit de diable (257) accompanied by a thrill like the purring thrill (206).
The
patient himself perceived
it.
19S
382. Fifth.
musical sound (224)
not unfrequently in anaemic cases.

a similar
sound would be
Cases
likely to
is
heard
in
which
be heard in the
and veins of the body (220), are liable to

have this sound in the brain. In fact, it is considarteries
ered by Dr. Whitney as strictly pathognomonic of

anaemia.
382
ily
a.
From
the above statements
perceived that, although,
it
auscultation will not enable you to
accurate differential diagnosis,

frequently of
some importance
nent organic disease.

neglected.
will
at present,
be readcephalic
make
a very
it,
however,
in
marking perma-
It therefore
will
be
should not be
AUSCULTATION,
AS APPLIED TO
OTHER
DISEASES, FRACTURES, ETC.
AUSCULTATION IN FRACTURES.
wm
diseases of the ear, auscultation might be applied,
by
examining
accurately
the sound produced by for-
cing the
air into the
Eusta-
chian tube in health, and
comparing these with the

variations produced by disease.
To
384.
use
is
fractures. It
made of
fracture
this
surprising that no
in
more
obscure cases of
particularly in those of the hip joint,
which sometimes,
If the ear
scure.
is
method
in
is
aged persons, are very obplaced over the part while an
moves the limb, a certain degree of

pitus must be produced (393).
assistant
385.
It
might be used
cre-
in diseases of the blad-
der, or rather to distinguish
them from
calculi in
202
the bladder.
When
a stone
of course more sound
of the catheter against

the bladder.
am
is
contained therein,
produced by the striking
is
it
than against the walls of
not aware that
it has been attended to by surgeons, and yet it seems to me that

it might be of service, at least, occasionally.
385
a.
Some have proposed
eases of the abdomen.
to apply
it
to dis-
have no doubt that the
auscultation of the abdomen would lead to some

curious results, but probably they could never
equal those obtained from the thorax.
AUSCULTATORY PERCUSSION.
ITSCULTATORY
Percussion
is
en by Drs.
the
name giv-
Camman
and
Clark to a new method for

investigating the diseases
of internal organs.
tically, I
about
in this section,
depend
it
chiefly
Prac-
know but
little
I shall therefore,
upon the
analysis of
the article published by these gentlemen a few
years since.*
As
the term implies, auscultatory
percussion consists in a union of the two methods
of examination.
387.
*
New
1840.
In the paper above alluded to, the plan
York Journal of Medicine and Surgery, July
20G
was applied
sions
chiefly to the discovery of the dimen-
of the heart, and
ample,
I shall
as that will
afford
an ex-
consider the question chiefly with
The operation is as folYou will place "the extremity of a cylinder
reference to that organ.

lows.
of wood (396), cut in the direction of

flat
its
fibres"
over the centre of the heart, and support
it
there by your ear resting at the other extremity.
Using
for a plessimeter either
your finger or an
in-
strument adapted to the purpose {fig- 24, p. 40),

if you will strike on the walls of the chest, about
an inch from the extremity of the stethoscope, you

will perceive " a clear, sudden, intense
sound of
high tone," attended with an almost painful, short,

abrupt impulse, appearing to be immediately under the instrument or produced within
if
you put the wood
you
it, i. e.
at the
Again,
it.
end of one of the diam-
and strike about three inches
eters of the heart,
from
at the
other extremity of the diameter,
will obtain a similar result, but less energetic
in degree.
" Strike where the lungs overlay the
heart, and you
will find that the
modified and mixed, but

Strike at
served.
still
its
sound
is
instantly
cardiac type
greater distances,
is
pre-
moving
by short steps towards the body of the lung, and

at a certain point the sound will suddenly change,
losing
its
intensity
and high tone, and being no
longer impulsive, but grave and distant.
It will
likewise be heard
much more
open ear than by that applied
207
distinctly
by the
to the instrument.
388. Explore, in like manner, the hepatic region, " and within short distances you will find that
the sound will be clear, intense, and immediately
under the instrument

less acute,
as before;
and more prolonged
semi-reverberant."
As
the sound will diminish

heart,
though
shall get
it
but less intense,

:
it
will
be even
augments,
the distance
more rapidly than over the

be lost entirely until you
will not
beyond the region of the
liver
and upon
another medium.
389.
The
method, they
inventors of the system think, by this

shall
be able to
fix
the boundaries of
the heart and of all the other organs
much more dis-
tinctly than by methods heretofore employed. In

reference to the heart I think the common meth-
ods are sufficient where
But
in cases in
itself
which there
is
alone
is
diseased.
disease of the adja-
cent parts, either of the chest or abdomen, and the

dullness, resulting from the ordinary
percussion in such disease,
is
methods of
immediately con-
tinuous with that produced by the heart, this meth-
od may,
I think,
when we might
become
means of
diagnosis,
find a difficulty with our other
methods.
this, it is hoped that by
be able " to distinguish with facility
390. But in addition to

it
we
shall
serous effusion
into the pericardium
from
any
208
form of disease of the heart
May
itself."
it
not
likewise help us to decide in cases of a doubt as to

the nature of a tumor
for
example, between aneu-
rism and a steatomatous or malignant tumor.

391.
It is
capable of being applied to the spleen,
and kidneys, upon both of which organs the com-
mon methods
may be
of physical diagnosis are wanting in
Especially does
accuracy.
it
seem
to
me
that
it
of great value in the recognition of or-
ganic enlargement of the kidneys.

392. In examining the liver Drs.
Clark say, that they can follow
it
Camman and
nearly an inch
higher on the chest than by ordinary percussion

they can trace
its left
lobe and
the extreme limits of
its
its
lower border to
thin edge.
They are
when
able to limit the upper surface of the liver,
adjacent to a hepatized lung, or to an effusion into

the right pleura.
They
limit the lower, thin
edge
of the organ while immersed in the serous effu-
mark
the
and spleen when both
ar<&
sion of ascites, and, finally, they can

line
between the
liver
enlarged and in contact.

393. It
is
percussion
true
and false
come under
od
hoped, likewise, that by auscultatory
we may be
at the
able to decide
anchylosis.
One
between
case only
had
the notice of the inventors of the meth-
time (1840) they wrote on the subject.
In that case, there was supposed to be a perfect
AUSCULTATORY PERCUSSION IN FRACTURES. 209

bony union
at the hip-joint,
and the sound of per-
cussion was transmitted, from the condyle of the
former to the pelvis, more distinctly by the
dis-
eased than by the healthy limb.
393
In fractures of the bones, if the ends

sound and impulse are trans-
a.
are in contact, the
mitted
but
if
they are separated, both impulse and
sound are chiefly

ces,
however,
lost.
this
In the majority of instan-
method of distinguishing
frac-
tures cannot be relied upon.
TYPE SOUNDS.
tv=^he following statement will afford an
idea of the relative powers of differ-
ent textures in the conveyance of
sound by auscultatory percussion.

" We find, for example, that
U\
^
among
the tissues of the body, bone
conductor of sound
ferior to
tense
is
ducts at
bone
that cartilage
in this respect;
is
ducts badly
14
that fatty tissue
the best
that muscle
a good conductor, relaxed,

all
is
but little in-
it
when
hardly con-
uncondensed con-
that (Edematous cellular tissue has a
210
minimum conducting power
that any tissue or
group of tissues under tension conducts better than
when
relaxed;
conductor
that the spinal
that both
column
is
a bad
sound and impulse are trans-
mitted from one bone to another, through inter-
posed
soft tissues, if
moderate pressure
state
such tissues be condensed by

that articulations in a healthy
conduct both sound and impulse, but with
loss of
energy
that
sound and impulse are not
entirely lost in passing through
ticulations
in
that fractures
two successive
ar-
and dislocations do not
most cases wholly interrupt the conduction of
sound
and that the sound
is
more intense than
natural in passing through certain diseased joints.
" Some of these
latter propositions
ticular consideration.
deserve par-
That bone should be both
sonorous and conductive, might be inferred from

its
structure
but that sound should
through an articulation where
it
make
its
has to pass,
way
first,
from bone to cartilage, then from one cartilage to

another, and lastly, from cartilage again to bone;
and even where the transitions are still more numerous, as in the joints which possess " moving
cartilages,"
would have been anticipated only by
a reference to two facts
note of cartilage differs

(of this one
may
satisfy
first,
little
the fundamental
from that of bone,
himself by examining the
bony and cartilaginous portions of the same
rib,)
TVP BOUNDS.
211
and consequently vibrations produced

easily taken
one are
in
up and carried forward by the other
and second, the union between cartilage and bone

in the joints
is
intimate, and between cartilage
and cartilage the contact

in every
the loss
It is true that
is firm.
such transmission something

is
no way proportioned
is lost,
to the
but
number
of medial changes."
The
395.
authors of the system therefore pro-
pose as type sounds those heard over bone, water,
The
the heart and the liver.
first,
osseous,
is
the
loudest and most energetic; the second, aqueous,

presents
the
least
of these
at opposite extremities
remarked
and
qualities,
of the scale.
that fluid in the chest
It
are
may be
is difficult
to dis-
tinguish by auscultatory percussion, owing to the
sonorousness of the parietes being so great.

obtain the true character of the
therefore,
it
must be sought
aqueous come,
first,
hepatic.
The
than the osseous
intense,
the abdomen, as
osseous and
the cardiac, and second, the
ductible
diate,
for in
Between the
in dropsy, for example.
To
aqueous type
former
rather
is
acute, clear, less

;
it
painfully
con-
quick, imme-
is
impulsive, and
gives, especially towards the circumference of the
organ, a sort of muffled ring.

graver,
more continuous,
the organ over which
The
less freely
it is
hepatic
is
conducted by
heard, clear, intense,
212
immediate, impulsive.*
varieties of
With these
types,
sound and impulse, heard over
ent parts of the body,
all
the
differ-
may be compared.
STETHOSCOPES FOR AUSCULTATORY PERCUSSION.

solid stethoscope of two shapes
used in these investigations.

are as follows.
Fig. 35
is
is
They
a solid
cylinder of cedar, shaped in the direction of the
woody
fibres, six
in-
Fig. 35. ches in length, and ten or twelve lines in
furnished with an ivory
diameter.
It is
ear
which
piece,
will
allow nearly the
whole cylinder to pass through
The
it.
It will
likewise serve for the
common
tion, but not so well as a
hollow instrument.
following definition
Immediate,
when
is
ausculta-
given of these terms.
apparently applied immediately to
the end of the stethoscope.
Abrupt, opposed to prolonged, &c., refers to the sud-
den termination of the sound or impulse.

Distant, opposed to immediate, impulsive.
Quick, used as
when
the
same term
is
applied to the
pulse.
Acute, as opposed to grave in the diatonic scale.
Impulsive, causing a shock to the ear.
STETHOSCOPES IN AUSCULTATORY PERCUSSION. 213

397. A modified form of this may be used when
examining the chest in order to avoid the sound of
the bony parietes. It is made in the form
of a trunFig. 36. cated wedge,
(Jig. 36) leaving the aural
extremity as before.
two
The narrow end is

wide and can be easily placed
lines
in the intercostal spaces.
398. In case
common
we have not these, the

may be used (19).
stethoscope
399. Finally, a plessimeter
The
Fig. 37. sary.

ses;
but
another
(Jig. 37).
is
finger will
It is
absolutely neces-
answer
sion
is
purpo-
been suggested
made of steel with an
ivory handle and place for the
press upon.
all
has
The
thumb
to
part used in percus-
of steel and oval, containing a small
piece of india-rubber (88).
DIFFICULTIES OF AUSCULTATORY PERCUSSION.

ifficulties, that require some notice,
are
met with
sion.
They
in auscultatory percus-
apply
chiefly
to the
heart, but they are suggestive with
regard to the examination of all other

organs.
214
To
401. First.
get
the
characteristic
full,
sound of the heart, the stethoscope must be placed
on a part of the chest with which the organ comes
Even
in contact.
may
the lung lying over the heart
interfere seriously with a novice in the art.
402.
Second.
heart and the liver
The
The
may
difference
between the
not be easy to perceive.
fundamental sounds of the two organs
differ
but two notes and a half on the diatonic scale in

the structure of their parenchymata, and they have
similar degrees of consistency.
The sounds
are
transmitted from one to the other, but they change
from acute to grave, and lose
a part of the impulse.
Practice will overcome this difficulty.
Third.
403.
It is, at times,
difficult to define
the right side of the heart, owing to the sternum

lying over
it.
By using
the
wedge we may gen-
erally avoid this.
404. Fourth.
ribs
The conducting power of
the
sometimes embarrasses the exploration of the
The wedge assists in this case likewise.

Emphysema may make the chest
heart.
405. Fifth.
very sonorous, and cause the lungs to cover the
In this case the wedge or a stronger pres-
heart.
sure with the cylindrical stethoscope will generally
overcome the
405
come
a.
difficulty.
Sixth.
The mammae
source of error, but
them aside
as in
common
in females
we can
may
be-
generally push
percussion.
DIFFICULTIES OF AUSCULTATORY PERCUSSION. 215
406. Seventh. Percussion

as to confuse
tor.
It
may be
too hard, so
and fatigue the ear of the ausculta-
should be performed with the single
ger, and so feebly as to be scarcely, if at

ble to a bystander.
all,
fin-
audi-
VETERINARY AUSCULTATION.
ETERINARY
cultation
seems
been much
Aus-
to
have
neglected
England, and
is
in
wholly un-
attended to in this country,

a fact which
is
by no means
creditable to us on the score
of veterinary science or of humanity.

408.
There
are certain general ideas which
who is at all acquainthuman subject. These
every physician must have
ed with auscultation in the

ideas depend
upon
his
knowledge of the diseases

human subject, and
of the thoracic viscera in the
the sounds produced by these diseases.
Similar
diseases are found in animals, and, of course, similar
auscultatory
phenomena must occur.
The
following remarks on veterinary auscultation are
merely supplementary
man
auscultation.
to
what 1 have given onhu-
220
409. I have examined
many healthy horses, and

murmur to be usually
have found the respiratory
man, and of the same breezy

The heart also has two sounds as in
quite as distinct as in
character.
They
man.
different
are very distinct, but they are not so
from each other, as
those in the
human
it
seemed
to
me,
as
subject (461).
410. In the following account of the auscultatory
phenomena
of the horse,
in diseases of animals, especially
depend
chiefly
on what Mr. Youatt*
and Mr. Percival f say, premising, however, that

they seem to derive
much
of their confidence in
auscultation from the writers of the
Delafond, Girard, D'Arboval,

I have
*
by
French school,
works
&c, whose
been unable to procure.
The Horse, by William Youatt, anew edition, &c,
J.
S. Skinner, Philadelphia, 1845.
f Hippopathology, a Systematic Treatise on the Diseases and Lamenesses of the Horse, &c, by William
Percival, London, 1840.
Also,
"The
Veterinarian,"
for April, 1840, a lecture on Auscultation by the
author.
same
PERCUSSION IN VETERINARY MEDICINE. 221
PERCUSSION IN VETERINARY PRACTICE.
Delafond
r.
sion,
uses mediate percus-
one of his hands being the
Some
simeter (83, 84).
ples-
use a wood-
en plessimeter, and a mallet covered

with india-rubber.
that, for all
sion
is
common
sufficient
if
Delafond says
purposes, immediate percus-
you remember
to strike,
perpendicularly to the surface sounded

to strike the ribs
third, to use the
first,
second,
and not the intercostal spaces
same force every where
compare the two sides of the chest
fourth, to
(4, 84).
The portion of the trunk in which percusmay be advantageously used, may be marked
412.
sion
by two
one
lines,
back of the posterior
let fall just
edge of the scapula, the other

lines into three equal parts,
upper,
The
rib,
lower
upper,
in the direction of
Divide this space by two horizontal
the last rib.
1,
which may be called
and middle (1,2,3, in Jig. 38).

extends from the scapula to the last
along the border of the longissimus dorsi, and
includes the superior third of the ribs; the lower,

3, includes the inferior third
the middle, 2, the
central third (Fig. 33, p. 224).
222
413. Percussion affords the loudest sound in the

middle region, between the seventh, eighth, and
ninth ribs
from
this to the fifteenth
and again, owing to
it
diminishes,
intestinal distention, increases
to the last rib.

On the right upper region, the
sound grows louder from the posterior border of
the shoulder to the last rib, whilst on the
gradually diminishes on the same line.
left
it
This
is
explained by the arch of the colon extending far

into the chest.*
obtained
In the lower region the sound
may be compared
gion behind the shoulder

the ninth rib,
abdominal.
whence
On
it
to that of the
;
and
this
upper
re-
continues to
lessens until
it
the right side the sound
becomes
is
a little
owing to the liver.

414. For the various modifications of sound,
would refer you to 89, &x. to 101.
duller,
* Delafond, in Percival s Hippopathology, page 68.

;
223
,mmediate auscultation is better than mediate (18).
Apply your ear accurately,
but lightly.
night
is
The
be amused with a
the
murmur
by exercise.
over the
Let the animal
little
chewing obscure the sounds.

rile or juvenile
quietness of the
the best time.
respiration
There
as in
diminishes in age.
It
human
hay, unless the

is
man
It is
augmented
resembles entirely the sound heard

chest.
416. In the following plate the chest
by two parallel
the pue-
(25), and
lines,
is
divided
forming upper, middle and
lower regions, as described (412).
224
THE yoUNG STETHOSCOPIST.

Fig. 38.
417. In the upper region,
murmur
is
1,
418. In the middle region, 2,

tinct
from behind the shoulder
little to
the respiratory
quite distinct.
it is
also very dis-
thence increasing
the ninth rib, and after that diminishing
to the last rib.
419. In the lower region, 3, the sound
is
quite
manifest from the elbow to the ninth rib, whence
it
225
diminishes to the seventeenth and there disapIt is the
pears.
same on both
place of the heart.

the
This
is
sides except in the
immediately back of
shoulder and marked 4, and there, of
left
course,
the
murmur
is
diminished.
It
best place to hear the heart; although

at 5.
The middle of the
may be an important place
perceived
6,
and
it
is
the
may be
it
trachea
is at
for ausculta-
tion (438).
420.
We
must be
careful,
so Percival says,
not to confound the sound produced by the contractions of the panniculus carnosus muscle with
the sounds
found any
made within
difficulty
the thorax.
on that score,
are essentially distinct, and
have never
as these
occur
at
sounds
different
times.
421.
Among
the peculiarities resulting from
the position of the horse,
is
the existence of a
strong supplementary respiration along the spine

in cases of pleuritic effusion, owing,
first,
to the
lungs being forced there, and, second, to those

portions of
them being obliged
to
do a double
share of duty in consequence of the compression

of the lower parts.
15
226
RALES IN VETERINARY AUSCULTATION.

ales are heard
in animals as in
man
they have the same general charac-
and
same diseases
are indicative of the
teristics,
as in
sounds as heard
to the former part of the
in
work
man.
man,
(62,
For these
you
I refer
&c).
The
following peculiarities in veterinary auscultation,

as given by veterinary writers, are worthy of notice.
In bronchitis the mucus,
at times, is so ad-
hesive, especially at the lower part of the organ,

as to clog up a bronchus, (as it does sometimes in
man, 113), and cause absence of respiration,
" leading one to believe that there

of the lung."
is
hepatization
If you trot the horse under these
circumstances the mucus
is
dislodged.
would
add, that percussion would likewise assist in the
diagnosis in such a case, as there would be dull-
ness in hepatization (123), whereas there would
be no change of sound
in
simple obstruction of
the bronchial tubes.
Bronchial respiration (123)
would probably
exist in hepatization, but not
also
in the other case.
RALES IN VETERINARY AUSCULTATION.
In pleuritic effusion, broncJiial respira-
423.
tion (41)
It
is
heard more frequently than in man.
occurs on a level with the upper edge of the lower
and
division (Jig. 38),

sides,
in
227
the same level on both
at
usually, in a horse
but on one side only
dogs and ruminants (owing to the different
construction of the mediastinum in the horse and

these others).
424. In acute pleurisy,
(134)
bronchial respiration
likewise said to be heard; but
is
it is
very
short and quick, owing to the rapid and painful

efforts
of breathing
made by the animal
accompanied by " a confused

detection
is
very
is
(180),
more frequent cause of rales,
(76), than
it is
and being
its
difficult.
425. Pulmonary emphysema
seem,
sort of noise,"
in
human
beings.
it
would
crepitation
They
are most
distinct in expiration.
426. Pleural sounds (77).
when
fluid
there
and
little cells
is air
false
and
A rumbling is heard
fluid, or
membranes, so
when
as to
there are a
make many
between the layers of the pleura.
22S
DISEASE OF THE NASAL CAVITIES.
tubal sound
heard in the nasal
is
cavities in health
but a swelling
of the schneiderian membrane, or

a polypus will contract their cali-
and produce a whizzing or
bres,
whistle (62,
Sometimes, these sounds are
&c).
continued even into the chest, but they are strongest opposite the part affected.
428. Percussion
polypus
may be
of use in indicating
dullness resulting from any solid sub-
stance in the cavities.
DISEASE OF THE FRONTAL SINUSES.

y auscultation
the
we hear only
But when
swollen there may
in health
a very slight
membrane
murmur.
is
be whistling (62)
or if the swelling
be very great, and thick pus be

fussd,
all
sound may be absent.
ef-
DISEASES OF THE LARYNX.
The resonance
430. Percussion.
clear in youth,
it
may become
more
so in the aged.
perfectly
229
is
tolerably
In disease
flat.
DISEASE OF THE LARYNX.
ounds of the
slightest
character, but
necessarily tubal (42) in their nature,
are heard over the larynx while

in a
normal condition.
it is
In disease the
there may become very

Le Blanc* mentions the fol-
rales heard
important (103).
lowing.
432. First, the dry whistle, from simple contraction of the calibre of the tube, either from natural
conformation, compression, or some lesion, physical or vital, of the recurrent nerve.
433. Second, a humid whistle (63), caused by

a swollen
is
This
membrane, covered with mucus.
sometimes intermingled with the mucous, and
sonorous rales as in
man
434. Sometimes the
gurgling (74), so that
(62, 71).
mucous becomes
it is
Hippopathology, vol.
heard
ii,
a loud
at a distance
from
p. 67, see above.
230
the animal.
If
cious that there

at the
it is
is
so loud as to
make you
suspi-
disease of the lung, put your ear
lower part of the neck, and
if
you
find the
and out, Mr. Youatt * says you

may be sure that there is " no disease of the traair passes freely in
chea or lungs, "t but on proceeding up the neck

the sound of gurgling will
become more manifest,
and, finally, over the larnyx
it
will
be very loud.
435. Percussion gives no results in this disease.
The
43C. Cough.
veterinarians say nothing of
using the cough as a means of diagnosis

think
it
might produce a
rattle,
or
but I
augment one
already existing, and therefore might be of service.
The Horse, &c,
f I doubt
p. 193, see above.
much whether Mr. Y. is not in error in this

He may say that there is no disease
broad assertion.
of the trachea, but certainly the fact that the air enters
the trachea freely
is
no proof that the lungs are healthy.
The
latter part
trace
up the course of the wind-pipe.
of his direction
is
excellent, viz.
to
DISEASES OF THE TRACHEA.
231
DISEASE OF THE TRACHEA.

istinct tubal (39) sounds are always
heard on auscultation along the
under part of the neckof the

horse,
i.
e.,
trachea {fig. 38,
The
438.
rales (71)
chea
p.
may
224).
(62) and mucous
sibilant, sonorous
owing
ealthy
the course of the
in
be heard in diseases of the tra-
all
simply to a dry contraction
either
of the tubes or to bands of coagulable lymph, parobstructing
tially
It is so called,
tion,
&c.
it,
unfrequently have
the
starts
the air enters with difficulty,

is
called
roaring.
because, during the act of inspira-
and when the animal
sound
we not
In these cases
disease
suddenly to
trot,
and of course, a
produced, which sometimes becomes so
loud as to be very unpleasant to the rider, and
makes the animal of
less value;
although
it
may
not really injure his health or powers of locomotion.
The
far-famed Eclipse
is
said to have been
a " roarer."
439. It has been necessary, at times, to per-
form the operation of tracheotomy
whether
for this
for
it,
and
cause or any other obstruction,
232
you

find
may
it
necessary to do this operation, the ear
enable you to decide the spot where the ob
struction exists.
440. Percussion gives no results.

441.
ing,
The cough may
be of service by removthe position of
or demonstrating
altering,
the obstruction,
when by
the respiration
we cannot
decide.
BRONCHITIS IN ANIMALS.
ales varying according
to the
amount
of the disease, are heard in most
When
cases.
the
membrane
is
simply inflamed, with no secretion,

there
may be simple wheezing, run-
ning into the sonorous (62). The veterinarians

do not mention the spot, but judging from analo-
gy (which, by the by,
is
often an unsafe guide), I
should expect that the rales would be most distinct towards the sternum, or
the chest, and

there
is
more
depending parts of
or less in both lungs.
If
general bronchitis, the rales, I think,
should be most conspicuous
at
these parts, and
PNEUMONIA IN ANIMALS.
grow
less
233
towards the withers or spine.
On
the
(416) they would be most manifest in 3,

thence through 2 to 1.
figure
443. Percussion teaches nothing.

444.
The
cough may be of service
out a rale in case there
is
but
or destroying the rattle that
little
is
in bringing
sound
of
it,
heard, in either
case showing the disease to be in the bronchi

chiefly,
and not in the parenchyma of the lungs.
(See bronchitis in man, from 105 to 117).
PNEUMONIA IN ANIMALS.
?~N
t seems singular, but neither Mr. Youatt

nor Mr. Percival give any but the
most vague directions
1-^
in regard to aus-
cultation in this disease.
The
crepi-
*-^ tous rale (70, 120) is mentioned as occurring, and being evident, and as distinct in
its
characters as the same sound in
Around the inflamed part the

murmur is frequently augmented.*
ings.
human
be-
respiratory
* Percival's Hippopathology, p. 74. 81.
234
446. Bronchial respiration (41, 123)
is
like-
wise observed, but the veterinarians are rather
obscure on
this subject also.
Mr. Youatt says nothing of
447. Percussion.
method of examining. Mr. Percival quotes

from Mr. Rigot, in which he gives the following
this
" The impermeability of the
very clear account.
lung prevents us from hearing the respiratory
murmur, by causing a
dullness of sound on per-
cussion, opposite the diseased parts."
A sentence
which proves that neither Mr. Percival, nor his

authority, had very definite views of what they
were
writing
upon.
We
point which analogy and
have told us previously,
however gain
physical
viz.
laws
one
would
that hepatization of
the lungs in a horse causes dullness on percussion, as in a
man
(98, 123).
Reasoning from
analogy, I should think the signs would be most

frequently manifested in 3 {fig. 38, p. 224).
448.
The cough might be
used, as I have
men-
tioned above, and I suspect instead of the voice as

a test of disease, and might
tant with bronchophony.
117, fec).
become equally impor-
(See pneumonia in man,
BROKEN WIND IN ANIMALS.
BROKEN WIND
^v n
235
IN ANIMALS.
veterinary medicine, broken wind
is
considered by writers as a kind of em'_
physema (175). Mr. Percival agrees

to this remark by Mr. Youatt, but says
it
may
result from injury of the pneu-
mogastric nerve, lesion of the diaphragm and
pulmonary inflammations.
450. Auscultation.
Respiratory
murmur
very
quiet (178).
451. Percussion.
Chest more resonant than
usual (177).
452. Inspection.
Chest rounded
intercostal
spaces prominent (176).

All these signs
may be
general or local.
453. In addition to these, Mr. Percival speaks
of a rubbing sound occurring
Laennec observed
writers have
it
doubted
curs, at times, in
in
in this disease in
it.
It
Does
man.
quently in veterinary practice?
it
this
man.
disease.
Later
undoubtedly ococcur more

I
fre-
cannot answer
the question.
454. Yet further.

cival
sign mentioned by Per-
as occurring in local vesicular
dilatation,

according to
corresponds somewhat with what,
Laennec, occurs
dry crepitous
phenomenon
common
dilated
in
It
rale.
in
human
we should
Analogy sugand sonorous
broken winded animals
in
(See emphysema in man,
than in others (180).

175,
may be more
beings, but
find sibilant
more frequently
viz.
certainly a very rare
in veterinary auscultation.
gests that
rales
is
bronchi,
&c).
PHTHISIS IN ANIMALS.
ubercles are found most commonly

at the anterior
and superior parts of
the lungs (143), near the withers of

the animal.
456.
minished respiratory
Auscultation shows
murmur (149)
di-
in the earlier
stages and rales (156), similar to those in
man
the later stages of the disease, where cavities,
at
&c.
exist.
457.
sound
Percussion affords
in the
do not know
same way
as in
its
modifications of
man
(146, &c).
that the bruit de pot fele has been
237
PLEURISY IN ANIMALS.
ever heard (148), but I see no reason
why
it
should
not be heard in brutes as well as in man.

458. The cough, though no notice is taken of it
by the veterinarians, must be an important aid in
recognition of rales.
(See phthisis in man, 144,
&c).
PLEURISY IN ANIMALS.
uscultation shows
a diminished res-
piration (132), and, at times, a rub-
bing sound (128), especially
at the
upper part of the chest, as the early

signs of pleurisy, with merely rough-
ness of membranes, and perhaps some slight effusion of lymph.

.fluid
may be
But, within three days, gallons of
effused, and, of course, the lung will
be pushed away from 3 {Jig. 38, p. 224) and the

It is said
respiratory murmur be wholly gone.
sound like that of the dashing of
that, at times, a
water
be
is
heard.
air as well as
It
seems to
me
that there
must
water, in order that this sound
should be heard (164).*

* Hippopathology, p. 116.
238
460, Percussion will afford, of course, but

dullness in the early stages, but
has taken place, you
may
when any
little
effusion
find an extensive dullness
varying with the amount of fluid (101, 131).
It
commence at the sternum and extend upwards.

will be much more difficult to determine wheth-
will
It
er one or both pleurae are affected in the horse
ox than
seems
to
in the
dog
and
because in the former there
be a communication through themedias-
trium, allowing the fluid of one side to get into
the other.
Mr. Percival describes a case
distinct fluctuation
was communicated
in
which
to the ear
placed on the affected side, while percussion was
made on the
128, &c).
other (14).*
(See pleurisy in man,
# Mr. Percival speaks of having heard

in one case
a dull rumbling sound as of fluid in a barrel.
DISEASES OF THE PERICARDIUM AND HEART. 239
CARDIAC DISEASES IN ANIMALS.
it.
Percival follows Dr.
Hope
description of the sounds
healthy heart (210).
in his
of the
The place
for
hearing and feeling this organ

just
bow of the
on the
left side, in
{Jig. 38, p. 224).
ribs
and behind the
the small space
The
hand, placed
is
el-
marked
flat
4,
against
the ribs there, will recognise the pulsations of the
heart (240).
462.
Pericarditis.
symptoms
will
as they
be "well
Mr. Percival gives the
occur in
man
as those
which
for veterinarians to set before
it
them
from observations on their part, they are

Mr. Youatt gives
until,
able to confirm or reject them."
nothing more definite than
this, viz.
bounding
action of the heart early in the disease, a confused
and
feeble,
fluttering
movement, when
takes place.
To
m-an,
means much
all
ready.
this
effusion
the experienced auscultator of

less
than he knows
al-
(See pericarditis in man, 258, &c.)
463. Carditis and endo-carditis are evidently
not recognised by the veterinarians;
though
do not think that they are, by any means, unrecog-
240
nisable by one accustomed to
human
auscultation.
(See carditis and endo-carditis in man, 269, &c.).

464. Hypertrophy of the heart.
again takes the
common
Mr. Percival
classification of simple,
But noth-
concentric and eccentric hypertrophy.
new
ing
is
by him or by Mr. Youatt.
stated, either
(See hypertrophy in man, 275, &c.).

465. Dilatation of the heart.
This
467. Disease of the valves.

a
(See dilatation
man, 277, &c).
in
new
given upon the subject.
Yet
it is
is
evidently
Nothing
subject to the veterinarians.
is
perfectly evi-
may exmay be heard (283,
dent that, as the same physical conditions

ist,
so the same physical signs
289, 294, 297, 302, 307).

468. Aneurism.
"it
Of
this,
Mr. Percival says,
has never become the object of veterinary
Judging from what we know of the

pathology, I cannot but think
that the veterinarians would do well to make it an
practice."
results in
human
object of study forthwith, in order that

after
may open one with
a lancet, as
no one here-
Mr. Percival
says was actually done by a veterinary surgeon.*
The
diagnosis of this disease in horses must be
very important, whether
it
occur
extremities, for either would
in the
make
* Hippopa'.hology, p. 70.
trunk or
the animal un-
VETERINARY UTERINE AUSCULTATION.
When
sound.
in the former,
course, incurably so
might
man, 335).
ration
when
241
he would be, of
in the latter, an ope-
(See aneurism in
relieve entirely.
VETERINARY UTERINE AUSCULTATION.

ounds of the
as
in the
foetal
heart
human
may be heard
subject.
have
never listened to them however, and

the only very obvious use to which, as
it
seems
to
me, that auscultation of
the uterus in animals can be applied,
discovery whether or not a mare

is
a very important item on
for
many
reasons.
(See
470. Percussion, also,

the size of the
with
is
to the
foal.
This
many occasions and
foetal
is
is
heart 358).
important as marking
womb, and may be
practised pre-
viously to auscultation in order to accustom the
animal to examination.
471. In
all
these examinations, great caution
should be observed to avoid injury from the animal, which frequently becomes restive under this
operation.
16
APPENDIX.
A, page
16.
STETHOSCOPES.
472.
Some few months
since, a friend
gave
me
one
of the stethoscopes used by Dr. C. J. B. Williams of Lon-
soon proved the truth of two assertions made

at the meeting of the British Assoin the
ciation, in 1842, and subsequently published
Medical Gazette for December of the same year. In
ever
the first place, it was the most perfect instrument I
don, and
it
by that gentleman
used
it
for its delicacy in
much while
it
lasted
conveying sounds, and I enjoyed

but, in the second place, it was
;
unfortunately too fragile and
The
was soon broken.
following plates represent the stethoscope, to-
gether with his plessimeter and hammer.
244
APPENDIX.
Fig.
Fig.
represents the instrument, prepared for use.
1
1.
It is
made of
It is
hollow
and
a
is
soft
sycamore wood. Fig.
2.
has thin parietes,
trumpet-shaped
mouth,
a moveable ear-piece, which
can be introduced into the other

end of the tube, as represented
in Jig. 2, to
make
the instrument
more portable and
less liable to
receive injury in the pocket
may
or
applied to the trumpet-mouth of the
may be
instrument, when
we wish
do this the stetho-
it
be placed on the chest, while the ear
to
To
examine the voice.
scope should be arranged as in Jig. 1.

Fig. 3 is a percussor or hammer made of a rod of
Fig.
whale-bone, four or
3.
five
inches long, and hav-
ing an oblate spheroid of lead, three quarters

of an inch in
extremity.
its
long diameter, fastened to one
This lead
Fig.
is
4.
covered with buff leather and velvet, to deaden
the sound.
Fig. 4
plessimeter,
made of a
is
stout narrow piece
a
of
whale-bone, about four inches long and slightly bent

by heat, so that one end forms a handle, whilst the
other, covered with leather
tween the
ribs
and velvet,
fits
and can be firmly applied.
readily be-
245
APPENDIX.
B, page 190.
AUSCULTATION IN MEDICO-LEGAL CASES.

473. First.
Among
the most deplorable cases on
record, in which innocent
human
life
was
deliberately
taken, according to legal forms and by the adjudication
of the supreme tribunals of the land, that of the child

of Mrs. Spooner,
who was executed July
stands preeminent.
2,
1778,
Under our modern means of diag-
nosis of the earlier periods of pregnancy, especially
with our knowledge of obstetric auscultation, such a

case I presume will never happen again.
me
most deeply,
because
it
may
stethoscopic
for
many
reasons
It
impressed
but I quote
it
now
stimulate you to the study of the minute
phenomena of early pregnancy.
You may
any time be placed in circumstances in which the

knowledge of these may be of the highest importance
at
to you.
Mrs. S. was convicted of having been an ac-
complice in the murder of her husband, and after having been condemned she begged a reprieve, on the ground
of being " several months advanced in pregnancy."
The execution was
stayed one month, and the court or-
dered a jury of" matrons,"
tion,
women
or, in other
words, of igno-
summoned to decide on the queswhether or notshe was" quick with child." This
rant old
to be
246
APPENDIX.
was put
practice, a relic of antiquated absurdity,
in ex-
ecution, and these twelve matrons wise in medical diag-
two men midwives, decided that she was

Mrs. Spooner immediately
sent to the Council a most touching petition in which
she says, "although the jury of matrons have not decinosis! with
no* " quick with child."*
ded
my
in
favor,
still
am
absolutely certain of being
pregnant state, and above four months (363) advanced in it, and the infant I bear was lawfully begot-
in a
ten.
am
earnestly desirous of being spared
delivered of
it.
withstanding
my
till
great unworthiness, to take
my
rable case into your compassion ate consideration

I bear
and clearly perceive to be animated
of the faults of her
who
bears
it,
to say, a right to the existence
Your
it.
even
am
and hath,
is
deplo-
What
innocent
beg leave
God has begun
to give
honors' humane, Christian, principles, I
very certain must lead you to desire
it.
most humbly desire your honors, not-
in this, its miniature state, rather
am
to preserve life,
than to destroy
Suffer me, therefore, with all earnestness, to be-
seech your honors to grant
me such a further length of

may be the fairest and full-
time, at least, as that there

est opportunity to
have the matter fully ascertained,
my
and, as in duty bound, shall, during

ance, pray."
a mother
in
Nothwithstanding
this
short continu-
urgent appeal of
behalf of her innocent unborn babe, the hon-
orable Council of Massachusetts ordered her execution,
and thus
inflicted a stain that
can never be erased from
the annals of the jurisprudence of the State

* American Criminal Trials, by Peleg
Carter &. Co., vol.
ii.
1845.
W.
and they
Chandler, Boston
T. H.
247
APPENDIX.
men midwives and one

of the "matrons" certified that they believed that Mrs.
did so, notwithstanding that two
S. was quick with child, and that they had been mista-
ken
they had previously given

It was
"Elizabeth Rice and Molly Tattman "
in the verdict
sufficient that
certified to the contrary,
and that they believed her to
be " not even
27, 1778) quick with child."
With
now (June
indecent haste, amid the fury of the elements,
and the shouts of the crowd, this legal murder was consummated. On the evening of the day of the execution, the " body was examined, as the prisoner had requested, and a perfect male foetus of the growth of five
months was taken from her
As
show
"!
have already stated,
quote this case chiefly to
the importance of every sign of early pregnancy in
medico-legal questions.
have no hesitation
ing that, had auscultation been
known and
in believ-
practised on
would have revealed the existence of

and this sad event would
have been prevented. Does not the reverse of the fact
that occasion,
it
the sounds of a
foetal heart,
prove to the medical student the importance of accurate

obstetric auscultation
somewhat
in the
seventy years,
For though we have improved
forms of jurisprudence during the last
we
are
still
liable to
have the
folly of
matron jury enacted over again by the advice of the

wisest on the bench.
The student of medicine ought
always
to protest against
such an absurdity, and
for the auscultatory signs their relative
place
among
the
474. Second.
to
claim
and important
phenomena of early pregnancy.

It
may be your fate
to
be called upon,
as physician of a prison, to state whether or not a pris-
248
APPENDIX.
oner has such disease of the lungs as to render his

longer sojourn in confinement absolutely detrimental to
life.
In like manner, the army and navy surgeon is always

liable to
meet such cases among the soldiery under his
charge.
In
all
such circumstances auscultation
may become
of infinite value to you.
C, page 186.
AUSCULTATION DURING LABOR.

475. I might have mentioned the possibility of dis-
covering the existence of two foetuses by means of auscultation.
If there is double pregnancy,
shall hear a foetal heart beating in
two
bly opposite, places of the abdomen.
we, of course,
distinct,
proba-
GENERAL INDEX.
THE NUMBERS REFER TO THE PAGES OF THE BOOK.
A. ART.
Abdomen auscultation
Adipose matter
Êgophonic
applied to
effects of on
murmur,
it,
202.
sounds of percussion, 45.
59.
JEgophony, 28. 59; cerebral, heard
in cases of hydroce-
phalus, 197, 198.
Age effect
Amphoric
cles,
of,
on heart, 112.
respiration, 24
&c,
in
pneumothorax, 24. 76; tuber-
24. 68.
Anchylosis auscultatory percussion in, 208.

Aneurism in animals, little noticed by veterinarians
di-
agnosis very important, 240.

auscultation in, 116. 168; inspection in, 114.
168
115.
Aorta
mensuration, 116. 168
168; percussion, 170.
palpation in,
see errata.
see errata.
Apoplexy as cause of impulsive sound of heart, 197.

Aqueous type of sound, 211; found best in abdomen, 211_
Armfalling of, downward and backward in pleurisy, 60. 63.
Arteries
auscultation of ; impulse and bellows
may or may
not indicate disease, 116.
murmur
;;
250
AUS.
ART.
Arteries Inspection of;

sels,
115
carotids,
114
tumors over ves-
effects of chlorosis, ib.
Mensuration
of
never used except in promi-
nence of aneurism, 116.
Palpation
115; discovers increased pulsa-
of,
tions, ib.
purring
important in
all
thrill, ib.
dicrotous pulse, ib.
Arteries of brain
of radial pulse,
cardiac diseases,
see
ib.
irregular
errata.
cause of bellows murmur, 196;
de diable and purring
of bruit
197.
thrill,
Atrophy of the heart no sufficient physical signs

Auscultation of arteries, 116.
Cardiac, in health, 93
Cephalic, origin
of,
193
in disease, 100.
;
(for
sounds, natu-
and morbid, see respiration, heart,
ral
deglutition,
voice,
aegophony, purring
sounds of;
cephalic
thrill,
bruit de diable,
bellows murmur, musical murmur)

its
136.
of,
uses,
applied
the
to
bladder,
ib.
Immediate,
ear, 201
fractures,
abdomen, (see
ib.
ear, &c.) 202.
13.
Mediate, 13,
for the heart, 90.
in medico-legal cases, 190

case,
its
196198.
appendix B;
Mrs. Spooner's
important to army,
navy, and prison physicians, appendix B.

Obstetric,
necessity of
179;
it
to
decide
quickening in medico-legal questions, 190

in
doubtful pregnancy,
murmur, 180
labor, 186
foetal
ib.
heart, 182
placental
;
during
diagnosis of pregnancy and tu-
mors, 187.
Preliminary
necessary
to
an accurate,
1.
AUS.
BEL.
251
Auscultation Pulmonary sounds
17; do. in
in health,
disease, 22.
Veterinary, 219, 221.
Auscultatory Percussion, 205, 206
applied to decide size of
heart, 206
208
ofliver, 207
kidney,
ib.
anchylosis, ib.
spleen,
existence
of
fractures, 209
difficulties of, 213.
Axilla?
percussion 43.
Murmur causes
in,
Bellows
of,
103; constant, indicates car-
diac disease, 103.
Cephalic
consequent
gestion, &c. 196
on cerebral con-
of little use in
diagnoses,
differential
ib.
minute
never in
children before dentition, unless in disease, 197.
102, from chlorosis,
different kinds of,

ib.
debility, ib.
endo-carditis, 127
exercise, 102.
insufficiency of mitral valve, very
ifest in
143
causes of
where heard
it
man-
in do., ib.
in do., 144.
in nervous cardiac diseases, 137.
not necessarily owing to disease, 102.

obstruction of
from obstruction, 104
aorta, 147; when heard; transmis;
sion
of, ib.
places
where
from regurgitation, 104

of
149
aorta,
;
148
heard, 105.
regurgitation
with second sound,
character
of, ib.
where heard,
ib.
from roughness of aorta, 167.

times
at
which
varieties of
it,
it is
103.
heard, 106.
;;
252
BLA.
BRO.
Bladder auscultation in diseases of, 201.

Bone best conductor of sounds in auscultatory percussion,
209.
Broken wind
235
in animals,
Bronchial respiration
causes,
natural, 23
ib.
dilated bronchi,
lung, 79
59
signs, ib.
from diseases, 22. 54
84
gangrene of
phthisis, 68
pleurisy,
pneumonia, 54.
heard more distinctly in pleurisy in

animals than in man, 227
pneu-
in
monia, 233.
Bronchitis
physical
signs, 47
may be
none,
ib.
exam-
ple, ib.
Acute,
most
stage, sonorous rale, 47
first
at
base of lung,
ling rales, 48
ib.
mingling of the two,
stage, disappearance of rales, ib
base, ib.
wavy
sibilant,
second stage, crack-
only on coughing,
ib.
ib.
third
heard best at
mucous
respiration at other times, ib.
or
impor-
tance of examining during cough, 49
case
illustrative of this, ib.
Chronic, no symptoms, 50
ib.
mucous
sonorous rale rare,
at base, ib.
Respiration, voice and results of percussion, nor-
mal in both kinds, ib.

Example of acute running
Voice and percussion
into chronic, ib.
if altered,
suspect dis-
ease, 51.
in veterinary practice, signs of,
heard,
Bronchophony
232
where
ib.
natural,
27
from diseases,
ib.
dilated
gangrene of lung, 79 phthisis, 68 pleurisy, 59

pneumonia, 27. 54 purest in this last, 54
resemblance to pectoriloquy, 27.
bronchi, 84
;
bru.
Bruit de
cou.
'253
118; heard in reins, character of
(liable,
cumstances best
produce
to
it,
it,
cir-
ib.
cerebral, 197.
de rape, 103
descie, 103.
de souffle, 103.
de
soufflet, 103.
Cardiac Region
prominence
of,
from pulsations of heart,
6. 91.
Cardiac type of sound, 211.

Carditis
by
exact
diagnosis impossible, 127
not recognised
veterinarians, 239.
Carotids pulsation
hypertrophy of the heart, 114. 132.
of, in
Cartilage, as conductor in auscultatory percussion, 209.
See bronchitis.
Cavernous respiration natural
Catarrh.
heard over cavities, 23.
68. 79. 84. 55.
Cellular tissue
least conducting power,
209.
Cephalic Auscultation, see Auscultation.
Change
nia,
Chest
of note, on percussion, 44
54
phthisis, 65,
expanded in
animals, 235
Chlorosis
important in pneumo-
&c.
emphysema, 81
pleurisy, 60
in broken
winded
pneumothorax, 76.
cause of bellows murmur, 102
of devil's noise
(bruit de diable), 118.
Churning sound in pericarditis, 110. 122.

Clavicle rales under, importance of, 67,
Comparison importance
auscultation
ence of note,
Cough in
123
when
especially
68.
of one lung with the other in
there
is
merely a
differ-
5.
Contraction of chest,
carditis,
of,
after chronic pleurisy, 7.
60
peri-
phthisis, 8. 64.
veterinary medicine, 230. 232, 233, 234. 237.
resonance
of,
69
producer of rales, 53. 69. 79.
254
Cough
cou.
dia.
without any physical signs, 87

bronchitis, ib.
ib.
ib.
ib.;
and phthisis,
in females,
usually connected with throat complaints,
loud and barking, 88

aphonia,
ib.
nervous patients,
diagnosis difficult, ib.
of rational and physical signs,
barking in nervous females,

Crackling Riles, 33, see mucous 34
co-crepitous, ib.
difficult to
different from
ib.
crepitous, 33
ib.
need
loud and
ib.
submucous,
ib.
mu-
gurgling, 35; varieties
be distinguished, 33.
Cracked-pot sound, 44; over cavity, 44. 68. 79; occasionally in
pneumonia, 44
Creaking sound
Crepitous Rale
nia, 34.
cautions in regard to, ib.
in pericarditis, 120.
characteristics, 33
53;
pneumonia of animals, 233
indicative of
pneumo-
and tubercles, 67. 34; in
oedema, 86;
;
in
broken winded animals,
235.
Cyrtometer,
to
measure prominence of heart, 93. 122.
Debility, as cause of diminution of heart's sound, 100
cause of bellows murmur, 102.

Deglutition
Diagnosis
cephalic sound
differential of
of,
194.
bronchophony, pectoriloquy, &c,
of little use, 29.

differential, of carditis, endo-carditis,
carditis, of little
ment
and peri-
importance in treat-
of an acute attack.
Table
of
symptoms,130.
of aortic and mitral valvular disease,
107. 144. 147. 150.
of aortic and pulmonary artery diseases, 151.
of carditis, almost impossible, 127.

of
pleural and pericardial
sounds, 110.
rubbing
DIF.
EFF.
255
Difference of note on percussion, 44;
importance of in
pneu-
phthisis, 65; in
monia, 55
44; in gangrene,
side,
78.
in pain of
over cardiac region, 112.

Dilatation of the heart
as
signs
an idiopathic
chest in
of
7.
60
of,
134
uncommon
rather
affection, 135.
emphysema,
pericarditis, 7.
7.
122
81
pleurisy,
malignant
dis-
eases,?. 175; aneurisms, 7. 170.
of the bronchi, 84
resonance of voice
in, ib.
bronchial, perhaps cavernous respiration,
mucous
ple
raie in, ib.
of, ib.
percussion in,
ib.
ib.
exam-
diagnosis difficult, 85.
Diminished resonance of the voice,
29. 66. 81.
importance of inspection in, 8.

Displacement of organs by abdominal disease, 157;
Diseases of children
risy,
Dress
60
pleu-
pneumothorax, 77; by nature, 164.
thin, necessary in auscultation,
Dullness on percussion
1.
89. 180.
over lungs, 38. 45.

in
gangrene of lung,
phthisis, 44. 65
pneumonia, 44. 54;
58;
78;
45.
pleurisy, 45.
pul-
monary apoplexy, 83.

over heart, 112
augmented
;
aneurism,
heart, 134
132;
114.
128
174;
;
dilatation
endo-carditis, 114.
pericarditis, 114. 121.
58
of
hypertrophy of do.,
Dyspepsia palpitations in, 154.

Ear auscultation in diseases of, 201.
change of posture useful
Effusion in pleurisy
it,
in
signs
of,
to discover
on both sides usually in horses, 237.
;;;;;
256
EMP.
Emphysema of the
EXA.
lung, 81
enlargement of intercostals,
motions of chest, 8. 81;
ib.; difficulty of
resonance on percussion great, 43. 81

piratory
murmur lessened, 18,
prolonged expiration,
less resonant, ib.
ted less clearly, ib.
ib.
sibilous, ib.
res-
or absent, 81
;
voice
sounds of heart transmit:
r&les, sibilant, sonorous,
mucous, 31. 34. 81.

example of, 82.
effects of,
on the results of percussion over the
heart, 113
interferes with auscultatory per-
cussion, 214.
in animals, 235
crepitation in do., 235.

(See
broken wind).
Endo-carditis no undoubted sign, 127 bellows murmur,
127; caused by lymph, 128; irregular impulse, ib.
;
dullness on percussion,
trophy,
ib.
ib.
morbid sounds with hyper-
example, 129.
Enlargement of chestin aneurism, 168

pericarditis,
122
in pleurisy, 60
Errors in auscultation, 157
emphysema, 81
pneumothorax, 76.
he hopeful in spite of them,

157; from trusting too much to physical signs, 157. 156.
Examination, of a case of cardiac disease, method of, 158.
Expiration
prolonged
suspected phthisis, 69.

ratio to inspiration,
at top
19
altered
of right lung, 21
by
disease, ib.
prolonged in phthisis,
25. 66
dilated bronchi, 19
emphysema, 81.
Example of aortic obstruction and regurgitation, 149
;
bronchitis without physical
chronic, 50
84;
signs,
47
do.
acute
running into
contraction of the chest, 7 ; dilated bronchi,

of the chest, 7; diminished motions of
dilatation
chest, 8; of diminution of sound on percussion,

45; oedeof lungs, 87 ; emphysema, 81 ; increased
motions of
chest, 8 ; endo-carditis, 128 ; enlargement of chest,
7
ma
EXA.
FIG.
257
gangrene of lungs, 79 hypertrophy, 133 importance of

comparing one lung with the other in auscultation, 5
;
obstruction of mitral valve, 141
123
pericarditis,
phthisis,
69
insufficiency
pleurisy, 61
of,
145
pneumo-
pneumothorax,
nia,
56
77
pulmonary apoplexy, 83.

Heart sounds of, heard easily during labor, 182
watch ticking, ib. altered by state of mother, men-
Foetal
like
tal
early stage of pneumonia, 53
or bodily, 183
great importance
metallic character
of,
184
extent
of, ib.
case, ib.
which they
to
are
heard in various periods of pregnancy, ib. earliest time

heard, 185 temporary absence of, no proof of not being
;
pregnant,
ib.
obstacles, ib.
position of foetus, 186
187
as a
means
in questions of
medico-legal cases, 190
of recognising
instrumental labor,
appendix B.
Fat, as conductor of sound, 209.
Figure
position of patient
in auscultation of breasts, 2.
do.
do.
do.
do.
do.
do.
callipers
Laennec's stethoscope, 14.
for
measuring the chest,
3.
4.
12.
do
do.
in
separate pieces,
Piorry's stethoscope, objections
8 do.
do.
9 do.
do.
15.
6
its
ib.
to, 14.
ib.
10
11
12
13
14
do.
Bigelow's,
do.
do.
do.
do.
do.
Pennock's
ib.
do. ib.; uses of,
do.
ib.
ib.
ib.
16
Golding Bird's,
Cammann and Clark's stethoscope,

16
do.
do.
15
17
18
ib.
ib.
ib.
Divisions of chest for auscultation, front, 20.
do.
17
do.
back,
ib.
258
Figure
GAN.
FIG.
19 bifurcation of bronchi, 22.
variations in inspiration and expiration, 25.

caoutchouc plessimeter, 39.
22 Bigelow's plessimeter,
23 Raciborski's
do
24 Cammann and Clark's, 40.
20
21
ib.
ib.
25
shades of sound on percussion, breast, 41.
26
27
do.
do.
back, 42.
do.
do.
sides, 43.
contraction of chest pleurisy, 63.

29 places
auscult different valves of heart, 98.
28
in
to
30
various motions and sounds of auricles and ventricles
and their mutual relations, 99.
transmission of sounds of heart, 105.

32 morbid valvular murmurs, relations to motions,
31
&c. of heart, 106.
time of sound in obstruction of mitral valve, 161.

34 aneurism of
173.
33
aorta',
35
stethoscope
36
for auscultatory
percussion, 212.
213.
do.
do.
214.
do.
plessimeter
38 divisions of the chest of animals, 224.
Flatness on percussion in gangrene, 78. see dullness.
Fluctuation observed very rarely in pleuritic effusion, 11.
37
for
in pleurisy of animals, 238.
Fluttering sensation in nervous affections of the heart, 137.
Fractures
auscultation, 201
Fremissement
cataire,
Gangrene of lung
signs
difference of note, 78;
example
cous,
of,
&c,
79
ib
auscultatory percussion, 209.
see purring
of,
78
thrill.
cracked-pot sound, 79
dullness on percussion, 45. 78
pectoriloquy,
respiratory
augmented, or diminished,
ib.
rales, irregular,
murmur,
ib.
ib.
mu-
voice altered,
Gurgling, 35
at
in a cavity, 55. 68.
bottom of lung, 35
259
HE A.
GUR.
79
35
at top of lung,
in diseases of larynx of animals,
229.
Haegophony
see asgophony.
Haemorrhage cause
Heart
atrophy
of bruit de diable, 118. 137.
irrecognisable before death, 136
of,
aus-
cultation, 95. 159; auscultatory percussion, as a
means
it
of
from
side of,
marking the
207;
liver,
207
diseases
of, in
diseases
of,
impulse,
of,
111
animals,
impulsive, sound
inspection
of,
214.
toauscult, 239.
errors of diagnosis, 155.

;
augmented,
ib.
di-
ib.
of, in
apoplexy,
&c,
197.
92. 158.
malformations, 163
;
where
natural, ib.
&c,
separates
194.
remarks on, 91
minished,
deciding right
by auscultatory percussion,
cephalic sounds
tal, ib.
size of, 206,
difficulties of
malpositions,
from disease,
164
congeni-
ib.
mensuration, 95, 159.

motions, diagram to show, 99.
palpation, 93. 159.
percussion over, 112

space,
ib.
difference of note,
ib.
dull
effects of position on, 159. 113.
physical signs of, less certain than those ot lungs, 89.

polypi
in, 165.
position of
it
altered in hypertrophy, 132.
rules for accurate examination

ib.
of,
91
positions for,
stethoscope, quite important in these ex-
aminations, 92.
sounds, 94
abnormal, 102
absent, 101.
in animals, 225.
augmented, 101. 135; causes of 101; small importance,
ib.
; ;
0U
Heart
HYP.
HEA.
sounds of;
bellows murmur, 102; not necessarily
from disease,
debility, ib.
causes
of,
96
ib.
in chlorosis, 102. 137
exercise, 102.
cephalic, 194.
diminished in debility, 100
fevers,
ib.
hypertrophy, 100. 132; dilatation, 100.

134
diminution,
little
use as a sign, 100.
increased in number, 101
important as
sign, 101. 159.

irregularity of, 101
not necessarily con-
nected with disease,

combinations, 102
persons,
ib.
serious in its
commonly
in
aged
ib.
letters to express, 108. 143.
musical note, 103. 149
causes, 103.
from obstruction, 104 regurgitation, ib.

over right side of heart, more flapping
;
than those over the
left,
96.
parchment like, 138.

rhythm, 96.
second, heard along aorta, 97.
where heard most distinctly, ib.

Hepatic type of sound, 211, 212
differences between
and cardiac, 214. 207,
;
Hypertrophy of the heart, 132
after
pericarditis,
it
123
causes diminution of sounds

of heart, 100. 132
of,
example
133.
in animals, indefinite signs
by
veterinarians. 240.
rare unless with valvular disease,
132
signs
varieties of, 133.
of,
ib
IMM.
261
INS.
Immobility of thorax in pleurisy,
60
8.
pneumothorax,
8. 76.
Impulse of heart
back-stroke, 132. 149.

diminished, 111
decreased in dilata-
134; in pericarditis, 111. 122;

hypertrophy, 132.
tion,
increased in hypertrophy, 132.

fluttering in nervous affections, 137.
irregular,
148
in obstructed
tion of mitral valve,
valve,
aortic
usually augmented,
ib.
240
obstruc-
softening
of heart and at times in pericarditis,
ib.
natural, 111.
in regurgitation of aorta, 149
of mitral
arteries,
valve, 144.
Inspection
in
aneurismal tumors,
114
ken winded
7.
81
114. 168
7.
blood vessels of neck, 92. 158

animals, 235
158
of heart, 92.
bro-
emphysema,
use com-
little
pared with other physical signs, 6
motions
of chest, very important in diseases of chil-
dren, 8.
in obstruction of mitral valve, of
little
mo-
ment, 141.
patient
must be naked
rately,
7.,
in pericarditis, 122
60, 63
little
in order to do
it
accu-
158.
;
phthisis, 6. 64
pleurisy,
valves,
in regurgitation of aortic
use, 149.
suspected disease of the heart, 158
veins,
117.
Insufficiency
Inspiration
25. 72
see
regurgitation.
ratio to expiration, 19.
diminished, 19.
25
altered
by
disease,
262
1ER.
Irregular
MEN.
sounds and motions of heart in pericarditis, 120

endo-carditis, 128
in nervous diseases of the heart, 137

tion of mitral valve,
hypertrophy, 132.
140
obstruc-
insufficiency of do.,
144; obstruction of aorta, 148
insufficiency,
149.
Jerking respiration, 24
importance of in phthisis, 72.
pulsation in hypertrophy, 92. 132.

Laennec great improvements in diagnosis in consequence
155 stethoscope, 13 his view
Laryngitis auscultation
46 inspection
Jugulars
of,
of, ib.
in,
Larynx
in, 8.
animals natural sounds, 229 moist and dry

whistling, ib.
gurgling, ib.
sometimes confused with
in
sounds from lungs, 230.
Latent pericarditis, 124
J-iiver
auscultatory
fever
pericarditis,
percussion
pneumonia, .53.
109
marks
when enveloped
heart, lungs, and
Lung
pleurisy, 61
Leather creak sound in
in
cause,
its
ib.
from
outlines
serum, 208.
see pneumonia.
Malformations of heart, 168.

Malpositions of
do.
164.
Mammse interfere
with percussion, 214.

Medico-legal questions auscultation in, 190.
Mensuration aneurisms,
pers, 12
116. 168;
;
appendix B.
arteries,
116;
calli-
cardiac disease, 95.
diseased blood-vessels, 116; performed

tape, 12
phthisis, 69
pneumonia,
by
pleurisy, 12. 60
12.
prominence over the cardiac region, instru-
ment
for, 13.
122.
small importance compared with other physical signs, 12, 13.
Mental emotions
mother on
effects
foetal
on respiratory murmur, 18
heart, 183.
of
MET.
Metallic echo, 33
in
Metallic tinkling, 32
263
MOT.
pneumothorax, 76.
artificially produced, ib.

explanamost perfect in pneumothorax, 33. 76 occurrence under other circumstances, 33.
tion of, ib.
Mitral
valve obstruction
139; example
of,
pulse, irregular in, 140
of,
141; im-
of radial pulse,
115. 140; similar felt in softening of heart,
pericardial effusion, 140.
sounds,
little
or none, 139
diagram
of,
161
times of occurrence, 104. 161.

Mitral valve insufficiency
manifest,
ib.
ib.
143
of,
ib.
bellows
times
of, ib.
where heard, 105.

diagnosis between
murmur very
;
varieties of,
107. 144; causes,
mitral and aortic
disease, 144. 160.
example
of,
145.
inspection, 144
ib.
Modification of voice, 28
mensuration,
ib.;
palpation,
little result, ib.
from disease, 28. 59
portant than asgophony, 28
Motions
percussion gives
more im-
in pleurisy, 28.
abdominal, indicative of disease, 9.

of chest, 8
absence of in pneumothorax, 76
pleurisy, 60.
augmented in
ib.;
laryngitis, 8
pneumonia,
pneumothorax, ib.; acute phthisis, 9.
diminishedin chronic adhesions of pleura, 10.60.
disease
tions
affecting
one
augments
mo-
of the other, 18.
important
to
be observed in diseases of
children, 8.
increased locally,
aneurism,
&c,
as in hypertrophy,
8. 132. 168.
264
MOT.
OBS.
Motions of heart, 92; inspection
of,
cardium, 10
122;
in pericarditis,
sight of, destroyed
by
effusion in peri-
in hypertrophy, 132.
Muco-crepitous rale, 34; example, 35.
Mucous
35
48
rale, 34; in bronchitis,
phthisis, 68
example,
dilated bronchi, 84.
Muscle as conductor
Musical
Musical note,
Musical
of sound, 209.
murmur cephalic in
to
anaemia, 198.
sounds of heart, 103.
rales, 30.
Nasal cavities
disease
228
in animals,
of,
sonorous rale
in, 228.
Note
difference
pneumonia, 54; phthisis, 65.

duty of, 187; diagnosis of
tumors from pregnancy, ib.; case, 188; during labor,
of,
44;
Obstetric auscultation,
186;
foetal
in
179;
heart, 182; medico-legal questions, 190, and
appendix B.; placental murmur, 180

Obstruction of the aortic valves, 147
rules for, ib.
bellows
murmur
in,
147.
between
diagnosis
and mitral
it
dis-
ease, 144. 147.
dullness
owing
to
enlarged heart, 144.
148.
example
148
of,
149
impulse of heart
ib.
pulse at wrist,
ib.
ular, ib.
or purring
of bellows
mitral valve
usually augmented,
feel,
148
murmur,
diagram
of, 1
in,
irreg-
thrill
transmission
147.
61
causes usu-
ally little sound, 108. 139.
example of, 141

inspection, 141
impulse irregular
tle use, ib.
when most
in, 140.
mensuration, palpation,
evident, 139. 161.
lit-
OBS.
PEE.
265
Obstruction of tricuspid valve rare, 146;
condi-
similar
tions to obstruction of mitral, ib.
spot of
most distinct murmur, ib

pulmonary artery, when it exists is commonly connected with aortic obstruction,
151.
diagnosis of this and aortic disease,
ib.
same
rules as in aortic obstruction, but different
place, ib.
very rare, ib.

(Edema of lung crepitus in, 86; example
cussion in, usually good, 86

ished,
ib.
voice well,
difficult to
and functional, 157.

Organs displaced in pleurisy, 60
Osseous type of sound, 211.
to
87; per-
ib.
Organic disease of heart
Palpation applied
of,
respiration slightly dimin-
decide between
it
pneumothorax, 77.
aneurism, 115. 168; arteries, 115.

chest, in health, 10. 93
94
disease of the heart, 94
of mitral valve,
disease, 10.
small advantage
of, 11.
obstruction
140
phthisis,
69; pleurisy, 60; veins, 118.

Palpitations
dyspeptic, 154.
Panniculus carnosus muscle in horses obscures sounds in

chest, 225.
Panting
importance
Parchment sound
of,
in acute phthisis, 9.
of valves of heart, from thickening of
valves, 138.
often move with difficulty,

natural, 26; from disease, 27;
Parietes of chest
Pectoriloquy
ib.
in phthisis, 68
Percussion
gangrene, 79
in aneurisms, 170.
9.
varieties of,
pneumonia, 55.
;;
266
PER.
PER.
Percussion in animals, mediate, &c, rules
pneumonia of do, neglect

in aortic obstruction
may be
normal, 148;
usually enlarged dullness,

regurgitation of
221
for,
234.
of,
ib,
aortic
in
use, 149.
little
in auscultatory percussion, 206. 213.

clear, in
broken winded animals, 235.
dilatation of the heart, 134.
endo- carditis, 128.
over heart, 112
113
difference of note, dullness,
inlluence of position on results,
in diseases, ib.
ease on
ib.
it,
of
effects
ib.
pulmonary
effects of its
own
dis-
diseases,
114.
gangrene of lung, 79.

in hypertrophy of the heart, 132.
importance
38
of,
rules for accurate performance,
experiment,
auscultation,
diate,
ib
ib.
ib.
;
more
ib.
used,
latter rarely
difficult
mediate,
simeters for performance
ib.
than
imme-
ples-
of, 39.
of nasal cavities of horse, 228.
nervous affections of heart, 137.

pericarditis, 121.
in phthisis of animals, similar results to those of
men, 236;
in pleurisy,
in phthisis, 65
238 on both sides, ib.

;
pleurisy, 5S
77; pneumonia, 53, 54
in
pneumothorax,
pulmonary apo-
plexy, 83.
sinuses, frontal, of animals, 228.
Percussor
Bigelow's, 15
Pericardiac sounds
ib.
rubbing sound, 110
sound,
ib.
Williams's,
musical
;
appendix A.
murmur, 109; new

to-and-fro sound, ib.
leather,
washing
PHT.
PER.
Pericardium
disease
267
animals, 239
of, in
place to exam-
ine for signs, 239.
Musical murmur, 119; leather

irregular sounds and
Pericarditis first stage.
creak sound, 120

motions of heart,
ib.
prolongation of
first
symptoms absent, ib.

second stage. Rubbing sound, 120 diagnosis between it and pleural sound of same
sound,
ib.
these
character,
sound,
ib.
ib.
;
Sounds of heart,
third stage.
impulse
varieties, ib.
to-and-fro
bellows murmur, 121.
less, ib.
indistinct, 121
respiration obscured or absent, ib.
nence of
Convalescence, disappearance
fourth stage.
ib.
returning rubbing sound,
123; disappearance
of, ib.
fifthstage. Irregularity of motion, 123
of hypertrophy
example
of,
promi-
122.
left breast,
of signs,
dullness increased, ib.;
signs
ib.
123126.
chronic signs, 126.

Pericarditis
in animals,
signs like those of pericarditis in
man, 239.
very vague accounts given by veterinarians,
ib.
Phthisis
amphoric
respiration, 68.
in animals, signs of, similar to those in
man, 236.
breathlessness or panting in, and rapid pulse, 9.

in acute phthisis, 9. 76.
in children, physical signs small, 76.
cavernous respiration
68. 23
in,
click
under
clavicle, importance of, 67.
cough, resonance
crackling,
ib.
of,
69
effects
on r&les, 68.
268
PLE.
PHT.
Phthisis
diminished inspiration,
example
of
66.
method of examining a case of sus-
pected phthisis, 69. 75.

gurgling, 68.
inspection in, 6. 64.
jerking respiration, 66.
mensuration, 12. 69.

modified voice, 66
obscured
do., ib.
palpation, 69.
pectoriloquy, 68
prolonged expiration, 66. 22 ;

prominence of clavicles, 64. 8
pulmonary
crumpling sound, 65 rude respiration, 66. 23.
;
percussion,
dullness
resonance,
signs
of, at
ib.
on,
diminished
67;
65.
increased resonance, 65.
top of lungs, 64.
transmission of cardiac sounds, 69.

Piorry's stethoscope, 14 ; plate of, ib. ; objections
to, ib.
murmur, 180 character, 181 inconstant, ib.

always in same place, ib. causes, ib. when ceases, ib.
Placental
corresponds with mother's pulse,
182
various opinions,
Places, in
which the
ib.
how
early heard,
ib.
rales are heard, importance of noting
exactly, 37. 51. 58. 64. 71.
Plessimeters varieties
of,
forefinger, 38
caoutchouc, 39
Raciborski's and Bigelow's,
appendix A.
ib.;
Cammann and
Williams's,
Clark's, 40.
in auscultatory percussion, 213.
Pleurisy
physical
signs of, diminished
rubbing sound,
58
respiration,
57
dullness of percussion, 45.
haegophonic murmur, 59
piration, ib.
ib.
ib.
modified voice,
ib.
returning rubbing sound,
bronchial res;
haegophony,
ib.
enlarge-
ment and subsequent contraction of chest, 60

falling of arm backward, ib.
immobility of
;
;;
PLE.
thorax,
ib.
POT.
269
vesicular thrill destroyed, 60
displacement of organs, 60
63, fig. 28
in animals, signs
Pneumothorax phys
mur,
ib.
sudden enlarge-
ib.
amphoric,
echo, 33. 76
77
ib.
metallic tink-
voice modified,
tympanites,
diminished, respiratory mur-
ling, ib.
28.
61
of,
on heart, 63.
237.
of,
signs of, 76
cal
ment,
example
effects of pleurisy
77
effects
on
heart, ib.
inspection in, 8
loud sound on percus-
sion, 77.
Pneumonia commences low in lung. First stage. Increased or diminished murmur, 52.
Example,
53. Second.
Crepitous rale and voice,
change of note on percussion, 54
Bron-
tance of first inspiration, 53. Third.

chial respiration, 54
chophony, ib.
tympanitis,
turning crepitus,
ib.; subcrepitus,ib.;
Crackling, gurgling, ib.
Pneumonia
signs
ib.
ib.
more
Fifth.
diminished purity
of bronchial respiration,
ib.
bron-
Fourth. Re-
ib.
caused by oedema,
dullness on percussion,
change of note important,

dullness, 55
ib.
ib.
impor-
ib.
signs of suppuration,
pectoriloquy,
ib.
less certain in children, ib.
example,
56.
in animals, 233
signs of, 234.
inspection in, 8.
Polypi of the heart, 165.

Position of patient in auscultation, 1, 2, &c.
91
effects of,
change
of,
on percussion,
1.
58
useful, 58.
Pot fele bruit de pot
fele, 44. 65. 79.
do of heart,
do. of heart,
113
270
KAL.
PRO.
Prolonged expiration
physema, 81
Prominence of
;
at top
of the right lung, 21
in
em-
&c.
phthisis, 66,
clavicles, 8. 64.
hreast in pericarditis, 122.
left
Puerile respiration
causesof, 17. 58;
along spine in pleu-
risy of animals, 225.
Pulmonary artery valve, obstruction,
rare, 151
sounds
like those of aortic obstruction,
but heard in a different
place, 152.
regurgitation or insufficiency
very rare, 152.
of,
example of dilatation of do., 153
obstruction, regurgita-
(see
tion).
Pulmonary apoplexy
physical signs
Dullness on per-
of.
cussion, 83
absent or modified
respiration, ib.
rales, ib
voice
altered, ib.
example of, 83.

Pulmonary crumpling sound when heard, 65
examples,
37.
Pulsation of jugulars, from diseases of heart, 117. 132. 147;

of capillaries, 117
diagnosis, ib.
Pulse in aortic obstruction, 148

ing, 149
Purring
do. in regurgitation, jerk-
obstruction, mitral, 140.
thrill,
115
most distinct
to tip of fingers, 11
148
aortic obstruction,
do.,
in
regurgitation of
149; in aneurism, 170.
cerebral, 197.
Quickening
tions,
Rales
auscultation
to
decide
it
in medico-legal ques-
Mrs. Spooner's case, appendix B.

a click under clavicle, importance, 67
crepitous,
33 gurgling, 35, 68. 79 metallic echo, 33. 76 ;
190
EAL.
metallic
RES.
tinkling,
mucous,
34. 48
ib.
271
muco-crepitous,
in phthisis of animals similar to those in
pulmonary crumpling sound,

sound, 36. 57. 59. 120
rous, 31. 81
34
musical, 30.
man, 236.
rubbing
36. 65
sibilant, 31. 81
sono-
subcrepitous, 34.
their situation in the
lung as important as their
characteristics, 37. 47. 51, 52. 58. 64.

in veterinary auscultation, similar to those in
man
226.
Regurgitation through aortic, 148
monary
Resonance
artery, 152
(see sounds)
mitral valve, 143
pul-
&c,
(See mitral,
examples of great resonance on
emphysema,
percussion, 43;
phthisis, 43. 65
pneumothorax,
26;
of voice,
tricuspid, 146.
in
pneumonia,
43.
43.
81;
in
54
in
43. 77.
see vesicular resonance, 27;
bronchophony,
27. 54
Eegophony, 28. 59
pectoriloquy, 27. 63. 79. 84.
Respiration
amphoric, most
76
distinct in
imitation
cephalic sound
of,
of,
pneumothorax,
24.
24.
194.
bronchial, natural, importance of
its
study,
22; from pneumonia, 54; pleurisy, 59;

68
tubercles,
grene, 79
dilated bronchi, 84
tumors of lungs, 23
gananeu-
risms, ib.
cavernous, heard over cavities,

nia,
55
rude, 23
66
phthisis, 68
ib.
pneumo-
in partial tubercular solidification,
or pneumonic, 52.
wavy or jerking, 24; usually of little moment

but may become of great importance in
phthisis, 24.
;
;
272
Respiratory
KES.
fremitus in
RET.
10
health,
augmented by
pneumonia, cavity in lungs, 10.

diminishe
tumors,
murmur, 17
in pleurisy,
&c,
inspiration and expiration, 17.
19. 21. 25
influence of age, 17
posture, ib.
disease,
18
60
10.
10.
temperament,
ib.
ib.
mental emotions,
rapidity of breathing, ib.
action of heart, ib.

variations of,
of chest, 18
piration, 19
19. 25
ratio
ease, 19. 66
ished,
19.
puerile, 17
in different parts
importance of exratio to inspiration,
changed by
dis-
inspiration dimin-
66;
expiration pro-
longed, 19. 22.66;
obscure in
phthisis, 29. 65.
absent in pleurisy of animals, 237
emphysema, 81
times in
at
pulmonary apoplexy, 83.

affected by exercise in animals,
223 in man, 17.
in animals, breezy as in man, 223.
;
lessened in
aneurisms, 169
broken wind, 235

81
121
in
emphysema,
in hypertrophy, 132
ma
oede-
of lung, 86; in pericarditis,

;
and changed in phthisis of
animals, 236.
diminished in pleurisy, 58; pneumothorax. 76 ; pulmonary apoplexy, 83.
Returning crepitous
rale, 34. 54.
rib.
Ribs conducting power
sou.
of,
in
273
auscultatory percussion,
causes embarrassment, 214.
Roaring as
a disease of horses, 231.
tracheotomy to relieve, 231.

Rubbing sound, in broken winded animals, 235 pericarditis, 120; time of occurrence, ib. ; an;
alogy
to
sound
tween them,
in pleurisy, diagnosis
ib.
when
be-
favorable, 123.
pleurisy of animals, 237.
roughness of pleurae, 36. 120.

varieties of, 36.
Rude
Rule
respiration, 23
in tubercles,
66
important in auscultation, 37.
Rumbling sounds heard among
pneumonia,
52.
pleural sounds in veteri-
nary auscultation, 238.

Sibilant rale, 31
81
indications, ib.
bronchitis, 47
Sibilous respiratory
Sinuses frontal
&c,
occurrence in asthma,
varieties, 31.
murmur
in
emphysema,
animals, diseases
in
of,
81.
228; whistling,
in, ib.
Sonorous rale, 31
do. imitated
tle in phthisis,
32
by
lips, ib.
a single whis67 ; fugitive character of,
;
in nasal cavities of animals, 228
in
larynx of animals, 229.

Sounds of heart abnormal, 102

ib.
diminished, 100
132
tis,
138
absent, 101 ; augmented,

;
diminished in hypertrophy, 100.
increased in number, 101
121
103
irregular, 101
indistinct in pericardi-
loud in dilatation, 134
prolonged in
pericarditis,
120
musical,
represented by
words, 108. 143. 146. 148, 149 ; transmitted

ly in
natural, 96; parchment-like in thickening of valves,
emphysema,
18
81.
less distinct-
274
sou.
Sound on percussion
absence
;;
ste.
of,
44
indications of severe
disease, 45.
augmented
in diseases,
pneumonia, 54
on back,
43; emphy-
pneumothorax, 77;
81:
sema,
phthisis, 65.
less clear
than front, 42
difference of note at top of shoul-
42; sides
ders, 42. 65; scapula,
of vertebra;, 42.
changed in note or character,

diminished, 44
44.
58
in pleurisy,
pneumonia, 54 examples of, 44.

in front, 41 importance of behind
pear-like shape of
clavicles, ib.
;
heart, 41, 113
muscles on, 42
effect of pectoral
where
least
mus-
cle, greatest, 40.
influenced by diseases, 43. 45

sition of
body,
po-
1. 44.
places vary in importance, 40.
show
plates to
differences
rious parts of chest
of,
figs.
in va-
25, 26,
27), 41,42,43.
on
sides,
most resonant
least im-
portant, 43; tops of shoulders, 42.
Spinal
column bad conductor
Stethoscope
Laennec's view
of sound, 210.
of,
13; relative merits of
dif-
ferent stethoscopes, 13.
when
needed, 14
figures 5 and 6, views of
Laennec's instrument,
Piorry's, ib.
Bigelow's, 15
objections
;
ib.
to, 14.
used as a plessimeter,
percussor attached
to
it, ib.
ib.
STE.
275
VEI.
Stethoscope Pennock's and Golding Bird's,

Hope's view ofit, ib.
Dr. Williams', appendix A.
Cammann
importance
Stethoscopes
flexible, 16
and Clark's instruments, 16. 212.

of,
in diseases of the heart, 92.
used in auscultatory percussion, 212, 213.
Symmetry of the chest rarely perfect, from curvature of

spine, &c, 6.
Thorax divisions of in man, 20
and animals, 224
;
sounds on percussion ofit in man, 38. 112; and animals,

221
man,
auscultation ofit in
17.
95
and animals, 223.
pulmonary, destroyed in cases of effusion, 11. 60.

Tinkling see metallic tinkling, 32.
Thrill
To and fro sound in pericarditis, 110. 120.

Top of lung important in phthisis, 37. 64. 71.
Trachea tubal sounds in animals, 231 sibilant, sonorous,
mucous r&les, 231 obstruction of, causes roaring in
;
horses, 231.
Tracheal respiration see cavernous, 23.

Tricuspid valves obstruction of, 146; regurgitation
or insufficiency
Tubercles
Tumors
of,
see phthisis.
over
Tympanitis
arteries simulating aneurisms, 168. 175.
in pneumonia, 54;
Type sounds
insufficient, 148
;
pulmonary artery, obstructed, 151
Valvular diseases
;
aortic, obstructed,
mitral, obstructed, 139
152; tricuspid, obstructed, 146
157
pneumothorax, 77.
in auscultatory percussion, 209.
Valves of heart, thickened, 138

143
thro',
146.
cautions
knowledge
of
them
147
insufficient,
insufficient,
insufficient, ib.
in regard
diagnosis,
to their
since Laennec, 155
unknown
to veterinarians, 240.
Veins
auscultation,
118
usually no sound, 118
devil's
noise (bruit de diable) in chlorosis, haemorrhage,
VEL WIL.
276
118; character of this sound, ib. circumstances

under which heard most strongly, ib.
;
Veins
Inspection, 117.
Palpation, 118.
Pulsation of jugulars in cardiac disease, 117. 132;
in capillary disease, ib. ; diagnosis of two, ib.
Vessels of neck
inspection
of man,
223
ib.
93.
of,
it from auscultation
immediate better than mediate,
Veterinary auscultation, 219

neglect
ideas of
219
of,
rules for,
rales, larynx, bronchitis,
223 see
&c.
percussion, 221.
uterine auscultation, uses, 241.
Vibration
from respiration, 11
rales, ib.
purring, over aneurism, 11. 115

10. 131
&c,
sonorous rale,
Voice natural bronchophony, 27
diseased heart,
10.
pectoriloquy, 26
ve-
27 modified by disease, 28 ;
(see bronchophony, pectoriloquy, haegophony
and modification of voice) unimportance of their
sicular resonance,
differential diagnosis, 29.
diminished resonance
changes, 29
emphysema,
of, less
common
in phthisis, 29. 66
than other
gangrene, 79
29. 81.
modified in pneumothorax, 77; pulmonary apoplexy, 83
pleurisy, 59.
augmented resonance
grene, 79
in dilated bronchi, 84
phthisis, 66.
68
pleurisy, 59
gan-
pneu-
monia, 54, &c.

cephalic sound of, 194.
Washing sounds
Wavy
in pericarditis, 110. 122.
respiration
see respiration, 24.
Williams's stethoscope, hammer and plessimeter
A.
appendix
ERRATA.
277
ERRATA
[By accident the following were omitted in the Index.]
Aneurism
of abdominal aorta, 174.

of arch of aorta, 168
murmur, 169
respiratory
inspection in, 168
mensuration
in, 168.
palpation in,
ib.
169
alteration of the
thrill,
170.
173.
fig.
murmur in,
bellows
dullness on percussion, 170
other arteries, 174.

subclavian, 175.
thoracic, 174.
Aorta
ally
rough interior causes bellows
murmur, 167; usu-
connected with disease of heart,
diagnosis between
Aortic valves
ib.
disease of
them and mi-
tral regurgitation, 105. 107. 147.
Insufficiency of or regurgitation through,
148
149
bellows
murmur after second sound,
where heard,
of, 108,
149
105. 149
characters
irregular impulse, 112. 149
back stroke, 149
jerking pulse,
ib.
in-
spection, mensuration, percussion, of no
use,
ib.
times,
ib.
palpation gives purring thrill at

;
example
of, ib.
ERRATA.
278
Aortic valves obstruction

sound,
ib.
of,
;
147, prolongation of first

105. 147; di-
where heard,
agnosis of this and insufficiency of mitral
valve, 107. 147; sounds like " s," 108.
148; impulse usually irregular, ib.

thrill, ib. ; small pulse,
palpation in,
percussion in, perhaps, dullness,
ib.
ib.
inspection, no results.
Arteries
diseases
of,
167
176.
in veterinary medicine, 240.
The
following corrections should be
Page 250,
Page 254,
Page 255,
after
" cardiac
after
after
" Dress," &c,
in health,"
cyrtometer,
&c,
1.
made
in the Index.
93 should be 95.
93 should be 95.
89 should be
1.
91.
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The Young Stethoscopist or The Student's Aid To Auscultation

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,;;,-:.'-^.^.->;:-:-w':".

Books, and all objects

1223 Belmont Ave.,

SurgeGn^ General's Office

Entered, according to act of Congress, in the year 1846,

in the Clerk's Office

of the District Court of the District of

whom, during the years

COUNSELLOR AND FRIEND,

For you have

cise, yet clear

book on physical diag-

preparation I have endeavored to be con-

complete view of what are technically called the physical signs.

But I have had another, and perhaps

ly important end in view, viz.

the time, the place, the circumstances in which you

meet with these morbid

and the relations which

they bear to the rational signs, are of as

tance as the physical signs themselves.

been, I think, too

to the particular sounds, a diffuseness of detail that has

served to discourage rather than to allure you onward

not intended to supersede

more elaborate character.

as a pocket companion merely

the essentials of auscultation, the details of which

more fully displayed

these last, there are

whence have flowed

the numberless host of his follow-

the greater part of the book, at least so far as

Laennec are the

have borrowed any ideas from them.

and higher works.

opinions during the experience of several

Bouillaud and Pennock I

diseases of the heart

due almost all I have given on cephalic

Cammann and Clark's

tions has arisen the article on auscultatory percussion

work of Dr. Kennedy

tings of Youatt and Percival, I have

meagre though they may

and from the wri-

be, of veterinary auscultation.

I cannot forbear stating in this connection

have consulted freely the

former preceptor and kind

caught a love for physical and rational diag-

means of cultivating the higher

the mind, which I trust I shall ever carry with me.

In conclusion, while presenting this

cing them higher than they really deserve.

years ago, they were sneered at by

very few would be foolish enough

niceties of our physical examinations

neglect the rational signs.

nosis of not a few diseases

strong to overrate them.

child in the diag-

and he who cultivates both