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Scientific
and Medical
A. E.
FOOTE,
D.
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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
BY
HENRY
Fi7m
I.
B.
I.
BOWDITCH,
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
Practice,
it
has "been
WORK
M2$
at
IS
35
GRATEFULLY
TO THE
STUDENT OF AUSCULTATION
In
its
object
I prepared this
and comprehensive.
viz.
Its
to give you, in a
name
indicates
compact form, a
to
make you
equal-
feel that
signs,
may
much impor-
There have
many minute
distinctions in regard
PREFACE.
VI
But
this
book
is
ers of a
summary
a kind of
many oth-
have prepared
Among
The immortal
debted.
fountains
on the
ers, 1
in other
many
labors
To
subject.
which
in-
subsequent writings
have endeavored
to give
due
whenever I
credit,
Nevertheless,
am
formed
you
of
all
it
of
my own
it
relates
mind, as
it
has
To Hope,
years' practice.
owe much on
ney and Smith
auscultation
to Fisher,
Whit-
from Drs.
publica-
on obstetric auscultation,
invaluable
drawn
this subject to
friend, Louis.
It
was
my accounts,
owe on
my
how much
in his
wards, at
La
Pitie, that
PREFACE.
I first
Vll
nosis, as a
faculties
of
me
disclaim
all
little
work on
intention of pla-
Fifteen
many
persons.
Now,
the tendency
is
The
to
truth
must necessarily be a
we
is,
do so, and
Amidst the
are apt to
that he
who
own
their
mutual
wise
useful, each
H.
Boston, 1846.
I.
B.
THE
YOUNG
STETHOSCGPIST.
ACCURATE AUSCULTATOR.
him
<C~ b
inasmuch
If possible, let
or stand
but
be impracticable,
lie
back
sit
perfectly flat
as a pillow, supporting
may change
if this
let
on
him
his
one shoul-
the character
the respiratory
these rules,
1.
for
The
examining the
front, back,
chest.
Fie.
1.
Fiff. 2.
3.
Fig.
This position
1.
is
easily
let the
fall
body
Fig.
2.
to be
is
is
that to be
examined) the
scapulae are
Fig.
in the
3.
This position
is
examination of the
axillse.
2.
the other.
3.
N. B. The above
with
my
median
is
it
accurately, I measure
Examples.
Again
other scapula.
This rule
where there
is
is
INSPECTION.
inspection,
;=s
as a
method of examination,
of some
than the
left,
by half an inch.
The
uncommonly causes
pulsation of
a slight
promi-
The slightest
make one side
INSPECTION.
To
is
perceptible at a glance.
must be naked.
7.
inspection.
8.
An
Examples of Dilatation.
old man,
In him
we
find,
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
is
effu-
Malignant
Aneurism of the
aorta
may
press out
and scapulas.
intercostal
spaces concave.
clavicle, so that
of the chest
is
Great mo-
abdomen, either
symptom.
It
inflammations of the
labored
breath
is
observed
in
erally
pleuritic effusion
acute phthisis.
is
observed gen-
pneumothorax,
emphysema, with
expiration.
may
in
11.
croup
Examples.
in children, the
object
is
which
is
Their
gradually closing.
A severe
pneumonia,
one
INSPECTION.
mentioned,
viz.
the other
is
perform the
Sometimes
respiratory function.
tom,
for
it
This
is
severe acute
is
The labored
is
owing
to the
sudden
is
fre-
is
is
almost pathognomonic
left
breast
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
of motion
13.
10
pleuritic
same
effusion,
effect
side.
PALPATION.
alpation of the chest
tion
the applica-
purpose of recog-
<&AB
may
is
thoracic viscera.
be felt in health, at
all
slight
tremor
by any one,
times,
if
it
is
The
effu-
sonorous and
times
felt
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
is
11
purring,
felt at
is
The
the blood.
likewise
is
varied by diseases.
be
more
still
felt in
Fluctuation
by the
distinctly
This likewise
may
is
very rarely
speaking
little
is
diminished,
if
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
most
distinct
lightly
on the
one cause,
viz.
to
is
&c,
are
part.
:
use
They
are
all
dependent on
MENSURATION.
ffss
ensuration,
is
name
as the
merely the
denotes,
admeasurement of
and
this
it
much
never would.
It is
used
effusion, hydrothorax,
in
emphysema,
phthisis,
pneu-
The
may
We
The
ilia.
ilia,
be observed.
poses some use callipers.
17.
Fig.
some"
AUSCULTATION.
times more than an inch.
13
Frequently, however,
same
much
when
real enlargement.
the
In
The
place.
scapula, in
chronic pleurisy,
The
falls
proposes a spring
AUSCULTATION.
uscultation may be mediate,
means of
a stethoscope
it
or by
may be
Laen-
art rested
numerous
steth-
find
it
14
I find a stethoscope
sufficient.
needed
is
most
in
dition of
ness,
19.
of the
is
give an idea of
some
Fig. 5
instrument.
Laennec.
"
parts,
It
shortening
a
plug
is
it
at its
divided
if
into
two
l
purpose of
for the
(Jig. 6)
'
jjjj
which
yj
lower extremity
for the
'
exam-
of the
The
voice;
wholly obsolete,
instrument
being
is
altogether
20. Figs. 7, 8, 9,
Fig.
7.
&
Fig. 7 shows
scope.
for auscultation.
resent
its
it
prepared Fig.
Jig.
screw
to
J>
fasten
it
to the
8.
15
STETHOSCOPES.
shaft
b, a
jY<r. 9,
nec's
{)
it
^.^
b
c,
Fig. 10 rep-
instrument.
resents
Laen-j^
This
is
edge
at
is
The
ausculted.
plug likewise
is
who
is
found to be un-
necessary.
21. Figs. 11, 12,
&
the instrument.
so that
its
It
is
wholly of
softwood.
side
may
be pressed on
Fig. 12
meter.
is
a worsted ball,
Oa
ony passes.
This
is
used as a
ment
its
in
portable condition.
This
16
stethoscope
is
As an instrument
for percussion, I
use
it,
at times,
my own
fore-finger.
is
the heart.
It
an elegant instru-
is
is
it
much
but
if
we ought to have
it
have
Dr. Hope's
would
it,
for
the auscultator.
similar
one
is
used by Dr.
23. Figs. 15
&
16.
intended to represent
scopes used by Drs.
These
the
plates are
Cammann
and Clark,
They
made of
soft
wood.
stetho-
solid
Fig. 15
is
are
a cylin-
an inch
is
like a
the ribs.
[Appendix, A.)
RESPIRATORY MURMUR.
17
n
K'Vrh
espiratory murmur.
breezy
delicate,
This
is
a very
which
sound,
is
^e
tion
cnes *
very
chiefly during
'
little
influenced
is
inspira-
in expiration.
by age
it
is
26.
By
position
example, a constrained
for
heard
By temperament
frequently
it
is
man, while
scarcely
it is
very
28.
By
diseases
cause puerile
murmur
in the other;
for
example,
is
&c,
is
filled
So, likewise,
with tubercles, or
if
is
18
one
part,
and increase
diminishes
By
29.
it
(178)
may destroy
murmur
Emphysema
in another.
it
pleurisy
which
is
it
(132).
examined
generally stronger
the
vesicular
the
is
is
at
when
it is
and there
will
may be
and
vice
entirely healthy,
fact.
between them.
30.
(2, 38.)
By emotions of
vented
in
the
all
mind
sound
if
child be
for a time
it is
is
pre-
sometimes
of breathing
the respiratory
fre-
quency.
32.
the
murmur.
33.
By any
injury
acting freely
for
ex-
ample,
19
off
much
dilate;
tion
that that
of the
side
34.
Though
it
is
is
slight,
equally important
The
being
30.
a
in the healthy
Any disease
change
in
this ratio
for
example, pneumonia
inspiratory
it
murmur
is
usually
first
The
changed and
soon prolonged.
When
perfect hepatization
we
The annexed
ferred to,
figures will
be occasionally re-
20
Fig. 17.
Fig. 18.
21
The
mark
arbitrary divisions
of the thorax.
1.
2.
From
clavicle to
3.
"2d rib
4.
"
&
to
2d
rib.
4th
"
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.
T.
is
B.
and bronchophony.
remote from
vesicular respiration
is
heard there,
37.
Remarks.
Nos.
1, 2,
&
7, are very
im-
& 4, on
and heart
&
most
17, 128,258.)
38.
in
1
in
22
hind,
owing
bronchus
is
right primary
that the
to the fact
left.
The
Fi-. 19.
left
primary bronchus.
crosses
The
it
aorta
The
off.
is
put
plate represents
But when
parts.
expiration
is
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
N. B.
Study
more
a,
this
sound thoroughly on
upon
whom
be prepared
which
It is
it
for
recognizing
may be heard
in
air
it
can be
Thus you
in diseases in
it
than the
is
produced by any
medium
better capable
It is
most
23
pneumonia;
less so,
condensation,
dilatation of the
bronchial tubes,
its
great branches.
is
only
usually
more
42.
It
last.
is
is
tubes
also over
from dilatated
On
air tubes.
lis-
Rude
respiration
is
it is
more expiration
which marks
It
it
as
usually heard
is
but
it
is
different
it
has usually
make
in
the
fact,
after
hepatiza-
enter
24
Amphoric respiration
is
merely a peculiar
It
is
in
It
has a peculiar
assist-
Wavy
ox jerking respiration.
This usual-
pansion.
In one case
when
it
it
nary disease
in
viz.
at
the
heard.
(110, 149.)
manner, the
relative
the inspiration
ease.
impor-
The
infinite
is
46.
may be of
differences that
and expiration
The diagram
is
appear in
in health
and
dis-
1,
'
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
&c,
to
marked by
Compartment No.
10.
shows
slight,
is
more or
to the expiration
as ten to two.
on
all
No
definite
more
become obstructed,
the vesicles
becomes manifest.
sound be heard,
the less
Compartment No. 3
indicates
26
the re-
of the voice
for
signs peculiarly
it
its
affords not
own,
out to distinctness
merely
but, in cer-
is
not heard
For example
act.
in
but
it
common
is
wholly im-
act of respiration,
in the
form of a slight
As in
we hear
the
elsewhere.
which are
to their proper
In proof:
or diseased.
oquy.
pectoril-
cheal respiration.
At
chophony.
It
the
it
The
may be
very
;
that
murmur.
natu-
resonance
little
18;
Jigs. 17,
in
vesicular
styled.
may modify
(25,
Bronchophony
51.
2,
same causes
spiratory
(39.)
is
resonance
in place, to the
corresponds,
bronchial respiration.
50.
marked by
in front,
ral
ii
is
is
affected by
&c
air-cells,
but allows
Its
can
it
most purely
in hepatization
from pneumonia, in
52. Pectoriloquy, or
may be heard
cause
highest
di-
less distinct-
(122, 158.)
resonance,
53. It
is
28
54.
in
of fluid
is
Hence
lung.
thought to be an important
it is
sign in pleurisy.
It
indicates,
when heard
per-
When
effused.
it
is
By compressing
of tone.
shows
sharpness
effused.*
it
your voice
if
tones.
5">.
(135.)
Pure hiegophony
is
rarely heard
but
some
bronchophony,
this I
is
haegophonic character
makes hasgophony
itself.
Another
* This in general
is
true
fact
:
it is
which
heard
was
filled
with
fluid.
VOICE
at
times
when
there
is
&c.
common
less
or increase of
with
it
in
still
it
is
much
tone,
have met
emphy-
(152, 119.)
on
is
its
trouble
to
resonance
may be remembered.
It
57. Finally
pupil
its
some
sema, &c.
29
DIFFERENTIAL DIAGNOSIS.
hccgophony
or
It is sufficient
part.
toms,
ly,
The
these, apparent-
correct diagnosis.
mind
He
must,
however, bear in
58.
tient
General Remarks.
for
In examining a pa-
we
must, in
remember
the rules
above given.
30
RALES, OR RHONCHI.
uring
inspiration,
sounds; called
[2]
They
various in
and they
are
\]j/J
their qualities,
other
in
cases,
indicate disease
they
same
may
acts.
to the ulceration
with equal
They always
may vary from
up
long inspira-
be,
membrane,
it
There
are
sounds produced
cavities
in
1st,
those
2d, those
con-
61.
The
first
of these divisions
may be
sub-
RALES
SIBTLANT, SONOROUS.
31
They
the air
is
They occur
in
swelling of the
it
enters with
typhoid
tubes,
They
ma, and
bronchitis,
this case
in
is
mucous membrane of
chial
in
difficulty.
usually
the bron-
&c.
fever,
attack of asth-
all
over the chest, and they vary from the sound pro-
duced by
tles,
a violent gale
down
ing
which blows
until
it
The
bass-viol.
(106, 180.)
wheez-
the nostrils, in
in
whis-
and
a kind of
the
Both of these sounds may, to a certain debe imitated by inhaling strongly through
lips, that
time are
is
flexible, in
By contracting
heard.
produced.
the latter,
perhaps
which case
in expiration, a
The
making
kind of whistle
will
same
This experiment
32
sounds.
we hear
we
They
moment and
are very
disappear-
tion,
single act of
Not
unfrequently, a
is
a healthy
vesicular
murmur.
is
This indicates
it
is
dis-
(153.)
sound resemblincr
produced by some wire toys, and can be produced very readily by the following experiment.
that
and
let
full
it
while you
have your ear upon the outside, and as the bladder becomes more tense, the sound of the bursting
at length,
33
CRACKLING RALES.
pure metallic tinkling
the
is
is
whenever
in diseases
On
produced.
heard.
a bron-
chial
In pneumothorax
most
perfect, but
it is,
at times,
it
is
it
stances.
crackling rales,
viz.,
is
The
crepitous rale
is a
fire,
salt,
It
may
also
34
be
produced by pressing
sponge
a dry
upon your
ear.
It
upon
it;
These
a hair pillow.
produce an explosion,
as
last
it
assist-
two experiments
were, of myriads of
When
heard in the
commonly
monia, or
its
human
first
tion,
followed
heard
for
by
fatal
phthisis,
pneumonia.)
71.
this
rale
was
it
the lung.
This
chest,
stage of pneu-
the autopsy.
of the sound.
(See
The mucous
rale
is
a louder, moister,
more
many bubbles
as the crepitous.
72. It
is
The
as
the sound
35
similar rale
is
not unfre-
Gurgling
74.
bubbling, and
is
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
duce
it,
in this
case
it is
may be heard
in
but
it
(171), or of pneumonia,
and there
is
lung, and
if
N. B.
mu-
anywhere,
they
in
mark
when
in a chronic case,
at the
bronchitis;
bottom of
when heard
36
pneumonia.
sound,
viz.,
ment).
It
occurs in
It
usually caused by
is
Any
pleurisy.
ma
of the pleura,
may cause
divisions, according
viz
as
it.
is
it
It
more or
less harsh,
on the
earliest
effusion
of lymph in pleurisy.
rough-
er.
(141.)
It is
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
as if
37
have heard
it
slight
ear,
crumpling of parchment.
tubercular disease.
It
and occurred
at the
end of
inspiration.
QJ * Remember
5
80.
trouble yourself so
sound;
Do
Rule.
this
much about
not
nice distinctions
first,
of
where the
N. B.
81.
lung
is
of
much more
one points
in
Remember,
therefore,
if
you
and, in case
find
only an
is
affected
mere
bronchitis.
Generally,
in
may be
more than
this case,
you
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,
its
results
the
now
rarely
are inaccurate, in
com-
we mean
the fore-finger of
simeter
is
to
The
a plessimeter.
my
hand
left
parts, so as to
is
object of a plessoft
is
examined.
After this
diate percussion.
you
will see
Be
itself,
as
careful
different effect
is
produced
in the
two
A wholly
cases.
The
39
PLESS1METERS.
must be more
strictly attend-
Among
practitioners.
Fig. 21.
is
chouc.
large
Fig. 21
should be of a size
enough
to be easily held
flat
finger,
space;
in a small
86. Fig.
Fig: 22.
fessor Bigelow. It
useful
is
chiefly
when examining
be-
by
it
we
make
equal
23
87. Fig.
ivory.
It
is
Fi-. 23.
is a
Raciborski's instrument.
is
at like
(21.)
similar, and
is
to his stethoscope.
ments give
Piorry's
usually fastened
These
instru-
40
ivory,
and therefore
is
not so pleasant to
me
as
Cammann
is
and Clark.
It
a very delicate
is
made
In the plate, a
ished steel.
and
chiefly of pol-
a handle
is
;
b,
a small
an oval plate
c,
fitted
it
is
is,
suspect
it
Beautifully con-
will
be rarely used
moreover
and
is
The
90.
there
The
is
natural resonance
is
greatest
where
91.
give so
These places
little
sound
the shoulders
glected by some
importance.
vary in
as, for
Some
auscultators, as giving
no
definite
41
results.
them
In
as the
all
most
regard
92.
The
have endeavored to represent the different degrees of sonorousness by the lighter and deeper
on percussion.
93. Fig.
thorax.
obtained.
sion,
but
phthisis.
This
is
a place
sound
little
of percus-
difficult
of
breasts,
from
Fig. 25.
the
over a somewhat
third
second or
downward
sixth.
the
to
This
is
tri-
rib,
owing
sels
sternum,
and on
second
tending
downward.
About the
fifth
rib,
42
is
is
quite
flat,
duller
space,
The
owing
are dull,
The mammae,
less
clear
outto
likewise, in
sounds can
the front.
For instance
column are
Below the angles of scapsounds; fully equal, and
we get very
flat.
clear
sometimes superior,
front of the chest.
to
The
those
on the
obtained
capable of producing
but
little
sound, are
when compared
The
together (2,5).
slightest difference
note
with
of
(99), combined
other
physical
and
rational
signs,
will
perhaps
decide
your
diagnosis.
In
43
must be com-
27 presents
and a
front
back and
profiles of the
Fig. 27.
portion
viz.
of
chest,
the
This
parts below.
part,
portance
because a
dis-
has
it
made
The sound
is
aug-
emphysema (177),
pneumothorax
&/C.
( 166 ),
by any thing that increases the quantity of air
Sometimes
in the chest.
also I
have recognized
(123.)
Examples.
sound
there
is
great
44
out the
is
An
air.
and other organic changes in the lungs; an unua constrained position of the
body
or pain
on motion of the
ribs
may produce
difference
ponding parts
is
not
uncommon, when
to
air.
is
Sometimes
It
there
is
no
occurs in cases
its
of phthisis
early or latest
stages.
100.
There
is
a peculiar
sound produced
at
much more
or sometimes, but
rarely, in
It is
and
its
name
explains
itself.
In itself
it is
not of
great importance.
is
duced.
101.
Hence caution
At
is
mill or absent, as
if
is
pro-
needed.
seems to be
as entirely
This
CRACKED-POT SOUND
SOUNDS ABSENT.
45
Usually
owing
it is
to an effusion of fluid
More
is
as
may cause
Examples.
Malignant and
a similar degree of
it is
local.
will,
of
degree of dullness
pneumonia
is
cause perfect
Tubercles rarely
rarely so perfect.
On the
flatness.
contrary
is
good
to
In
gangrene
fat
people,
compress the
is
of
vital
importance
adi-
The
in ex-
symmetry
in the
Pain sometimes
the ingress of
air,
hence
in pleurisy
prevents
is
of great importance in
all
peri-
4G
the
laryngeal respiration,"
2d,
"harsh
)\p)
^C
is))
;"
as
The
Spasms
2d.
or
oedema of the
croup.
glottis
stridulous
Laryngeal
ulceration,
and
vegetations
croup.
4th.
Membranous
nosis
It
;
may, however,
but
for-
croup.
tions.
death-rattle.
aid
you
in
these affec-
in
their diag-
much more
important.
47
OF.
s there are
viz
may
kinds, you
Example.
105.
in the larger
no physical
expectoration.
to
get
signs.
there
a case,
is
is
little
nothing
nothing
sence of signs
very
is
common
air
This ab-
in chronic cases.
heard
in various parts
of the chest
chiefly,
how-
If they be found
more
ally,
all
part.
the
107.
tion
As
commence, and
48
All these
(73).
the sono-
less
As
heard
last in the
109.
all
mucous
secretion
is
is
little less
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
were needed
to
little
rale.
more
This
ACUTE BRONCHITIS.
49
of coughing
the
membrane
alone
is
but
is
at other
drier,
heard.
111. N. B.
3
fl^r
Hence
112.
for the
Example.
A. B. called
Infirmary
at the
He
had chronic
coughing early
delayed
my
in the
diagnosis.
mucous
I learned
severe periods of
morning.
Visiting
Accordingly, I
him
at
six the
had no cough.
The
effort,
to
and having
were heard
at the
respiration
day.
was heard
at
or,
where mucous
in
two views,
viz.
1st,
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
owing
to
mucus
rales, or
in
being
temporarily
resonance
114.
is
is
rarely heard,
acute form.
and
the base,
is
is
mucous
rale (71)
heard occasion-
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.
Examples.
A man
will
is
At
may
this
;
indicating conges-
CHRONIC BRONCHITIS.
tion
51
This stage
lasts,
They may
gestion.
last
In a se-
indefinitely.
weeks
and, in
ternate
some
fee-
mucous
or they
respiration,
al-
de-
Finally;
During
no
serious
It
may be
a time,
all
owing
but a
There
it
to a portion
full
is
breath, or
no change
in the
it.
and
if,
perchance,
in
a tube,
is
murmur.
may be
may be
sure that
some
disease
probably
much more
either
with
serious,
pneumonia
52
in any part of
may occur
the lung,
?.
The
first
(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
Sometimes there
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
to the surface
because
At
murmur
which a crepitous
is,
that
you
will
In such a case,
hear crepitation
;;
PNEUMONIA
Example.
119.
53
CREPITUS.
itous
rale
came
and a
120.
The
is
usually
first
flamed portion.
it is
is
a very
hear this
The
commenced.
voice
may be
slightly altered,
only
for
may be both
3
fl^r
(99.)
is
heard
examination
at others,
inspiration, or both
it.
entirely normal.
When
a cough, or a long
combined,
will alone
distinct,
it
produce
resembles an
The
is
third sign,
and
marking, what
is
54
red hepatization,
With
you
this
is
will
123. {/=
ration,
Sometimes, however,
of pneumonia.
it
is
scarce-
ly heard,
hardly at
all,
at
slight
others,
(47, 52).
The
it
modification of
is
almost like
and
The
being
voice;
the
pectoriloquy
dullness on percussion
is
very
(101.)
quence
I
this stage of
of a lung;
viz.:
hear
crackling
becomes
The
it
softer,
This
and the
is,
air
at first,
rale"
again
minute;
voice becomes
more
natural.
But
PNEUMONIA
GURGLING.
signs improve.
presume
this
is
to that
owing
55
to an
which conies
after
parts
IN CHILDREN.
if
and gurgling.
The
clear
cavity forms; in
will
probably
hear gurgling (74), an obscure cavernous respiration (42), and perhaps pectoriloquy (52).
12(5.
Q^3 The
in these latter
fine,
and
is
heard,
more
for,
although
in children, still,
is,
usually, less
may
dren as in adults.
If,
in a child
affected with a
monary
lfear
monia.
If,
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
is
&c.
and
if
you are
call-
the
ma-
will, in
change
and a difference
or, in other
words,
of the lungs.
The
bronchial
The
respiration
(41),
and
bronchophony.
very marked
results,
modification of note,
(98.)
probably nothing
now
but
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
less
and
less clear
the crack-
continues to augment.
Finally
by the sixteenth
57
may
weeks
refor
^=\ f
as
s I
f^-J
the chest.
doing
is
on the affected
The
to the
so.
a rubbing sound,
owing
side,
?>.
it
moves most,
(77),
will
first
owing
sound heard
to the dryness
either in
4,
6 or
10, (Jigs.
17 and 18).
129. Explanation.
tion, the
health,
two
move
the other.
With each
pleurae, lubricated
noiselessly
a thin deposite of
rubbed together.
58
Among
the
symptoms
first
is
dullness on
it
the chest.
all
sound as
Of
pleuritic effusion.
great as to
fill
sometimes
it
so
is
you
will
In
lung
is
the spine.
131.
may
be,
When
where
in
effused,
is
if
the
while the
uppermost.
produce
same
parts
Nothing but
this effect.
are
resonant
when
a pleuritic effusion
can
no difference;
in
consequence,
presume, of old
As an
fluid.
we have
may be
murmur
entirely absent;
is
and
diminished, or
in
murmur
this
in the
case
we
healthy
pleurisy;
Some speak
133.
murmur.
It
seems
hcegohony, etc.
of a hoegophonic respiratory
to be a mingling of the bron-
chial
59
an
is
it
indistinct
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
pneumonia and
inasmuch as, in
pleurisy
is
none
is
monia.
The
135.
times
is
is
it
voice
is
always modified
only
is
chest,
(55)
at
When
thin layer
we
Hoegophony
if it
it
is
marks
be followed
is
usually
cured.
136.
OJ^ This
nec, and
of
late,
may
it is
is
the old
statement by Laen-
exist
when
there
is
a great effusion.
have
60
heard
it,
found so
in
full
wholly compressed.
137.
When
amount, there
side,
there
is
is
an effusion to a great
is
down
138. N. B.
falling
known
this
whereby
upon
a large effusion,
of
is
consequent
thrill
to the
destroyed by
with others.
(10, 14.)
140.
When
cent organs
the effusion
are
liable
to
is
great,
all
the adja-
displacement.
The
organs
may be drawn
same
Example.
141.
First.
61
ed above become of
ease
is,
ally;
vital
after
some
fever
and pain
we
The
importance.
witbin the
find,
first
dis-
Usu-
with
in the side,
without expectora-
two days
either a
on
Second.
The
full
ex-
disease goes
a small extent,
is
ob-
With
this
of the respiratory
comes
murmur
still
greater diminution
in the
same
parts
al-
though owing
in the side,
the
lung.
it
slight modification
generally in
of the voice
on the back.
Change
let
an
you strike
Keeping your finger upon the highback that becomes dull in this
most depending
parts, will
be
G2
flat,
tity
emit a
will
flat,
clear sound.
The
Third.
ef-
and
flat-
is filled
with fluid
the
(28) or
The
is
sides
of effusion
compressed
the
become
flat
even up underneath
null (28)
is
usually disappears.
heart,
&c,
At this period
state of things,
months; and,
cases,
may
it
This
finally, as
and
happens
it
in a
may
few
may commence
sorption
Fifth.
The
ab-
scapula?
at the
63
may remain
for
it
is
fall
142.
a pa-
from severe
The
vertebrae, and
angle
left.
It
in
downward
so that
is
ward the
arm,
con*
la to fall
its
is
tracted.
is
likewise
farther to-
vertebrae, so that
the
64
Div. 1,)
and
Divisions 2, 7, 8,
we must
in the
Fig.
17,
upper parts of
at the
(Fig.
17,
18,
first
signs of phthisis
(37, 117.)
144.
As
uncommon
we
Hence;
if,
on inspection, we perceive a
is
not seen
N. B.
To judge
fairly
on
1).
146. Dullness on percussion (93) in the post-clavicular space, or at the tops of the shoulder,
It
may be
in
times
if the
it is
it
is
one of
some-
be in either
we may be
65
ence
mur, or resonance of the voice, this change of resonance becomes of still greater importance.
147.
As
the
number of tubercles
increases, the
is
an augmentation
much
dilated
occurrence.
a fact
which
admission of more
come
air
is
uncommon
not of
and, finally,
it
named
is
and consequently an
may
be-
and co-
is
alters.
It
is
the
indicates
number of tubercles.
more tubercles may almost wholly obscure
A kw
The ear-
of rare occurrence,
66
may make
seems
it
air
by jerks, (45,) as
before
is
it
if it
could enter
had
at
to
overcome obstacles
much
is
shorter
QJ^ Hence
150.
in fact,
becomes a
two
A natural exception to
this has
been mentioned
As
151.
the tubercles
we may
apices,
in (38).
augment
number and
in
enough
to
murmur
(41), or to destroy
(24.)
and
it
was dimin-
consider this as
it
for
it
indi-
cates
a want
owing
in-
When
the lung
is
in this condition, if
at
you
times
RUDE RESPIRATION
MURMDR ABSENT.
67
Either of
shoulder, (while in
is
as a very un-
percussion
If
especially,
trivial, rational
if
whom was
I heard, for
many weeks
When
in succession, a very
heard
I first
it
I sup-
as
minute and
as copious
me
a tuber-
may,
at times,
cause
an explosion of crepita-
auscultating a patient,
have hcemoptysis.
finally,
to
68
When
will hear,
more
or less
still
better, after
re-
spiration.
to either Nos. 1, 2,
somewhat tubal
murmur.
).
may
gene-
distinctly so as in hepatization
(39, 41
It
from pneumonia,
As
the disease
still
158.
When
cavities
is
form you
will
have pectorilo-
is full
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.
it
&c, when
becomes important
as a sign in
itself
hence
it
and as a
little
importance in
by a
for, as
solidified part
you may
more
ample
the
left
will
For ex-
under the
we may
right.
If the re-
right.
162.
Example of chronic
phthisis.
As
it
is
an idea of
my method
first
In
hereditary tendencies
been subject
to
during his
life
his profession
and
70
upon
Having
his health.
exact
commencement
discover whether
it
showed
eral state of
itself, first
the
and to
by symptoms
all
fix
endeavor to
moment
of examination.
In doing
commencement of
our views,
cough
for
In order that
let
proceed then
us suppose that a
to the physi-
definite in
man
has had
had trouble
still
we may be more
some months
had haemoptysis
may
all this, I
is
Let us imagine,
In a word
let a
man
sit
or
stand very
make
the
{fig. 1).
PHTHISIS,
prominent
ed
sis,
if
if
METHOD OF EXAMINING.
the chest
is
flattened in front, I
fear phthi-
(9).
71
I fear still
more
that, in the
apex corresponding to the most prominent clavicle, (9,) I shall find tubercles
more
especially,
do
"rheumatic pains,"
in
that part.
may
at
times
fall
the nipple
is
little
be of service,
is
(10).
observe
fallen in behind,
causing the
depressed,
all
proceed to percussion.
examine,
(4).
Any
existence of tubercles.
my
suspicion of the
72
If there
is
if
there be a deci-
my
trials,
faith is, as
tubercular disease.
dullness extends
if
all
am
If,
am
it
dullness
part
is
ease
is
adult.
is
If the
clear, I
am
not tuberculous
If
doubtful
it
i.
the patient
e. if
be a child, there
is
is
some doubt,
an
be-
in
all
nutest shades,
respiratory
My
murmur.
object
is
to
examine the
is
normal (36)
it ought
longer than
spiration
is
full
whether one
to
be (46)
is
shorter or
whether the
in-
and
to
felt to rise
is
heard
whether there be
whether
some
METHOD OF EXAMINING A
PHTHISIS,
CASE.
73
if there be,
whether
of the chest.
it is
and,
For example
are confirmed.
simple case.
Suppose
than the
left
if,
its
let
I find a difference
of note
in the
same
ence of tubercles.
If,
phthisis, I shall
of
But, suppose
I find
then I
am
common measured
is
accustomed
to.
upon
ined.
Thus,
all
examsome of
I frequently
am
murmur,
able to find
or
some of the
rales,
74
am
Many
transmitted.
glect
I
on
Having
this point.
is
not
make
Through
marks
am examining
may be
very manifest
fever, emaciation,
&c,
is
owing
hosmoptysis, hectic
being present.
may then
to the equal
may
decide unfavorably
rude, or coarse,
is
or
if
still
become
both lungs, I
there
it
these re-
is
(43,)
for
my
may have
which indicates
mur
bal
(28)
bronchial or tu-
may
comes
to
find a
me
it
a small cavity,
(41).
Final-
METHOD OF EXAMINING A
PHTHISIS,
CASE.
75
tions in the
For example.
hear.
and
often heard in
is
it is
then indicative
remember
Hence
full
breath, or a cough.
al-
is
useful in itself as a
in
any
marked
reso-
nance of the voice or any manifest difference between the two apices, except, perhaps,
resonance
at the top
a little
my prognosis
is
what
is
more common,
left
more
is
indica-
76
162
The
a.
In
fact,
the
(12.)
the same
presents
children rarely
manifest and regularly ordered signs as are found
Phthisis in
in adults
chiefly
on the rational
we must depend
signs.
neumothoras causes
a sudden en-
permanent
disten-
chest which
There
164.
is
is
diseased.
there
is
if
there
if a
is
a metallic
little
fluid
be
produced either
PNEUMOTHORAX.
165.
The
voice, usually,
is
not
is
77
much
modified
am-
a very clear
resonance
is
is
pended
entirely
167.
The surrounding
&c,
Neverthe-
on the resonance,
in
N. B. This
signs,
or,
in
fact,
might have
Example.
pneumothorax
is
a rupture
cause of
of a portion of the
tu-
bercle, or of a small
becomes
filled
with
air.
all
a large
its
functions
these
78
are,
of themselves,
The
per-
amphoric
is
it.
The
other
toms.
may
appear, you
is
suspect
foetid
its exist-
sputa; but
if
in
it,
and
if
deep
tone (99)
between
When
a cavity
forms, you
if
it
The
170.
respiratory
roughened, and
murmur
is
lessened, or
There
irregular
various
are
when
crackling
As soon
common mucous
is
as
(71)
heard with
The
172.
either
voice
afterwards
resonance
is
augmented
Its
altered.
is
it
of convalescence.
173. N. B.
The
Example.
174.
and
if
there
is
man
months.
It
is
any expectoration,
it is
not peculiar
This augments
This
state of things
80
is
As
the patient
mur
the reso-
frequently by a
full
is
brought out
where
in a spot
it is
eighteen months
in
is
moderate time
slight-
year or
for a
person
cases of gangrene.
for phthisis.
Of
course, the
may
middle or base of
it is
not a
be more
difficult
and
flat
EMPHYSEMA
RESPIRATION
81
RALES.
76.
in the intercos-
pression
As
spaces.
tal
effort, as if
177.
On
percussion there
is
an extraordinary
The
178.
respiratory
At times
ing (28).
it
at
murmur
times
it
is
usually di-
wholly want-
is
the expiration
is
much
becomes, as
it
were, a con-
longer
179.
or
is
The
is
as in health,
diminished (56).
180.
The
sometimes
is
sibilant rale
is
above described,
6
viz.
all
this
the sounds
82
&c.
pitous,
in
all
They
The sounds
181.
less clearly.
182.
is
In
tics.
to
Example.
This disease,
some
fact,
old asthma-
writers,
tient rarely
in its severity,
among
The
pa-
Soon
ing,
tion.
there
On inspection, you
is
will
difficult
expectora-
is
not
;
much mo-
the muscles
On
still
more manifest,
sonorous rale
is
heard (62).
per-
occasion-
This
state
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.
RALES. 83
or fortnight longer.
liability
somewhat diminished
respiration.
disease
its
con-
When
of the lungs,
severe,
184.
murmur
it
is
There may be
186.
a slight alteration
in the
sound
in the healthy
187.
lung (80).
Haemoptysis happening in a
case,
is
Example.
The
As an idiopathic
we meet with.
disease.
rarest
disease
it is
one of the
84
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
slightly
in early
ill,
if at
my room
into
until five
haemoptysis.
life
diminished (98).
A youth walked
when he had
found that
base and
at the
some months,
rale for
one
if
enlarged.
is sufficient
caused,
is
minutes
On
inqui-
had been
ed
As
to find little or
no physical
signs.
was
sur-
the
BO
EXAMPLE.
DILATED BRONCHI.
and not
at all
Otherwise,
my
er, the
My
suspicions.
when young-
ma
in
it,
itself,
owing
to firm
become
you
may
one of
man above-mentioned
haemoptysis occurred.
phthisis.
There
is
accurately
all
this
the ra-
86
tional
carefully
rarely occurs.
In
may
(143, 162,80,81).
=^x
if at all
The
there
is
altered
merely a change of
vesicular respiration
is
it is
At times
note.
usually obscu-
The
is
normal.
87
Example.
197.
Pulmonary oedema,
as a idi-
consequence
elsewhere
&c.
fine (70),
usually
You
will generally
such as
it is
and
signs
may
may
is
is
last
73).
These
;
they
105
or
).
phthisis,
without signs,
of,
88
Warm
"barking."
commonly
has
weather or a change of
relieved
it,
but
it
air
It
severe symptom.
patients; viz.
cough
There
is still
another class of
In one of
to last for
most
vio-
disappear.
199.
is
The diagnosis in
sometimes
difficult.
Yet,
if
we
are accurate in
we
shall generally
mer
be able to decide.
cough
In the
and
for-
exists as a single
it
save
chest, after a
fit
absence of
all
curate diagnosis.
PHYSICAL SIGNS
RELATING TO THE
CIRCULATORY ORGANS
CIRCULATORY ORGANS.
LMOST
all
the physical
are less
sure
indications
are
in
them.
If you keep
you
er-
roneous diagnosis.
201.
The
of the patient
),
&c.
92
is
arise differences
on percussion, auscultation,
&c,
There
zontal posture.
will
likewise be greater
horizontal position.
is
usually
the
stethoscope
spots,
much
greater
This point,
moment in
as
we
shall see, is of
it
Dr. Pen-
flexible steth-
necessary (22).
make
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
neck
also
diseases
slight
perceptible
is
10
),
the
the pul-
manifest.
The
of the heart
which there
is
usually
but
little
At
10).
if
any motion
in the
back or
front, in
prominence of the
is
somewhat
left breast,
raised (8).
left
is
nipple
and the
Sometimes,
tumor
tion to be perceptible.
94
PALPATION.
alpation should be attended
to in
all
or
no
impulse
when
felt
is little
between the
fifth
left breast.
may
whole of the
with effusion
is
is
It
some
is
so.
or chronic disease
of the aorta
In pericarditis
destroyed (260).
It
fevers of a
sometimes intermitting.
always
may, moreover, be
breast (275).
impulse
all
very feeble in
It is
it
left
much
Aneurism
may cause
it
in
Or
aneurism of
frcmisscmcnt cataire.
thrill
It is so called
called
because
it
of a cat that
is
purring.
It is
felt
on the chest
CARDIAC diseases;
mensuration.
95
It
may however be
felt in
various valvular
its
heart (14.)
MENSURATION.
in compari-
it is
writer,
done
much
use in
An
named
has,
instrument,
however,
rarely of
cyrtometer,
to
with
mark more
the
eye,
is
the various
prominences
diseased (262).
in the
sounds and
The sounds
ral, diminished,
augmented, absent,
96
The
210.
dull
about the
fifth rib
the second
is
the
left
first is
nipple,
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
But besides
tricles.
motion of the
of the
the auricles, the rush of the blood from the ventricles, all
owing
having an influence.
The
second
is
The sounds in health take place in reguFrom the commencement of the first
211.
lar order.
sound
time
occupied.
is
by the
first
and the
rest.
Of
less than a
this,
one half
is
second of
occupied
last quarter
more
left.
to a healthy heart,
CARDIAC AUSCULTATION.
The sounds
212.
97
SOUNDS.
where they
originate.
Thence
at the left
left.
On
the
At
We
may
monary
213.
artery
The
more
sternum and
distended.
diagram
its
It will
valves.
during
life,
when
fully
to the ribs,
we should
auscult in order
98
it
visible
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.
n Right
ventricle.
CARDIAC AUSCULTATION.
The
214.
following diagram
of the ac-
tual
curs
astole
tole,
made and
at
which
and
rest, to
The
externally.
active dilatation
rest
felt
of
descriptions by Drs.
99
DIAGRAM.
and dilatation.
to be at sixty per
minute
one
and
of a second
this
will
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
214
a.
While the
First.
214
b.
Second.
While the
214
c.
Third.
fill
gradually distending
becoming swollen
finally,
more blood
filled
the
when
the auricles.
un-
This throws
a little
stimulated to
active systole.
when
They
the heart
is
vers
also, in
congestion
(260).
also,
in pericarditis
with effusion
is
not,
it.
They
(216)
are
101
in in-
&c.
in
sometimes
at a
the patient
are heard
Andral).
now
it is
considered to
mean nothing
of itself
(277).
217. I have
patient, in
to work,
The
absence of
to the sluggish
con-
218.
four
in number,
mony between
are three
owing probably
to a
are heard
and even
want of har-
of
for
heard,
but similar
Bouil-
number of sounds
or pericardium.
may
By
it is
102
of
as increased
Many
old persons
symptom, while
what seems
in health, and,
at first
only
when
affected with
some acute
disease.
Among
murmur.
It
cause
it
it is
severe haemorrhage.
It
may be
caused, in peculiar
respiration
up
be present
For example
at
heard
is
none are so
may
is
which the
stairs, coitus,
&c.
In general,
it
may be
said to
What
may
I
yet obstruct
its
motions (315).
murmur.
222. There are several degrees to this sound,
may run
and may
all
be
SOUNDS
103
its
of harshness.
223. In
its
mildest form,
it is
slight, short
and
ciently indicates
The
fiet, Fr.).
indicating
also
we
its
Then
name suffi-
Fr.).
its
its
the decided
gives
souffle,
nature by
its
appellation,
roughness (289).
first
Finally,
The
Fr).
viz
last
scie,
224. Occasionally
sical note,
which
is
all
mu-
chest.
225.
The
tumor compressing
it;
of
3d,
a reflux
orifices
of
its
7th,
fibres
of the
104
sion of the
chlorosis,
will
&c. various
clavicle in
has heard
some
it
in
it
8th,
pneumonia.
Dr. Graves
presume these
mentioned by Andral.
under the
first
cause
Be of good courage
The
mystery
study a case
off than
or, if
it is
not,
you
will not
be worse
when
and
as
obstruct or allow
rent,
it
but, 2d, to
whether before,
to,
227.
the places
its
branches.
aortic orifice
A. auricle, V.
b auriculo-ventricular
The
orifice.
direc-
hence
aortic
evident
is
it
obstruction
of the
would
orifice
insufficiency of
it
and
consequently regurg-
2 would
itation
slighter
be
would produce
left
if at all,
Insufficiency 4 of the
would be
focus and
and much
less dis-
it
its
the
and
ventricle as
made
in regard to
227.
tfcf"
with limitations
strong bellows
106
simple
will be well to
caution,
murmur
for definiteness
as a
is
dis-
over the
Nevertheless,
of purpose, as an auscultator,
it
thereupon.
228.
The
following diagram
is
intended to pre-
is,
in
fact,
the
same
as Jig. 30,
(214), and
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.
228
a.
From
this
diagram we perceive,
107
first,
that
se-
that
murmurs from
insufficiency of the
same valves
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
at
up along
whereas the
auriculo-ventricular
31 (227),
murmurs
are
230.
Third.
We
231. Fourth.
We can understand
how
a sound,
108
From
232. Fifth.
left for
it
becomes
evident
that
only
all
consid-
is
mur-
slight
ceptible, even
when
there
is
233. Sixth.
It is
plain that a
murmur from
may
occur
at
is
to
said to occur
A priori,
however,
it
Hope (297)
to
sounds,
one
I believe,
"*"
it is
would be induced
there
By some,
first.
most commonly
from
Aortic
Murmurs from
obstruction of au-
who"
those
same
much
louder,
and more
PERICARDIAC SOUNDS.
235.
late
ment-like character
which, though
109
to the
difficult
a parch-
of description,
is
very dis-
am
PERICARDIAC
235
In
some appear
a.
it.
SOUNDS.
In disease
236.
This sound
cair neufj.
fore
hear
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
mentions a case
110
writers to
some
in pericarditis
in
any disease
In pericarditis,
it
may be heard
at the
when
it
contact (2G3).
It
resembles in
come
characters
its
is
very superficial.
It
may be
distinguished
Occurring
heart.
carditis,
it is,
in
effusion in peri-
after a large
some degree,
a favorable sign
is
the fore-
is
It is of little
b).
washing or
im-
*more
superficial,
the case.
* Graves' Clinical Medicine.
is,
Hi
The
240.
of the heart
is
It is
slight.
This
the impulse.
is
usually very
and
felt
In health,
it is
scarcely perceptible,
and sixth
ribs,
on the
left
breast (2C5).
it
may be
242.
It is
in fever
soft-
by pericardial effu-
more
It is
by
all
It is
by great haemorrhage
But
it is
112
(275)
a
much
it
may be
246. Irregularity
is,
is
years, and
it is
so
lies.
it
from their
earliest
is
that usually
ular.
I think
it
irregularity
sign
for
is
not very
whom
in children in
dis-
uncommon
If no other
little
it.
is
usually
on
a level with
The
is
per-
the second
and about a
rib
finger's breadth
from the
113
left
may be
viz.:
in
rib,
it
This space
is,
from the
let fall
at times,
a small spot, at
is
left ribs
some
extensive (275).
The
considerable influence,
mented when
forward
in
left
flat-
nipple (260),
dull
lower part,
In health, this
ment of
nipple.
left
its
to with-
no where completely
ards
of the
is
displace-
disease, as peri-
you
find
more
it
the
may be
lying
upon.
248. Various diseases of the lung modify
Emphysema
tends to
it.
over
Pneumothorax does
more marked degree, and at the
same
in a
its
its
usual place
tended stomach
8
usual
will
A dis-
114
The
liver,
when
it is
filled
with
air or food.
dull-
248
Its
a.
own
percussion.
dilatation (277)
Endo-carditis
same
effect
all
is
course diminish
dium.
It
said
it.
Some
my
fortune to meet
it.
ARTERIES.
INSPECTION OF ARTERIES.
nspection
may
115
PALPATION OF ARTERIES.
250.
hence
arises a neces-
Chlorosis
is
apt to
example (280).
arteries, for
PALPATION OF ARTERIES.
imple increased throbbing in a part
.;
eurism
((>)
^W
sat
'
may give,
in
on tne peculiar
in-
an an-
addition to a pul-
thrill called
>
purring
206)
this,
however,
is
not constant.
portance
at times,
in
in all diseases
by
its
is
The exam-
of the heart.
It
suggests
changes
A full pulse, in
any chronic
(275).
small,
irregular,
or dicrotic
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
in
some aneurism,
the
as of the arch of
aorta (344),
the
abdominal
AUSCULTATION OF ARTERIES.
Tfrir^N y auscultation we always obtain a
very slight sound, and an impulse
over the various arteries of the body.
(336)
felt in
the part,
in cases
if it
of aneurism, a
is
is
A tumor, over a
the external skin (344, fig. 34).
healthy artery, may produce the same effects (343).
attends a local
to be considered
it
has
At
pres-
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
character.
VEINS.
INSPECTION OF VEINS.
ulsation of the jugular veins
is
not
and conse-
cles
phenomenon
similar
is
them
ed by the
blood
course
is,
;
be distinguish-
it is
its
usual
118
PALPATION OP VEINS.
disease of the veins
is
never recog-
method
AUSCULTATION OF VEINS.
arely
is
for
in
hemorrhagic, and
patients; in
all,
in
in fact,
anhaemic
who, from
in the blood,
heard (311).
It
that
it is
murmur of
continuous.
cases, musical in
its
It
is
re-
It is simi-
becomes,
in very
marked
119
VEINS.
It is
very varia-
culiarity
on the vein.
ceases.
a pressure
it
wholly
it
most distinctly
rested
It is
and
sterno-mastoid
amining.
It is
right jugular.
may appear
in the
in other parts.
nomonic of no serious
This sound
is
it
pathog-
disease.
is,
murmur
heard
it
but
when
the two
page 910.
120
move
upon each
other,
owing
Iofs
to their
where
in the
there will be
some
Probably,
and
first
may be
absent, or they
tracting.
may be of
we may
not
later date.
rubbing or
to
very
rough thereby.
When
is
any
difficulty arises as to
if
you
re-
quest the patient to hold his breath, you will be usually able to decide, for if
it
in pleural
same
ing.
nock's Edition.)
p.
175, Pen-
121
sounds.*
2G0.
will
all
disappear,
if
is
very
Sometimes
ists.
case.t
261. Fourth.
much obscured
the lung
is
or if there
pushed aside to
is
very
and
have known
to be observ-
is
a large effusion,
General Hospital in
at the
Massachusetts
whose
liver
was
felt
membrane was found covwas not rough, and scarcely explained the phenomenon.
It
f C. J. B. Williams's Lectures.
122
201
will
a.
With
left
this
nipple.
The
wholly
latter,
the pericardium
lost, if
is
may be
much dis-
in fact,
very
261
At
b.
period likewise
this
is
sometimes
You
262. Fifth.
of the
and
left
breast,
fluid (238).
will perceive a
prominence
the right,
As
263. Sixth.
valescence from
all
when
contact,
we may
commences,
and, finally,
come again
in
to
Andry )
to
me
1
.
le
Docteur Felix
it
seems
formation that
is
really necessary.
it
it is
123
favorable so far
in
one
spot, for
diac space, or
it
may be
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
all
its
train of se-
is
drawing
it is
said
Nothing
is
more
indefinite
its
existence, unless
is
as follows.
healthy, or,
A man
is
most
It is
common
seized, either
im-
we have
when
affected with
is
it
more common
This
is
the
case.
124
With
these
may come
other,
more or
oedema of the
legs,
&c.
but
less
marked,
such as dizziall
these symp-
if
to inform us of
its
If you
existence.
may
signs
happen to see
Any
may
lead
any
you
palpitation,
mented.
&c,
in
If,
and
if
it
Yet
it is
If
you hear
it,
you
less ease
than ordinary
125
the third
it
Hearing
attack.
first
and fourth
would be most
rally,
over
all
either locally,
this,
rib,
about
likely to
commence,
or,
gene-
may be moral-
ly certain that
This
moment
is
it
before.
At
this period
the
you
you may
little
no increased dullness on
or
and
if
the disease
fluid will
take place
In a few hours,
stead,
sound (238),
fluid
in
against the
the
left
side (248 a)
left
breast (ow-
126
204
These are
).
of pericarditis.
If the disease
is
prepared to yield,
all
it
will
dimin-
be again
will
be very favorable, as
commence near
and pulmonary
artery,
will
may
last for
weeks
But
will
and
it
It will
remains
all
the
and
symptoms
common
for
felt
course,
not unfrequently will this symptom go on augmenting until the patient will finally sink under the
signs of confirmed hypertrophy of the heart (275).
much
disease, therefore
pertrophy.
127
^nhe
that I doubt
dare
make
is
such
a differential diagnosis so
uncombined
endo-carditis.
firm
my
And
as
with
pericarditis
or
eldom can we be
entirely satisfied of
is
no
perfectly, un-
tis.
tion thereto.
The
chief sign
This
is
first
is
a bellows
murmur
or second sounds of
usually dependent
upon ob-
128
it is
and then
murmur
it
re-
(223).
270. In addition to
larity
is
this,
we may have an
irregu-
in the
271
a.
Finally
is
checked,
lining
This disease
membrane of
during
this
most frequent-
is
Not uncommonly,
the heart.
more
cardiac region.
It
be
may be
felt
in or
near the
it,
and
he able to move.
cessary
and,
if
Thus
daily auscultation
endo-carditis
is
is
is
ne-
commencing, you
129
first
you
tively speaking,
there
will
Generally,
is
This
stage
palpitation and of
murmur
The
some dyspnoea.
bellows
Remedies may
disease
&c,
for the
will
valves,
apparatus.
more
ill,
and be
finally affected
with hypertrophy of
ing
in the train
of this combination.
This may be
130
affect-
it is
of
fied
the covering
(car-
ditis), or lining
ditis),
sis,
Let them be
may
is
efficient
worker,
God
speed the
for either
of these
Endo-
more or
Filess
their various
DIAGNOSIS
signs
want
combined together
to
make
more
But
in the case.
if
you
may
help you.
I shall unite
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
Not strong
first,
usually
at
null
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.
132
left
times,
sion (248 a)
a throwing
is
find at
irregu-
and in
times a diastolic
left
ventricle
be
felt at
&c. (251).
the carotids,
If the
and
may
same
the jugulars
vere cases,
is
frequently
there
is
* This
is
it
was
In
se-
owing
to
slight,
(255).
trophy in which
felt
respiration
less
133
different
(viz.
diminished cavity
cavity normal
augmented
is
first,
hypertrophy with a
hypertrophy with
third,
in size), is
as treatment
of
In a word,
concerned.
you
will usually
cavity
importance so
little
first
it
far
may be
be able to
and third,
normal
normal size
in the
first.
When
call-
EXAMPLE OF HYPERTROPHY.
may occur
276. This
at
any age.
scure
the breast;
a tendency
to palpitation;
but the
fresh
becomes perceptible
pressed away
the lung
seems
134
stronger;
its
The symptoms
is
is
more marked
good.
less
Finally,
cussion (247)
(215)
vere rational
dropsy,
you
will
have
all
a heaving impulse
some
and, generally,
murmur
are greater;
movements (219)
lows
irregularity in the
With
(223).
these
bel-
come more
se-
signs,
&c.
r^HERE
is
than usual
(248
a).
The sounds
very
much
impulse
and much
alike
in character
the
respiratory
murmur
is
is
less
135
Such
But
doubt
if
The
fact
is, it is
it
in cases
this
remember
are
any one
Still
is
it
well to
much
alike,
when,
"Lup tup"
instead of
"Lubbtup"
(210); for
bined with a
when com-
and an augment-
to sus-
278.
The
somewhat
gulars
upon the
ju-
He
&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.
The
physical
136
was
than usual.
less abrupt
On
feeble impulse
slight
Finally
The pa-
and
at the
usual.
The
Those of
sides
were enlarged.
The
the
cavities
valves were
left
were
of both
all
well.
it
so as to be able to recognise
before death
that
it
will ever
nor do I believe
137
this
You
better.
know what
will
after
time.
means
very
It is
it
in practice a short
distinguish
diseases.
The
mur
dency
mur
at
in the veins
first
sound and
a ten-
and arteries
281. Example.
The
may
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,
anhaemia.
The
She was
to be,
in a state
of
ty of its fluttering
138
murmur, sometimes of
character,
is
was not
felt
In such a case
a very
rough
The
is
any times
there
is
thickening mere-
ly,
is
it;
possible to recognise
As
it
it
to be
it is
Maladies du
cceur,
(262).
139
^w
yja^V
is
force,
traction,
we
really
it is
orifice, is
times very
at all
slight.
owing
generally slight,
is
with
happen which
that to
the
that
an autopsy,
at
mark
before
tl
rst or dull
life.
to
latter part
sign to
It
during
it
it.
By
referring
which
there
At
is
latter
is
immediately begins
its systole.
But
most
dilated.
falls
into
it
hence
this
140
obstruction-sound
after the first
may occur
last case, it
would
mur
is
The
moment
over the
left ventricle,
i.
e.
ribs,
{Jig. 29, p.
96)
Irregular beating
owing
distend
Hence
it,
before
the ventricle
the
commences.
more small spas-
systole
makes two
or
pulse, but
sometimes not
so,
full
beats of the
The amount
of irregu-
larity
It is
may be
Hope on
But
effusion
is,
usually,
141
in
no valvular murmur,
Inspection,
little
results of importance,
revealed by auscultation.
288.
The
been
stated.
of
fatal polypus.
Mrs. L
She had
27, 1829.
attenuation
n consulted
livid lips
me Dec.
a defined purplish
of
stairs;
con-
mu-
cata-
Hope on
page 518.
142
her,
saw
to difficult parturition.
greatly aggravated by
to
humid atmosphere.
Auscultation.
Both were
short,
right clavicle.
of the heart.
flat,
and audible so
far as the
removed
in six
She was
The
dropsy
week
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
Auricles.
Right,
dilated
its
greatly
dilated,
most completely
firmly to
slightly
membrane.
cartilaginous,
Valves.
Aortic,
but unimpeded.
Mitral,
slit
quill.
Remarks.
This case
is
brown
color.
remarkable as present-
exceeded,
al-
filled
lining
its
Left,
if
ever
amount of disease
life
a series
of years."
Auscultation.
The most
striking phe-
is
supposed
same
to pro-
of
it
290. This
the
Hope speaks
first
murmur
is,
sound, because
who (234).
144
may
It
sound; but
tinctly
It is
over the
left ventricle.
is
Hence
{fig.
29)
It radiates
heard
arises a
only
means
passing along
latter
ing (227).
we
are
now
treat-
by adhesions of
finally,
mental excitement
may
may occur
(220, 225).
no certain signs of
this disease,
af-
though pal-
An
145
is like-
common.
The
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
He
more.
for a
week
or
cular meningitis.
The
with a bellows
cles,
murmur
first
The
valve. It
disease to seriously
valve,
into the
The
obstruct
10
systole.
146
s the
mitral valve,
must bear
First,
it is
in
to the
But you
mind these
facts
exists alone.
exist in
this
that,' the
their operation.*
"who"
it
will
you may
refer to
see that
will
and
it
fifth
diagram
(Jig. 29, p.
96) and
and
found (Hope).t
*
Hope on Diseases
f Ibid., p. 105.
not unfrequently.
is
almost never
it is
heard
147
article
duced (289).
It is liable to
It is
usually
strongly
down
the back,
It
carotids,
is
transmitted very
and
less
It
this
distinctly
Hence
and diseases of
148
The
to
It is generally
ficial,
impulse
is
very super-
"r"
or " s."
owing
its
duty
monly there
is
an irregularity in
pen
in
may
hap-
The
great obstruction.
be small
if
there
is
is
Percussion.
larger space
hypertrophy.
owing
This, of course,
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).
Of
course
it
immediately
murmur
slight musical
ond sound.
masking the
sec-
ventricle.
It
generally slighter than the sound from obstruction, and sounds like a whispered " awe " (234).
is
The
trophy exists.
little
unless hyper-
may be somewhat
impulse
is
is
perceived,
305. Palpation
may
Hope
give a
The
306. Example.
206).
thrill (14,
following taken
from
monly found
causing,
first,
regurgitation
disease
valve (289);
valve (297)
and,
the
third,
regurgitation
through
same (302).
winded.
phy),
(205).
Hope on Diseases
150
the sternal
the
first
and a
(The position,
first
was
became again
with the
still
audible, and
became
it
cal note
ascending
first
superficial
This musi-
sound,
seemed more
musical note
dimi-
perfectly dis-
was
during
its
On
insufficiently closed).
these indi-
all
seat,
its
little to
accompanied
accompanying the
first
(The
sound,
becoming more
superficial,
some roughness
of that vessel).
creased on going
prolonged
(The
to
down
the
time, viz.
"awe"
ensuing
ventricular
that of the
it,
systole.
this
was heard,
viz.
cumstance.
Consequently, a mark-
uncommon.
In
fact, I
it
exist-
some
affec-
for
There
is
con-
is al-
some malformations
very
is
should rarely
mean
to say that
308.
Still
therefore
it
there
is
proper to
152
on
it,
mind.
in
Another
Usually
the
fact should
clapping
be borne
sound of the
when
even
there
is
upon.
If,
is
wanting, you
dis-
may
be sure of it,
murmur
for a
ularity of the
loud bellows
or irreg-
arte-
ry valve.
The
seen a case.
less
is
very rare.
I have never
of
it
The
following case
is
instructive.
Hope on Diseases
W.
S.
winded
short
strik-
Dyspnoea on en-
full,
rather tense.
Great
left ribs.
(The
point was
last
ar-
partic-
Pulsation,
felt
first
(The place of
ribs.
more
side.
Hypertrophy and
on the
still
left
facts
were as follows
left.
Hyper-
ed
pulmonary artery
dilated to a circumference
half.
154
tom
dents.
ally
is
a very
common symp-
in old dyspeptics,
and
in stu-
no severe
rational signs;
the
and sometimes
increased impulse,
at the first
come of
great importance.
Not
at times, be-
unfrequently, in
very rarely,
if ever,
omen
because
155
Laennec
mense.
The following
are
knew
before
seen to be im-
is
was never
definitely recog-
it
even
it
has become an
in its earlieststages
(258).
Second.
The common
known
and
This
differ-
156
times very
difficult, if
not impossible.
when the
slightest
approach
Thanks
of.
dis-
attempt to solve
was
to the fol-
we now can
all
come
to an
accurate decision.
cases,
314.
Still
times, even
further
ought we to complain
lished
at
is
is
some of the
if,
a case
accuracy of
157
action by
its
315.
would, therefore,
make
the following
Be
First.
much from
Second.
Do
a diagnosis.
Third.
If you
make an
and judgment.
ful, at
thinking
despair of becoming
Fifth.
Above
more accurate
all,
in future.
when
perhaps,
* See
mock your
New York
fatal
exists,
prognosis.
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
316.
man who
If possible, I
viz.: palpi-
remember
the erect
in
particularly
remove
all
if
there
any
is
evi-
(245)
er
whether
it is
it is
it
and irregular
rolling
whether there
if
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;
).
Passing
is
my
eye upwards,
or prominent distention of
there
is
rally.
ganic disease.
If
all
it is
I ob-
of them occur
The
am
nearly
differential diagnosis,
examination.
then proceed
to,
METHOD OF EXAMINING
317 Palpation.
pulse (205)
especially, if
of the auscultator
the heart,
if
be irregular, or con(206)
is
a back-stroke (275), or an
of them are
felt,
my
if
these or any
the head
if
is
there
it
thrill
is
318. Mensuration
may be of importance
in giv-
but
never
ter for
me
make
use of
319. Percussion.
by
it
it.
Inspection
is far
bet-
(262).
I rely very
much on
this, for
If there
is
it
and
decide
320.
Finally;
I auscult,
first,
my
with
ear
oscope
is
absolutely necessary.
Dr.
Hope
advises
ICO
on the
do
I frequently find
pulse.
it
important to
so.
321.
If,
in-
idea of
first
severe
of the heart, I
disease
second,
hear
sound, whether as
it,
or the severest
if,
moreover, this
sound
is
less distinct
third, if this
at the
is
and that
If,
carotids
the
left
perhaps not
suppose
it still
is
heard lower
exists
heard alongthe
left
auricle,
or,
be
in other
the
if
the sound
same place,
if
it
is
DISEASES. 161
precede
immediately
period of
rest,
would cause a
tempting to force
its
325.
slight
some
for, in that
end of the
murmur on
at-
last.
when
the
fer to
To make
this
more evident
let
us re-
B, a fluid
auricle
is
of time,
This sound,
in
some
both
162
cases,
is
tible
it is
always slight
it is
sometimes impercep-
cle contracts
it is
fluid
onward, whereas
fluid
325 a. Similar remarks might be made in regard to the pulmonary artery and tricuspid valves.
The
only inference
make
is,
that both of
it is
It
must
impossible to
In such a case
think
it
do
so,
shall
and
by percussion, or auscul-
me
to
I find
on inspection and
pal-
163
pation
and
may
tell
say I
him he has no
may be
risk of being so
ble
my
in
small, whereas if I
make him
misera-
am satisfied
that the
patient I
number of cases
Very
deceived.
is infinitely
express a doubt to
my patient,
Some
severe disease.
are congenital
it is
of
little
practical importance
lows sound
in the
is
the most
common, with
They
164
The
The
the
is
left
hypochondrium
left,
&c.
dull
left is
clear.
of
its
may
usual position
up towards
OF THE HEART.
POI/VPI
165
side.
&c. of the
Pneumothorax
left
right side,
left
may
332. Auscultation
may
mislead you.
The
ob-
its
Be
careful of inferring
is
any
^hat we can
am
heart, I
to
deny
can make
we
generally
166
The symptoms
some
irregularity of
murmur
their relief.
and usually
se-
much
notice.
its
it
becomes of
producing a roughened,
from an obstruction-sound of
It is
say that one able writer (Dr. Graves) has given the
report of a case in which there was great rough-
168
When
nothing.
is
superficial perhaps,
tumor appears,
may
it
teaches
simple inspection
thereof,
Gradually,
become
still
336. Palpation.
tumor
is
thrill
is
cause there
which
last
337. Mensuration
spection
Simple
impulse, however,
is
much
feel
before the
is
of
little
the aorta,
it.
It
may
may remain
part,
latent to auscultation.
it is
mary bronchi.
larger, or of the
same
pri-
mur throughout the whole of one lung. One primary air-tube may be compressed and will then
allow, perhaps, only half
to enter.
its
As
may hear
(28, 223).
sometimes very
may
very rough in
Formerly,
its
character.
It
Still further
if
buzz
merely sug-
341.
this
swift rushing
it.
murmur
to
sternum
(28, 41).
170
Of itself,
(206).
it
thrill,
&c. accompany
it
still
342. Finally,
when
pulsates (251)
and
is flat
206, 251)
if
;
the
if it
on percussion (101)
especially, if, com-
we
find the
that there
343.
is
we may
feel
very certain
Percussion.
Of
is
it is
When
underneath, even
sternum, you
part (99).
if it
may
When
The
will find
if it
complete dull-
malignant or other tumor over the arch may possibly be gained by auscultatory percussion
(390),
344.
A. M., porter
The
follows
a patient of Dr.
Health, in early
Diseases of the
for
He was
warehouse,
in a large wholesale
life,
good
seven years
cough without expectoration, and with these symptoms he had occasionally suffered from that period.
At
was soreness
in the cardiac
left
shoulder and
sternum
at the left,
by a line
let
sternum
fall
from the
below, by the
The
On percussion,
On palpation,
it
a purring sensation
On
was
flat
more
distinct
(101).
was perceived
it
was
left
172
were heard
it
was bronchial or
The sounds
of the heart
ically the
ued
second,
murmur
lows
to
augment
till
The
invest-
seemed
it
as if
it
it
In November, 1841,
would break.
beyond the
made
It
so formida-
his labor so
much,
it.
he
one and
The
and
a halfinches
all
developed.
his
The accompanying
appearance
at that time.
it,
much
plate represents
the tumor.
173
Fig. 34.
The
last
22, 1842),
its
ways of
at a
great distance
Having been
mained
al-
until
where
it
re-
At
174
the autopsy, an
ceding section,
may be
in the pre-
present in an-
signs,
more manifest
at
however,
The
would be
There
is
prominence of the
ribs at their
346.
In
prominence, &c.
in
the loins.
but
front,
we must
may
This, combined
lead us to a diagno-
175
much stress upon any amount of bellows murmur that may be heard, for the pressure of the
lay
apt to produce
is
For
it.
343).
may have
bellows
murmur
as
(223),
in
the tumor,
thrill
(14), the
aortic
aneurism
less
and about
is
the clavicle.
The tumor
will,
of course,
arte-
a.
At
subject, for
times, you
you may
hear a bellows
percussion,
ly,
may be
feel a
murmur
&c. (101),
in
doubt upon
this
if
Ordinari-
we compare
176
much
The
each other.
ter with
lat-
in aortic
tube frequently interferes with the arteria innominata or the left subclavian, and, consequently,
&c,
according as
348
6.
fre-
on the femoral
likely to
It
might have
arteries.
produce
a similar effect
tumor would be
gland
will, at times,
appear
to pulsate,
we
will
less
this effect.
it
fall
with
to be evidently
tumors
will be
found
in the legs.
Frequently,
bed and
raise
it
a little
is
difficult,
Notwithstanding
relieved.
and requires
experienced surgeon.
its
what
we
all
is at
times some-
OBSTETRIC AUSCULTATION.
12
OBSTETRIC AUSCULTATION
dN
the course of
my
midwifery practice I
labor,
will
all
women when
in
be hereafter mentioned.
have made
life,
pregnancy.
I shall
make
So
in
that
in the
earlier
But
months of
regard to
You may
Pregnancy," by
W.
Medicine,
New
1837.
York, 1843
" Signs of
F. Montgomery, M. D.
Obser-
by Evory Kennedy,
180
You
may
men,
your
You
will press
own powers
of hearing.
ing
ry, but
it is
is
absolutely necessa-
the placental
phenomena
murmur
(bruit placentaire)
foetal heart.
PLACENTAL MURMURS.
s early as the fourth
month, or per-
rus
is
is,
be-
if you
have
a sharp
PLACENTAL MURMUR
murmur of Laennec.
Now
murmur up to the
sawing sound (223). At times, like
most violent
it
becomes
softly cooing,
dron-
it
354. But
when
heard,
it is
355.
Some
womb
between
has enlarged.
owing
is
to the
356.
is
It usually
thrown
off.
It
ceases the
moment
little
womb
the placenta
owing apparently
and the
when
these vessels
uncontracted.
It
still
to the
pervious,
may continue
It alter-
ponding
to the
* Dr.
182
357.
liest
Some doubt
be
cir-
from repeatedly hearing, on two or three successive days, a souffle just over the pubes.
it
Dr. Mont-
month
endeavored
covers
it
to hear
it
earlier.
Dr.
Kennedy
dis-
=^v
JwJJ
good practice
for
you to en-
183
thirty in-
you
will
have a very
fair
idea of the
foetal
pulsa-
tion.
may
be very
much
altered,
Yet
ed,
it
quickened or weakenparent.
down
amount or character of
But they may become of vital im-
in regard to the
these changes.
The
fol-
360. Example.
on
woman
in labor.
He had
heard the
foetal
to beat.
He
foetus
was
had ceased
internal haem-
consequence thereof.
He
immediately turned
184
feet.
The
child
haemorrhage, as he anticipated,
By
place.
child
was
still-
was restored.
had taken
respiration the
From
rax.
iliac region,
believe, that
its
owing
it is
362.
ccecum (66).
The
extent over
of course,
is
which you
much.
You
will
hear the
radiates.
It,
at
later.
As
ness.
little
higher, but
it
is
it
will
be heard a
umbilicus.
In
363.
The
of the head.
earliest time at
WHEN HEARD
FCETAL HEART,
is
heard
city has
somewhat
is
heard
it
doubtful.
FIRST.
later.
commonly
185
it
little
at
the
When
we need
After the
fifth
month
it
much
perseverance.
nancy?
the position
365.
may be
Among
tion
young
auscultators.
nervous female
may have
Tumay cause
murmur
is
should
murmur
of the moth-
obscures delicate
we
er, especially if
branches,
it
its
make
foetal
sounds.
In these cases
* 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
is at
fetus.
The
fetal
ligament,
we might
low
it
to
if
we might,
much
* I
am
less definite
in this section.
is
on the application
If the child
we might not
death
is
try
Now,
it.
absence of the
Again, sometimes, a
heart.
foetal
woman
has
no motion
felt
tator
the
may
for
many
The
hours.
foetal heart,
is
if otherwise,
sound of the
187
if
She
auscul-
he hears
thereby instilled
is
Hence
it
becomes right
performance of
who
neglects
illustrating
domen
will, I
trust,
&c.
188
into a pregnant
woman, on
Tympanitis, too,
still
may
destroy the
all
such
oc-
me
to give her
my
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
irregular,
is
tense.
ago,
when she
fainted,
woman
at the full
period of pregnancy.
much
swollen and
felt
since
fre-
Some weeks
cal
'
Kennedy on
Obstetric Auscultation,
as that I
Collins,
page 182.
who
her to understand, that her swelling and other appearances of pregnancy depended upon wind.
With
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
whether
its
The
ed uterus.
more
it
feel
little
the os
under examination.
was
irritable
to auscul-
symptoms.
The
oil
it
for
some
did eventually
However, she
190
considerable
expelled in
quantity,
and
all
the
b.
a souffle (352).
fcetal
heart (358).
foetal heart.
common law
death-punishment to be inflicted on
a
woman quick
woman
be pregnant,
it
seems
is
allow-
examination.
Not unfrequently
are
we consulted
know
us,
and
pregnancy or
not.
cultation will be of great use, and the skilful auscultator has vastly the
mus
(357, 3D3).
CEPHALIC AUSCULTATION.
CEPHALIC AUSCULTATION.
was examining
applying his ear over the open and pulsating anterior fontanelle, " he heard a bel-
Czrg) movement of the fontanelle, and synchronous with the pulsations of the heart."
This
Dr. F.
all
ages,
This section
tings of J. D. Fisher,
M. D.,
published by S. S. Whitney,
in the
edition of
from the
article,
in
work on
Hydrocephalus, published by Thomas Smith, M. D., in
Oct. 1843
the Medico-Chirurgical
13
194
be used
but the
as the ear
may
former,
The
372.
The
culting a
first
young
in aus-
sound of respi-
&c.
It is called
is
distance.
This,
It is the
&c.
come from
to
is
called
of the
voice.
it
It varies
somewhat
sound
in its tones
and
we hear it frequently
Dr. F. calls
is
it
is
likewise heard
in auscultation
the cephalic
of the chest.
sound of deglutition.
is
nursino-.
It
CEPHALIC SOUND OF
375.
They
heart especially
more
distant,
many
times.
sity
195
VOICE, ETC.
The sounds
by age.
Dr. Fisher,
of the
coarser, but
at the
time of
his publication,
bel-
bel-
lows
murmur.
376.
The sound
diseases,
soft,
The
peculiarity.
It
seems
as if the brain
were moved
came
Dr. F.'s results, except in regard to the " impulsive " sound, which Dr. W. says he had never
all
Dr.
W.
own
tion of three
new
signs, viz.
The
subject
page 310.
196
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
may sometimes
account,
wish to bring
for
forward.
it
with closer
very
it
The
378.
following
is
The
in ce-
any source.
Dentition,
It is
mation
and scrum
the brain,
tion
of the
ease.
It
can be of
is
arteries,
little
When
pret other
evident that, of
itself,
(223, 225),
it
and
it is
its
absence, at least,
symptoms
is
favor-
may
serve to inter-
or those other
symptoms may
present,
it
197
It
379. Second.
means a sensation
as if the
it
in six cases
he thinks
it
may be
that disease.
ceived.
has
accompaniment of
a constant
seems
It
He
arteries.
it,
it.
the case.
Dr.
states
is
He
contradicts him-
it
(377).
apoplexy.
hregophony
ter either in or
distinctly says
ter
to
was
it
sound (54).
381. Fourth.
in a case of
Dr. Whitney
in
The name
some
This
depends on wa-
in the chest,
it
when
the wa-
have heard
cles.
Third.
380.
like the
The purring
thrill
was
felt
once
There
was a continuous sort of bruit de diable (257) accompanied by a thrill like the purring thrill (206).
The
it.
19S
382. Fifth.
sound would be
Cases
likely to
is
heard
in
which
be heard in the
382
ily
a.
From
it
some importance
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
AUSCULTATION IN FRACTURES.
wm
by
examining
accurately
cing the
Eusta-
To
384.
use
is
fractures. It
made of
fracture
this
surprising that no
in
more
obscure cases of
which sometimes,
If the ear
scure.
is
method
in
is
385.
It
might be used
cre-
them from
calculi in
202
the bladder.
When
a stone
am
is
contained therein,
is
it
385
a.
to apply
it
to dis-
AUSCULTATORY PERCUSSION.
AUSCULTATORY PERCUSSION.
ITSCULTATORY
Percussion
is
en by Drs.
the
name giv-
Camman
and
of internal organs.
tically, I
about
in this section,
depend
it
chiefly
Prac-
know but
little
I shall therefore,
upon the
analysis of
years since.*
As
of examination.
387.
*
New
1840.
20G
was applied
sions
ample,
I shall
as that will
afford
an ex-
its
fibres"
it
Using
your finger or an
in-
sound of
you
it, i. e.
at the
Again,
it.
from
at the
in degree.
served.
still
its
sound
is
instantly
cardiac type
greater distances,
is
pre-
moving
its
intensity
It will
AUSCULTATORY PERCUSSION.
likewise be heard
much more
207
distinctly
by the
to the instrument.
388. Explore, in like manner, the hepatic region, " and within short distances you will find that
as before;
semi-reverberant."
As
though
shall get
it
it
will
be even
augments,
the distance
will not
liver
and upon
another medium.
389.
The
method, they
be able to
fix
the boundaries of
But
in cases in
itself
which there
is
alone
is
diseased.
is
methods of
immediately con-
od may,
I think,
when we might
become
means of
diagnosis,
methods.
this, it is hoped that by
be able " to distinguish with facility
we
shall
serous effusion
from
any
208
May
itself."
it
not
for
It is
mon methods
may be
Especially does
accuracy.
it
seem
to
me
that
it
it
Camman and
nearly an inch
its left
lobe and
its
its
lower border to
thin edge.
They are
when
They
edge
mark
the
ar<&
between the
liver
is
percussion
true
and false
come under
od
we may be
at the
able to decide
anchylosis.
One
between
case only
had
at the hip-joint,
dis-
393
a.
mitted
but
if
however,
lost.
this
method of distinguishing
frac-
TYPE SOUNDS.
tv=^he following statement will afford an
idea of the relative powers of differ-
U\
^
among
conductor of sound
ferior to
tense
is
ducts at
bone
that cartilage
in this respect;
is
ducts badly
14
the best
that muscle
is
it
when
hardly con-
uncondensed con-
210
when
relaxed;
conductor
that both
column
is
a bad
posed
soft tissues, if
moderate pressure
state
loss of
energy
that
ticulations
in
that fractures
two successive
ar-
sound
is
latter propositions
ticular consideration.
deserve par-
structure
it
make
its
has to pass,
way
first,
and even where the transitions are still more numerous, as in the joints which possess " moving
cartilages,"
may
satisfy
first,
little
the fundamental
rib,)
TVP BOUNDS.
211
one are
in
is
the loss
It is true that
is firm.
no way proportioned
is lost,
to the
but
number
of medial changes."
The
395.
The
first,
osseous,
is
the
the
least
of these
at opposite extremities
remarked
and
qualities,
of the scale.
It
are
may be
is difficult
to dis-
it
must be sought
aqueous come,
first,
hepatic.
The
intense,
the abdomen, as
osseous and
ductible
diate,
for in
Between the
To
aqueous type
former
rather
is
it
painfully
con-
quick, imme-
is
impulsive, and
more continuous,
The
less freely
it is
hepatic
is
conducted by
212
immediate, impulsive.*
varieties of
With these
types,
all
the
differ-
may be compared.
Fig. 35
is
is
They
a solid
woody
fibres, six
in-
diameter.
It is
ear
which
piece,
will
The
it.
It will
common
hollow instrument.
following definition
Immediate,
when
is
ausculta-
Quick, used as
when
the
same term
is
applied to the
pulse.
extremity as before.
two
lines
398. In case
common
stethoscope
The
but
another
(Jig. 37).
is
finger will
It is
absolutely neces-
answer
sion
is
purpo-
been suggested
made of steel with an
press upon.
all
has
The
thumb
to
met with
sion.
They
in auscultatory percus-
apply
chiefly
to the
214
To
401. First.
get
the
characteristic
full,
Even
in contact.
may
402.
Second.
The
The
may
difference
between the
differ
The sounds
are
Third.
403.
It is, at times,
difficult to define
it.
By using
the
404. Fourth.
ribs
the
heart.
405. Fifth.
heart.
overcome the
405
come
a.
difficulty.
Sixth.
The mammae
them aside
as in
common
in females
we can
may
be-
generally push
percussion.
It
may be
too hard, so
all,
fin-
audi-
VETERINARY AUSCULTATION.
VETERINARY AUSCULTATION.
ETERINARY
cultation
seems
been much
Aus-
to
have
neglected
England, and
is
in
wholly un-
is
by no means
There
upon
his
Similar
auscultatory
The
merely supplementary
man
auscultation.
to
220
quite as distinct as in
character.
They
man.
different
those in the
human
it
seemed
to
me,
as
subject (461).
phenomena
of the horse,
depend
chiefly
much
of their confidence in
by
French school,
works
&c, whose
J.
f Hippopathology, a Systematic Treatise on the Diseases and Lamenesses of the Horse, &c, by William
Percival, London, 1840.
Also,
"The
Veterinarian,"
author.
same
Delafond
r.
sion,
Some
ples-
use a wood-
sion
is
common
sufficient
if
Delafond says
you remember
to strike,
first,
second,
fourth, to
(4, 84).
The portion of the trunk in which percusmay be advantageously used, may be marked
412.
sion
by two
one
lines,
upper,
The
rib,
lower
upper,
in the direction of
1,
222
from
it
diminishes,
left
it
This
is
obtained
may be compared
abdominal.
whence
On
it
to that of the
;
and
this
upper
re-
continues to
lessens until
it
becomes
is
a little
VETERINARY AUSCULTATION.
223
VETERINARY AUSCULTATION.
,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
little
quietness of the
respiration
There
as in
diminishes in age.
It
human
man
It is
augmented
by two parallel
the pue-
(25), and
lines,
is
divided
224
murmur
is
1,
little to
the respiratory
quite distinct.
it is
thence increasing
is
quite
VETERINARY AUSCULTATION.
it
225
pears.
same on both
This
is
immediately back of
left
course,
the
murmur
is
diminished.
It
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,
have never
as these
occur
at
sounds
different
times.
421.
Among
is
the existence of a
first,
to the
to
do a double
15
226
in animals as in
man
and
same diseases
teristics,
as in
sounds as heard
to the former part of the
in
work
man.
man,
(62,
For these
you
I refer
&c).
The
at times, is so ad-
is
hepatization
is
dislodged.
would
be no change of sound
in
simple obstruction of
would probably
also
423.
tion (41)
It
is
and
in
227
at
usually, in a horse
(134)
bronchial respiration
is
it is
very
of breathing
is
very
is
(180),
(76), than
it is
and being
its
difficult.
seem,
sort of noise,"
in
human
beings.
it
would
crepitation
They
are most
distinct in expiration.
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
22S
tubal sound
is
cavities in health
but a swelling
bres,
whistle (62,
&c).
continued even into the chest, but they are strongest opposite the part affected.
428. Percussion
polypus
may be
of use in indicating
we hear only
But when
swollen there may
in health
a very slight
membrane
murmur.
is
be whistling (62)
or if the swelling
all
ef-
The resonance
430. Percussion.
clear in youth,
it
may become
more
so in the aged.
perfectly
229
is
tolerably
In disease
flat.
ounds of the
slightest
character, but
normal condition.
it is
In disease the
rales heard
important (103).
lowing.
432. First, the dry whistle, from simple contraction of the calibre of the tube, either from natural
This
sonorous rales as in
man
(62, 71).
mucous becomes
it is
Hippopathology, vol.
heard
ii,
a loud
at a distance
from
230
the animal.
If
it is
is
so loud as to
make you
suspi-
if
you
find the
it
will
be very loud.
The
43C. Cough.
it
might produce a
rattle,
or
but I
augment one
f I doubt
broad assertion.
of the trachea, but certainly the fact that the air enters
the trachea freely
is
The
latter part
trace
of his direction
is
excellent, viz.
to
231
i.
e.,
The
438.
rales (71)
chea
p.
may
224).
sibilant, sonorous
owing
ealthy
in
all
either
tially
It is so called,
tion,
&c.
it,
unfrequently have
the
starts
called
roaring.
sound
we not
In these cases
disease
suddenly to
trot,
and of course, a
less value;
although
it
may
The
far-famed Eclipse
is
a " roarer."
whether
for this
for
it,
and
232
you
may
it
struction exists.
or demonstrating
altering,
the obstruction,
when by
the respiration
we cannot
decide.
BRONCHITIS IN ANIMALS.
ales varying according
to the
amount
When
cases.
the
membrane
is
is
should expect that the rales would be most distinct towards the sternum, or
is
more
depending parts of
If
at
PNEUMONIA IN ANIMALS.
grow
less
233
On
the
The
is
but
little
is
in bringing
sound
of
it,
heard, in either
PNEUMONIA IN ANIMALS.
?~N
1-^
in regard to aus-
The
crepi-
*-^ tous rale (70, 120) is mentioned as occurring, and being evident, and as distinct in
its
ings.
human
be-
respiratory
234
is
like-
obscure on
447. Percussion.
this
murmur, by causing a
A sentence
writing
upon.
We
however gain
physical
viz.
laws
one
would
that hepatization of
man
(98, 123).
Reasoning from
448.
used, as I have
men-
117, fec).
BROKEN WIND
^v n
235
IN ANIMALS.
is
may
pulmonary inflammations.
450. Auscultation.
Respiratory
murmur
very
quiet (178).
451. Percussion.
usual (177).
452. Inspection.
Chest rounded
intercostal
may be
general or local.
Laennec observed
writers have
it
doubted
curs, at times, in
in
in this disease in
it.
It
Does
man.
it
this
man.
disease.
Later
fre-
cannot answer
the question.
dilatation,
Laennec, occurs
dry crepitous
phenomenon
common
dilated
in
It
rale.
in
human
we should
in
may be more
beings, but
find sibilant
more frequently
viz.
in veterinary auscultation.
gests that
rales
is
bronchi,
&c).
PHTHISIS IN ANIMALS.
456.
minished respiratory
Auscultation shows
murmur (149)
di-
in the earlier
man
at
&c.
exist.
457.
sound
Percussion affords
in the
do not know
same way
as in
its
modifications of
man
(146, &c).
237
PLEURISY IN ANIMALS.
ever heard (148), but I see no reason
why
it
should
&c).
PLEURISY IN ANIMALS.
uscultation shows
a diminished res-
at the
may be
that, at times, a
water
be
is
heard.
air as well as
It
seems to
me
that there
must
238
may
when any
little
effusion
It
will
It
ox than
seems
to
in the
dog
and
the other.
distinct fluctuation
was communicated
in
which
to the ear
made on the
128, &c).
other (14).*
it.
Hope
in his
of the
The place
for
bow of the
on the
left side, in
ribs
The
hand, placed
is
el-
marked
flat
4,
against
heart (240).
462.
Pericarditis.
symptoms
will
as they
be "well
occur in
man
as those
which
it
them
until,
this, viz.
bounding
and
feeble,
fluttering
movement, when
takes place.
To
m-an,
means much
all
ready.
this
effusion
than he knows
al-
though
240
human
auscultation.
common
Mr. Percival
classification of simple,
But noth-
new
ing
is
stated, either
This
(See dilatation
in
new
Yet
it is
is
evidently
Nothing
is
perfectly evi-
"it
Of
this,
practice."
results in
human
a lancet, as
no one here-
Mr. Percival
The
it
occur
in the
make
* Hippopa'.hology, p. 70.
trunk or
When
sound.
in the former,
course, incurably so
might
man, 335).
ration
when
241
he would be, of
(See aneurism in
relieve entirely.
in the
foetal
heart
human
may be heard
subject.
have
seems
to
for
many
reasons.
(See
with
is
to the
foal.
This
foetal
is
is
heart 358).
important as marking
practised pre-
animal to examination.
471. In
all
should be observed to avoid injury from the animal, which frequently becomes restive under this
operation.
16
APPENDIX.
A, page
16.
STETHOSCOPES.
472.
since, a friend
gave
me
one
don, and
it
by that gentleman
used
it
much while
it
lasted
The
244
APPENDIX.
Fig.
Fig.
1
1.
It is
made of
It is
hollow
and
a
is
soft
2.
trumpet-shaped
mouth,
make
the instrument
less liable to
may
or
may be
instrument, when
we wish
it
to
To
Fig.
whale-bone, four or
3.
five
its
This lead
Fig.
is
4.
the sound.
Fig. 4
plessimeter,
made of a
is
a
of
tween the
ribs
and velvet,
fits
readily be-
245
APPENDIX.
B, page 190.
Among
human
life
was
deliberately
stands preeminent.
2,
1778,
me
most deeply,
because
it
may
stethoscopic
for
many
reasons
It
impressed
but I quote
it
now
You may
to you.
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."
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
in ex-
ded
my
in
favor,
still
am
pregnant state, and above four months (363) advanced in it, and the infant I bear was lawfully begot-
in a
ten.
am
delivered of
it.
withstanding
my
till
my
who
bears
it,
Your
it.
even
am
and hath,
is
deplo-
What
innocent
beg leave
to give
it.
am
to preserve life,
than to destroy
my
a mother
in
Nothwithstanding
this
short continu-
urgent appeal of
and thus
ii.
1845.
W.
and they
Chandler, Boston
T. H.
247
APPENDIX.
S. was quick with child, and that they had been mista-
ken
in the verdict
sufficient that
With
now (June
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
As
show
"!
medico-legal questions.
have no hesitation
known and
in believ-
practised on
that occasion,
it
the sounds of a
foetal heart,
somewhat
in the
seventy years,
we
are
still
liable to
have the
folly of
to protest against
place
among
the
474. Second.
to
claim
and important
to
be called upon,
248
APPENDIX.
charge.
In
all
may become
C, page 186.
two
we, of course,
distinct,
proba-
GENERAL INDEX.
A. ART.
Abdomen auscultation
Adipose matter
^Egophonic
applied to
effects of on
murmur,
it,
202.
59.
in cases of hydroce-
Age effect
Amphoric
cles,
of,
on heart, 112.
respiration, 24
&c,
in
24. 68.
di-
168
115.
Aorta
palpation in,
see errata.
see errata.
may or may
murmur
;;
250
AUS.
ART.
115
carotids,
114
Mensuration
of
Palpation
of,
tions, ib.
purring
important in
all
thrill, ib.
Arteries of brain
of radial pulse,
cardiac diseases,
see
ib.
irregular
errata.
of bruit
197.
thrill,
of,
193
in disease, 100.
;
(for
sounds, natu-
ral
deglutition,
voice,
aegophony, purring
sounds of;
cephalic
thrill,
bruit de diable,
136.
of,
uses,
applied
the
to
bladder,
ib.
Immediate,
ear, 201
fractures,
abdomen, (see
ib.
13.
Mediate, 13,
its
196198.
appendix B;
Mrs. Spooner's
important to army,
necessity of
179;
it
to
decide
doubtful pregnancy,
murmur, 180
labor, 186
foetal
ib.
heart, 182
placental
;
during
mors, 187.
Preliminary
necessary
to
an accurate,
1.
AUS.
BEL.
251
17; do. in
in health,
disease, 22.
heart, 206
208
ofliver, 207
kidney,
ib.
anchylosis, ib.
spleen,
existence
of
fractures, 209
Axilla?
percussion 43.
Murmur causes
in,
Bellows
of,
Cephalic
consequent
on cerebral con-
of little use in
diagnoses,
differential
ib.
minute
never in
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.
sion
of, ib.
places
where
149
aorta,
;
148
heard, 105.
regurgitation
character
of, ib.
where heard,
ib.
at
which
varieties of
it,
it is
103.
heard, 106.
;;
252
BLA.
BRO.
209.
Broken wind
235
in animals,
Bronchial respiration
causes,
natural, 23
ib.
dilated bronchi,
lung, 79
59
signs, ib.
84
gangrene of
phthisis, 68
pleurisy,
pneumonia, 54.
pneu-
in
monia, 233.
Bronchitis
physical
signs, 47
may be
none,
ib.
exam-
ple, ib.
Acute,
most
first
at
base of lung,
ling rales, 48
ib.
base, ib.
wavy
sibilant,
only on coughing,
ib.
ib.
third
heard best at
mucous
or
impor-
case
Chronic, no symptoms, 50
ib.
mucous
at base, ib.
if altered,
suspect dis-
ease, 51.
in veterinary practice, signs of,
heard,
Bronchophony
232
where
ib.
natural,
27
from diseases,
ib.
dilated
bronchi, 84
;
bru.
Bruit de
cou.
'253
(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,
6. 91.
by
exact
not recognised
veterinarians, 239.
Carotids pulsation
of, in
See bronchitis.
Cavernous respiration natural
Catarrh.
Cellular tissue
209.
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.
of devil's noise
Comparison importance
auscultation
ence of note,
Cough in
123
when
especially
68.
there
is
merely a
differ-
5.
Contraction of chest,
carditis,
of,
60
peri-
phthisis, 8. 64.
resonance
of,
69
254
Cough
cou.
dia.
ib.
ib.;
and phthisis,
in females,
ib.
nervous patients,
different from
ib.
crepitous, 33
ib.
need
loud and
ib.
submucous,
ib.
mu-
be distinguished, 33.
pneumonia, 44
Creaking sound
Crepitous Rale
nia, 34.
in pericarditis, 120.
characteristics, 33
53;
indicative of
pneumo-
oedema, 86;
;
in
235.
Cyrtometer,
to
Diagnosis
cephalic sound
differential of
of,
194.
ment
and peri-
importance in treat-
of an acute attack.
Table
of
symptoms,130.
of aortic and mitral valvular disease,
107. 144. 147. 150.
sounds, 110.
rubbing
DIF.
EFF.
255
importance of in
pneu-
phthisis, 65; in
monia, 55
44; in gangrene,
side,
78.
in pain of
signs
an idiopathic
chest in
of
7.
60
of,
134
uncommon
rather
affection, 135.
emphysema,
pericarditis, 7.
7.
122
81
pleurisy,
malignant
dis-
of the bronchi, 84
resonance of voice
in, ib.
mucous
ple
of, ib.
percussion in,
ib.
ib.
exam-
risy,
Dress
60
pleu-
Dullness on percussion
1.
89. 180.
gangrene of lung,
phthisis, 44. 65
58;
78;
45.
pleurisy, 45.
pul-
aneurism,
heart, 134
132;
114.
128
174;
;
dilatation
endo-carditis, 114.
58
of
hypertrophy of do.,
in
signs
of,
to discover
;;;;;
256
EMP.
Emphysema of the
EXA.
lung, 81
enlargement of intercostals,
ib.; difficulty of
prolonged expiration,
less resonant, ib.
ib.
sibilous, ib.
res-
or absent, 81
;
voice
heart, 113
cussion, 214.
in animals, 235
dullness on percussion,
trophy,
ib.
ib.
example, 129.
122
in pleurisy, 60
emphysema, 81
pneumothorax, 76.
prolonged
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
;
chronic, 50
84;
signs,
47
do.
acute
running into
dilatation
ma
EXA.
FIG.
257
123
pericarditis,
phthisis,
69
insufficiency
pleurisy, 61
of,
145
pneumo-
pneumothorax,
nia,
56
77
Foetal
like
tal
or bodily, 183
great importance
metallic character
of,
184
extent
of, ib.
case, ib.
which they
to
are
pregnant,
ib.
obstacles, ib.
187
as a
means
in questions of
of recognising
instrumental labor,
appendix B.
Figure
position of patient
in auscultation of breasts, 2.
do.
do.
do.
do.
do.
do.
callipers
for
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.
ib.
ib.
16
Golding Bird's,
17
18
ib.
ib.
ib.
do.
17
do.
back,
ib.
258
Figure
GAN.
FIG.
21
ib.
ib.
25
26
27
do.
do.
back, 42.
do.
do.
sides, 43.
28
in
to
30
31
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
Fractures
auscultation, 201
Fremissement
cataire,
Gangrene of lung
signs
example
cous,
of,
&c,
79
ib
see purring
of,
78
thrill.
cracked-pot sound, 79
pectoriloquy,
respiratory
augmented, or diminished,
ib.
rales, irregular,
murmur,
ib.
ib.
mu-
voice altered,
Gurgling, 35
at
bottom of lung, 35
259
HE A.
GUR.
79
35
at top of lung,
229.
Haegophony
see asgophony.
Haemorrhage cause
Heart
atrophy
of,
aus-
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.
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.
difficulties of
malpositions,
from disease,
164
congeni-
ib.
ib.
difference of note,
ib.
dull
in, 165.
position of
it
of,
91
positions for,
aminations, 92.
sounds, 94
abnormal, 102
absent, 101.
in animals, 225.
ib.
; ;
0U
Heart
HYP.
HEA.
sounds of;
from disease,
debility, ib.
causes
of,
96
ib.
exercise, 102.
cephalic, 194.
fevers,
ib.
diminution,
little
important as
ib.
serious in its
commonly
in
aged
ib.
causes, 103.
left,
96.
after
pericarditis,
it
123
example
133.
by
veterinarians. 240.
132
signs
of,
ib
IMM.
261
INS.
60
8.
pneumothorax,
8. 76.
Impulse of heart
decreased in dilata-
irregular,
148
in obstructed
valve,
aortic
usually augmented,
ib.
240
obstruc-
softening
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.
158
of heart, 92.
bro-
emphysema,
use com-
little
motions
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.
veins,
117.
Insufficiency
Inspiration
25. 72
see
regurgitation.
diminished, 19.
25
altered
by
disease,
262
1ER.
Irregular
MEN.
hypertrophy, 132.
140
obstruc-
insufficiency of do.,
insufficiency,
149.
Jerking respiration, 24
of,
of, ib.
in,
Larynx
in, 8.
J-iiver
auscultatory
fever
pericarditis,
percussion
pneumonia, .53.
109
marks
when enveloped
Lung
pleurisy, 61
in
cause,
its
ib.
from
outlines
serum, 208.
see pneumonia.
do.
164.
Mammse interfere
Mensuration aneurisms,
pers, 12
116. 168;
;
appendix B.
arteries,
116;
calli-
phthisis, 69
pneumonia,
by
pleurisy, 12. 60
12.
ment
for, 13.
122.
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.
Mitral
valve obstruction
139; example
of,
of,
141; im-
of radial pulse,
sounds,
little
or none, 139
diagram
of,
161
ib.
143
of,
ib.
bellows
times
of, ib.
murmur very
;
varieties of,
example
of,
145.
inspection, 144
ib.
Modification of voice, 28
mensuration,
ib.;
palpation,
Motions
percussion gives
more im-
in pleurisy, 28.
absence of in pneumothorax, 76
pleurisy, 60.
augmented in
ib.;
laryngitis, 8
pneumonia,
disease
tions
affecting
one
augments
mo-
important
to
be observed in diseases of
children, 8.
increased locally,
aneurism,
&c,
as in hypertrophy,
8. 132. 168.
264
MOT.
OBS.
of,
cardium, 10
122;
in pericarditis,
by
effusion in peri-
in hypertrophy, 132.
Mucous
35
48
phthisis, 68
example,
Muscle as conductor
Musical
Musical note,
Musical
of sound, 209.
murmur cephalic in
to
anaemia, 198.
rales, 30.
Nasal cavities
disease
228
in animals,
of,
sonorous rale
in, 228.
Note
difference
44;
Obstetric auscultation,
186;
foetal
in
179;
bellows
murmur
in,
147.
between
diagnosis
and mitral
it
dis-
dullness
owing
to
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-
impulse irregular
when most
in, 140.
mensuration, palpation,
lit-
OBS.
PEE.
265
condi-
similar
spot of
ib.
same
place, ib.
ib.
voice well,
difficult to
to
87; per-
ib.
Palpation applied
of,
decide between
it
pneumothorax, 77.
94
of mitral valve,
disease, 10.
small advantage
of, 11.
obstruction
140
phthisis,
dyspeptic, 154.
Panting
importance
Parchment sound
of,
in acute phthisis, 9.
valves, 138.
Parietes of chest
Pectoriloquy
ib.
in phthisis, 68
Percussion
gangrene, 79
in aneurisms, 170.
9.
varieties of,
pneumonia, 55.
;;
266
PER.
PER.
may be
normal, 148;
221
for,
234.
of,
ib,
aortic
in
use, 149.
little
113
in diseases, ib.
ease on
ib.
it,
of
effects
ib.
pulmonary
effects of its
own
dis-
diseases,
114.
importance
38
of,
experiment,
auscultation,
diate,
ib
ib.
ib.
;
more
ib.
used,
latter rarely
difficult
mediate,
ib.
than
imme-
ples-
of, 39.
men, 236;
in pleurisy,
in phthisis, 65
pleurisy, 5S
in
pneumothorax,
pulmonary apo-
plexy, 83.
sinuses, frontal, of animals, 228.
Percussor
Bigelow's, 15
Pericardiac sounds
ib.
sound,
ib.
Williams's,
musical
;
appendix A.
leather,
washing
PHT.
PER.
Pericardium
disease
267
animals, 239
of, in
place to exam-
ib.
prolongation of
first
ib.
these
character,
sound,
ib.
ib.
;
Sounds of heart,
third stage.
impulse
varieties, ib.
to-and-fro
less, ib.
indistinct, 121
nence of
Convalescence, disappearance
fourth stage.
ib.
123; disappearance
of, ib.
of hypertrophy
example
of,
promi-
122.
left breast,
of signs,
signs
ib.
123126.
in animals,
man, 239.
very vague accounts given by veterinarians,
ib.
Phthisis
amphoric
respiration, 68.
man, 236.
cavernous respiration
68. 23
in,
click
under
cough, resonance
crackling,
ib.
of,
69
effects
on r&les, 68.
268
PLE.
PHT.
Phthisis
diminished inspiration,
example
of
66.
obscured
do., ib.
palpation, 69.
pectoriloquy, 68
percussion,
dullness
resonance,
signs
of, at
ib.
on,
diminished
67;
65.
to, ib.
Placental
182
various opinions,
Places, in
which the
ib.
how
early heard,
ib.
Plessimeters varieties
of,
forefinger, 38
caoutchouc, 39
appendix A.
ib.;
Cammann and
Williams's,
Clark's, 40.
Pleurisy
physical
rubbing sound,
58
respiration,
57
haegophonic murmur, 59
piration, ib.
ib.
ib.
modified voice,
ib.
bronchial res;
haegophony,
ib.
enlarge-
;;
PLE.
thorax,
ib.
POT.
269
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,
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
sion, 77.
Pneumonia commences low in lung. First stage. Increased or diminished murmur, 52.
Example,
53. Second.
Bron-
chophony, ib.
tympanitis,
turning crepitus,
ib.; subcrepitus,ib.;
Pneumonia
signs
ib.
ib.
more
Fifth.
diminished purity
of bronchial respiration,
ib.
bron-
Fourth. Re-
ib.
caused by oedema,
dullness on percussion,
ib.
ib.
impor-
ib.
signs of suppuration,
pectoriloquy,
ib.
example,
56.
in animals, 233
inspection in, 8.
91
effects of,
change
of,
on percussion,
1.
58
useful, 58.
do of heart,
do. of heart,
113
270
KAL.
PRO.
Prolonged expiration
physema, 81
Prominence of
;
at top
in
em-
&c.
phthisis, 66,
clavicles, 8. 64.
left
Puerile respiration
rare, 151
sounds
place, 152.
regurgitation or insufficiency
of,
obstruction, regurgita-
(see
tion).
Pulmonary apoplexy
physical signs
Dullness on per-
of.
cussion, 83
absent or modified
respiration, ib.
rales, ib
voice
altered, ib.
examples,
37.
diagnosis, ib.
Purring
thrill,
115
most distinct
to tip of fingers, 11
148
aortic obstruction,
do.,
in
regurgitation of
cerebral, 197.
Quickening
tions,
Rales
auscultation
to
decide
it
in medico-legal ques-
EAL.
metallic
RES.
tinkling,
mucous,
34. 48
ib.
271
muco-crepitous,
34
musical, 30.
man, 236.
rubbing
36. 65
sibilant, 31. 81
sono-
subcrepitous, 34.
man
226.
monary
Resonance
artery, 152
(see sounds)
pul-
&c,
(See mitral,
emphysema,
percussion, 43;
phthisis, 43. 65
pneumothorax,
26;
of voice,
tricuspid, 146.
in
pneumonia,
43.
43.
81;
in
54
in
43. 77.
bronchophony,
27. 54
Eegophony, 28. 59
Respiration
amphoric, most
76
distinct in
imitation
cephalic sound
of,
of,
pneumothorax,
24.
24.
194.
its
study,
tubercles,
grene, 79
dilated bronchi, 84
tumors of lungs, 23
gananeu-
risms, ib.
55
rude, 23
66
phthisis, 68
ib.
pneumo-
or pneumonic, 52.
;
;
272
Respiratory
KES.
fremitus in
RET.
10
health,
augmented by
murmur, 17
in pleurisy,
&c,
19. 21. 25
influence of age, 17
posture, ib.
disease,
18
60
10.
10.
temperament,
ib.
ib.
mental emotions,
of chest, 18
piration, 19
19. 25
ratio
ease, 19. 66
ished,
19.
puerile, 17
in different parts
changed by
dis-
inspiration dimin-
66;
expiration pro-
obscure in
emphysema, 81
times in
at
lessened in
aneurisms, 169
121
in
emphysema,
in hypertrophy, 132
ma
oede-
animals, 236.
Returning crepitous
rib.
sou.
of,
in
273
auscultatory percussion,
Roaring as
alogy
to
sound
tween them,
in pleurisy, diagnosis
ib.
when
be-
favorable, 123.
Rude
Rule
respiration, 23
in tubercles,
66
pneumonia,
52.
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
diminished, 100
132
tis,
138
121
103
irregular, 101
indistinct in pericardi-
prolonged in
pericarditis,
120
musical,
represented by
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
42; sides
of vertebra;, 42.
44.
58
in pleurisy,
muscles on, 42
effect of pectoral
where
least
mus-
body,
po-
1. 44.
show
plates to
differences
of,
figs.
in va-
25, 26,
27), 41,42,43.
on
sides,
most resonant
least im-
Spinal
Stethoscope
Laennec's view
of sound, 210.
of,
dif-
when
needed, 14
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.
Cammann
importance
Stethoscopes
flexible, 16
man,
auscultation ofit in
17.
95
Thrill
horses, 231.
Tubercles
Tumors
of,
see phthisis.
over
Tympanitis
in pneumonia, 54;
Type sounds
insufficient, 148
;
Valvular diseases
;
aortic, obstructed,
157
pneumothorax, 77.
thro',
146.
cautions
knowledge
of
them
147
insufficient,
insufficient,
insufficient, ib.
in regard
diagnosis,
to their
unknown
to veterinarians, 240.
Veins
auscultation,
118
devil's
VEL WIL.
276
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,
ideas of
219
of,
rules for,
223 see
&c.
percussion, 221.
Vibration
from respiration, 11
rales, ib.
&c,
sonorous rale,
diseased heart,
10.
pectoriloquy, 26
ve-
27 modified by disease, 28 ;
(see bronchophony, pectoriloquy, haegophony
and modification of voice) unimportance of their
sicular resonance,
diminished resonance
changes, 29
emphysema,
of, less
common
in phthisis, 29. 66
than other
gangrene, 79
29. 81.
pleurisy, 59.
augmented resonance
grene, 79
in dilated bronchi, 84
phthisis, 66.
68
pleurisy, 59
gan-
pneu-
Washing sounds
Wavy
respiration
A.
appendix
ERRATA.
277
ERRATA
[By accident the following were omitted in the Index.]
Aneurism
murmur, 169
respiratory
mensuration
in, 168.
palpation in,
ib.
169
alteration of the
thrill,
170.
173.
fig.
murmur in,
bellows
Aorta
ally
diagnosis between
Aortic valves
ib.
disease of
148
149
bellows
where heard,
of, 108,
149
105. 149
characters
jerking pulse,
ib.
in-
use,
ib.
times,
ib.
example
of, ib.
ERRATA.
278
ib.
of,
;
where heard,
palpation in,
ib.
ib.
inspection, no results.
Arteries
diseases
of,
167
176.
The
Page 250,
Page 254,
Page 255,
after
" cardiac
after
after
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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