Diseases of the heart and arterial system, designed to be a practical presentation of the subject for the use of students and practitioners of medicine

Front matter

COLUMBIA LIBRARIES OFFSITE

HEALTH SCIENCES STANDARD

^yiM

Preface

Ix the preparation of this work the author has endeavoured to present the subject in a simple, practical fashion that would suit the needs of the student and practitioner of medicine. Theories and speculations have been omitted or given but scantv consideration, in the belief that they tend to confuse the student. The anatomy and physiology of the circulatory organs have received only such notice as was thought necessary to a better understanding of the matter in hand, since an extended consideration of them was believed out of place in a work devoted to diseased conditions. Although aware that physical signs are properly a part of the symptomatology of disease and should be considered under that head, still the author has thought it best to consider them separately, for the sake of facilitating the knowledge of that most difficult subject, the diagnosis of cardiac disease. Special attention has been paid to treatment, and this part of the subject will be found far more detailed than is the case in most books dealing with diseases of the heart. It was hoped that by so doing the work might be given a more practical value to the general practitioner, although of course the author realized that he would lay himself open to adverse criticism, and could do but little more than lay down principles for management. The phraseology has been kej)t simple and free from needless technicalities, while in the terminology an attempt has been made to employ the terms which are in most familiar use among American and English physicians. Xo claim is laid to originality, as is apparent from

iii iv DISEASES OF THE HEART

tlie lUTmcrous references to authors from whose works valuable suggestions and information have been derived. To all such authors, grateful acknowdedgment is made.

In conclusion the writer desires to express particular thanks to the following gentlemen : Drs, O. L. Schmidt, for the article on Gaertner's Tonometer ; Edward F. Wells, for that on the Sphygmograph; Gustav Fiitterer, for anatomical specimens and photograjihs ; W. A. Evans, for post-mortem examinations and other aid ; and Milton W. Hall, for preparing the illustrations. Finally, the author wdshes to publicly express his indebtedness to his wife, for her encouragement to undertake this work, for her perusal of his manuscript, and suggestions, without which many passages might have been obscure, and for her invaluable aid in the revision of proof.

Robert H. Babcock. 103 State Street, Chicago, III.

Contents

GENERAL CONSIDERATIONS, PERTAINING TO THE ANAT- OMY, PHYSIOLOGY, AND EXAMINATION OF THE HEART

PAGE

Location of the heart 1

Chapter I V

VI

PAGE

Locatioti of the pericardial frictio)i-sou7id 58

Rhythm of the friction-sound 58

Intensity of the friction-sound 59

Quality of the friction-sound 59

Effect of pressure on the pericardial niurniur 59

Differential diagnosis 60

Secondary jj/iysical signs referable to the lungs 80

Differential diagnosis 83

Treatment in the stage of effusion 90

Ph sical signs. Inspection 385

Summary of physical signs of valve lesions of the right heart .... 389'

Chapter XIV Combined Valvular Lesions

Combined mitral stenosis and regurgitation 390"

Mitral stenosis and aortic stenosis 392

CONTENTS

XI

PAGE

Mitral stenosis axd aoktic regurgitatiox ....... 393

Inspection 395

Mitral regurgitatiox and aortic stenosis 396

Aortic regurgitation and mitral regurgitation 397

Aortic stenosis and aortic regurgitation 398

Chapter XV

the prognosis of valvular heart-disease in general

Complications 405

Rheumatic diathesis 406

Digestive and bronchial disorders 407

Age 407

Temperament . 408

Sex 409

Occupation 409

Habits 410

Home surroundings 410

The probable effect on the patient of the knowledge of his lesion . . .411

The effect of digitalis on the patient 411

The relation of prognosis to life insurance 412

Chapter XVI

I. Compensation being still perfect Exercise .

Occupation Habits Marriage .

Clothing .

Baths Food .

Hlnesses .

Use of drugs Change of climate, with special reference to high altitude

CHAPTER XVII THE TREATMENT OF VALVULAR HEART-DISEASE {continued) p^^j

II. Compensation being imperfect 485

Medicinal agents 444

Rest 448

Exercise 454

Resistance exercise ■ . . . . 455

Nauheim baths 464

Diet 470

Clothing, habits, occupation 476

CHAPTER XVIII THE TREATMENT OF VALVULAR HEART-DISEASE (concludecl)

III. Compensation lost 478

The treatment of dropsy 489

Cathartics 492

The use of digitalis 494

Accessory heart tonics 499

Hypnotics 500

Rest 503

Exercise •'502

Baths 503

Receiving visitors 503

Diet 503

SECTIOX III

DISEASES OF THE MYOCARDIUM

FATTY HEART — CARDIAC INADEQUACY OF THE CORPULENT ^^^^^

Pathology 599

Pliysical signs. Inspection 604

Faljxition 604

AxhSCuUation 605

Chapter XXIV

CARDIAC ASTHMA — CHEYNE-STOKES RESPIRATION — BRADYCARDIA — STOKES-ADAMS

DISEASE

I. Cardiac asthma

II. Cheyne-Stokes respiration

Diseases in ichich Cheyne-Stokes hreathing is observed Theories to explain Cheyne-Stokes respiration Prognosis , Treatment

III. Bradycardia .

IV. Stokes-Adams disease Etiology and pathology Symptoms Prognosis .

Treatment

CHAPTER XXV Definition 637

History 637

Pathology and etiology 640

Clinical history and features of an attack 649

Chapter XXVI

SYPHILIS OF THE MYOCARDIUM — NEW GROWTHS IN THE MYOCARDIUM — ATROPHY OF THE HEART — SEGMENTATION AND FRAGMENTATION OF THE MYOCARDIUM

I. Syphilis of the myocardium 663

CONTENTS XV

PAGE

II. New growths in the myocardium 666

III. Atrophy of the heart ' 667

SymjJtoms 668

IV. Segmentation and fragmentation of the myocardium .... 668

CONTENTS XVll

Chapter XXXIII

ACUTE AORTITIS — ACUTE ARTERITIS — SYPHILITIC ARTERITIS — ENDARTERITIS OBLITERANS — PERIARTERITIS NODOSA — STENOSIS OF THE AORTA AND PULMONARY ARTERY" — CONGENITAL SJIALLNESS OF THE ARTERIES

I. ACUTE AORTITIS „.„„

PASE

Inspection 761

II. ACUTE ARTERITIS

Physical signs. Inspection — Palpation 763

III. SY'PHILITIC ARTERITIS

IV. ENDARTERITIS OBLITERANS

V. PERIARTERITIS NODOSA

Syn. : Congenital Aneurysm

XVIU DISEASES OF THE HEART

VI. STENOSIS OF THE AORTA AND PULMONARY ARTERY

Stenosis of the aorta, congenital and acquired 770

Stenosis of the puhnonary artery 772

Prognosis and ti'eatment 773

VII. CONGENITAL SMALLNESS OF THE ARTERIES

CHAPTER XXXIV Pai?i 782

Dyspnoea 783

Cough 784

Expectoratio7i 784

Physical signs. Insjpection 800

Modes and causes of death 808

Appendix

Mechanical devices as aids to determining cardiac disease . . . 815

The X-ray 815

Gaertner's tonometer 826

LIST OF PLATES AND ILLUSTKATIONS

PLATE

I. Anatomical relations of thoracic and abdominal A'iscera . . . . II. Aortic regurgitation with calcified vegetation that swung in blood current, causing atheroma of endocardium and of intima of aorta . III. Exterior of heart of Fig. 42, showing hypertrophy and dilatation of both ventricles

FACING PAGE cxisjis and

Cardiac valve areas, sliowing where sounds are most distinctly heard

Normal deep-seated cardiac dulness

Auscultatory percussion

Hein's palpatory percussion

Ebstein's palpatory percussion

Maguire's palpatory percussion

Normal cardiac cycle

Cardiac valve areas, indicating sounds jproduced at various valves Interior of left ventricle, shoiving fibrous hand connecting aortic

responsible for musical murmur

Heart of a buffalo calf, showing aberrant chordce tendime in left ventricle

Cor villosum of acute plastic pericarditis

Usual location of pericardial friction sound and fremitus

Absolute dulness in case of acute pericarditis ....

Case of pericarditis in which the sac contained 3A pounds of fluid (Bramwell)

Absolute dulness in case of pericarditis with effusion

Rotch's sign of beginning effusion

Pins and Ewart's signs of pericardial effusion .... Apex-beat and area of cardiac dulness in case of pericarditis with effusion The various sites for puncture in paracentesis pericardii . Cardiac dulness and location of border of liver in special cases Verrucose endocarditis of aortic and mitral valves .

Verrucose endocarditis

Malignant verrucose endocarditis of mitral valve

Malignant verrucose endocarditis of aortic valve, with perforation of a cusp

Apex-beat and relative dulness in case of acute endocarditis .

Apex-beat and absolute dulness later in same case .

Apex-beat and relative cardiac dulness ; special case

Area of maximum audibility and transmission of murmur; special

Chart I. Temperature in case of acute endocarditis

Chart II. Temperature in case of acute endocarditis

Diminution of relative cardiac dulness in one week under treatment

Relative dulness in case of chronic endocarditis

Condition of mitral valve causing regurgitation and obstruction

108,

PAGE 4

8, & 10, 11 11 12 14 25

31 33 39

58 63 65

XX DISEASES OF THE HEART

PACK

Diagram showing effects of a mitral leak on the circulation .... 220

Relative dulness in case of mitral insufficiency 227

Apex-beat and relative dulness in mitral regurgitation 230

Sphygmogram, showing irregular pulse in case of mitral regurgitation . . 240

Relative dulness in a typical case of mitral regurgitation .... 241 Point of maximum audibility and area of transmission of mitral regurgitant

murmur 242

Time of mitral regurgitant murmur 243

Interior of left ventricle, showing buttonhole slit 250

Case of mitral stenosis, showing ascites and clubbing of finger-tips . . 258

Sphygmogram, from case of mitral stenosis 260

Location of apex-beat and area of deep-seated dulness in mitral stenosis . 2G0 Rhythm of characteristic murmur of mitral stenosis, "auricular systolic" . 261 Area of audibility of the presystolic murmur of mitral stenosis . . . 262 Rhythm of occasional variety of mitral stenotic murmur through entire ventricular diastole 264

" Interrupted modified presystolic " murmur of mitral stenosis . . . 265 Location of apex and relative dulness in case of mitral stenosis . . . 271 Location of apex and relative dulness in case of mitral stenosis and regurgitation 273

Location of apex and relative dulness in case of mitral stenosis . . . 276

Location of apex and relative dulness in case of aortic regurgitation , . 285

Sphygmogram of aortic regurgitation 299

Sphygmogram of pulsus bisferiens 300

Type of relative dulness in well-compensated aortic regurgitation . . . 302

Type of relative dulness in poorly compensated aortic regurgitation . . 302 Spot of maximum intensity and area of transmission of typical aortic

regurgitant murmur 303

Rhythm of aortic regurgitant murmur 303

Relative dulness in case of aortic regurgitation 311

Skiagram of chest in case of aortic regurgitation 312

Relative dulness and lower border of liver shortly before death . . . 316

Heart of aortic stenosis with adherent cusps and also acute endocarditis . 320

Heart of aortic stenosis showing calcified vegetations in sinuses of Valsalva . 321

Sphygmogram from case of aortic stenosis 329

Sphygmogram of uncomplicated aortic stenosis 336

Typical relative dulness in case of well-comjjensated aortic stenosis . . 336

Rhythm of aortic obstructive murmur 337

Place of maximum intensity and propagation of aortic stenotic murmur . 337

Relative dulness in case of primary tricuspid regurgitation .... 351 Relative dulness in case of tricuspid regurgitation secondary to dilatation of

right ventricle 352

Place of maximum audibility and area of propagation of tricuspid regui'gi-

tant murmur 352

Location of thrill and murmur in a typical case of tricuspid stenosis . . 361 Relative cardiac dulness in typical case of tricuspid stenosis .... 362 Area of deep-seated cardiac dulness in case of pulmonary regurgitation . . 368 Area of maximum intensity and of propagation of murmur in ease of pulmonary regurgitation 369

The rhythm of murmur in typical case of pulmonary regurgitation . . 373

Heart of a boy, showing congenital stenosis of the pulmonary orifice . . 379

LIST OF PLATES AXD ILLUSTRATIONS xxi

PAGE

Relative cardiac dulness in case of pulmonary stenosis 381

Location of thrill and systolic murmur in ease of pulmonary stenosis . . 381

Heart from case of pulmonary stenosis 383

Same heart, left auricle open, showing patent foramen ovale .... 384

Rhythm of typical pulmonary stenotic murmur 387

Resistance exercises 456, 45 T, 460-463

Shape of relative dulness in hypertrophy 543

Heart showing left ventricular hypertrophy 566

Perforate interventricular sreptum 687

Cut showing cyanosis of congenital heart-disease, drum-stick finger-tips,

bulging prjecordia, etc. . 691

Heart showing concentric hypertrophy of left ventricle 699

Sphygmogram case of paroxysmal tachycardia 733

Skiagraph showing aneurysm of the aorta 778

Dilatation of superficial veins secondary to pressure by aneurysm on ven;e

cavae 786

Photograph: aortic aneurysm, showing slight bulging of anterior chest-wall . 788

Cut showing dulness and liver outline in case of aneurysm .... 789

Two figures showing external tumour in case of aortic aneurysm . . . 790

Post-mortem specimen of heart and aneurysmal sac 791

Trachea, from case of rujatured aneurysm, showing point of rupture . . 797

Opposite side of same specimen, showing interior of sac 798

Skiagraph of chest, showing tuberculosis of right apex and tuberculous pericarditis with effusion 817

Sphygmogram of healthy man 819

Sphygmogram of woman during an attack of paroxysmal tachycardia . . 819

From man with recurrent bradycardia 819

From man with acute general gonorrhceal infection 820

From man with declining typhoid fever 820

Hyperdicrotic pulse from woman after twelve hours recurring haemoptysis . 820

From woman with moderate aortic insufficiency well compensated . . 821

Initial high-tension pulse from man with arteriosclerosis 821

Sustained high-tension pulse from woman with chronic interstitial nephritis . 821

From a man with chronic interstitial nephritis 822

From a woman with mild myxcedenia 822

From a man with well-compensated mitral iusufficiency .... 823 From a woman with arteriosclerosis and fairly well-compensated mitral

incompetence 823

From a woman with arteriosclerosis and mitral insufficiency fairly compensated 823

From a man with arteriosclerosis, chronic interstitial nephritis, and mitral

insufficiency, with failing compensation, Cheyne-Stokes respiration . . 824 From a woman with mitral obstruction and regurgitation with failing compensation 824

From a man with mitral regurgitation, lost compensation, relative tricuspid

insufficiency, ascites, etc 824

From a woman with mitral obstruction and insufficiency, lost compensation

and relative incompetence of the tricuspid. Delirium cordis . . . 824

From a boy with acute rheumatism on second day of endocarditis . . 825

From same patient, two years later, with developed aortic stenosis . . 825

Cardiogram from a girl with mitral insufficiency 826

PLATE I

ANATOMICAL RELATIONS OF THORACIC AND ABDOMINAL VISCERA.

GENERAL CONSIDERATIONS PERTAINING TO

THE ANATOMY, PHYSIOLOGY, AND

EXAMINATION OF THE HEART liN" this chapter are presented certain facts which, because of their bearing on the examination and the diseases of the heart, shouki be well understood.

Location of the Heart. — This main organ of circulation is situated in the central and lower part of the thoracic cavitj, resting upon the upper convex surface of the diaphragm (see frontispiece) in such a manner that its long axis forms an angle of sixty degrees with that of the body (Rosenstein). The base of the organ is directed upward, backward, and towards the right side, while its apex points downward, forward, and to the left, so as to strike against the chest-wall in the fifth left intercostal space an inch inside the nipple-line. The larger portion of the heart, therefore, lies to the left of the median line. It is attached at its base to the great vessels and is inclosed by the pericardial sac, which invests it loosely below, being bound to the central tendon of the diaphragm beneath, to the sternum in front, to the mediastinal pleura at each side, and behind to the anterior surface of the oesophagus, trachea, and large Ijronchi. In consequence of the oblique position of the heart, the ^pericardial sac forms a loose fold at the lower right-hand corner, so that when it becomes distended by an effusion the earliest evidence of the fluid is obtained in the fifth right interspace in what is known as the cardio-hepatic angle. Further details on this matter are contained in the chapter on Acute Pericarditis.

1 1

The Relations of the Heart to the Anterior Thoracic Wall are

highly important, and have been the subject of numerous investigations. As it is difficult to fix the heart in position for the purpose of investigation, attempts have been made to accomplish this either by thrusting long needles through the organ immediately after death or by freezing the cadaver, and subsequently sawing it into sections. Consequently the statements of investigators differ somewhat as to the limits of the heart in health, especially the level of its upper border. I shall state the lower of the two levels usually given, therefore, as it seems to me to correspond with what is most often observed clinically.

The sujjerior boundary of the heart lies on a level with the upper border of the third costal cartilages and extends transversely from the third left costo-chondral articulation across the sternum to a point about an inch to the right of the right sternal margin. The right border of the heart, formed by the slightly convex base of the right auricle, extends from the upper edge of the third right costal cartilage, at the point where the superior cardiac boundary ceases, downward in a slightly convex direction as far as the middle of the fifth right interspace, about an inch from the breastbone. Here, curving sharply inward, the inferior border of the organ passes across the base of the xiphoid process on a level with the upper margin of the sixth left costal cartilage at its junction with the sternum and terminates in the fifth left interspace at the site of the apex-beat, an inch inside the nipple-line. The left cardiac border corresponds to a line drawn from the apex-beat upward and somewhat inward to the junction of the third left rib with its cartilage, about 2 inches from the left sternal margin, A diagonal line extending from the junction of the third costal cartilage with the left edge of the sternum downward to the seventh right chondro-sternal articulation, represents the usual position of the auriculo-ventrieular sac'ptum (Broadbent). A line which passes from the inner side of the apex upward through the fifth and fourth to the third left costo-chondral articulation, corresponds as closely as can be with the interventricular sseptum. The somewhat triangular area thus inclosed represents the right ventricle with its broad base forming the lower boundary of the heart, which rests in the sulcus between the anterior chest-wall and the upper surface of the diaphragm. The upper extremity of this triangular area is tilled by the pulmonary artery and the tip of the left auricular appendix as it curves around the outer border of the left ventricle to appear in front to and terminate near the trunk of the great artery. It is obvious, therefore, that only the upper third of the right auricle lies behind the sternum, while its lower two thirds are to the right of this bone. The left auricle is situated behind, being completely invested by the left lung and entirely obscured from view from the front. The same is the case also with the left ventricle, excepting a narrow strip which forms the left border of the heart and is visible anteriorly. It is the inferior extremity of this narrow strip which, propelled against the wall of the thorax, occasions the apex-beat. Consequently it is a portion of the right ventricle only which is exposed to view after removal of the breastbone and adjacent costal cartilages. The remainder of the heart, even that which lies anteriorly, is covered from view by the lungs.

The anterior lung borders are in apposition behind the middle of the sternum from the level of the second to that of the fourth costal cartilages. At this latter situation they diverge, the border of the right lung passing on downward to the level of the fifth right costal cartilage, where it turns off to the right to unite with the inferior margin of the same lung. The anterior margin of the left lung diverges abruptly at the level of the fourth cartilage, passing outward along the lower edge of this cartilage as far as its union with its rib. It then turns downward, and, after curving slightly inward and then outward, unites with the inferior border at the level of the sixth costal cartilage near its point of articulation with its rib. In consequence of this peculiar arrangement of the left lung a portion of the anterior surface of the right ventricle comes into immediate contact with the chest-wall, and, being uncovered l)y lung, forms the area of superficial cardiac dulness. By many this area is considered of great importance in the determination of the size of the heart by percussion, as will be shown in dealing with the subject of cardiac percussion.

Position of the Great Vessels and Valves. — The pulmonary artery lies about half an inch to the left of the breastbone and extends from the level of the centre of the third left interspace upward to the level of the second costal cartilage, where it divides into its two main branches. The position and course of the ascending aorta may be represented by a line drawn from the third left chondro-sternal articulation upward across the breastbone to the junction of the right edge of that bone with the second right costal cartilage, which, therefore, is sometimes spoken of as the aortic cartilage, because at this point the aortic valve-sounds are most distinctly heard. The superior vena cava passes downward along the right cardiac border from the level of the second costal cartilage to a point opposite the middle of the third right intersj^ace.

The four sets of valves are bunched closely together not far from the junction of the third left costal cartilage with the border

of the sternum, the pulmonary being most superficial, the mitral most internal, the tricuspid most inferior, and the aortic the most central. They cannot, V - P therefore, be auscultated in the region ^ if one is individual of their anatomic seat to differentiate their sounds. For this reason we take advantage of the laws governing the conduction of their sounds and auscultate them in certain areas named after the respective valves.

Thus the mitral area is situated at the apex-beat and includes a limited district immediately roundabout. The tricuspid area includes the lower end of the sternum and a portion of the surrounding region. The pulmonic area is located in the second left intercostal space close to the edge of the breastbone, while the aortic area lies in the corresponding situation on the opposite side. It must not be supposed that the valve-sounds and murmurs are heard only in these situations — they are widely propagated and blend with one another, and in particular endocardial murmurs are often so widely conducted as to be distinctly audible in other areas than those to which they properly belong.

Fig. 1. — Cardiac Valve Areas.

Sounds produced at various valves indicated : p, pulmonary ; a, aortic ; t, tricuspid ; m, mitral.

Leaving further consideration of this subject at this time, we now pass on to the discussion of the methods bv which the size of the heart is ascertained during life (Fig. 1).

Cardiac Percussion. — In employing this means of examination we aim to determine, first, the boundaries of the area of superficial dulness, and second, the limits of deep-seated dulness. To accomplish the former, percussion must be made lightly, whereas the latter requires a firm, heavy percussion-stroke.

The area of superficial or absolute cardiac dulness corresponding with the portion of the right ventricle uncovered by lung during inspiration, extends vertically from the upper edge of the fourth left costal cartilage to the sixth, and transversely from the left border of the sternum to a point midway between the parasternal and mamillary lines. As its outer or left boundary is irregular, and, roughly speaking, passes obliquely downward towards the left, this area is broader at its lower than at its upper margin. Enlargement of the heart crowds the lung-borders aside, and hence generally increases the dimensions of superficial dulness, especially to the right in cases of hypertrophy and dilatation of the right ventricle. But a variety of conditions outside of the heart may increase or diminish the extent of superficial dulness, and hence render this not always a trustworthy indication of the actual size of the heart. Thus the lung-borders may be retracted by pleuritic adhesions and expose an abnormally large portion of the right ventricle, or being distended by pulmonary emphysema, they may diminish or entirely obliterate this area.

Consequently it is preferable to rely upon deep rather than superficial percussion in endeavouring to ascertain the size of the heart, since when the limits of deep-seated or relative cardiac dulness are found increased we know it is due to increase in the size of the organ itself. Vierordt objects to this latter method because of its greater difficulty and uncertainty, since pulmonary resonance shades so gradually into the relative dulness overlying the heart that two observers of apparently equal skill may not agree in their results. Doubtless individual judgment depends very largely upon practice and delicacy of hearing, and doubtless emphysema, inelasticity of the ribs, great thickness of the parietes, etc., often make it impossible to accurately determine deep cardiac limits. Xevertheless the cases in which relative dulness is possible of detection are so numerous that I prefer to rely upon it rather than on superficial dulness, and always urge students to make use of this method.

The Deep Boundaries of tlie Heart (Fig. 2). — It is well known that all hearts are not of the same size even in health, the male heart being larger than the female, and that of a child relatively larger than that of an adult. Moreover, the right auricle measures more during diastole than during systole. Consequently measurements cannot be given that are invariable. Yet the following figures taken from Vierordt may be stated as the average. The

adult heart " extends from about 8 or 9 centimetres to the left of the median line (apex of the heart) to about 4 or 5 centimetres to the right of the same, i. e., about one and a half finger-breadths to the right of the right border of the sternum (right auricle)." Busse, who employed Ebstein's palpatory percussion, found the left border of the heart in health never passed outside the mamillary line, while Hornkohl determined the average in adults to be 7.3 centimetres from the left sternal margin.

On the right side the heart ex-

FiG. 2. — Normal Deep-seated Cakuiac

DULNESS.

PP, parasternal line ; MM, mamillary line.

tended a variable distance beyond the sternum, depending on the stature of the man, being 2.0 centimetres for one 130 centimetres tall, and 3.0 centimetres for a male of 190 centimetres in height. In women these figures are slightly less, while in children the area of the heart measures relatively more than in adults. If the median line is taken as the landmark from which to measure, Hornkohl's figures must be increased by 1 to 1.5 centimetre, which, according to Ebstein, is half the width of the sternum. Consequently it is found that Vierordt's and Hornkohl's estimates are not so much at variance as they at first appear.

Three methods of percussion are in use, and mentioned in the

INTRODUCTORY T

order of their popularity are: (1) plessimetric, (2) auscultatory, (3) palpatory percussion. I do not propose to discuss the advantages or disadvantages of employing a pleximeter and hammer, but merely to express my very ^^ositive preference for the use of the fingers, for the reason that thereby one is enabled to obtain valuable information from the sense of resistance.

In ascertaining the area of absolute dulness light strokes are essential, while the reverse is the case as regards deep-seated dulness. Moreover, in outlining the area of relative dulness the pleximeter finger should be pressed firmly against the chest-wall, to exclude so far as possible the vibrations of the bony structures. This is the " abgeddmpfte " percussion of the Germans. The finger is placed firmly at right angle to the ribs at a point well outside the cardiac area, and percussion is made with considerable force at ever decreasing distances from the sternum until a slight rise in pitch and increase of resistance indicate that the airless organ (the heart) has been reached.

In tliis manner one is to percuss from above downward along the left parasternal line, beginning in the first intercostal space and ceasing when the flatness of the liver has been reached. At the sides, percussion is to be performed first in an oblique direction from above downward and inward, and next on a transverse line from without towards the centre. If, wherever comparative dulness is perceived, a mark is made with a dermographic pencil, these marks can subsequently be united, and will then represent the probable limits and shape of deep-seated cardiac dulness. If one prefers he can, instead of placing his finger across the ribs, press it strongly into the intercostal space parallel with the ribs, and if his finger is slender can thus convey his percussion-strokes more directly to the heart without eliciting so much vibration from the elastic structures intervening.

Sansom makes use of a narrow pleximeter, which is of such small size as to fit well down into the intercostal space, and claims remarkably accurate results, more precise indeed than in any other way.

It may be well to here remark that, when in women accurate percussion of the heart is impossible on account of the large size of the mammip, fairly trustworthy information concerning the size of the heart may be gained by careful palpation of the apex-beat. Since the mamillary line is not a trustworthy guide in females, it is better to measure the site of the apex impulse from the mid-sternal line or from the mid-clavicular line, it being in the fifth interspace, an inch within the latter.

Two statements should also* ])e made regarding percussion of the heart in children. In the first place, the area of superficial dulness is said by Hornkohl to be somewhat more extensive than in adults, particularly above, where it is asserted to reach up into the third intercostal space, while its outer margin passes somewhat further beyond the left parasternal line, i. e., to a point a little nearer the mamillary than the parasternal line. In the second place, it is important to bear in mind the great elasticity of the child's chest, and hence to percuss with far more delicacy than is advisable in grown people. Otherwise the note of pulmonary resonance and the vibrations of underlying structures will assuredly prevent accurate and trustworthy results. For these reasons it is far preferable to rely on the other modes of percussion now to be described.