A tabular handbook of auscultation and percussion. For students and physicians

Preface

In the preparation of this little book, I have consulted the works and compared the views of many who have been eminent in the physical exploration of the chest, such as Laennec, Avenbrugger, Corvisart, Piorry, Skoda, Barth and Roger, Walshe, Hope, Stokes, Fuller, Grisolle, Bennett, Latham, Flint, Balfour, Hayden, Ziemssen, Fothergill, and Loomis, and here desire in a general way to acknowledge my indebtedness to them, as it has seemed impossible to do so in the text in each instance.

Since the illustrious Laennec discovered the art of auscultation in 1816, very many investigations have been made and much has been written on the subject. While on the one hand it is perfectly surprising how little the master mind of Laennec left to be done, and how many of his descriptions, classifications, and meanings of sounds still remain unimproved upon in spite of sharp criticism, yet on the other hand, as would naturally be expected, other experimenters since have discovered new facts, and by a wider experience have been able to point out more or less error here and there in the works of the father of auscultation. I have endeavored to give, arranged in tabular form, a condensed summary of the most authentic observations down to the present time.

IV PREFACE.

As to the theories of the mechanism of the production of some of the sounds, there has been a great deal of controversy, in which Skoda with his " consonance " and " tension " and other theories has taken quite a prominent part. Those theories have been given in the following tables which seem most rational and which are at present most generally accepted.

In the nomenclature of the physical signs, care has been taken not to use those terms which merely express somebody's theory of their mode of production. Skoda's " consonating rale," for instance, is a very ill-advised term, as the theory of consonance is far from being universally accepted, and no one who rejects the theory would like to use such a term. Even the common term " mucous rale " has been made to give place to the much more expressive " bubbling rale," which does not imply that it is always caused by mucus, but leaves room for its production sometimes also by pus, serum, softened tubercle, etc.

To avoid confusion, and for the convenience of those who may have become familiar with some particular authority, many of the synonyms have been added in small type in parentheses.

In determining what classification to follow, it has been thought desirable to avoid the excessive and complicated refinements of some authors, without, on the other hand, losing sight of the necessity for sufficient thoroughness.

There has been an effort to make the arrangement of material in the following tables so systematic, that any special point needing investigation can be immediately referred to, without a tedious and laborious

PREFA CE. v

search through many pages and perhaps many volumes. The condensed tabular arrangement will be found especially advantageous also in differential diagnosis, as it brings into such close juxtaposition information which is usually widely scattered, rendering comparison easy, point by point.

Studied in connection with Chapter IV. of Da Costa's excellent work on Diagnosis, with its graphic descriptions and convenient, helpful diagrams, these tables will probably furnish the student with all that is really necessary in the majority of cases coming under observation. If, however, he desires to make a special study of the subject, he is referred to the two large and valuable treatises on the "Diseases of the Respiratory Organs" and "Diseases of the Heart," written by Dr. Austin Flint of New York, who is probably the greatest authority on the physical diagnosis of such diseases in this country, and to whom I desire to acknowledge myself especially indebted. It should be remembered, however, that the pathology of these works is not quite up to date.

It is also hoped that this handbook may be found useful by physicians in active practice. It is hardly to be expected that practitioners who do not make a specialty of lung and heart diseases, even if they have at some time carefully studied into the subject, and have been well posted, can retain in their memories for immediate use at all times every point necessary for a delicate physical diagnosis. If the case be at all obscure, they feel the necessity of consulting some authority. In such emergencies, the busy doctor may appreciate such a time and labor saving contrivance as the present. It often needs only a word here and there to revive memories of extensive reading.

vi PREFACE.

It is very doubtful if at this late day any well educated physician could be found to despise the value of auscultation and percussion as aids to diagnosis. Such a contempt would at once stamp the man who showed it as an ignorant pretender. But there are many who do not feel thoroughly at home in this branch, and on account of too slight practical acquaintance with it, and lack of time or inclination for a laborious research into its theory, prefer to trust for the most part to the symptoms alone rather than to the uncertainties (to them) of physical signs. Here most truly " a little knowledge is a dangerous thing." For if the practitioner, finding jerking respiration, for example, in a given case, knows that jerking respiration is a sign of phthisis, and does not remember that it may be a sign of several other diseases, too, and on the strength of this sign alone diagnosticates the case as phthisis, it would, indeed, be far better for him to have known nothing whatever of auscultation and percussion, and to have been guided entirely by the symptoms. It is such partial knowledge, to say nothing of the utter ignorance of others, that has to some extent brought auscultation and percussion into disrepute in certain places.

It is very desirable to have a proper appreciation of the comparative value of physical signs and symptoms, without enthusiastically overestimating either. He who trusts to symptoms alone for his diagnosis of heart and lung diseases will very, very often be led astray. On the other hand, the mistake may be made in the opposite direction of placing too exclusive reliance on physical signs alone. In fact, they must be taken together and complement eachj)ther. If they

PREFACE. vii

are, and proper attention is paid to the history of each case, and also to its well-known pathological laws, an accurate diagnosis can be made in the great majority of instances.

When speaking of heart diseases, Da Costa says : " A knowledge of the physical signs is the solid foundation, without which any structure that may be reared will soon tumble to pieces."

In fact, the symptoms of heart disease are comparatively insignificant. Quite so much cannot be said of the comparative value of signs and symptoms in lung diseases ; but even here the great importance of the former is attested by the immense strides which have been made in the diagnosis of such affections since the discovery of the present methods of physical exploration, which would have been utterly impossible before.

The plates have been reproduced (with slight alterations), by the " direct transfer " process, from the " Handbuch und Atlas der topographischen Percussion," by Professor Weil of Heidelberg, published

at Leipzig in 1877.

H. C. CLAPP.

Contents

PAGE

INTRODUCTION xi

PART I. Respiration in Health

Vesicular, puerile, senile, and tracheal or laryngeal .... 20

Respiration in Disease. (1.) Abnormal Intensity.

Exaggerated, feeble, and suppressed 22

Respiration in Disease. (2.) Abnormal Rhythm.

Jerking respiration and prolonged expiration 24

Respiration in Disease. (3.) Abnormal Quality and Pitch.

Bronchial, broncho-vesicular, cavernous, and amphoric .... 26

Rales.

I. Tracheal and laryngeal ; dry and moist 30

II. Bronchial ; dry (sonorous and sibilant), and moist (coarse and fine

bubbling and subcrepitant) 30

III. Vesicular ; crepitant 34

IV. Cavernous ; gurgling 34

Morbid Pleural Sounds.

Friction sounds, metallic tinkling, and splashing 36

X CONTENTS.

The Voice in Health.

Tracheal or laryngeal voice and whisper, normal thoracic vocal resonance and fremitus, and normal bronchial whisper .... 40

The Voice in Disease.

Suppressed, diminished, and increased vocal resonance and fremitus, increased bronchial whisper, bronchophony and whispering bronchophony, cavernous whisper, amphoric voice and whisper, pectoriloquy and whispering pectoriloquy, segophony, and metallic tinkiing 42

Percussion Signs.

Normal vesicular resonance, flatness, dullness, and tympanitic, exaggerated, amphoric, and cracked-metal resonance .... 46

PART II. The Physical Diagnosis op Diseases op the Lungs

Acute and chronic pleurisy, empyema, hydrothorax, pulmonary oedema, pneumo-hydrothorax, pneumothorax, emphysema, asthma, bronchitis, capillary bronchitis, plastic bronchitis, croupous pneumonia, catarrhal pneumonia, chronic pneumonia, acute miliary tuberculosis, phthisis, dilatation of bronchi, carcinoma of lung, and intrathoracic tumors, especially aneurism 54

The Physical Diagnosis of Diseases of the Heart.

The healthy heart, pericarditis, endocarditis, hypertrophy of the left and right hearts, dilatation, valvular lesions of the left heart (aortic obstruction and regurgitation, and mitral obstruction and regurgitation), and of the right heart (pulmonic obstruction and regurgitation, and tricuspid obstruction and regurgitation), fatty degeneration, and cardiac neuroses 78