Diseases of the chest and the principles of physical diagnosis . M Smith: Br. Med. Jour., .Jan. 19, 1918. 17 258 THE EXAMINATION OF CIRCULATORY SYSTEM by the patient himself, l)ut also by the examiner at some distance fromthe patient. A clear cut metalhc click, usually double in rhythm andsynchronous with the heart; often transient and influenced by respira-tion, it is best heard near the cardiac apex. The genesis of this ratherstartling sound has been ascribed to (a) emphysema of the mediastinalconnective tissue or (5) free air in the interstitial connective tissue of thelung. Pericardial Eff
Diseases of the chest and the principles of physical diagnosis . M Smith: Br. Med. Jour., .Jan. 19, 1918. 17 258 THE EXAMINATION OF CIRCULATORY SYSTEM by the patient himself, l)ut also by the examiner at some distance fromthe patient. A clear cut metalhc click, usually double in rhythm andsynchronous with the heart; often transient and influenced by respira-tion, it is best heard near the cardiac apex. The genesis of this ratherstartling sound has been ascribed to (a) emphysema of the mediastinalconnective tissue or (5) free air in the interstitial connective tissue of thelung. Pericardial —Unless the pericardial inflammation is promptlyarrested, the exudate poured out into the pericardial sac increases andbecomes more liquid in character—serum, pus or blood. Such a peri-cardial effusion muffles the heart sounds so that they become feeble oreven inaudible. Under such circumstances the friction sound disappears. Exaggerated breath sounds, scattered rales Muffled breathsounds, distant bron-cho-vesicular breathing small pleural effusion). To and^fro frictionsound,synchronouswith the heart Apex impulse feeble,sounds muffled, adistant systolic mur-mur is heard Fig. 216.—Percussion outlines in case whose heart is depicted in Fig. 215. The heartdulness is very large and merges with that of the liver; it is somewhat pyriform in cardiohepatic angle is obtuse. The abdomen is distended and bulges in the flanks(ascites). The patient suffers from orthopnea—the shoulders are raised and the accessorymuscles of respiration brought into play. The breath sounds were harsh and exaggeratedand associated with crackling rdles (congestion). The scar between the umbilicus andpubis results from paracentesis abdominalis. Such a condition is associated with an increase of heart dulness, whichforms an obtuse cardio-hepatic angle. The inflammation and effusioncause a softening and distention of the pericaidium, which in some casesmay become so large as to simulate a
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