CHAPTER XXVIII enttan Heart Disease... 2 2. ce ee 698 (Part 1)

CHAPTER XXVIII enttan Heart Disease... 2 2. ce ee 698 CHAPTER XXIX Awyeina Pecroris .. . 5 ee a ee eu ete a FOB Angina pectoris major, 708; Incipient angina pectoris, 712; Angina peetoris vasomotoria (pseudo-angina), 713. CHAPTER XXX Aorvimis 2... a . ce ee TIE Acute aortitis, 716; Syphilitic aortitis, 718; Chronic aortitis, 721. CHAPTER XXXI ANEURISM OF THE THORACIC AORTA... Le 731 752; Arterio-venous ancurism, 756; Aneurism of ; Rupture of the aorta, 757. Dilatation of the a innominate artery rt PART | THE EXAMINATION OF THE LUNGS By teorce W. Norris, A. B., M.D. CHAPTER I PHYSICAL DIAGNOSIS s in employing our senses—sight, touch, and to determine the condition of the tissues. These are altered in tates. They may become more solid or of fluid or of air than normal, their elas- ticity may be increased or diminished. Again, it may be that organs be- come larger or smaller than normal, or are shifted more or less out of place. Such alterations we can often demonstrate by means of physical signs. The data thus obtained, used in conjunction with a knowledge of the patient’s history, and symptoms, together with a familiarity with the pathology, often permit us to estimate very accurately the nature, charac- ter, location and extent of the disease from which the patient is suffering. “The significance of morbid signs relates immediately not to diseases, but to the physical conditions incident thereto. Signs are not directly diag- nostic of particular diseases” (Flint). The methods employed in physical diagnosis are: inspection, palpation, percussion, and auscultation. These methods are frequently combined with mechanical, chemical, electrical, microscopic and bacteriologie examination, as well as with the data obtained by means of the X . Physical diagnosis con: hearin; character by many pathologic less, may contain more or le: INSPECTION Although seemingly the most obvious, the simplest and the easiest of the four methods mentioned, accurate, useful and skilled inspection is in reality often the most difficult to acquire and the last in which the practitioner becomes proficient. It is in this method especially that the seasoned physician far excels his younger confrére. This i part due to carelessness on the part of the younger man, but is perhaps even more due to the fact that the senior has become accustomed to make note of many items at a glance, and also that he has learned not only what to look for, but where to look for it, and how to read the facts which are presented before his eyes. He has acquired the faculty of seeing with the mind as well as with the eye. ‘We can only see what we have learned to see.” Corrigan’s rema: ill as apt as the day it was uttered: “The trouble with most doctors isn’t so much that they don’t know enough, as it is that they don’t see enough!’ We feel 2 17 18 THE EXAMINATION OF THE LUNGS Fis. Clubbing of the fingers due to congenital heart disease. I. 2.—Radiogram of the fingers depicted in Fig. 1, showing not only hypertrophic sues, but also new bone formation in the distal pha (pulmonary Tt f 'y hypertrophic osteo- stage of the Fic. changes in the soft ti osteo-arthropathy). “Simple clubbing of the fingers and seconds arthropathy should he considered as identical, the former representing an ea latter.” (HE. A. Locke.) INSPECTION 19 that we cannot over-emphasize the importance of careful, intelligent inspection. The Examination of the Lungs.—For the purposes of examination, the body, especially the chest and abdomen, must be stripped. The light should be good. Its source, as to whether it falls directly, obliquely or vertically, upon the patient, must often be varied. Many physiologic and pathologic conditions can be seen only with oblique illumination. It is therefore desirable to have the patient first face the window, later turn his side toward it. In the latter position most of the shadows become intensified. The following points are especially to be noted: GENERAL INSPECTION General appearance, posture, gait, facial expression, nutrition, color. Absolute symmet unknown. As a general rule the right side of the body better developed than the left. The right chest is about 3 Fic. 3.—Pulmonary osteo-arthropathy of the hands and forearms in a ease of sarcoma of the lung. 114 inches larger in cireumference than the left. The spine curves to- ward the right, the right arm is longer and the corresponding shoulder is often narrower and lower, There are, of course, well-marked dif- ferences which depend upon: (a) Sex: These involve the hones, the pelvis, the genitalia, the panniculus adiposus, etc. (b) Age: Tn the child, ‘the ribs are more horizontal, the heart and liver larger, the lungs 20 THE E> AMINATION OF THE LUNGS smaller, the thymus is present, the bones are more cartilaginous (see p. 136). The Skin.—(a) The color (pallor, cyanosis, jaundice, pigmentation, mottling, ete.); (b) the character (texture, moisture, edema, eruptions, gloss, subcutaneous fat, wasting, distended blood-vessels). The Muscles.—Development, wasting, tremo: ymmetry. The Face.—Intelligence, expression, symmet: spas edema, myxedema. The Hair.—Dryne: coloration. The Eyes.—Prominence of the eyeballs metry, equality, reaction to light, etc.), conjunctiva (color, eechymo: discharges), cornea (transparency, arcus senilis, leacoma) The Mouth.—Teeth, gums, tongue, pharyr herpes, ulcerations, moisture, deposits, drooping, rhagades). The Ears.—Shape, dis cars. The Nose.—Discharges, obstruction, motion of the nostrils (dyspnea), dilated venules. The Neck.—Pulsations—arterial and venous, swelling—adenitis, thyroidal enlargement, sears. The Hands.—Cyanosis, curved or ridged nails, clubbed fingers, joints, deposits (tophi, Heberden’s nodes), shape, symmetry, nutrition, capillary pulse (Figs. 1, 2, 3, 310, 311, 312). The Abdomen.—Shape, distention, varico edema, eruptions. The Legs and Feet—LEdema, clubbing of the toes, deformities, vari- cosities, cyanosis, scars, pigmentation. paralysis, sparsity, distribution, ¢ parasites, local di the pupils (size, color S, lips (cyanosis, ities, asymmetry, pulsation, INSPECTION OF THE CHEST This method of physical examination is too frequently omitted, or made so hastily and cursorily that little or no information is obtained. Inspection, properly done, yields more valuable information than any other procedure at our disposal, with the exception of auscultation; and furthermore, it has this to commend it, namely, that no special training is required, and the beginner, providing he is taught to use his eyes in- telligently, is as capable of seeing defects as the experienced ceed This is in marked contrast to the training necessary to educate the ear to differentiate sounds, particularly those produced by percussion, the latter method often requiring years of practice. Inspection, on the other hand, requires no special technique; the only requirement is that one should keep in mind constantly that every abnormality, however slight it may appear, ts worthy of consideration. One who has been taught to make a proper inspection can, in many instances, come to a faitly definite conclusion from this procedure alone. Since inspection requires no special training, it ticularly valuable to the student, and to those who see chest ca: eidentally, and not constantly In order that inspection should yield the best results, it is absolutely essential that the patient be séripped lo the “The unpleasant- ness and inconvenience to a patient of undressing for this purpose, the time occupied in so doing, the trouble it gives, and a sense of delicacy in INSPECTION , cles Laennec xamination of a chest which has not been exposed is in the vast majority of instances worse than no ex- females” are no longer to be considered the serious obst believed them to be. An entirel amination at all. In regard to women it ean be safely asserted that no difficulty will be encountered if the importance of the procedure is e3 plained and they are not unnecessarily exposed. For some years we have used the following method. A piece of linen or fine muslin a yard square is slit from one corner to the center and the free edges hemmed (see Figs. 4 and 5). This is thrown over the shoulders. In examining the anterior aspect of the chest the cape is loosened over the shoulders. When the area below the breasts is examined the cape still affords pro- tection. In examining the back the cape may be pushed up exposing Fics. 4 axp 5.—The examining cape in use. the entire back as no objection is ever offered to this. s the capes are inexpensive a number can be kept on hand and a fresh one used for each patient. It must be borne in mind that a patient stripped to the waist should not be subjected to the discomfort of a cold examining room. The next requisite is that the patient shall be so placed that the light falls directly on the parts under inspection. In comparing the two sides of the chest, the illumination must not come from one side as errors nay occur if one-half of the chest is less well lighted than the other. The chest should be inspected not only from the anterior and posterior aspects but also in profile; the latter method is of value in estimating the depth of the chest and also in determining the presence or absence of pulsation. In addition the chest should be inspected from above downward. This is done by the examiner standing behind the patient and looking down over the shoulders. The Posture of the Patient—As to the posture of the patient, the sitting position is the one of choice. The patient should be instructed to 22 THE MIN, ION OF THE LU me a natural posture and not, on the one hand, to sit too rigidly, or, on the other, to assume aslouching position. The standing position may It is not as convenient and if the tiring both for the patient and the examination takes much time examiner. nspection of the chest in patients who are confined to bed and acutely s in those who can sit or stand up. Further. more, only the anterior aspect of the chest, as a rule, is available for the method. Another diffic ulty is that in private houses the light frequently ‘om one side only, so that half of the che: in a shadow which y interferes with a good view. In very ill patients this method ] examination, in common with the other procedures, suffers from a lack of thoroughness which is often unavoidable. If the exami- nation of the patient in the recumbent attitude is unavoidable, care ANT. AXIbbe be Fic. 6.—The topography divided into certain regions which ly. For purposes of description the chest is shown in this and in the following figure. should be taken to see that the body rests on an even plane; otherwise the results may be affected very materially (see p. 196). To fix a standard of what constitutes a normal chest which shall serve as a criterion by which to estimate either the existence of or the degree, of abnormal variations, is not possible. Individuals entirely free from thoracic disease present the greatest variations in the conforma- tion of their chests. The Conformation of the Normal Chest.—Providing that the chest does not present some one of the recognized deformities, it is assumed to be normal if it is symmetrical, not only generally but in its different parts. The shoulders should be on the same level and the line from the neck to the point of the shoulder slightly conv Tn men the clavicles are usually more or less prominent and the supraclavicular spaces a little depressed. In women the clavicles are not uncommonly hidden by adipose tissue and there are no depressions above the clavicles. Beneath the clavicles the chest wall is slightly convex. The intercostal spaces are INSPECTION 23 rface unless the individual is well covered with fat. Owing to the progressively increasing obliquity of the ribs from behind forward the inte interspaces are broader in front than behind. In the majority of individuals a projection of the sternum is visible at the level of the second costal caertil This projection or angle is of variable degree and is formed by the articulation of the upper and middle portions of the sternum. It is known as the Angulus Sterni or Angle of Louis. In ain thoracic conditions, particularly emphysema, the bulging forward of the upper ribs tends to accentuate this angle. The lower part of the sternum just above the ensiform cartilage is normally slightly depressed. Viewed from behind the angles of the seapula should be on the same level (corresponding to the spine of the eighth dorsal vertebra) and closely approximated to the chest wall. slightly below the 7.—The topography of the chest posteriorly. The spine should be straight and slightly concave from above down- ward, Slight deviations of the spine are not uncommon, however, and may or may not be an indication of thoracic disease. They are frequently due to faulty posture. The points especially to be noted in inspecting the thorax are: the size and development, the contour and s the mobility or degree of expansion, the type of breathing, the rate of respiration, the degree of the subcostal angle, local bulging or pulsation, and the prominence of the clavicles. The Size of the Chest.—The development of the chest depends to a considerable degree upon the general health and activity of the individual. Hence, large, deep, well-muscled thoraces are found in robust, physically active men, Small flat chests are seen as the result of early dis sitating long periods spent in bed; rachitis, and nasal obstruction (ade- 24 THE EXAMINATION OF THE LU noids) are also common causes. Lack of thoracic development or chest deformity in early life is chiefly due to these cau In adult life abnor- malities generally result from tuberculosis, pleur that the two sides of the chest be compared with eac! other. There is of course no absolute normal standard, but merely a variable range of the normal. Disease of the chest is so frequently unilateral that by choosing the “better” side we are enabled to estimate a given individual’s normal. Asymmetry of the tho: is often due to abnormal curvature of the spine—scoliosis, kyphosis, lordosis—which, when present to a marked degree, often renders examination by auscultation and percussion very difficult (Figs. 17 and : At birth the chest is ey lindrieal (Fi ig. 19); this form gradually develops, beginning at the second year, into the elliptic shape of adult life (Fig. 20), Fig. 8.—Position of the bony thorax during inspiration and expiration. (fter Barth.) to revert again during old age to more or less the circular contour of childhood (Figs. 25 and 33). The exact contour can be accurately deter- mined by means of the cyrtometer—a band of lead, hinged in the middle, which is firmly applied and moulded to the chest, the contour of which it afterward maintains. The Mobility of the Chest.—Chest expansion, the difference in cir- cumference between forced inspiration and expiration is in normal men, about 2 inches. Much greater degrees of mobility are found in indi- viduals accustomed to severe physical exercise. C hest expansion can be greatly developed during adolescence by practice; it is medically of minor importance (Fig. 8). Inequality of expansion has great significance. The main point to be determined is whether both sides of the chest expand equally. The most, important cause of unilateral diminished or delayed expansion is tuber- culosis of the lungs or pleura, but such a condition also results from one- INSPECTION 25 sided pneumonia, pleural effusion or pleuritis (pain), pneumothorax, ete. The last two conditions may also alter the shape of the intercostal space. In chronic cases, inequality is generally due to local adhesions and con- tractions of the subjacent tissues. Unequal expansion may rarely be due to rachitis, hemiplegia, and muscular atrophy. Diminution or delay of apical expansion can be best detected by standing behind the seated patient and looking downward over his shoulders. Fie. 9.—Cross section of the right lung showing the direction of expansion, (Keith.) Fic, 10.—Rizht lung from the side showing the d sion. (Keith.) The spirometer is an instrument for gauging the capa by noting the amount of air the patient can blow into individuals the measure of lung capacity development, provided that the patient br conclusions may be drawn from spirometer r tion be given to the method of breathing. Ca y of the lung In normal varies directly with muscular thes properly, but crroncous adings unless special atten- ities of 190 c.e. (9 cubic 26 THE EXAMINATION OF THE inches) and possibly less are consistent with normal lungs. Low values obtained by either the spirometer or by the degree of chest expansion merely indicate poor development or improper breathing. In suspected pulmonary disease very little if any additional aid in diagnosis can be thus obtained. 11.—Vertical section of the right lung showing the direction of expansion. (Keith.) The Type of Breathing.—In men respiration is mainly diaphragmatic, in women, costal. “By study of the living thor: phragm is the great e we learn—That, the dia- means of inspiration: That, in quiet breathing, the chief use of the intercostal m s is to maintain the position of the ribs (or the expansion of the chest) during the descent of the diaphragm: That, when the di nt of the diaphragm hindered, or when inspiration becomes more laboured than natur: , the intercostals contract more ¢ the chest by raising the ribs: That, when in- spiration becomes as ple as possible, other muscles, which act by raising’ the collar bones and first ribs, come into pl ely, the sternomastoids, sealeni, omohyoi and upper part of, the e trape That quiet expiration is due to the cessation of all at forced expiration is performed by means of the abdom- rect imi dorsi, and lower part of the trapezii. f and inte Is are antagonist, although they coneur to produdé one and the sane eresult:’ “That foreed inspiration tells upon the upper chest and true ribs: That forced expiration tells upon the lower chest. and false ribs” (Gee). in health and dis Whether respiration be mainly costal or mainly abdominal depends on the relative part taken in the