CHAPTER XVHOT (Part 2)

of the pericardial sac there will be symmetrical narrowing or constraint of the subcostal angle during inspiration, if the anterolateral portion of the diaphragm is depressed beyond the eritical point by the enlarged heart or peri- cardium. INSPECTION 27 THE VITAL CAPACITY OF THE LUNGS The Vital Capacity of the Lungs.—The amount of air which can be ex- pired after a forced inspiration varies in normal individuals with sex and height as well as with muscular development. It depends largely upon the latter factor and upon proper breathing. It can therefore be increased, especially in youth, by training. Low values mean simply poor develop- ment and improper breathing, and are of practically no value in the diagnosis of pulmonary lesions such as tuberculosis. In heart disease, however, the pulmonary ‘‘vital capacity”? corresponds more or less to cardiac efficiency. ‘The degree to which it is reduced below the normal standard corresponds closely to the tendency to dyspnea. Thus patients with marked decomposition show values of only 40 per cent. or less of the normal, while patients with well compensated lesions, who have no greater dyspnea on exertion than normal persons yield values of about. 90 per cent. of the normal.* The Type of Breathing.—In men respiration is mainly diaphragmatic, in women, costal. “By study of the living thorax in health and disease we learn—That the dia- phragm is the great means of inspiration: That, in quiet breathing, the chief use.of the intercostal museles is to maintain the position of the ribs (or the expansion of the chest) during the descent of the diaphragm: That, when the descent of the diaphragm is hindered, or when inspiration becomes more laboured than natural, the intercostals contract more strongly, so as to dilate the chest by raising the ribs:’ That, when in- spiration becomes as foreible as possible, other muscles, which act by raising the collar bones and first ribs, come into play, namely, the sternomastoids, sealeni, omohyoids, and upper part of the trapezii: ‘That quiet expiration is due to the cessation of all muscular contraction: That foreed expiration is performed by means of the abdom- inal muscles (especially the recti), the latissimi dorsi, and lower part of the trapesii. ‘Add these corollaries: That the diaphragm and intercostals are antagonist, although they concur to produce one and the same result: That foreed inspiration tells upon the upper chest and true ribs: That forced expiration tells upon the lower chest and false ribs” (Gee). “Whether respiration be mainly costal or mainly abdominal depends on the relative part taken in the act by the ribs and the diaphragm.” The better developed the abdominal muscles are, the more easily can the diaphragm elevate the ribs, and the more “thoracive” the type of respi- ration. It also depends on “the order in which different parts of the body wall come into action. If the wave begins in the abdomen and passes upward, the type is abdominal; if it begins above and passes down, the type is costal” (Hutchison). The types of breathing are often modified by disease; thus the pain of * an acute pleuri tis diminishes expansion especially on the affected side. Peritoneal pain diminishes downward movement of the diaphragm and produces relatively more costal breathing. Phe vital capacity of the lungs is measured by means of the spirometer. Normal values are: Men; Height 15 5 em, 4000 e.c.j from 173.5-182.5 em, 4800 o.0.; 182.5 and above, 5.100 c.c. Women: Height from 15 em., 2825 ec.; from 162-167 em., 3050 c.c.; 167 and above, 3275 cc. (MeClure, ow & Peabody, F. W.: Relation of Vital Capacity of Lungs’ to Clinical Condition of Patients with Heart isease. J. A.M. A., Dec. 8, 1917, Isix, 1954. 28 THK EXAMINATION OF THE LUNGS The Rate of Respiration.—The rate of respiration in adult man is from 16 to 20 per minute. In healthy adults breathing is rhythmic as long as they are unconscious of it. In infants, in whom the function is imperfectly established, it is often irregular. To insure accuracy the patient should never know that we are observing the manner and the fate of his breathing. The respiration and the pulse normally bear the relation of about 1 to 4. Radiogram showing the position of the diaph spiration. Note the effect upon the position a m during expiration and in- shape of the heart. A constantly increased rate of respiration generally indicates disease of the heart or lungs, but discase ‘of the peritoneum and hysteria may also cause rapidit \ decreased respiratory rate occurs in sleep (25 per cent. slower), in obstruction to the air passages and in opium poisoning. Normat Ratio Between AGE, Potse, Inspiration AND TEMPERATCRE Birth to 2 2to5 Stoo 9 to 12 yeurs y ‘years years Adult Pulse rate... . 103 so 76 Respiratory rate. ‘t, 17 sof I 27 : T. 102") Pulse 106 oy. ose Respiratory 4 34 P. 105°! Pulse 161 136 The Subcostal Angle.—By this is meant the angle at which the ribs meet at the ensiform cartilage. It is important in classifying the type of chest with which we have to deal. It is narrow or acute in the long, flat chest; and broad or obtuse in the cylindrical or barrel-shaped thorax (Fig. 13, also p. 26). Local Bulging or Pulsation.—Local prominence of the chest is often due to rachitis in childhood and to spinal curvature. ‘The precordium INSPECTION 29 (that part of the chest which overlies the heart) is often normally promi- nent, although much greater degrees of bulging are seen when the heart is hypertrophied (Fig. 15, 217), especially in children. The most im- portant pathologic prominence is that seen at the base of the heart in aneurism of the aorta (Fig. 16). Occasionally disease of the ribs and empyema cause local swelling. In emaciated subjects pulsation of the subclavian arteries may be visible. Rhythmicity practically indicates that a pulsation is directly connected with the circulatory apparatus. Pulsating empyemata are very rare. —— " ‘ De agicpa 2 60712 owls yee Fic. 13.—Illustrating the angle of the ribs in the barrel-shaped and in the long, flat eh (Fowler and Godlee.) Prominence of the Clavicles——This depends largely upon the shape of the chest. It is marked in thoraces conforming to the “long, flat” type and hence is common in enteroptotic individuals. It is often seen in tuberculosis of the pulmona apices, and when unilateral, may be regarded as an index of the degree to which the subjacent tissues have sunken in or have been retracted (Fig. 30). The Diaphragmatic Shadow.—(Phrenic wave, Litten’s phenomenon) (Fig. 18)—If a moderately thin person, lying on a bed with the chest ex- posed and with the feet pointing directly toward the window, takes slow, deep, “abdominal” inspirations, a shadow will be seen to move down the lateral aspect of the chest wall, between the h and the ninth ribs. This shadow is caused by the fact that during inspiration the diaphragm “eels off” from the inner chest wall and by means of the negative pres- sure thus produced, causes the soft tissues to fall inward. These altera- tions of pressure correspond with in- and expiration and create the im- pression of a shadow moving down the chest wall. By the mobility of the shadow and by the extent of its excursion, we are enabled to deter- mine the degree of diaphragmatic motion and its equality on the two sides of the body (Fig. 18). Local adhesions, a pneumonia, or a pleural effusion would diminish or inhibit the shadow. A subdiaphragmatic abscess would, on the 30 THE EXAMINATION OF THE LUNGS Fic, 14.—Bulging of the left lower chest, which pulsated synchronously with the heart even after aspiration of the pleura, due to an aneurism of the left ventricle. The dotted area represents approximately the degree of pulsating excursion. (Patient of Dr. J. N. Henry.) . Fic. 15.—Bulging of the precordium due to an hypertrophied heart (mitral obstruction) in a boy of 14 years. Note the poor nutrition and underdevelopment often caused by cardiac lesions in childhood INSPECTION Fig, 17,—Deformity of the chest resulti om kypho-scoliosis. mustibe construed with great caution in these cases. (See,Figs, 2 Abnormal}; 31 32 THE EXAMINATION OF THE LUNGS ernie) Fis. 18. of left lang (New York City Hospital). ‘The linear Shadow has been emphasi reproduction of the photographs. L. Full Expiration.—Note the height of the shadow aud the slight concavity of the abdomen corresponding to the respiratory phase, 2. Medium Inspiration. Note the descent of the linear shadow and the slight chansze of contour of abdomen corresponding to the respiratory: phase. 3. Deep Inspiration.—Note the further descent of the linear shadow and the rigid abdomen corresponding to the respiratory pl ‘Although the artist has intensified the shadow in the reproduction, the excursion of the right lung and right side of the diaphragin were <o pronounced in this patient that the dise tance hetween the shadows in the extreme positions of respiration was greater than has been represented. ‘The patient's left lung was practically useless; hence the abnormal extent of the right lung's exeursion. (Sahl! and Potter Diaphragm phenomenon (Litten's sizn), from a patient with fibroid phthisis ed in the INSPECTION 33 other hand, have per se no effect on the excursion. ‘The shadow is seen with difficulty in (1) obese subjects, (2) if there is more than one source of light, (3) if costal breathing is practised. The extent of the normal excursion ranges between 2!4 and 34 inches, depending upon the depth of respiration. The observer md i and patient, or may have the patient between himself and the window. The patient should be told to “breathe with his belly.” Diaphragmatic mobility can, of course, be much more accurately determined by means of the fluoroscope but in the absence of such an apparatus the shadow test may be of considerable diagnostic utility. Unilateral immobility or diminished diaphragmatic excursion generally results from pleurisy. Among 83 cases studied by Pryor 53 showed com- plete immobility, and 17’some restriction of motion, in patients who had previously had pleural effusions. ABNORMAL THORACIC CONFORMATION As a result of disease, the shape of the chest often becomes altered from the average normal type. There are, of course, also congenital tendencies which have their influence, but practically the shape of the chest is due to postnatal influences. Freund and others maintain that Fic. _ 19,—Transverse section of an infant’s chest. 20.—An adult's chest, elliptical in Its shape is cylindrical. shape. thoracic development, is absolutely determined as regards its ultimate form by the rapidity of growth and time of calcification of the first rib. The length of the normal first rib: : . Male Female According to Freund is... 3.8m. 3.1. em. According to Hart is 3.6 em. 3.02 em. In flat-chested (phthisical) individuals it measures from 3 down to 2.2cm. This makes the upper chest much narrower and since the rib is also more sloping, makes the whole antero-posterior thoracic diameter small. ‘The first costo-sternal articulation is frequently ossified. In thoraces having this conformation the pulmonary apices slender and respiratively less mobile. Tt is to these factors that the pre- ion to tuberculosis is supposed to be in part due. Pathologic deformities of the chest may be classified among the fol- lowing types: I. The Rachitic Chest.—The rickety (rachitic) chest (due to unduly soft bones during its development) is typically characterized by (1) beading 3 34 THE EXAMINATION] OF THE LUNGS Fie. 21.—The rachitie chest. Fic, 22.—The funnel-breasted chest. (Compare Fig. 30.) Fic. 24.—Unilateral retraction of the chest due to pulmonary fibrosis, Fre. 2 Fic. 25.—The’emphysematous chest. Fic. « he chest in_ scoliosis. ompare Fig. 33.) (Compare Fig. 17.) INSPECTION BS of the costo-chondral junctions (rachitie ross 2) a transverse fur- row corresponding to the at ichment of the diaphragm (Harrison’s groove), (3) prominence of the sternum (pigeon breast), (Aja longitudinal groove parallel to the sternum extending to the costal margin. During infancy respiration is mainly abdominal, because the thorax is already « cylindrical and admits of but little further outward expansion. The negative intrathoracic pressure oceasioned by the descent of the diaphragm exerts its effects mainly on the lower ribs. The atmospheric pressure causes the most yielding portion of the thorax to cave in (cos Prondral articulations) and thus a depressed groove, parallel to the ation and muscular development. The is the result of a recent blister. Normal chest with excellent confor pigmented area above the left nipp It from normal breathin, ernum is formed. Such deformities w but are much enhanced in case of inspirator tion, which overexpands the upper ch the sternum which results in “ pigeon brea. y unequal in degree on the two sides as the The chest is usually shortened, and the costal angle acute. ionally there may be a depression of the sternum extending from the middle of the gladiolus to the ensiform cartilage (funnel bre trichter brust, pectus excayatum), (Figs. 28 and 30). “Althoug! this deformity is usual: genital, it may be occupational huster brust, cobbler’s brea 36 THE E <AMINATION OF THE LUNGS Fie. 28.—A rachitic deformity of the Fre. 29.—Pigeon breast in a eretinoid chest which produced a very pronounced dwarf, aged 23 years: dextrocardia Fic, 30.—Puunel_ breast due to rachiti Fie. Long, flat chest with inarked in a patient who ultimately developed pu retraction and emaciation, im a case of monary tuberculosis. (Pafient of Dr. Ward — chronic pulmonary. tuberculosis. (Cour Brinton.) (Compare Fig. 32.) tesy of Dr. Fresealn.) INSPECTION 37 to external pressure from tools of trade. A tran: breast is triangular in form (Fig. 21). I. The Long Flat Chest——The flat (phthisinoid, paralytic) chest is commonly met with in pulmonary tuberculosis, and while apparently predisposing to, is often the result of, this disea: It is a chest of dimin- ished capacity and functionation. The thorax is elongated; the normal elliptical shape is flattened (antero-posterior diameter relatively de- creased), the subcostal angle is acute, and the obliquity of the ribs increased. In association we often see ‘faulty posture (stoop shoulders, pot bellies), poor expansion, a long neck with a prominent larynx and the head carried forward. Increased obliquity of the ribs makes the vse section of a pigeon Fic. 32.—Plaster cast of a long flat, and a normal chest. (Houseman.) scapule prominent (winged) and in such cases we speak of the “ptery- goid” or ‘“alar”’ chest, especially if the lateral diameter be small. The clavicles are prominent, the supra- and infraclavicular fosse exaggerated and the interspaces wide. Not infrequently rachitic deformities, and especially unilateral deformities due to pulmonary fibrosis are superadded (Figs. 30, 31, and 32). Ill. The Barrel-shaped Chest——In the emphysematous (barrel- shaped) chest the normal elliptical form tends to become cylindrical (the cylinder has a greater cubic capa ity). The ribs are elevated and everted (position of forced inspiration); as a result of this the costal angle en- larges, the lower ribs ‘fare upward, and the sternum is arched; while Louis’ angle becomes prominent. These changes are bilateral and result from enlarged thoracic con- tents—enlarged lungs, emphysema. If the spine is also involved it becomes bent backward, the shoulders are thrown forward and the back is rounded (Figs. 8, 33, 34 and 35). 38 THE EXAMINATION OF THE LUNGS —Barrel-shaped chest, a case of long-: eating pulmonary emphysema. (Compare Fig. 25.) matous chest with marked kyphosis. (Patient of Dr. Ward Brinton.) Fig. 34.—Emphy INSPECTION 39 This type of chest is the result of prolonged dyspnea—asthma, emphysema—owing to which the accessory muscles of respiration (sterno- mastoids, serrati postici superiores, serrati antici majores, trapezii, rhomboids, levatores scapul#, and the pectoral muscles) hy pertrophy. The neck becomes thick and short, the thorax being drawn upward. Inasmuch as the expiratory muscles are also called upon for increased effort the abdominal muscles, the quadrati lumbori. and serratus anticus major also become enlarged. a Fic. 35.—Contrasted Types. The young man on the left—a case of advanced pulmo- nary tuberculosis—has a long, fat chi ‘The ribs are obliquely placed, the antero-posterior ost nil. The neck is long, the larrnx, elavicles and seapulz prominent. ‘The old man on the right—a case of pulmonary e1 The ribs are horizontal, the spine is arched, the antero-posterior diameter is incre neck is short, the acce: distended. d, the ry muscles of respiration are hypertrophied, the jugular veins are In some cases only the upper part of the chest is involved. The emphysematous chest is in varying degree a normal senile change, it is also seen in individuals whose occupations require habitual stooping, especially if associated with great respiratory demands—laborers, sawyers. The most typical examples occur in sufferers from emphysema especially if associated with asthma. The supraclavicular fosse are full and may actually bulge during expiration (see Figs. 13, 25, 32, 3¢ 40 THE EXAMINATION OF THE LUNGS Mixed Deformities.—Various combinations of the foregoing types may sometimes exist. “Phere may also be unilateral enlargement, depression or bulging. Such changes are usually due to spinal abnormalities, or to pleural and pulmonary fibrosis, Fic. 36.—Chest deformity ting from kypho-scoliosis. (See p. 93.) (Compare Fi e Figs. 17, 26, 34.) ABNORMAL RESPIRATION Dyspnea.— This term is applied to various types of “shortness of breath.” It generally means rapid, labored respiration but is also applied to the slow difficult breathing which occurs when the larynx or the trachea is obstructed. Dyspnea may oecur in isolation, during either phase of respiration, inspiration or expiration, but usually both acts are affeeted It is due to either (1) lack of oxygen, or (2) excess of carbon dioxid in the blood. As a general rule the rate and the depth of respiration bear an inverse ratio toward each other. Recent investigations’ have shown that increased Hydrogen ton con- centration of the blood (excess of CO®) inereases the depth of respiration, without essentially altering its rate, whereas anoremia (Oxygen defi- ciency) produces first, a peculiar periodicity of the respiratory rhythm: and secondly, if anoxemia becomes still more marked, very rapid and shallow breathing. Inspiratory dyspnea without obstruction simply causes _inereased thoracic movement; with obstruction