The Chest in Health

CHAPTER I. THE CHEST IN HEALTH. Physical Diagnosis is the art of distinguishing health from disease, and one disease from another by means of the physical signs presented in each case. It approaches nearer to an exact science than any other branch, and may truly be termed the mathematics of medicine. It embraces various methods of examina- tion, including the use of instruments to be hereafter described. The Physical Signs of health,as well as of disease, are those that are to be recognized. by the examiner’s special senses, particularly sight, touch and hearing. There are certain physical signs characteristic of health and others that belong respectively to individual dis- eases. In order to understand the physical signs of disease it is evidently necessary first to know them in health. Then, by the application of principles of well-known physical laws, a logical and correct conclusion may be arrived ea each case, which is more reasonable than 2 PHYSICAL DIAGNOSIS. to attempt to commit isolated facts to memory, only to be forgotten. For the sake of convenience the chest walls are marked out into different regions, the limits of which, though arbitrary, should always be made with due re- gard to the anatomy of the underlying thoracic organs. There are an anterior, posterior, and two lateral regions of the chest, and each of these is subdivided into other regions. Anterior Region.—This is divided into two similar parts, right and left, and a middle part. The right and left parts comprise, each from above down, the following regions: 1, supra-clavicular; 2, elavicwlar; 3, sub-clavicular (infra-clavienlar, supra- mammary); 4, mammary, and 5, sub-mammary (infra- mammary, hypochondriac). The middle part is divided into the, 6, supra-sternal; 7, superior (upper) sternal, and §, inferior (lower) sternal regions. The supra-clavicular region is triangular in shape and is situated above the clavicle. It is bounded below by the upper border of the clavicle, within by the lower portion of the sterno-mastoid muscle, and withont by a line drawn from the inner end of the outer fourth of the clavicle to a point on the sterno-mastoid muscle cor- responding with the upper ring of the trachea. On both sides the apices of the Jungs rise into the neck above the sternal ends of the clavicles, aceording to Gray, about an inch anda half, but in persons with Jong necks as much as two inches; in women rather higher than in men, and on the right side than the left. The clavicular region corresponds to the inner three- fourths of the clavicle. The sub-daviewar region (also called in‘ra-clavien- REGIONS OF THE CHEST. 3 Jar, or supra-mammary) is bounded within by the edge of the sternum (sternal line), without by a line let fall perpendicular from the inner end of the outer fourth of the clavicle, and continuous with the anterior axillary line; above by the lower border of the clavicle, and helow by the upper border of the third costal car and ribs, corresponding exactly with the base of the heart. In order to find the upper border of the third ages + 2. Clavicular; 3. Sub-clavicular; 4, Mammary; superior Sternal; 8. Inferior Sternal Region. Fig. 1.1. Supra-clavicular 5. Sub-mammary; 6. Supra-stei rib, especially in fat people, feel for the horizontal ridge on the sternum that marks the line of union be- tween the manubrium and gladiolus. At this point, on either side, is the articulation of the second costal cartilage with the sternum. Immediately below is the depression between the second and third ribs, or the second intercostal space, the upper border of the third rib, as well as lower border of the second being dis- tinctly felt. The right and left second intercostal 4 PHYSICAL DIAGNOSIS. spaces, called respectively aortic and pulmonary, have special significance in the study of the heart, as we shall see. The sub-clavicular regions are chiefly occu- pied by lung tissue, but the right primitive bronchial tube, le teriorly, and given off higher up, causes important dif- ferences in the physical signs of the two regions, as will be fully described. The study of these two regions in health is of the first importance, the more so as tuber- cular pulmonary consumption usually manifests itself first in one or the other. : The mammary region is bounded above by the wpper border of the third rib, below by the upper bor- der of the sixth rib, within by the edge of the sternum (also called the sternal line), and without by the anterior axillary line which is continuous with the outer boun- ‘ger than the left, more superficially situated an- dary of the region above. The heart is chiefly situated in the left mammary region, the apex-beat correspond- ing to a point between the fifth and sixth ribs, one inch and a half below, and half an inch within the left nipple. Gray and others, however, place it two inches below, and one inch within the left nipple. The super- ficial area of cardiac dullness lies almost wholly within the left mammary region. The right mammary region extends down to the liver, the lower border of the former exactly corresponding with the upper border of the latter. The sub-mammary region (infra-mammary, hypo- chondriac) is bounded above by the upper border of the sixth rib, below by the free margin of the ribs; within it comes almost to a point at the edge of the sternum and without it is bounded by the anterior REGIONS OF THE CHEST. axillary line. The region on the right side is oeeupied. by the right lobe of the liver. On the left side, we Jobe of the liver and the large end of the have the le! stomach. The outer boundary of the region on the left side corresponds to the anterior border of the spleen from the ninth to the eleventh ribs. Between these two regions is the epigastrium. The supra-sternal region lies above the sup mal notch and between the supra-clavicular regions. In it lies the trachea, but by firm pressyre downward with the finger, the patient's head being inclined for- ward, pulsations of the transverse portion of the arch of the aorta may be felt, especially in the case of an- eurism. The superior sternal region (upper sternal) corre- sponds to that portion of the sternum above the line of the upper border of the third ribs. The inferior sternal region (lower sternal) corresponds to that part of the sternum below that line. Posterior Region.—This is divided on each side, from above down, into the, 1, supra-scapular; pu- Jar, and 3, stb-seapular (infra-scapular) regions, and between the scapulee is, 4, the inter-scapular region. The supra-scapular region corresponds to the supra- spinous fossa of the scapula, and is occupied by lung tissue. The scapular region corresponds to the infra-spi- nous fossa of the scapula, and is also occupied by lung tissue. It is much larger than the former, and extends, according to Gray, down to the eighth rib. The inter-seapular region is situated between the scapule on both sides of the spinal column. which di- 6 PHYSICAL DIAGNOSIS. vides it into the inter-seapular regions of the right and left sides. It extends downward to a line drawn hori- zontally from the inferior angle of one scapula to the other. In front and on each side of the spinal column in this region the bronchi enter the lungs, the right bronchus opposite the fourth dorsal vertebra, accord- Fic, 2-1. Supra-scapulur Region; 2. Seapular; 3, Sub-scapular; 4, Tnter-seapular Region, ing to Gray, and left opposite the fifth, about an inch lower. The sub-scapular (infra-scapular) region is bounded above by the lower borders of the scapular and inter- scapular regions, below by the lower border of the twelfth vib, within by the spinal column and outside by the posterior Hary line. ~ REGIONS OF TILE CHE Lateral Regions.—These are divided, right and left, into, 1, the axillary and, 2, sub-axillary (infra-axilary) regions. The axillary region corresponds to the axilla. Tt is bounded below by a line connecting the lower border of the mammary region with the lower border of the scapular region; in front by the anterior axillary 8 PHYSICAL DIAGNOSIS. line and behind by the posterior axillary line. They are both occupied by lung substance. The sub-axillary (infra-axillary) region is bounded. below by the lower border of the twelfth rib, above by the lower border of the axillary region, in front by the anterior axillary line and behind by the posterior axil- lary line. On the right side is the liver, on the left is the spleen and large end of the stomach. A line drawn perpendicularly downward from the middle of the axilla is called the middle axillary line, or simply the axillary line. It is important in connection with aspiration or drainage in case of pleuritic effusion, whatever be the character of the latter. Other lines de- scribed by authors, but less frequently mentioned per- haps, are the mammillary line, drawn perpendicularly through the nipple on either side; the sternal line, cor- responding with either edge of the sternum; the para- sternal line, drawn between and parallel with the two preceding; the scapular line, drawn vertically through the inferior angle of the scapula, and the vertebral ight and left, on each side of the spinal column. The methods adopted in the physical examination of the chest are, principally, inspection, palpation, per- cussion, and auscultation. There are other methods of less importance to be described hereafter. The use of the thermometer, or calormetation, as well as the ex- amination of the sputa, are well-known methods of line, 1 physical examination. I. INSPECTION. Inspection is the act of looking at the patient, and naturally comes first in order. In examining the chest INSPECTION. 9 in health the patient should ordinarily be strippea to the waist in a warm and comfortable room, and should hh other stand in the erect position, the heels near ea and on the same line, the arms being dropped loos by the side. The front of the chest should be inspected first. For this purpose the observer should stand di- rectly in front of the patient and at a convenient dis- tance for inspection. It is rare to find a perfectly in health. The right side me the left, especially in right-handed people with extra development of muscle, as among carpenters and black- smiths. Not infrequently one shoulder is lower than the other owing to occupation, as is sometimes the ease among hod-carriers and tailors; or to previous fracture of the clavicle, or curvature of the spine. Such deviations from the perfect symmetry of the chest may be compatible with perfectly healthy lungs. The apex- beat of the heart may, or may not, be seen, depending a good deal upon the thickness of the chest walls. There is general and even expansion on both sides dur- symmetrical chest even y be a little larger than ing inspiration, forced or quiet, and respiratory move- ments are not usnally more noticeable on one side than on the other. Abdominal respiration is more notice- able in men, superior costal respiration in women. The upper part of a woman's chest expands more on inspi tion than a man’s to allow for child-bearing, the dia- phragm in men being a more powerful and important muscle of respiration than in women. On the other hand, abnormal centres of pulsation, the presence of or flattening of the chest movements on one tumors, abnormal bulging walls, and exaggerated respirator, 10 PHYSICAL DIAGNOSIS. side with diminution of those movements on the other, would indicate disease. ¥ For examination posteriorly the patient may be turned around, but should stand in the same erect posi- tion. Sometimes a slight lateral curvature of the spine may be noticed, owing to the greater traction of the stronger muscles of one side drawing it in that direc- tion. The shoulders may not be on the same level, as already stated. The scapulze should move evenly dur- ing respiration, as a rule, but there are exceptions. In choreic children, for instance, nervous and hysterical women, or those who chance to be in a nervous condi- tion from the abuse of alcohol, tobacco, or the like, to say nothing of impostors who have heard lectures on the subject, we may find very uneven movements of the chest walls, and especially the scapule, though the srgans of respiration be perfectly healthy. The un- even movements due to these causes, however, instead of being uniform, as in disease, usually vary and change from one side to the other. When one side steadily and uniformly expands more than the other to any noticeable extent, it is usually indicative of disease, as we shall see hereafter. In lateral inspection the patient shonld place the hands. on the head. Abnormal bulging or retraction of the sides would indicate disease. But these are ob- served better from the front, or posteriorly, than the side. IL Paupatron. Palpation is the act of feeling, and has reference to the special sense of touch. It is the second step in the PALPATION, ia regular order of examination. It is usually performed by laying the palms of the hands on the patient, but it is sometimes convenient to palpate with the ear in com- bination with auscultation. The palms of the hands, when they are used, should previously be warmed, if necessary, and then laid gen- tly, and lightly, on corresponding parts of the chest walls at the same time. This is usually sufficient, but some prefer to apply the hands alternately, or even to cross them, with or without closing the eyes, so as to make the test in every way, in doubtful cases. It is important that the examiner should stand directly in front of, or behind, the patient, according to circum- stances, in order to perform this act with proper care. For palpating in front, the patient should stand erect, as for inspection. But when palpating posteriorly, the patient should cross the arms in front and gently grasp the left shoulder with the right hand and the right shoulder with the left hand, keeping the elbows close in to the body, which should be bent slightly forward. In this position the scapulee are moved out of the way and the tissues on the back rendered more tense. Vocal Fremitus— What is the object of palpation? Chiefly to ascertain the presence or absence of vocal fremitus, which is the vibration, thrill, or jarring of the chest walls cansed by the sound of the voice. And if present, to know whether it is abnormally increased or diminished. Fremitus, or jarring of the chest walls, may be pro- duced in various ways and is designated accordingly. If produced. by the voice it is called vocal fremitus or voice thrill. From the fact that the chest walls vibrate 12 PHYSICAL DIAGNOSIS. it is sometimes called pectoral thrill. As vocal fremi- tus is the kind of fremitus by far the most commonly observed and referred to, it is often called fremitus simply, without being specified as vocal fremitus. It is more or less generally felt over the whole chest, but more marked on the patient’s right side, as will be presently described at length. Other kinds of fremitus are tussive (or tussile) fremi- tus produced by the cough, and of use perhaps when the voice is much impaired or lost; rhonchal (or rhon- chial) fremitus caused by large rales, or gurgles, and more or less localized at that point; friction fremitus, sometimes felt over a pleuritie friction; and splashing fremitus produced by succussion in case of large cavi- ties containing air and fluid, as in pneumohydrothorax. Besides detecting fremitus we may also, by means of palpation, be enabled to accurately count the number of respirations to the minute, should it be impossi- ble to do this by inspection. For this purpose the hand should be lightly applied to the abdomen in men, or the upper part of the chest in women, for reasons already stated By palpation also we may be enabled to locate the apex-beat of the heart, and ascertain the character, frequency and rhythm of its movements, as well as of the radial pulse. To a very limited extent we may also conjecture the amount of expansion and contraction of the chest walls during respiration, but these are better told by inspection or measurement if necessary. The surface temperature should be noted. sence or absence of the vocal To determine the pr fremitus in any given case by palpation, it is necessary, of course, for the patient to make use of the voice. clap VOLE vm Low PALPATION, 3 For this purpose the patient should pronounce sonie- what londly,the words “one, two, three,” during the act of palpation, and repeat them as often as nece ary. Any short simple phrase would answer the purpose, but these words are as good as any others, and besides they have the sanction of time-honored custom. Some, however, prefer the words, “ninety-nine,” or nine- teen.” The reason for speaking these words, or some simple phrase, is chiefly because they can be repeated over and over again on the me key by any one. This is very important. In ordinary conyer tion on any subject the key, or pitch, of the voice being constantly changed, the fremitus varies accordingly. The lower the pitch of the voice the more marked, as a rule, will be the resulting fremitns. It is important to understand that the normal voeal fremitns is more marked in the right than the left suh- elavicwlar region. In other words there is normal ex- aggerated vocal fremitus in the right sub-clavicular region of the healthy chest. How tant fact to be explained? this very impor- rht Ss mply because the primitive bronchial tube being larger than the left, a larger volume of voice is conveyed into the right lung than the left. The trachea, about four and a half inches in length, extends from the lower part of the lar: 1x on 2 level with the fifth cervical vertebra to opposite the third dorsal, where it divides into the two primitive bronchi, © right and left. The right bronchus, shorter, more hori- zontal, and larger than the left, enters the right lung opposite the fourth dorsal vertebra, just behind the upper border of the second costal cartilage of the right 14 PHYSICAL DIAGNOSIS. side. The left bronchus, longer, more oblique, and. smaller than the right, passes under the arch of the aorta and enters the left lung opposite the fifth dorsal vertebra, one inch lower than the right. Moreover, the septum between the two is to the left of the median line, so that foreign bodies getting into the trachea naturally drop into the right bronchus or main chan- Fic, 4.—Division of the Trachea into the two Primitive Bronchi, showing the Right Bronchus much larger than the Left and giveu off higher up. (Schematic Diagram.) nel. It is reasonable to suppose, therefore, that a larger amount or volume of the voice is conveyed into the right lung, especially the upper part, than the left, and hence more vocal fremitus is obtained on the right side. For the same reason more fremitus is felt posteriorly in the inter-scapular region of the right side, as also slightly more in the right sub-scapular region than the left. There being no lung tissue over the superficial PALPATION, 15 area of cardiac dullness in the left mammary region, and over the liver, in front, below the sixth rib, we do not expect to find much fremitus at those points usu- ally, and then only so much as may be extended there by the chest walls. The normal spleen and kidneys do not perceptibly affect the fremitus. Over the scapule the fremitus is interrupted more or les by the bone which intervenes. The amount of vocal fremitus differs in different healthy individuals, as it depends for its production on certain important factors. These may be embraced chiefly under two heads: (1) the character of the voice and (2) the conditions of the chest walls. In the first place, a loud, low-pitched, harsh voice will, other things equal, cause more yoeal fremitus than a high- pitched esft voice. For this reason men hare more fremitns as a rule than women, and grown people more than children. The b: notes of the large pipes of an organ produce more fremitus, or jarring