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THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF Dr. Emil Bogen •te-. o* % LESSONS IN PHYSICAL DIAGNOSIS. BY ALFRED L. LOOMIS, M.D., PB0FZ8S0B OF THE INSTlTnTES AND PRACTICE OF MEDICINE IN THE MEDICAL DI- PAETMENT OF THE UNTVXRSITT OF NEW YORK ; PHYSICIAN TO BELLEVDE AND OUAEITT HOSPITALS, ETC. NEW YORK : ROBERT M. DE WITT, PUBLISHER, NO. 13 FEANKFOKT STREET. Entered, according to Act of Congress, in the year 1868, hj ROBERT M. DE WITT, In the Clerk's Office of the District Court of the United States for the Southern District of New York. Electrotyped by Printed by Smith <fc MoDouoal, The New York Pbintinq Co., 82 & 84 Beekman St. 81, 83 & 85 Center St. m PREFAC E In compliance with the request frequently made by members of my classes in Physical Diagnosis to furnish them a guide in the practice of this art, I have pre- pared the following lessons. Had I attempted originality on such a subject, I should have committed error. My sole object has been to collect into a plain and comprehensive compend the results of the research of many inquirers. A. L. L. 249 West 23d St., New Yoek, May, 1868. CONTENTS. LESSON I PHY OF THE WaL Contents op the Vakious Regions 9 Introduction. — Topography of the "Walls of the Chest. LESSON II. Inspection, Palpation, Mensuration, and Succussion 16 LESSON III. Percussion 23 LESSON lY. Auscultation 33 LESSON V. Abnormal or Adventitious Sounds 43 LESSON VI. Auscultation of the Voice 50 LESSON VII. A Synopsis op Physical Signs in the Diagnosis op Pulmonary Diseases '^^ LESSON VIII. A Synopsis op Physical Signs ln the Diagnosis op Pulmonary G4 Diseases — Continued "^ Vi CONTENTS. LESSON IX. PAGS Topography op the Heakt and Aorta — PHYsiOLOGicAii Action OF THE Heart 79 LESSON X. Methods op Cardiac Physical Examination 87 LESSON XI. Abnormal Sounds op the Heart 95 LESSON XII. Synopsis op the Physical Signs of Pericarditis. — Hypertrophy, Dilatation, and Fatty Pegener.vtion of Heart, and Aneurisms of Thoracic Aorta 109 LESSON XIII. Introduction. — Topography op the Abdomen. — Contents of the Various Regions.— Abdominal Inspection, Palpation, Per- cussion, and Auscultation. — Diseased Conditions of the Peritoneum 119 LESSON XIV. Physical Signs op the Abnormal Changes in the Different Abdominal Organs. — Stomach. — Intestines. — Liter. — Spleen 128 LESSON XY. Physical Signs op the Abnormal Changes in the Different Abdominal Organs — Continued . . 143 LUNGS, LESSON I. Introduciion,—Topoffrap/iy of t?ie Walls of the Chest. -~ Contents of the Various Heffions, Gentlemen • Physical Diagnosis is a term used to designate those methods which are employed for detecting disease during life, by the anatomical changes which it has produced. The nature and extent of such changes can be recognized and ap- preciated by the deviations which they cause in the affected organs from the known physical condition of these organs when in health. The significance of physical signs in disease can be determined, not by theory, but only through clinical observation confirmed by examinations after death. There are six methods of ehciting these physical signs, termed "physical methods of diagnosis;" viz., Inspection, Palpation, 3Iensuration, Succussion, Percussion, and Auscultation. The most important of these are Auscultation and Percussion. The other methods are only subsidiary to these two, and can seldom be regarded as furnishing positive evidence of disease. For a complete and accurate physical exploration, you must sometimes employ all these different methods, and with all, therefore, you should become familiar. In order to localize physical signs, the chest has been divided into artificial regions, but as the limits of these regions are arbitrary, the boundaries adopted by different writers vary. The following divisions, which correspond very nearly to those proposed by many authorities, you will find, I think, sufficiently small and well-defined for practical pur- 10 PHYSICAL DIAGNOSIS. poses. It is important that you should be famihar, not only with the boundaries of these regions, but with the relative position of the structures and organs or portions of organs included within them. The surface of the chest may be divided into three general regions, — Anterior, Posterior, and Lateral The Anterior re- gion, on either side, may be subdivided into Supra-Clavi- cular, Clavicular, Infra-Clavicidar, Mammarij, and Infra-Mam- manj. Between these two regions we have the Supra-Sternal, Superior Sternal, and the Inferior Sternal. The Posterior region, on either side, may be subdivided into the Siiperior Scapular, Scapular, and Inferior Scapular. Between these you have the Inter- Scapular. The Lateral region, on either side, may be subdivided into Axillary, and Infra-Axillary regions. The Supra-Clavicular region is a triangle whose base cor- responds to the trachea, lower side to the clavicle, upper side to a line drawn from the outer thhd of the clavicle to the upper rings of the trachea. This region contains, on either side, the apex of the lung, with portions of the subclavian and carotid arteries, and the subclavian and jugular veins. The Clavicular space is that which lies behind the inner three-fifths of the clavicle, and has the bone for its boundary. It is occupied on both sides by lung tissue ; on the right side, at its outer extremity, lies the subclavian artery : at the stemo-clavicular articulation, the arteria innominata. On the left side, almost at right angles with the bone, and deeply seated, are the carotid and subclavian arteries. Tlie Infra-Clavicular region has for its boundaries, the clavicle above, the lower border of the third rib below, the edge of the sternum inside, and outside a line falling verti- cally from the junction of the middle and outer third of the clavicle. Within these hmits, on both sides, you will find the superior lobe of the lung and the main bronchi ; the right bronchus Hes behind, and the left a little below the second MAMMARY REGION. 11 costal cartilage. On the right side, close to the sternal border of the region, He the superior cava and a portion of the arch of the aorta ; on the left, a portion of the pulmonary artery. The aorta and pulmonary artery are immediately behind the second sterno-costal articulation ; the one on the right, the Fig.l. The Anterior Region, the Boundaries of its Subdivisions, and the Organs Corresponding to these Subdivisions. other on the left side of the sternum. On the left side the lower boundary of the region very nearly corresponds to the base of the heart. The Mammary region is bounded above by the third rib ; below by the inferior margin of the sixth rib ; inside by the edge of the sternum ; and outside by a vertical line, continu- 12 PHYSICAL DIAGNOSIS. OU3 ■with the outer border of the infra-clavicular region. Tou will find this region to differ materially in its contents on the two sides. On the right side the lung is found extending in front, down to the sixth rib, where its thin, sharp border very nearly corresponds to the lower boundary of the region. The right wing of the diaphragm, though not attached higher than the seventh rib, is usually pushed up by the liver as high as the fourth interspace ; a portion of the right auricle of the heart, and the superior angle of the right ventricle, lie close to the sternum, between the third and fifth ribs. On the left side, the lung is in front as far as the fourth stemo-costal articulation, where its anterior border passes outwards, until it reaches the fifth rib (leaving an open space for the heart) ; then it crosses forwards and downwards as far as the sixth rib ; a small portion of the apex of the right ventricle is also found within this region. The Infra-Mammary region is bounded above by the sixth rib ; below by a curved line corresponding to the edges of the false ribs ; inside by the inferior portion of the ster- num ; and outside by the continuation of the outer boundary of the mammary region. This region contains, on the right side, the liver, with a portion of the lung in front, on a full iQspiration. On the left, lying in front, near the median hne, you have a portion of the left lobe of the lung, the stomach, and the anterior border of the spleen. The stomach and spleen usually rise to a level with the sixth rib. The Supra-Sternal region is the space which lies immedi- ately above the notch of the sternum, and is bounded on either side by the stemo-mastoid muscle. It is occupied chiefly by the trachea, by the arteria innominata at its lower right angle, and by the arch of the aorta, which sometimes reaches to its lower border, where, on firm downward pressure with the end of the finger, you will often be able to feel it. The Upper Sternal region is the space bounded by that INFEA-SCAPULAR REGION. jo portion of the sternum which Hes above the lower margin of the third rib. In this region the lung hes in front ; immedi- ately behind it are the ascending and transverse portions of the aorta, and the pulmonary artery from its origin to its bifurcation. The pulmonary valves are situated close to the left edge of the sternum, on a level with the lower margin of the third rib. The aortic valves are about half an inch lower down, and midway between the median line and the left edge of the sternum. The trachea bifurcates on a level with the second ribs. The Lo-wer Sternal region corresponds to that portion of the sternum which lies below the lower margin of the third rib. Throughout the whole extent of this region on the right side, the lung is in front ; it also extends down on the left side as far as the fourth stemo-costal articulation ; below this lies the greater part of the right ventricle, and a small portion of the left. The mitral valves are situated close to the left edge of the sternum, on a level with the fourth rib ; the tricuspid valve is nearer the median hue, and is more superficial ; infe- riorly is the attachment of the heart to the diaphragm ; be- low this is a smaU portion of the Uver, and sometimes of the stomach. The Supra-Scapular and Scapular regions together oc- cupy the space from the second to the seventh rib, and are identical in their outhnes with the upper and lower fossae of the scapula. These regions are occupied by lung substance. The Infra-Scapular region is boimded above by the infe- rior angle of the scapula and the seventh dorsal vertebra ; below, by the twelfth rib ; outside, by the posterior border of the lower axillary region; and inside by the spinous jDro- cesses of the vertebrae. Immediately underneath the sur- face, as far as the eleventh rib, this region is occupied by the lungs. On the right side the liver extends downwards beyond the level of the eleventh rib ; on the left, the intestine occu- u PHYSICAL DIAGNOSIS. Fig. 2. The Posterior Jtegion, the Boundaries of its Subdivisions, and the Organs Corresponding to these Subdivisions.— After Sibson. INFRA-AXILLARY REGION. ng pies the inner part of tliis region, and the spleen the outer. Close to the spine, on each side,— more on the left than on the right,— a small portion of the kidney is found ; along the left side of the spine runs the descending aorta. The Inter-Scapular region is the space between the inner margin of the scapula and the spines of the dorsal vertebrge, from the second to the sixth. This region contains, on both sides, lung substance, the main bronchi, and the bronchial glands. It also encloses on the left side the oesophagus, and from the upper part of the fourth dorsal vertebra do^vnwards, the descending aorta. The bifurcation of the trachea will be found opposite the third dorsal vertebra. The Axillary region has for its limits, the axilla, above ; below, a line carried backwards from the lower boundary of the mammary region to the inferior angle of the scapula ; in front, the outer margin of the infra-clavicular and mammary regions ; and behind, the external edge of the scapula. This region corresponds to the upper lobes of the lungs, with the main bronchi deeply seated. The Infra-Axillary region is bounded above by the axil- lary region ; anteriorly, by the infi-a-mammary ; posteriorly, by the infra-scapular ; and below by the edges of the false ribs. This region contains, on both sides, the lower edge of the lung sloping downwards and backwards. On the right Bide is the liver, and on the left the stomach and spleen. LESSON II. Inspection, Palpation, Me7isuration, and Succussion. Inspection is the ocular examination of tlie external sur- face. Though usually secondary in importance to Ausculta- tion and Percussion, it should not be lightly regarded, for it often furnishes you much information respecting the condition of the thoracic and abdominal viscera. By Inspection you recognize changes in the size, form, or symmetry of these cavities, and in the movements of their walls during respira- tion, as regards their rhythm, frequency, or force. As students of anatomy you are familiar with the form of a well-proportioned chest ; a description of it is therefore un- necessary ; suffice it to say, that in a normal state the two sides are symmetrical in every part : the intercostal spaces are more or less distinct, according as the individual is more or less fat. In quiet respiration, you will notice the abdomen rise with inspiration, and fall with expiration ; at the same time you wiU observe a lateral expansion of the lower ribs, and a slight upward movement of the upper part of the chest with inspiration, and a downward movement with expi- ration. The movements of respiration in these three situa- tions are called, respectively, abdominal, inferior costal, and superior costal hreatldng. In the female, the superior costal breathing is most marked. In the male, the inferior and abdominal. Considerable alterations in the form and movements of the chest are compatible with a healthy condition of the thoracic INSPECTION. 17 viscera. You rarely meet with a perfectly symmetrical chest, even among the healthy. In my examination of 1,500 per- sons, I found only one well-proportioned, symmetrical chest in seven. As you can easily recognize these healthy deviations from symmetry, I shall not enter into details concerning them. I would however mention that sUght curvatures of the spine, either acquired or the result of former disease of the verte- brae, cause the majority of these deviations. We will first consider only those changes in the size, form, and movements of the thoracic cavity which are the result of disease of the thoracic organs ; confining ourselves at present to the lungs and pleurce. The readiest way of presenting these changes to you, it seems to me, is to consider them as they occur in the different thoracic affections. First, we will consider the signs obtained by inspection in pleurisy ; in the first stage, prior to the occurrence of much hquid effusion, there is no apparent change in the size, but the movements of the af- fected side are diminished, and those of the healthy are in- creased ; you have what is termed a catching respiration. This sign is not distinctive of pleurisy : it is present in intercostal neuralgia, and in pleurodynia. In the stage of fluid effusion, if the liquid is sufficient to compress the lung and dilate the tho- racic walls, the affected side will be increased in size, and in pro- portion to the dilatation its movements are restricted or ar- rested. If the cavity is completely filled with fluid, there wiU be bulging and widening of the intercostal spaces, with more or less displacement of the adjacent viscera. As the fluid is re- absorbed the lung expands, but not to the same volume it had before. It remains more or less contracted, and the conse- quence is, retraction of the affected side from atmospheric pres- sure. Generally, if the fluid effusion shall have existed a length of time previous to absorption, the subsequent reti-action is marked, and you can determine at once by inspection, that pleurisy has existed at some period more or less remote. 13 PHYSICAL DIAGNOSIS. In Pulmonary Emphysema, if it is a well-marked case, on inspection you will notice a dilatation of the upper portion of the chest, while its whole aspect appears more rounded than in health, so that it has received the name " barrel-shaped " chest ; the shoulders are elevated and brought forward, the movements in respiration are limited to the lower portions of the chest and to the abdomen. On inspiration, there is no outward expansive movement of the ribs ; the sternum and ribs seem to move up and down as if they were composed of one sohd piece ; in some cases of long standing you will have actual falling in instead of expansion of lower ribs during inspiration. In a well-marked case of emphysema, inspection is quite sufficient for a diagnosis, but where the lungs are but slightly emphysematous, inspection furnishes no positive in- formation. In pneumonia, the only sign furnished by inspec- tion is that the movements of the affected side are restrained as in the first stage of jpleurisy. In phthisis pulmonalis, in- spection furnishes you important information. Depression in the infra-clavicular region on the affected side is an early sign of tubercular deposit. In advanced phthisis the depression is still more marked, in some instances amounting almost to deformity. The expansive movements in inspiration on the affected side in the infra-clavicular region are diminished or entirely wanting, and this want of expansion is often notice- able at a very early period in the disease. Bulging or partial enlargement of the chest, determinable