Complete Text (Part 2)

by inspection, occurs in various affections. Enlargement of the prsecordia is observed in certain cases of hypertrophy or dilatation of the heart, or from fluid effusion in the pericar- dium. Bulging occurs also over aneurism al and other tumors. In cases of membranous croup, acute and chronic laryngitis, and oedema glottidis, inspection will disclose to you the seat of the obstruction to the passage of air to the lung by a sinking ia during inspiration of the parts of the chest which yield PALPATION. jg most readily to atmospheric pressure. TMs sinking in on inspii-ation you will notice, jfirst in the supra-clavicular spaces, then in the infra-clavicular spaces, and as the obstmction in- creases, the sternum is depressed and the sides contracted. Although furnishing few positive evidences of disease, you should always employ inspection prior to the other methods of physical exploration. This is important in all cases where the evidences furnished by the other physical signs are not conclusive. Palpation, or the act of laying on the hand and feehng the external surface of the body, is less useful than inspection in ascertaining deformities, and the amount of general movement ; but it is more useful in determining the amount of local expan- sion, and the character of vibration or impulses communicated to the external surface. In order to arrive at satisfactory results from its employ- ment, you should observe the precautions already named as influencing accurate inspection ; beyond this, I need only mention that in thoracic examinations the hand or the fingers should be gently and evenly applied to the surface of the chest, and that corresponding portions of the two sides of the thorax should be examined simultaneously, the one with the right hand, and the other with the left. K you lay your hand lightly upon the surface of the chest of a healthy person while speaking, a dehcate tremulous vibration will be felt, varying in intensity with the loudness and coarseness of the voice and the lowness of its pitch ; this is called normal vocal fremitna. As a rule, vocal fremitus is more marked in adults than in children, in males than in females, and in tliin than in fat per- sons. In the right infra-clavicular region it is more marked than in the left. Variations in the vocal fr-emitus are the most important evidences of disease furnished by palpation ; in fact aU other evidences of pulmonary disease afforded by palpation are better obtained by inspection. 20 PHYSICAL DIAGNOSIS. In disease the normal vocal fremitus may be increased, diminished, or entirely absent. Increased vocal fremitus occurs in those affections in which lung tissue becomes more or less soHdified, as in tuberculosis, pneumonia, pulmonary apoplexy, and oedema of the lung. When the consolidation is extreme, involving bronchial tubes of considerable size, the vocal fremitus may be diminished or even absent ; while increase in the size of the bronchial tubes, with the slight adjacent consoHdation met with in chronic bronchitis, often gives rise to increased vocal fremitus. Diminution or absence of the normal vocal fremitus occurs whenever the lung substance is separated from the chest walls by gaseous or liquid accumulations in the pleural cavity, as in pneumo-thorax, serous, plastic, hsemorrhagic, or purulent pleu- ritic effusions. In vesicular emj)hysema, owing to the dilated condition of the air cells, vocal fremitus is diminished. Besides these valuable indications furnished by vocal fremitus, you may employ palpation to detect the friction caused in pleurisy by the rubbing together of the two roughened surfaces of the pleural membrane, and which is termed friction fre^nitus. Sibilant and sonorous rales also sometimes throw the bron- chial tubes into vibration, sufficiently strong to be felt on the surface of the chest ; this is termed sonorous or rhoncMal frem- itus. Cavernous gurgles produced in excavations near the surface may be accompanied with a marked fremitus. Mensuration is another method of physical exploration, employed for obtaining information similar to that furnished by inspection and palj)ation. We seldom employ it in physical examinations of the lungs unless great accuracy is requii'ed, as in the record of cases. The instruments which have been devised for the measurement of the chest and the different lines of measurement are numerous. The circidar measure- ment is the only one that I have found of practical value in investigating pulmonary disease. The simplest and most MENSURATION. 21 accurate mode of measuring the circular dimensions of the chest is by means of the instrument devised by Dr. Hare, which consists of two pieces of tape similarly graduated, joined together, and padded on their inner surface close to the line of junction ; the saddle thus formed when placed over the spine readily adjusts itseK to the spinous processes, and be- comes fixed sufficiently for the pui'pose of mensuration. For comparing the expansive movements of the two sides you will find Dr. Quain's stethometer very useful. The object of the circular measurement of the chest is twofold — first, to ascer- tain the comparative bulk of the two sides ; second, to ascer- tain the amount of expansion and retraction accompanying inspiration and expiration of the two sides. The points of measurement are the spinous processes behind and the median line in front, on the level of the sixth costo-stemal articula- tion. The average circular dimension of the chest at this point in 1,500 healthy persons was thirty-two and a half inches. I also found in these examinations that about four-fifths of healthy adults have irregularity of the two sides. In right-handed individuals the right side is about one-half inch larger than the left ; in left-handed, the left. This is true of both sexes. The really important point of mensuration in pulmonary diseases, is the comparison of the two sides of the chest, in rest and in motion. When a i^lem-al cavity is distended with air or fluid, the measurement of the affected side may exceed that of the healthy side, by two or three inches ; after the removal of the fluid, there may be an equal diminution in the measurement of the affected side, as compared with tho healthy one. Deficiency of expansion is also very marked in certain dis- eases. In empyema, for instance, you will often find the total difference between the fullest inspiration and the fullest expi- ration on the affected side will scarcely exceed one sixteenth of 22 PHYSICAL DIAGNOSIS. an inch, while on the other side, there may be a difference of two or three inches. The list of affections in which variations in expansion are to be estimated by measure are the same as those referred to imder the head of Inspection. The measurement of the capacity of the lungs for air, by means of Dr. Hutchinson's spirometer, or of the " vital capacity of the chest," as he terms it, has been shown by experience to be very unrehable, and his instrument has fallen almost entirely into disuse. Succussion, as a method of physical diagnosis, is almost exclusively appHcable to the diagnosis of a single disease ; viz., pneumo-hydrothorax. It is performed by suddenly shaking the trunk of the patient, while your ear is apphed to the surface of the chest ; the sound produced resembles that ' perceived on shaking a bottle partly filled with water close to the ear ; it is a gurgling, sj^lashing noise, and varies in tone with the density of the fluid, and the relative quantities of fluid and air present. It is almost always accomj)anied by amphoric respiration and metallic tinkling. I shall reserve its further consideration until I detail the physical signs of pneumo-hydrothoras. LESSON III. S^ercussion. Percussion, as a means of diagnosis, is not of recent date, for we find it mentioned by Hippocrates. But as the only mode of practising it was by striking the surface itself with the tips of the fingers, or knuckles, now termed technically, immediate percussion, its uses were very Hniited. Within our time, however, M. Piorry gave it an entirely new value by introducing mediate percussion ; the stroke being made, not on the surface, but on some intervening substance applied to it ; and he so demonstrated, by experiments on living and dead bodies, its superior applicabiHty for determining changes in the subjacent parts, that mediate percussion ranks now only second to auscultation among the methods of physical explo- ration. To estimate the value of percussion and to understand its true significance, you must first learn to appreciate correctly the elements of sound. Authors have employed a variety of terms to designate them, such as clearness, dulness, empti- ness, fulness, etc. ; but I think, that a classification based upon analysis of the elements of sound in general, will afford us the truest and most practical distinctions, especially in estimating the sounds in thoracic percussion. Those elements or acoustic properties of percussion sounds which concern us clinically are termed, respectively, Intensitij, Pilch, Quality, and Duration, of which Pitch ranks first in importance. The Intensity of a percussion sound may be increased or diminished, by increasing or diminishing the force of the per- 24: • PHYSICAL DIAGNOSIS. cussion blow. But in puhnonarij percussion, you will find that the intensity depends not only on the force of the blow, but is further modified by the amount of air contained in the lung tissue, or by the thickness of the soft parts covering the tho- racic walls, and also by the elasticity of the costal cartilages. The Pitch of the percussion sound is always low over healthy lung substance, and, as a rule, the greater the quantity of air contained in the corresponding pulmonary tissue, the lower the pitch : consequently, you will find the pitch of the percussion sound varying very perceptibly in the different re- gions of a healthy chest. You can however famiharize the ear with the characters of normal pitch, only by constant practice. Quality in sound is that element by which we distinguish any given sound from every other. Thus it is by the quality that you know the sound of one musical instrument from another. The quahty of the note emitted on percussion over healthy lung substance, and termed normal vesicular reso- nance, is sufficiently marked and peculiar to be easily recog- nized, though it cannot be easily described, and is to be learned only by experience. The Duration of a given sound you will find varying according to the pitch of that sound ; the higher the pitch, the shorter the duration, and vice versa. For example, the dura- tion of the percussion sound is perce23tibly longer in the infra- clavicular region of a healthy chest than over the heait. Tou will find that a certain definable relationship exists be- tween these respective elements of the percussion note, which has a correspondence to the different regions of the chest. Thus after noting the intensity, pitch, quality, and duration of the j)ercussion sound in the infra- clavicular region, you will find that over the heart it has a higher pitch and harder quality, but a less intensity and a shorter duration. The substance which receives the stroke in mediate per- cussion is termed a lolessimeter, of which many varieties have PERCUSSION. 2g been devised, made of wood, ivory, gutta percha, etc. They are in nowise superior, however, to the left index or middle fingers, when their palmar surface is appHed evenly to the chest, for these, besides being of course the most lianthj, also answer best the chief requisite of a plessimeter in that they can be easily fitted with accuracy to any part of the thoracic walls. Moreover, their own proper sound, on being sti'uck, is inappreciable, which is not the case with ivory, wood, etc. Likewise, you will discover nothing better to strike ivitli than the finger tips of the other hand, brought into line ; while for gentle percussion, the middle finger alone may suffice. Now, as the practice of percussion requires some manual dexterity, and the correctness of its indications depends in great measure upon the mode in which it is performed, you will find it useful to have recourse to the following rules as your gTudes : First. You should attend as carefully to the position of your patient as a photographer would if he were going to take his likeness. Whether lying, sitting, or standing, his body should rest on the same plane, and his hmbs be dis- posed similarly, on either side, so as to render the muscular tissue covering the thoracic walls equally tense. In percuss- ing particular regions, however, the first aim is to make the intervening tissue, as firm and thin as possible. Thus \ hen you percuss the front of his chest, the arms should hang loosely down, but the head be thrown back. On the contrary, the arms should be raised to the level of the head when you are percussing the lateral regions, and should be crossed in front, the patient leaning moderately forwards when you per- cuss the back. It is better to percuss on the naked skin ; but various considerations often make this unadvisable, when you should then aim to have the covering as soft, thin, but especially as even as possible. Second. The two sides of the chest should, for comparison, 26 PHYSICAL DIAGNOSIS. be percussed in the same stages of the respiratory act. You should also take care to compare only corresponding portions in the two sides. Thus you should not compare a note during inspiration on the right side with one during expiration on the left, nor that over a rib with that of an interspace. TJiircL The finger or plessimeter should be apphed with equal firmness, and in the same parallel to both sides in suc- cession, and the force of the percussion should be exactly the same ; for the sound will vary considerably even on the same spot, whether you press lightly or firmly with your finger, whether it is across a rib or along it, and finally, whether you strike gently or forcibly. Fourth. The stroke in percussion should be made from the wrist alone, the arm and forearm not participating in it ; and its force should be proportioned to the depth of the part to be examined, — gentle if superficial, and forcible when deep seated. Percussion in Health. — The significance of the percussion sounds in disease depends so entirely on their variation from the sounds which are proper to the part in health, that you cannot pay too much attention to the various characters of normal thoracic percussion ; for on this, almost every deduction which results from your examination is based. Now the per- cussion sounds differ materially in a healthy thorax according to the region percussed. Taking the percussion note of the infra-clavicular region as the standard for pulmonary percus- sion, we find each of the other regions has its own variations fi'om it. In the right infra-mammary region 30U wiU get, by gentle percussion, the same note as in the infra-clavicular ; but forcible percussion, at and below the fourth interspace, will raise the pitch and harden the quality, owing to the presence of the liver within the shelving border of the lung. Over the left infra-mammary region, the pitch is similarly varied from the presence of the heart, until it reaches complete flatness at its inner border. The resonance of the rigid itfra-mammary SCAPULAE REGION. 27 region lias a harder quality, higher pitch, and shorter duration, from the presence of the liver immediately beneath. The left infra-mammary region is similarly affected at its inner part by the left lobe of the liver, and at its outer border by the spleen, while the intermediate space gives a tympanitic reso- nance from the subjacent stomach. Over both clavicles you will get a mixed pulmonary and osseous resonance, while in the supra-sternal region, the percussion sound has a distinctly tubular charactei. In the superior sternal region, it has a bony tubular resonance down to the second rib ; below this, to the third rib, it is raised in pitch and hardened in quahty. The dulness on percussion becomes complete in the next region, or inferior sternal, owing to the presence of the heart and great vessels, together with the left lobe of the liver. The Superior and Middle Axillary regions are extremely resonant as far down as the fourth interspace ; the pitch is even lower than in the infra-clavicular region, but below the fourth interspace, the pitch rises, till complete dulness is found on a level with, and below the seventh rib. Tliis dul- ness continues through the infra-axillary regions on either side. In the Superior Scapular and Scapular regions the per- cussion sound is high-pitched and hard in quality, except in the supra-spinous fossae, vfhere it has the soft quahty, charac- teristic of pulmonary percussion. In the infra-scapular region you have pulmonary resonance as far down as the tenth rib, and complete flatness below. In the inter-scapular region, the percussion is high-pitched and tubular in quality. Besides variations in percussion sounds dependent on differ- ence in regions, there are stiU others ascribable to age, sex, idiosyncrasies, etc. You will find the percussion sound in children of a softer quahty and lower pitch than in adults : while in the aged it rises in pitch, and measurably loses its pulmonary quality. In females, the percussion sound is rela- 28 PHYSICAL DIAGNOSIS. tively more pulmonary in all its cliaracters than in males. Marked deformity of the chest, whether congenital or acquii-ed, also modifies the normal resonance. But it also varies mate- rially in different individuals who are equally healthy. In some persons this difference may be accounted for, w^hile in others it cannot ; but as a nde the thinner the chest walls, the greater is the intensity, the lower the pitch, and the more pulmonary the quahty of the percussion sound. Percussion in Disease. — It is obvious, from what pre-