Complete Text (Part 7)

and they are superficial, there will be a slight rise in the pitch of the percussion sound on the affected side ; but if some emphysematous lung intervene between the consohdated lung and the chest walls, the percussion sound may be nor- mal, or extra-resonant, over the affected portion. To detect this last, the percussion sound must be lightly made, and the percussion blow must be du-ected from and not towards the trachea. If doubts exist, percussion should be performed at the end of a full inspiration, and then at the end of a full expi- ration. Auscultation. — The results of auscultation vary. The res- piratory murmur in the infi-a-clavicular and supra-scapular PHTHISIS PULMONALIS. 73 regions may be weak and almost suppressed at some points, and exaggerated at others. It may also be jerking or " cog- ged-wheel," in its rhythm, and rude or bronchial in its quaHty. The inspiratory sound loses its soft, breezy character, and be- comes high-pitched and tubular ; while the expiratory becomes higher pitched than the inspiratory, and is prolonged. Pro- longed expiration, however, if unattended with any alteration Fig. 11. Ende respiration. . . . . Slight dulnesB Increased vocal fremitus. . Increased vocal resonance . Scattered Tubercular Deposit at the Apex of the Lung.— DACoefr a. in quahty, is insignificant, or, if it is low-pitched, it furnishes no evidence of tubercle. The value of these states of the respiration corresponds to their position. If they exist above, and are imperceptible below the second interspace, they are seriously significant. The only adventitious sound belonging specially to this stage of phthisis is the mucous clicl% which is more frequently audible in the supra-scapular fossae than in front. The auscultatory signs of bronchitis, pneumonia, and dry pleurisy may be superadded to these, but they cannot, strictly speaking, be regarded as physical signs of tubercle. "When the deposit of tubercle is extensive, and includes bron- chial tubes of considerable size, the evidences are rendered more conclusive by the presence of bronchial respiration, etc. The heart sound over the affected lung will also be increased in intensity. Vocal resonance is subject to so many varia- 74 PHYSICAL DIAGNOSIS. tions as to render it valueless as a basis of diagnosis. Ex- aggerated vocal resonance at the right apex can hardly be re- garded as even suggestive of tubercle ; at the left apex it is of more importance. Second Stage. — Many of the signs already described as characteristic of the first stage now become more marked, and new auscultatory signs referable to the stage of softening are developed. Inspection. — You will now perceive a greater frequency in the respiratory acts, a more marked depression above and below the clavicles, and an increased deficiency in local ex- pansion, especially during a forced inspiration. Percussion eMcits a wider spread and more intense dulness, and it often assumes a wooden or tubular character. Auscultation. — The respiration grows more extensively and markedly bronchial, and moist crackling rales of a metallic character are heard. When the elimination of the softened material commences, the rales become cavernous in character. Vocal resonance and vocal fremitus are extremely variable and cannot be relied upon. Third Stage.— Inspection. — The signs obtained by inspec- tion remain as in the second stage, except that the rapidity of the respiration is increased, and the depression in the infra and supra-clavicular regions becomes marked, and there is more complete absence of the respiratory movements during the respiratory acts. Palpation is stiU unreliable, although when a cavity is large and superficial, vocal fremitus is increased, and some- times a gurghng fremitus is detected. Percussion. — The percussion sound varies according to the condition of the cavities, and the lung tissue surrounding them. If the cavity is of small size and surrounded with con- sohdated lung tissue, the percussion sound will be absolutely dull or tubular in quality. If a layer of healthy lung tissue PHTHISIS PULMONALIS. 75 intervene between the chest walls and the cavity, the latter being full, gentle percussion will give normal resonance, while forcible percussion wiU elicit deep-seated dulness. Large, empty, superficial cavities with thin, tense walls, yield an am- phoric, pr " cracked-pot " resonance. Auscultation. — If the cavity is empty and communicates freely with a bronchial tube, and no healthy lung tissue lies between it and the chest walls, the respiration will be either cavernous or amphoric, as shown in fig, 6 ; cavernous, when the cavity is of small size, with flaccid walls, so that they col- lapse with expiration, and expand with inspiration ; amphoric, when the cavity is large, and surrounded with consohdated lung, so that its walls are tense and do not collapse in ex- piration. If fluid has accumulated in the cavity sufficiently to rise above the opening into it, large or smaU sized gurgles will be heard, as shown in fig. 6 ; metallic tinkling wiU some- times be heard over cavities of large size. Vocal resonance may give us either pectoriloquy, or be amphoric, broncho- phonic, weak, or entirely absent. SmaU cavities partially filled with fluid deeply seated, do not give rise to signs char- acteristic of cavities, but simply furnish blowing respiration and small sized gurgles, which resemble very closely mucous rales. HEAET AID THOEACIC AORTA. LESSON IX. Topography of tlie Heart and Aorta.— Thj/siological Action of the Heart. The diagnosis of many cardiac diseases rests upon our knowledge of the relations of the different compartments and orifices of the heart to the chest walls. It is therefore neces- sary to be familiar with this relationship, and with the physi- ological acts which constitute a complete cardiac pulsation, before we can intelligently study the physical signs involved in the diagnosis of these diseases. By referring to fig. 1, the relations of the heart to the adja- cent viscera will be readily a23preciated. In the healthy chest, the auricles are on a line with the third costal cartilages. The rujlit auricle extends across the sternum, a little beyond its right border. The left auricle lies deeply behind the pulmonary artery. The middle portion of this auricle corresponds to the cartilage of the third rib. The o'igM ventricle lies partly behind the sternum, and partly to the left of it ; its inferior border is on a level with the sixth car- tilage. The left ventricle lies also for the most part behind and to the left of the sternum, between the third and fifth intercostal spaces. Only a narrow strip of the ventricle is visible anteriorly. The heart, then, as a whole, extends verti- cally from the second space to the sixth costal cartilage, and transversely fi^om about half an inch to the right of the ster- num to within half an inch of the left nipple. Posteriorly, the base lies opposite the sixth and seventh dorsal vertebrae. The entire left ventricle, the greater part of the left auricle, and a 80 PHYSICAL DIAGNOSIS. large portion of the apex of the right ventricle, he to the left of the sternum. Behind the sternum He a greater portion of the right auricle and ventricle, and a small portion of the left. To the right of the sternum lie a portion of the right auricle, and the upper portion of the right ventricle. The whole of the anterior surface of the heart is overlapped by the lungs, except a triangular space corresponding to the lower portion of the right ventricle. The Surface Measurements of the heart are as follows : Ventricle measurement from the second interspace to the fifth interspace, five inches ; from the median line to the left, on the third rib, two and a haK to three inches ; on the fourth rib, from three and a haK to four inches ; in the fifth inter- space, from three to three and a haK inches. JRelative Position of the Valves. The Tricuspid Valve lies behind the middle of the sternum, on a hne with the articulation of the cartilages of the fourth ribs with the sternum. The Mitral Valve hes behind the cartilage of the fourth . left rib near the sternum. The Aortic Valves he behind the sternum, a little below the junction of the cartilages of the third ribs with the ster- mun, and near its left edge. The Pulmonary Valves He behind the junction of the third left rib with the sternum. A circle of an inch in diameter with its centre at the left edge of the sternum, a Httle below the junction of the third rib with the sternum, wiU include a portion of aU these four sets of valves. The Aorta arises from the left ventricle behind the sternum, opposite the tldrd intercostal space, and passes from left to right ; the ascending portion of the arch comes to the right of the sternum between the cartilages of the second and thu'd ribs ; in this part of its course it is within the pericardial sac ; ACTION OF THE HEART. gj thence the transverse portion of the arch crosses the trachea just above its bifurcation, at the centre of the first bone of the sternum, on a hne with the lower margin of the articulation of the cartilages of the first ribs with the sternum ; thence the descending portion passes backwards and downwards towards the left side of the third dorsal vertebra, and rests ultimately upon the left side of the bodies of the fifth and sixth dorsal vertebrae. The arch of the aorta approaches most closely to the chest walls, at the point where the arteria innominata is given off ; that is, on a line with the junction of the cartilage of the second right rib with the sternum. The Pulmonary Artery arises from the right ventricle to the left and behind the sternum, on a line with the junction of the cartilages of the third ribs with the sternum ; it as- cends upwards and backwards about two inches, when it bi- furcates opposite the second costal cartilage. The Pericardial Sac encloses the heart, and may be repre- sented as a cone, extending from the second to the seventh left costal cartilage. The base of the cone rests on and is attached to the diaphragm, and the apex embraces the lower two inches of the great vessels. The larger portion of the sac lies to the left of the median line, and is farther from the an- terior chest walls superiorly than it is inferiorly. Physiological Action of the Seart, The actions which constitute a complete cardiac pulsation are the contraction, dilatation, and rest of each of its cavities. These acts are attended by alteration in the form, size, axis, and position of the heart. The contraction of the ventricles, or their systole, as it is termed, constitutes the active state of the heart ; as soon as this ceases, the muscular tissue relaxes, the cavities enlarge, and the ventricles are said to dilate, this process constituting what is termed the diastole of the heart. 82 PHYSICAL DIAGNOSIS. Auricular Systole. — The heart's action begins witli the contraction or systole of the auricles. By it a small additional quantity of blood is propelled into the ventricles ; but its con- traction is too slight, either to empty the auricles or to cause the dilatation of the ventricles. Its duration is about the eighth part of an entire beat of the heart, the mitral and tri- cuspid valves being open, while the aortic and pulmonary valves are closed, as shown in the diagram fig. 12. Fig. 12. Diagram, showing the Changes that occur in the Valves and Cavities of One Side of the Heart during a Cardiac Pulsation. Auricular Diastole. — The dilatation or diastole of the auri- cles is a passive movement ; these cavities are gradually dis- tended by the blood which enters from the venae cavse and pulmonary veins, the mitral and tricuspid valves being closed, and the aortic and pulmonary being open, as is shown in the diagram (fig. 12). It continues from the termination of one auricular systole to the commencement of the next. Ventricular Systole. — The contraction or systole of the ventricles succeeds immediately upon that of the auricles ; or, in other words, the sudden distention of the ventricles by the blood propelled into them, during the systole of the auricles, is rapidly followed by the contraction of the ventricles. During PERIOD OF REPOSE. 83 their contraction the vertical diameter of the heart is dimin- ished, the ajpex is approximated to the base, and describes a spiral motion from right to left, and from behind forwards, coming in contact with the walls of the thorax between the cartUages of the fifth and sixth ribs on the left side, where the impulse of the heart is felt. With the ventricular systole the blood is propelled with considerable force from the ventricles into the aorta and pulmonary arteries. The mitral and tricus- pid valves are closed, and the aortic and pulmonary valves are open, as is shown in the diagram (fig. 12). It occupies about one-half of the entire beat of the heart. Ventricular Diastole. — The dilatation or diastole of the ventricles immediately succeeds their contraction, during which the blood flows in full stream from the auricles into the ventricles ; the mitral and tricuspid valves are open, and the aortic and pulmonary are closed (as shown in fig. 12) ; the heart becomes elongated, and it assumes the shape and posi- tion which it had before the systole. The duration of the diastole occupies about one-fourth of the entire beat of the heart ; the second sound of the heart is synchronous with it. Period of Repose. — From the termination of the diastole of the ventricles, to the commencement of the auricular sys- tole, the ventricles are in a state of perfect rest, their cavities remaining full but not distended ; the duration of this period is less than one-fourth the entire beat of the heart. As soon as the auricles become distended, they contract, and another heart action commences. If the duration of all these move- ments, from the commencement of one pidse to the com- mencement of another, be divided into five equal parts, two- fifths will be occupied by the contraction of the ventricles ; one-fifth by dilatation of the ventricles, and the remaining two-fifths by the period of rest and the contraction of the auricles. In order that you may readily appreciate the whole series 8i PHYSICAL DIAGNOSIS. and sequence of these elements in the heart's action, I will employ the diagram of Prof. W. T. Gairdner. It consists of two circles. The physiological action of the heart, apart from its external manifestations, is indicated by the inner circle and its divisions ; the external rim is occupied by marks corresponding to the sounds; and the different Foot 2'L'SoaND Diagram showing the Pkgaiological Action of the Heart in C<mnection toUh its External Manifestations-— Gajsdhsr. pulses or impulses are portrayed by lines projecting from the circumference of the outer circle. The physiological facts which constitute a cardiac pulsation are thus apparent. " Be- ginning with the contraction of the ffuricles, then that of the ventricles, then the rapid dilatation of the ventricles, and then the pause, succeeded by the contraction of the auricles again." "It is apparent also that in this succession of action, the phe- nomena which we can appreciate externally are a little later than the real commencement of the heart's action ; they do not RHYTHM OF THE HEART. 85 correspond to the very first beginniiig of movement, for, before there is either sound or impulse, the contraction of the auricles has already taken place ; and when the impulse is perceptible in the carotid, the contraction of the ventricles has commenced, and by the time it is perceptible in the foot, it is almost com- plete. During the diastole of the ventricles and the period of rest aU external manifestations are lost." This series of actions constitutes what is called the rhythm of the heart. There are certain difficulties that are apt to occur in esti- mating the normal rhythm of the heart. The entire period of the heart's action may be divided into a period of motion and one of rest ; the former is subdivided into three distinct stages or periods indicated in the diagram (fig. 13). Now, it is im- portant to observe that when the heart's pulsations follow one another with great rapidity, the period of rest is reduced to a minimum; and when, on the contrary, the heart's action is slow, the period of rest is much lengthened, in proportion to the period of motion; the consequence of this is, that the normal sounds which occur during the contraction and dilata- tion of the ventricles change their relation to one another according as the pulsations are in rapid succession or the contrary. In the former case the interval, between the second and first sound (which includes the period of rest, and the contraction of the auricles) is very short ; in the latter, it is very long. Hence the altered relation which is indicated to the eye in fig. 14, and which is very embarrassing to the be- ginner. The larger circumference of each successive circle indicates the lengthening of the pause ; and, accordingly, you have the interval between the first and second sounds occupying a less and less arc of the circle, as the heart's action gets slower, while the interval between the second and first sounds is cor- respondingly lengthened. In the first and smallest circle, in- dicating the most rapid action, the two intervals are nearly 86 PHYSICAL DIAGNOSIS. Fig. 14. alike, and each occupies about one-half the circumference ; in the last or largest circle (indicating very slow action), the interval between the second and first sounds is four times as long as that between the first and