Percussion outlines

Front matter

otitu*

PERCUSSION OUTLINES.

BY

Preface

•

Tms book is intended to teach students the anatomical position of the thoracic and abdominal viscera in the living subject, and to portray such boundaries of those orgalis as are accessible to percussion. The almost daily necessity in every physician’s practice for determining the position and size of some concealed organ will, we trust, prepare a cordial welcome for our book from those who prefer well-defined knowledge to uncertain guess-work. We have devoted our attention mainly to the normal condition, and what we say regarding pathological phenomena is intended rather as a guide to the proper methods for detecting abnormal deviations than as a full description of the same. With regard to the preparation of the book we will add that it is essentially a condensed abstract of the German literature upon this subject, as contributed by Weil, Ferber, Lusclika, and Gerhardt. We have, however, repeatedly and carefully reviewed, in our own practice and at the autopsy table, the points which we present, and have convinced ourselves that they are correct.

Contents

PAQE

CHAPTER L

Method in Peecussion I

Chapter I. Method In Percussion

TnE first essential to intelligent percussion is a correct method. Much has been written about pleximeters of varied form and size — about hammers of different weight and material, but the secret of successful percussion lies in little details of method rather than in the fibre of any instrument. According to our own opinion the best pleximeter and hammer are the human finger. It is always available. It is never forgotten or lost. As a pleximeter it furnishes a wide scope in size, from its tip to its entire palmar surface, and it need never frighten the most timid child. It affords the best and most instantaneous information regarding the resistance of the parts percussed. The skillful use of the fingers is somewhat more difficult to acquire than that of a pleximeter and hammer, but any one who can percuss well with the fingers can also do well with instruments, although the reverse of this proposition is by no means true.

It is a matter of choice whether one or more fingers be used on each hand. We always employ the last phalanx of the middle finger of the left hand as the pleximeter, while the other fingers are raised from the chest, so as not to interfere with the sound vibrations, l

PERCUSSION OUTLINES.

The rounded end, of the middle finger of the right hand forms our hammer, and we strike the pleximeter just behind the nail in such a manner that the hammer nail shall not touch the skin of the underlying finger — that is, we strike with that fleshy part of the finger where the distal surface curves into the palmar.

The pleximeter should be applied firmly with sufficient pressure to prevent the slipping about of the soft parts when the blow is given ; and this pressure should be uniform for the two sides of the chest. What is of still more importance, the percussion blows should be given with uniform force, especially when comparing opposite sides of the chest. We have seen students unable to demonstrate the most striking differences of percussion tones simply because they delivered their blows with constantly varying force. The relative merits of light and heavy percussion will be discussed later, but whether light or heavy, the blows must be uniform.

Again, in comparing two sides of a chest, one should always percuss symmetrical spots. If the pleximeter finger be laid upon a rib on the one side, it should not be transposed to an intercostal space on the other, but should be placed on the symmetrical point of the companion rib.

Taking into careful account the correct use of the hands, attention should next be turned to the position of the patient. If the subject of percussion be a man, he should be exposed to the skin, due regard being paid to the temperature of the room. Our rule is as foh lows : We tell a patient to strip to the waist and then to put on his coat. This leaves the front of the body bare and easily accessible. When we reach the axillary region one arm can be slipped out of its sleeve, and while the back is examined the coat can be put on in the

METHOD IN PERCUSSION.

reversed position. A similar amount of exposure is not usually advisable with women, but the judicious combination of a thin undershirt and a shawl, or an unstarched dressing-sack alone, will allow ample scope for a skillful percussor. The patient should be told to sit quietly and naturally, with the chest muscles relaxed. Most men, when stripped and approached for percussion, will throw back their shoulders and protrude their chest as if on dress parade. The muscular tension thus produced will always modify the sounds from the organs beneath. The two sides of the body should be held symmetrically, and the face should be directed straight forward, in order that the sounds of the apices may not be obscured by tension of the overlying muscles. It is immaterial whether the hands hang at the side or are placed on top of the head. Hanging at the side, the arms are out of the way, except during percussion of the axillary regions. A slight withdrawal of the arm backward, however, will give access to the anterior part of the axillary region, while a similar slight advance of the arm will expose the posterior part of the same space. If one hand is placed upon the head, which is on some accounts the most convenient position during percussion of the lower border of the lung, it should be remembered that such elevation of the arm carries the skin and ribs a trifle upward, and an allowance must be made for this deflection in the subsequent record of the border obtained.

Patients should not stand during percussion. They should be allowed to sit on a stool or on a chair without arms. If they are too weak to sit up and we are obliged to percuss them in bed, we should be careful to note that the body is straight, and that the shoulders are squarely placed and not twisted out of symmetry by underlying bolsters or pillows. Reference should also be made to

PERCUSSION OUTLINES.

tlie fact that the position of the internal organs varies with changes in the position of the body, a point which will be treated of later under the head of the passive mobility of the percussion boundaries.

Examination of the abdomen is best made with the subject lying upon the back, with the head slightly raised and the knees drawn up, so as to relax the abdominal wall. To expose the spleen, the subject should lie upon the right side, or half way between the right lateral and the prone position.

Having thus discussed the preliminary stages of our task, we will now describe the manner in which an internal organ may be outlined. It will be learned later that only a small portion of all the anatomical borders are accessible to percussion. Piorry, in the enthusiasm of a new study, claimed that every organ of the body emits a sound peculiar to, and distinctive of, itself. If this were true, all the internal organs might be mapped out with anatomical nicety. Skoda was the first to vigorously attack this idea. He maintained that aerated organs are resonant by reason of the contained air. Those organs which contain no air are simply non-resonant, and the sounds which they emit when struck are indistinguishable from each other. The question of percussion outlines resolves itself into the tracing of boundaries between organs which are very resonant, and those which are less resonant or possessed of a different quality of resonance, and those which are non-resonant. Thus it is easy to trace the boundary between the lung and the liver where they lie in apposition, but impossible to distinguish the line of contact between the heart and the liver.

In order to define any border which comes within the province of our search we should percuss toward that border from either side — and alternately from both sides — in lines which are perpendicular to its known anatom-

METHOD IN PERCUSSION.

ical course. Inasmuch as most of the percussion boundaries run transversely across the body, we have adopted the following series of perpendicular lines, which should be followed methodically and in succession : —

•Sternal line ....

Parasternal line

Mammillary line . .

Anterior axillary line Axillary line . . .

Posterior axillary line Scapula line . . .

Vertebral line . . .

Along the border of the sternum.

Half way between the sternal and mammillary lines.

Through the nipple on the male. On the female this line should be drawn perpendicularly downward from about the middle of the clavicle.

Along the anterior border of axilla.

From the summit of the axilla downwards.

Along posterior border of axilla.

Through the apex of the scapula when the arms are hanging at the sides.

Between the scapular and vertebral column.

To illustrate the use of these lines, let us suppose that the lower border of the right lung is the object of investigation. In such case one should begin on the sternal line, and percuss downward until a point is reached where the resonance of the lung ceases, and the flatness of the liver begins. Having repeated the percussion often enough to be sure of such change, this point should he designated by a pencil mark on the skin. Then the same steps should be repeated along the parasternal, mammillary, and anterior axillary lines, and so on to the vertebral line, the point of change of sound in each case being marked. Then if these points be connected by a continuous line, one will have a sketch of the lower border of the lung. It is always serviceable to percuss toward the border sought, not only from above downward, but also from below upward, in which case one

PERCUSSION OUTLINES.

would mark the points where flatness changes to resonance.

In outlining the heart one should percuss in the sternal, parasternal, and mammillary lines, and even in the anterior axillary and axillary lines. Under normal conditions, the left border of the heart, as shown in Plate IV., curves downward and runs parallel with the mammillary line, hence, to define this border, it will be necessary to approach it in oblique lines from the left shoulder and left axillary region.

It is difficult to find a good pencil for marking the skin. Ink spreads and dries slowly. Burnt cork is very good, but inconvenient to carry, and an ordinary lead pencil is too hard to make a mark on soft skin. Chalk and carbon work well for a time, but they rapidly absorb oil from the skin, and cease to mark unless refreshed with sand paper. We have found a very convenient marker in the pencils which actresses use for staining their eyelids. These pencils are made, like ordinary cosmetics, from grease stained with lamp-black or vermilion. They are put up in little tin cases, with slides for pushing them in and out, and can be carried about in the pocket. They can be obtained at any perfumery store.

We must again emphasize the necessity of percussing in straight lines, and of carefully completing one line before beginning another. Students are very apt to percuss across the chest in a zigzag direction or wander about in circles. Such percussion teaches nothing, and only serves to confuse the examiner.

A word in regard to the relative merits of light and heavy percussion. Undoubtedly heavy percussion has its place and serves a good purpose, especially over thick muscles on the back, and in bringing out the dullness of deep-seated consolidation. In outline percussion, however, on the lateral and anterior aspects of the body,

METHOD IN PERCUSSION.

light percussion alone should be employed. In crossing the boundary between a resonant and a non-resonant organ, if our blows are heavy, the resonance of the former organ will be so transmitted over the latter tbat the line of demarkation will apparently lie several centimeters away from its actual position. We have found that the best results are obtained with extremely light percussion. The blow should never be given from the elbow, but from the wrist or from the metacarpal joint of the hammer finger. Where the chest is at all tender, and especially in percussing children, we always keep the hand quiet, and deliver our blows with the finger alone.

The burden of this book is the normal percussion outlines of the body, and we devote but relatively small space to pathological deviations. In presenting the subject thus, we have been actuated by the conviction that perfect familiarity with the normal is the only true guide to the abnormal. One who has a systematic method of searching for the normal, and pursues that method rigorously in every case, will never fail to detect abnormal deviations.

Chapter II. Sternum

The sternum consists of the manubrium, corpus sterni, and the ensiform cartilage. It ordinarily lies in the median line, opposite the vertebral column. Congenital and acquired deformities of either side of the chest' will of course alter its position. With pleuritic effusions the sternum swings toward the affected side like a pendulum, the lower end traveling four to five centimeters, while the upper end moves only two centimeters.

The manubrium is normally quite resonant — the sound is neither tympanitic nor vesicular, but has a quality of its own. It may be rendered dull by an overfilling of the veins from valvular disease of the heart ; by aneurism of the arch of the aorta ; by pericardial effusion, and by pus gravitating from abscesses in the neck. In the last-named case it is important to notice that the dullness does not extend below the manubrium, because the firm adhesion of the membranes of the anterior mediastinum deflect the gravitating pus into the posterior mediastinal space.

The resonance of the sternum is clearest and loudest between the second and fourth ribs. It is also clear between the fourth and sixth ribs, although it here crosses the heart, and is to a great extent in direct contact with that organ. It would seem that the sternum is an excellent conductor of sound from the neighboring lungs, and thus conceals the flatness of the underlying heart.

ANATOMY.

DIAPERAGM.

Anatomy.

Viewed from above, the diaphragm presents a domelike projection into each side of the thorax, with a nearly horizontal plane connecting the summits of the domes. The upper surface is somewhat elliptical in shape, the transverse diameter being the longest. The diaphragm consists of two parts, a tendinous portion — pars phrenica — which forms the plane above, and a muscular portion — pars costalis — which constitutes the sides of the domes. The muscular portion has a long line of attachment extending from the sternum along the border of the ribs to the vertebral column. The sternal segment rises chiefly from the apex of the ensiform cartilage, and is immediately lost in the tendinous layer. The costal segment begins with one serration from the seventh costal cartilage, and another from the outer portion of the eighth cartilage. On the ninth rib the serrations extend about a finger-breadth beyond the cartilage, on to the costal bone. From here to the twelfth rib, the muscle is attached to the osseous parts and the intercostal spaces. Its serrations also interdigitate with the corresponding projections of the transverse abdominal muscle. The vertebral segment takes its origin from the first four lumbar vertebras.

Starting from this long line of attachment, the pars costalis rises directly upward, and lies in contact with the chest wall for a distance which varies on different sides of the chest and with different phases of respiration. On reaching the lower border of the lung and the heart, it is reflected beneath those organs and becomes the pars phrenica.

The summit of the diaphragm changes with every

PERCUSSION OUTLINES.

stage of respiration, but at tlie end of ordinary expiration it coincides on the right side with a horizontal line drawn through the sternal ends of the fifth pair of ribs, and it is a costal space lower on the left side. On the back it corresponds to the ninth dorsal vertebra.

Percussion of the Diaphragm.

The position of the diaphragm cannot be defined by means of any sound or modification of resonance peculiar to itself. It is only by comparing its anatomical relations to other organs with the percussion boundaries of those organs that we are able to form any opinion concerning it.

The most important points to determine, are : —

1. The line of transition from the pars costalis to the pars phrenica. This corresponds to the lower border of the lung, and may therefore be deferred to the discussion of that border.

2. The position of the dome. Gerhardt says it is idle to try to define the arch of the dome, owing to its distance from the chest wall. Weil and Ferber think it can be defined by strong percussion, but this is a difficult task, and usually we can determine the probable height of the diaphragm only by inference from the position of other organs. When the dome of the diaphragm is de pressed into the abdomen by a large pleuiitic effusion, it becomes readily accessible to percussion, and may often be felt.

PLEURA.

Anatomy.

The pleural membranes are divided into four parts, according to the organs with which they are associated. These parts are : —

ANATOMY.

.11

Pars pulmonis , which directly envelops the lung and cannot be detached from the same.

Pars phrenic a, which covers the diaphragm.

Pars mediastinalis , which helps form the partition between the two halves of the chest.

Pars costalis , which lines the inner surface of the ribs, intercostal spaces, and a portion of the sternum.

At the apex of the chest, behind the sternum and along the vertebral column, the pars costalis is reflected inward, to form the pars mediastinalis, and these lines of reflection constitute respectively the superior, anterior, and posterior borders of the pleural cavity. The inferior border of that cavity is formed by the reflection of the costal into the diaphragmatic layer, or pars phreniea. The most important of these borders, for percussion, are the superior, anterior, and inferior.

The superior borders coincide accurately with the superior borders of the lungs, and therefore require no separate notice at this point. See description of lungs, page 14.

The anterior borders start on either side at the articulation of the clavicles with the sternum, Plate I., A B, 0 D. They advance obliquely downward and inward, behind the manubrium, until they reach the level of the inner extremities of the second ribs, where they come into contact with each other. Thence they proceed together downward a little to the left of the median line, as far as the fourth pair of ribs, when they separate. The right border continues still downward, with a slight inclination to the right, until it meets the inferior border of the right pleura, in the median line of the sternum, at the level of the sixth intercostal space.

The left anterior border bends somewhat sharply to the left at the fourth rib, and crosses the cardiac ai’ea in an irregularly diagonal direction until it reaches the

PERCUSSION OUTLINES.

parasternal line in the sixth intercostal space. Here it sweeps in an easy curve across the seventh costal cartilage, and is lost in the inferior border of the left pleura.

The inferior borders of the pleurae convex downward on either side. The left one runs obliquely downward and outward from the outer third of the sixth or seventh costal cartilage to the bony portion of the twelfth rib behind. Its termination is about on a level with a horizontal line which halves the twelfth pair of ribs. In its course it crosses the bony end of the eighth rib in the mammillary line, and from there on it comes in contact only with the bony portion of the ribs. It reaches the tenth rib in the axillary line. The lowest point of the pleural cavity is sometimes close to the vertebral column and sometimes a little out from the same. It maybe as far out as the scapular line in some cases.

The right inferior border runs from the median line of the sternum outward and downward along the sixth costal cartilage or the sixth intercostal space to the outer third of the seventh costal cartilage, whence it proceeds in nearly the same manner as on the left side. It is noticeable, howevei’, that the pleural border on the left side is a trifle lower than that on the right side, which harmonizes with the fact that the left lung is longer though smaller than the right one.

The posterior borders of the pleurae form perpendicular lines on either side of the vertebral column.

Notice: 1. The inferior border of the pleura does not reach so low as the line of attachment of the diaphragm, which runs along the costal arch from the ensiform cartilage to the outer extremity of the twelfth rib. The diaphragm in this region is intimately attached to the ribs and intercostal spaces.

2. A portion of the pericardium has no pleural cover-

ANATOMY.

ing, owing to the oblique course of the anterior border of the left pleura. This exposed region has a triangular shape with its apex upward, and within this triangle the pericardium lies in direct contact with the chest wall. The portion of the pleura ( pleura pericardiaca') which does overlie the pericardium is intimately attached to the latter.

3. The anterior borders of the pleurae touch each other only between the second and fourth pair of ribs, and it is here only that the posterior surface of the sternum is wholly covered by pleura.

4. A triangular space behind the upper part of the manubrium is free from pleural covering. Certain important organs lie behind this space. A needle thrust through the manubrium at the angle formed by the pleural layers would pierce the upper part of the pericardium, which rises as high as the first pair of ribs. Above the pericardium one would wound first the vena innominata, and, back of that, the aorta. In childhood this space also contains the large thymus gland.

Chapter III. Lungs

Anatomy. — The lungs present three surfaces and five borders for consideration. The external or costal surface is convex outward, corresponding to the concavity of the chest wall, and it is a sort of spherical triangle with its apex above, and the lower pulmonary border for the base. The inferior surface is also a spherical triangle with its concavity looking down upon the diaphragm. The median or mediastinal surface looks toward the centre of the body, and is pierced by the trachea and bloodvessels which administer to the functions of the lungs.

Pulmonary Borders. — The superior border passes jokelike over the shoulder at three to five centimeters (two to three finger-breadths) above the clavicle. Plate IV., G, H. Anteriorly, it runs close to, and parallel with, the posterior border of the sterno-cleido-mastoid muscle, until it reaches the ster no-clavicular articulation, when it becomes the anterior border. On the back it is slightly "concave upward, and terminates at the level of the spinous process of the seventh cervical vertebra. Plate VII., A B.

The anterior border of the right lung corresponds accurately to the anterior border of the right pleura, as given on page 11, Plate I.

The anterior border of the left lung runs also parallel with its pleura, as far as the inner extremity of the fourth rib. Here it bends sharply to the left, and lies along the

LUNGS.

fourth costal cartilage as far as the parasternal line. rl hen descending slightly across the fourth intercostal space, it turns again toward the median line in a half-moon curve — Incisura cardiaca — and approaches the sternum until it reaches the sixth costal cartilage, when it again bends to the left and is lost in the inferior border. This peculiar deflection of the border produces a, tongue-like projection — lingida pulmonis — which overlies the apex of the heart.

The inferior border of the left lung is, in front, a little lower than that of the right lung. . This difference amounts to one and a half centimeters between the mammillary and parasternal lines, but no perceptible difference exists on the back. The following table shows the relative positions of the inferior border on the two sides.

RIGHT.

LEFT.

Parasternal ami mammillary.

Upper border of 6th

Lower border of

lines

rib.

6th rib.

Axillary line

Scapular line ....

Vertebral line ....

This table represents the position of the borders at the end of normal expiration. The respiratory modifications of the same will be noted later.

The posterior borders run parallel with the vertebral column. Little or no information can be obtained regarding them by percussion, except in cases of pleurisy, when we find them shortened by the general contraction of the lungs.

The antero-posterior borders, which bound the lower part of the mediastinal surfaces, are inaccessible to percussion.

Incisurce Interlobular es. — Each lung is divided into lobes by incisures, which extend from the surface to the root of the lung, and are lined by reflections of the

PERCUSSION OUTLINES.

visceral pleura. The right lung has three lobes, the left lung two.

The main incisura begins on either side, behind, at the level of the spinous process of the third dorsal vertebra. This also coincides with the spines of the scapulae, when the arms hang at the sides.

On the left side, the incisura runs obliquely downward and forward, so as to cross the fourth rib in the axillary line, and ends in the lower border of the lung on the sixth rib in the mammillary line. Plate II., E D.

On the right side the incisura divides into two branches, about five to six centimeters above the apex of the scapula. The upper branch runs forward, with very slight descent, and ends in the anterior border of the right lung at the fourth or fifth costal cartilage. In the mammillary line it stands at the level of the third rib.

The lower branch runs obliquely downward and forward until it reaches the inferior border of the lung at the sixth costal cartilage near the mammillary line. These incisurse cannot be defined by percussion, except in cases of lobar infiltration of pneumonia.

Notice : 1. In the position of ordinary expiration, the lower boi’der of the lung on either side does not reach to the bottom of the pleural cavity, but is elevated above the same by a distance varying on different sides of the chest. Plate II. During inspiration the lung descends until, with the fullest breath, it occupies the entire cavity. With the following expiration, the lower border glides upward to resume its former position. The space which is thus alternately occupied and abandoned by the lung is called the complemental space (Gerhardt), or the sinus phrenico-costalis (Weil). As the lung deserts this space, the diaphragmatic and costal layers of the pleura are brought into contact, and thus the space becomes temporarily obliterated.

LUNGS.

The variations in the depth of this space on different sides of the chest are shown in the following table (Weil) : —

RIGHT SIDE.

LEFT SIDE.

Parasternal line .

24 ctm.

3 ctm.

Mammillary line

6 “

Axillary line ....

10 “

10 “

Scapular line ....

Vertebral line ....

These figures represent the condition of ordinary expiration. With forced expiration they may be much increased.

2. The anterior border of the left lung, in the cardiac region, does not occupy the whole of the space allotted to it. Plate I., Q. This excess of room, reserved for the play of the pulmonary border, is called the sinus mediastino-costalis, and it will be seen later that the recognition of its condition is very important, especially for the diagnosis of emphysema. The widest portion of this sinus is in the fourth intercostal space, where it is over three centimeters.

3. The apex of the heart does not touch the chest wall, but is separated from the same by the lingula pulmonis.

4. The lowest point of the lung is in the scapular line.

PERCUSSION OF THE LUNGS.

The only boundaries of the lungs which can be defined by percussion are the superior and inferior borders, and so much of the left anterior border as lies across the cardiac area.

Superior Borders. — The apex of the lung rises above the clavicle from three to five centimeters. The superior border extends from the inner end of the clavicle, at first upward along the posterior edge of the sterno-cleido-mastoid muscle, and then over the shoulder 2

PERCUSSION OUTLINES.

in a gentle sweep, to the spinous process of the seventh cervical vertebra. Plate VII., A B. On the back, these borders concave upward.

The distinction between the pulmonic resonance of the apex and the tympanitic resonance of the trachea in front can best be made out by light percussion, and with the patient’s mouth open. The importance of determining these boundaries may be noticed in phthisis, when one apex is often found considerably retracted. Plate VII., O P.

Anterior Borders. — Owing to the peculiar resonance of the sternum and to the fact that we cannot distinguish the sound of the right from that of the left lung, it is impossible to outline those portions of the anterior borders which underlie the sternum. Plate IV.

In percussing down the left sternal line, we notice a dulling of the resonance at the third rib. This dullness is due to the underlying heart, and will be further mentioned in connection with that organ. On reaching the fourth rib there is a sudden change from pulmonary resonance to flatness, which indicates the transition from lung to heart. The line of this transition extends a short distance outward along the fourth rib, and then turns perpendicularly downward across the fifth rib. At the sixth rib it turns again to the left, and is lost in the lower border. The line a to e, along the left edge of the sternum, indicates the change from cardiac flatness to sternal resonance.