Physical diagnosis of diseases of the chest

Front matter

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V

Preface

This book is intended for students and, so far as I am aware, contains nothing original. I have written it because I have not been able to find any small work upon the subject which does not contain glaring errors. The correct books are too large; the small books are out of date and repeat such well-worn myths as that the aortic second sound is normally louder than the pulmonic second, that aortic regurgitant murmurs are usually best heard in the second right interspace, that a hypertrophied left auricle can produce dulness and pulsation near the left sternal border, that systolic retraction at the cardiac apex means adherent pericardium, that epigastric pulsation denotes hypertrophy of the right ventricle, etc. Further, none of the smaller text-books contains any adequate account of muscle sounds, of pulmonary atelectasis, or of adherent pericardium. To record the well-known but often forgotten truth on such matters as these has seemed to me of importance in small books as well as in encyclopaedic treatises.

The diagrams illustrating respiratory types are modifications of those used by Wylie and Sahli.

I am indebted to Mr. Eliot Alden, of the Harvard Medical School, for his kind assistance in the preparation of the illustrations and to Drs. E. C. Bradford and R. W. Lovett for permission to use three cuts from their well-known work on orthopedic surgery.

I am also indebted to the editor of the Archives of the Rontgen Ray for permission to use two radiographs from that journal.

Chapter I. Inspection

Shape, ....

(a) The Rachitic Chest,

(6) The Paralytic Chest,

(c) The Barrel Chest, .

Deformities, .

(a) Curvature of the Spine,

(6) Flattening of One Side of the Chest,

(c) Prominence of One Side of the Chest

(d) Local Prominences, .

Respiratory Movements,

(a) Normal Respiration,

(6) Anomalies of Expansion,

1. Diminished Expansion,

2. Increased Expansion, (c) Dyspnoea,

The Respiratory Rhythm, (a) Asthmatic Breathing, (6) Cheyne-Stokes Breathing,

(c) Restrained Breathing,

(d) Shallow and Irregular Breathing.

(e) Stridulous Breathing,

PAGE

VI. Diaphragmatic Movements (Litten's Phenomenon), . . .23 VII. The Cardiac Movements, . 26

1. Normal Cardiac Impulse, . 26

2. Displacement of the Cardiac Impulse, 29

3. Apex Retraction, .... .... 31

4. Epigastric Pulsation, . . . ... . . .32

5. Uncovering of the Heart, 32

VIII. Aneurism and Other Causes of Abnormal Pulsations or the

Chest Wall, 33

IX. The Peripheral Vessels, 34

(a) Venous Phenomena, . . 35

(b) Arterial Phenomena, . .36

(c) Capillary Phenomena, ........ 38

X. The Skin and Mucous Membranes, ...... 39

1. Cyanosis, 39

3. Pallor, 40

5. Scars and Eruptions, 41

XI. Enlarged Glands, . 41

Chapter II. Palpation And The Study Of The Pulse

1. The Cardiac Impulse, . . . . . . . . .42

3. Tactile Fremitus, 44

4. Friction, Pleural or Pericardial, . . . . . . .46

5. Palpable Rales, ' . . . . .47

6. Tender Points, 48

7. Abnormal Pulsations . 48

8. Tumors, 48

9. Temperature and Quality of the Skin, 49

II. The Pulse, . 49

1. The Rate, 51

2. Rhythm, 51

3. Compressibility, 52

4. Size and Shape of Pulse Wave, 52

5. Tension, 53

6. Size and Position of Artery, 55

7. Condition of Artery Walls, 55

TABLE OF CONTENTS.

Chapter III. IX

PERCUSSION.

I. Technique,

^ Mediate Percussion, .... ' a ' } Immediate Percussion,

(b) Auscultatory Percussion, . . .

(c) Palpatory Percussion, ....

II. Percussion-Resonance of the Normal Chest (a) Vesicular Resonance, .... (6) Dulriess and Flatness, ....

(c) Tympanitic Resonance,

(d) Cracked-pot Resonance,

(e) Amphoric Resonance. . (/) The Lung Reflex, .

III. Sense of Resistance, ....

PAGE

Chapter IV. Auscultation

1. Mediate and Immediate Auscultation, . . „ . 77

2. Selection of a Stethoscope, ........ . . . „• 7.8

3. The Use of the Stethoscope, ......... 83

A. Selective Attention and What to Disregard, . „ „ .84

B. Muscle Sounds, . . . .86

C. Other Sources of Error, ...... „ . . 88

4. Auscultation of the Lungs, . . . . . . .91

I. Respiratory Types, . 92

(a) Vesicular Breathing, ...... . . 93

(6) Tubular Breathing, ......... 95

(c) Broncho-vesicular Breathing, ...... 96

(d) Emphysematous Breathing, . 97

(e) Asthmatic Breathing, 97

(/) Cog-wheel Breathing, 98

(g) Amphoric Breathing, 98

(h) Metamorphosing Breathing, 98

II. Differences between the Right and the Left Chest, . . .99

III. Pathological Modifications of Vesicular Breathing, . . . 99

(a) Exaggerated Vesicular Breathing, ..... 99 (6) Diminished Vesicular Breathing, ..... 100

IV. Bronchial Breathing in Disease, ....... 102

: TABLE OF CONTENTS,

PAGE

V. Amphoric Breathing, 103

VI. Rales, 103

(c) Musical, 106

VII. Cough. Effects on Respiratory Sounds, 107

VIII. Pleural Friction, . ......... 107

IX. Auscultation of the Voice Sound, . 109

(a) The Whispered Voice, 109

(6) The Spoken Voice, . 110

(c) Egophony, Ill

X. Phenomena Peculiar to Pneumo-Hydrothorax, .... Ill (a) Succussion, . . . . . . . . . Ill

(6) Metallic- Tinkle, 112

(c) The Lung Fistula Sound, 112

Chapter V. Auscultation Of The Heart

1. The Valve Areas, 113

2. Normal Heart Sounds, ..... .... 114

3. Modifications in the Intensity of the Heart Sounds, . . . 116

(a) Mitral First Sound, .117

2. Doubling, 118

(6) The Second Sounds at the Base of the Heart, . . . .118

1. Physiological Variations, . 118

2. Pathological Variations, . , 120

(a) Accentuation of Pulmonic Second Sound, . . . 120

(6) Weakening of Pulmonic Second Sound, . . . 121

(c) Accentuation of the Aortic Second Sound, . . . 121

(d) Weakening of the Aortic Second Sound, . . . 121

(e) Accentuation of Both Second Sounds, .... 122 (/) Summary, 122

(c) Modifications in Rhythm of Cardiac Sounds and Doubling of Sec-

ond Sounds 123

(d) Metallic Quality of the Heart Sounds, 124

(e) " Muffled " Heart Sounds, 124

4. Sounds Audible Over the Peripheral Vessels, .... 124

(a) Arterial Sounds, 124

TABLE OF CONTENTS.

XI

CHAPTER VI. (Auscultation of the Heart Continued.)

CARDIAC MURMURS.

PAGE

I. Terminology, . 126

1. Mode of Production, .'.''.. 126

2. Place of Murmurs in the Cardiac Cycle, ..'.'.. 128

3. Point of Maximum Intensity, . . . . . . . 129

4. Area of Transmission, 130

5. Effects of Respiration, Exertion, and Position, . . . . 135

6. Intensity, Quality, and Length, ...... 132-135

7. Relation to Heart Sounds,. ....... 135

8. Metamorphosis of Murmurs, ....... 136

II. Functional Murmurs, . . . . . . . . .136

III. Cardiorespiratory Murmurs, 138

IV. Venous Murmurs, .......... 139

V. Arterial Murmurs, 140

PAET II.

DISEASES OF THE HEAET.

Chapter VII. Valvular Lesions

1. Valvular and Parietal Disease,

2. The Establishment and Failure of Compensation.

3. Hypertrophy and Dilatation, .

4. Valvular Disease,

I. Mitral Regurgitation,

(a) Pre-compensatory Stage, (&) Stage of Compensation, .

(c) Stage of Failing Compensation,

(d) Differential Diagnosis, .

II. Mitral Stenosis,

1. First Stage,

2. Second Stage, .

3. Third Stage, .

4. Differential Diagnosis, .

III. Aortic Regurgitation,

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xii TABLE OF CONTENTS.

PAGE

(a) Arterial Jerking, . ....... 172

(6) Capillary Pulsation, ....... 173

2. Palpation, 174

5. Summary and Differential Diagnosis, , . . . . 178

7. Complications, 179

IV. Aortic Stenosis, . . 180

1. (a) The Murmur, 181

(6) The Pulse, 183

(c) The Thrill, 184

(d) Feeble Aortic Second Sound 184

V. Tricuspid Regurgitation, 187

1. (a) The Murmur, 188

(6) Venous Pulsation, . 188

(c) Cardiac Dilatation, 189

(d) Feeble Pulmonic Second Sound, ..... 189

2. Differential Diagnosis, . . . „ . . . .190 VI. Tricuspid Stenosis, 191

VII. Pulmonary Regurgitation, ... . . . . . 192

VIII. Pulmonary Stenosis, . .193

IX. Combined Valvular Lesions, 194

(a) Double Mitral Disease, . . . o . . . . 195

(6) Aortic and Mitral Regurgitation, ...... 196

(c) Aortic Stenosis and Regurgitation, . . . . . 197

CHAPTER VIIL

PARIETAL DISEASE AND CARDIAC NEUROSES.

I. Acute Myocarditis, . 198

1. Acute Moycarditis, 198

2. Chronic Myocarditis, 199

3. Fatty Overgrowth, 201

4. Fatty Degeneration, . . . 201

II. Cardiac Neuroses, . . . . . . . . . . 202

1. Tachycardia, 202

2. Bradycardia, 203

3. Arrhythmia, 204

4. Palpitation, 205

5. Congenital Heart Disease, 206

TABLE OF CONTENTS.

xm

Chapter IX. Diseases Of The Pericardium

PAGE

I. Pericarditis, 209

(a) Dry or Fibrinous, 209

(b) Pericardial Effusion, . 212

1. The Area of Dulness, 213

2. The Cardiac Impulse and the Pulse, 214

3. Pressure Signs, . . .215

(c) Adherent Pericardium, 216

1. Retraction of Interspaces, 217

2. Limitation of Respiratory Movements, . . . .217

3. Absence of Cardiac Displacement with Change of Position, 217

4. Hypertrophy and Dilatation not otherwise Explained, . 217

5. Capsular Cirrhosis of the Liver, . . . . . 218 II. Htdropericardium and Pneumopericardium, ...... 219

Chapter X. Thoracic Aneurism

. 220

. 221

. 222

. 222

. 223

. 224

. 224

. 225

. 225

. 226

. 227

. 227

. 229

Abnormal Pulsation, .

Tumor,

Thrill, ....

Diastolic Shock, .

Tracheal Tug,

Pressure Signs,

Percussion Dulness,

(a) Murmurs,

(6) Diastolic Shock Sound

Radioscopy, .

Diagnosis, .

Part III. Diseases Of The Lungs And Pleura

CHAPTER XL BRONCHITIS, PNEUMONIA, TUBERCULOSIS.

1. Tracheitis,

2. Bronchitis,

. 283 . 233 xiv TABLE OF CONTENTS.

PAGE

(a) Physical Signs, . -234

3. Croupous Pneumonia, 237

(a) Inspection, 237

(c) Percussion, 238

(d) Auscultation, 239

5. Pulmonary Tuberculosis, 245

(a) Incipient Tuberculosis, 245

(6) Moderately Advanced Cases, ....... 249

(c) Advanced Phthisis, 252

(d) Anomalous Forms of Pulmonary Tuberculosis, . . . . 256

CHAPTER XII. (Diseases of the Lungs, Continued.)

1. Emphysema, 258

(a) Small-Lunged Emphysema, 258

(6) Large-Lunged Emphysema, 258

(c) Emphysema with Bronchitis and Asthma, ..... 261

(d) Interstitial Emphysema, ........ 262

(e) Complementary Emphysema, 262

(/) Acute Pulmonary Tympanites, ....... 262

3. Syphilis of the Lung, . . . . . . . . . 264

4. Bronchiectasis, 264

5. Cirrhosis of the Lung, 265

Chapter XIII. Diseases Affecting The Pleural Cavity

I. Hydrothorax, 266

II. Pneumothorax, 266

III. Pneumohydrothorax and Pneumopyothorax, 268

Differential Diagnosis of Pneumothorax and Pneumohydrothorax, . 270

IV. Pleurisy, 271

1. Dry Pleurisy, , 271

TABLE OF CONTENTS.

xv

Pleuritic Effusion,

(a) Percussion, ....

(b) Auscultation,

(c) Inspection and Palpation, .

Pleural Thickening, Encapsulated Pleural Effusions, .

Pulsating Pleurisy and Empyema Necessitatis, Differential Diagnosis of Pleural Effusions,

PAGE

Chapter XIV

ABSCESS, GANGRENE AND CANCER OF THE LUNG, PULMONARY ATELECTASIS, CEDEMA AND HYPOSTATIC CONGESTION.

1. Abscess and Gangrene of the Lung, 290

2. Cancer of the Lung, 291

3. Atelectasis, . .292

4. Oedema and Hypostatic Congestion, .,..*.. 293

APPENDICES.

Appendix A. — Diseases of the Mediastinum,

1. Mediastinal Tumors, ....

2. Mediastinitis,

3. Tuberculosis of Mediastinal Glands, .

Appendix B. — Acute Endocarditis, Appendix C. — Examination of Infant's Chests, Appendix D. — Radioscopy of the Chest, Appendix E. — The Sphygmograph, .

293 293 295

296 296 297 298 305

PHYSICAL DIAGNOSIS

OF

DISEASES OF THE CHEST.

Introduction

I. Methods of Examining the Thoracic Organs.

To cany out a thorough examination of the chest we do five things: 1. We look at it; technically called " inspection." 2. We feel of it; technically called "palpation." 3. We listen to the sounds produced by striking it; technically called "percussion." 4. We listen to the sounds produced within it by physiological or pathological processes; technically called "auscultation." 5. We study pictures thrown on the fluoroscopic screen or on a photographic plate by the Roentgen rays as they traverse the chest; technically called "radioscopy."

Measuring the dimensions or the movements of the chest ("mensuration ") is often mentioned as co-ordinate with the above methods, but it yields very little information of practical value, and is at present very little used.

The data obtained by examining the sputa, blood, and urine are frequently of great value in helping us to interpret the signs revealed by examination of the chest, but do not fall within the scope of this book. Accordingly, I shall confine myself in the first part of this book to a description of the methods of inspecting, palpating, percussing, and auscultating the chest, with a brief account of the physical signs which we have learned to appreciate by the use of these methods. (For radioscopy, see Appendix.) 1

PHYSICAL DIAGNOSIS OF DISEASES OF THE CHEST.

Without some knowledge of the regional anatomy of the chest no intelligent investigation of the condition of the thoracic organs can be carried on. Accordingly, I shall begin by recalling very briefly some of the most essential anatomical relations.

II. Eegioxal Axatomy of the Chest.

It seems to me a mistake to divide the chest into arbitrary portions and to describe physical signs with reference to such division. The seat of any lesion can best be described by giving its relation to the clavicle, sternum, or ribs on the front and sides of the chest, and to the scapulae and ribs behind. Thus we may speak of rales as heard " above the left clavicle in front, " " below the right scapula behind, " " between the seventh and ninth ribs in the axilla," and so on. When we want to state more exactly what part of the axilla anteroposteriorly is affected, we may refer to the " mid-axillary line " (see Fig. 1) ; or better, we may place the lesion by measuring the number of centimetres or inches from the median line of the sternum. In a similar way the place of the apex impulse of the heart (whether in the normal situation or farther toward the axilla) can be determined by measuring from the median line of the sternum. Measurements referring to the nipple are entirely useless in women and not very reliable in men. It is better to measure as above.

If, then, we confine ourselves chiefly to the bones of the chest as landmarks, and fix, with reference to them, the position of any portion of the internal organs which we desire to study, it becomes unnecessary to memorize any technical terms or to learn the position of any arbitrary lines and divisions such as are frequently forced upon the

FIG. l.

The Mid- Axillary Line.

INTRODUCTION. 3

student. The only points which it is necessary to memorize once for all are :

1. The position of the heart, lungs, liver, and spleen with reference to the bones of the chest.

2. The position of certain points which experience has taught us have a certain value in physical diagnosis. I mean (a) the so-called "valve areas" of the heart, which do not correspond to the actual position of the valves, for reasons to be explained later

Upper lobe of left lung.

Right lung Right auricle. —

Liver.

Left ventricle.

Lower lobe of left

lung.

" Stomach.

Fig. 2.— Position of the Heart, Lungs, Liver, and Stomach. The dotted lines correspond to the outlines of the lung ; the heavy continuous line represents the heart ; while the position of the liver and of the lower border of the stomach is indicated by light continuous lines. The ribs are numbered.

on, and (b) the percussion outlines of the heart, liver, and spleen. These outlines do not correspond in size with the actual dimensions of the organs within, yet there is a definite relation between the two which remains relatively constant, so that we can infer the size of the organ itself from the outlines which we determine by percussion. The position of the organs themselves is shown in Figs. 2, 3, and 4. It will be noticed in Fig. 2 that the lungs extend up above the clavicles and overlap the liver and the heart — facts of considerable importance in the physical examination of these organs, as will be later seen. It is also to be noticed how small a portion of the stomach is directly accessible to physical examination, the larger part of it lying behind the ribs and covered by the

Upper lobe.

Lower lobe.

Spleen.

Lower lobe.

Upper lobe.

Middle lobe.

Liver

Fig. 3.— Position of the Left Lung from the F.'u. 4.— Position of the Right Lung from the Sides and of the Spleen. Side, and of the Liver.

liver. The normal pancreas and kidneys are practically inaccessible to physical examination.

The percussion outlines — corresponding to those portions of the heart, liver, and spleen which lie immediately beneath the chest walls — will be illustrated in the section on Percussion (see page 58).