How to examine the chest; a practical guide for the use of students

Front matter

^h

A PRACTICAL GUIDE FOR THE USE OF STUDENTS

SAMUEL WEST, M.D. Oxon., M.E.C.P.

Section I.— The Lungs

a. The Shape of the Chest Its Measurement

Named Varieties of Thorax

Changes of Shape due to Disease

Deformities

The Condition of the Superficial Veins

b. The Movements of the Chest on Respira

tion The Types of Respiration The Amount of Air Respired Alterations in the Respiratory Movements The Number of Respirations Synopsis

How to Count the Ribs .

The Shape and Movements of the Chest

Abnormal Sensations

The Vocal Vibrations

Sense of Resistance

PAGE

1 1

3 3 5

9 10 12 18 19 19

20 20 21 22 23 26

27 27 28 28 29 30

Vlll CONTENTS.

SECTION L— THE LUNGS (continued).

PAGE

Method of Percussion

. 31

Resonance and Dulness .

. 31

Boundaries of the Lungs . .

. 37

The Surface Markings of the Liver

. 39

Do. of the Spleen

. 43

Do. of the Stomach

. 43

Alterations in the Boundaries of the Lungs

. 45

Symmetrical

. 47

Unsymmetrical

. 49

Varieties of Percussion Sounds

. 51

Want of Symmetry on Percussion .

. 56

. 59

Of Stethoscopes

Vocal Resonance and its Varieties .

The Sounds of Breathing and their Varieties

Use of the Facts ascertained in Diagnosis

Other Pulmonary and Pleural Sounds

Conclusion

Suggestions for the Construction of Diagrams

General Synopsis of the Examination of the Lungs

SECTION II.— THE HEART. The Shape of the Precordial Region

The Movements in the Precordial Region :

Apex Beat :

Its Normal Position

Normal Peculiarities

Displacement .

Its Character .

Changes in Disease

Pulsation in Abnormal Places .

Synopsis .

CONTENTS. IX

SECTION II.— THE HEART (continued).

PAGE

How to Fix the Apex

Abnormal Sensations

.

The Size of the Heart and the

Cardiac

D ulness

Alterations in the Cardiac Dulness

The Sounds of the Heart

Asystolism

Their Classification .

How to Time them .

Subdivision of

Their Cause

Their Place

The Position of the Valves

The Axes of the Heart

The Diagnosis of Valvular Disease .

Inorganic Murmurs — Endocardial .

Exocardial .

Murmurs Audible in other Parts of the

Thorax

Synopsis .

General Synopsis of the Examination of the

Heart

SECTION III.— THE PULSE. Its Cause

The Pulse Eate

The Artery.

Its Course

Its Coats

Its Calibre b

X CONTENTS.

SECTION III.— THE PULSE {continued).

The Pulse Wave. page

The Sphygmograph . . . 165

The Khythni of the Pulse . . 170

Want of Symmetry . . .173

Section Iv.— The Mediastinum

Dislocation of the Mediastinum . . 179 The Parts of the Mediastinum . . 181 Diseases of the Mediastinum and their Diagnosis . . . . 184 Synopsis .... 190

LIST OF ILLUSTRATIONS.

7,

8,

12. 13. 14. 15. 16.

18. 19.

1. The front of the thorax

2. The back of the thorax Cyrtonieter tracings :

3. of the healthy chest

4. of an emphysematous chest

5. of a rickety chest

6. of a pigeon-breast

of an alar or pterygoid chest

of an unsymmetrical chest

tracing of Cheyne Stokes's breathing

Diagram showing position of the thoracic and abdo

minal organs, with their surface markings 11. Diagram showing the boundaries of the lungs in

health

in emphysema

in senile emphysema

in compensatory hypertrophy

in pneumothorax

in pleuritic effusion

Figure of stethoscopes :

the single

the binaural and differential

Diagram showing the position of the bronchi behind 20. Diagram showing the real size of the heart, and the

size of the absolute cardiac dulness

PAGE

4 5

10 13 15 16 16 19 25

42 46 48 50 52 54

62 63 72

Xll

LIST OF ILLUSTKATIONS.

PAGE

Alterations in cardiac dulness :

21. in aortic disease

22. in mitral disease

23. in pericardial effusion

24. Diagram of the heart's action

25. Diagram of a systolic murmur

26. Diagram of a presystolic murmur

27. Diagram of a short postsystolic murmur

28. Diagram of a long postsystolic murmur

29. Diagram of a systolic and postsystolic murmur Diagram of a presystolic and systolic murmur Diagram of the position of the different parts of the

heart, and of the places at which to examine the

orifices and the axes of the heart 32. Diagram of the hand on the chest to represent the

heart .....

Diagram of the area of cardiac dulness in a case of

mitral stenosis . . .

Diagram of the murmurs and of the heart sounds in

the same case ....

Pulse tracings :

35. diagrammatic ....

41. of the pulsus paradoxus . . . 172

42. Diagram of the chest in a case of mediastinal

30. 31.

HOW TO EXAMINE THE CHEST.

INTRODUCTORY CHAPTER.

THE THORAX.

The Chest or Thorax is a "box, the sides of which are formed by the spine, the ribs and intercostal muscles, and the sternum.

Above, it is closed by muscles and membrane, between which the vessels and other structures pass into, or out of, the cavity of the chest.

Below, it is completely closed by the diaphragm, which is attached, posteriorly to the spine, anteriorly to the sternum, and all round to the free margin of the ribs, or, as it is called, the Costal Arch.

The Parts of the Thorax.

Externally, the thorax is mapped out into certain regions (figs. 1 and 2), named according to the anatomy of the part :

In the middle line, the Sternal, divided into the Upper and Lower Sternal, with the Episternal above : On either side of the sternum,

the Parasternal : Further outwards,

the Clavicular,

the Supraclavicular and Infraclavicular, the Mammary and Inframammary : Laterally,

the Axillary, upper and lower : Posteriorly,

the Supraspinous, and Infraspinous, the Infrascapular and the Interscapular. These terms are useful as indicating roughly the particular region under examination, but, when greater accuracy is required, the locality should be fixed by reference to parts of the bony framework, such as the ribs, sternum, &c.

Measurements are often taken from the nipple as a fixed point, or from a vertical line passing through the nipple, and called the Nipple line ; but from the varying position which the nipple occupies, in different persons, especially in women, such measurements are not satisfactory.

The line which is usually described as the nipple line is a vertical drawn from the middle point of the clavicle downwards. This cuts the edge of the costal arch, usually at the tip of the

THE THORAX. 3

eighth rib, and in ordinary cases passes through the nipple.

The Contents of the Thorax.

The thorax contains :

1 . The Lungs.

2. The Heart.

3. The parts in the Mediastinum. Closely related as all these organs are to one

another, it is impossible to limit our examination absolutely to one or other of them ; but for convenience we may divide our subject in this way, making reference, in our description of one organ, to the others, only so far as may be necessary for clearness.

Position of the Patient.

When the chest is being examined, it should, if possible, be completely bare.

To examine the front of the chest, the patient should stand, or sit, straight up, with the arms hanging down, or, if lying down, should be flat upon the back, with the arms by the side and the legs straight.

To examine the back of the chest the patient should sit or stand with the arms folded, the shoulders rounded, and the head bent forward, so as to make the back as broad and round as possible, and to widen the interscapular spaces.

HOW TO EXAMINE THE CHEST.

Fig. 1

Diagram of the front of the thorax and abdomen. The vertical lines are the nipple lines. The figures refer to the named regions.

1. The supraclavicular.

2. The clavicular.

3. The infraclavicular.

4. The mammary.

5. The inframammary.

6. The hypochondriac.

7. The epi sternal.

8, 9, 10. The upper, middle, and lower sternal. 11. The epigastric.

The umbilical.

The hypogastric.

The lumbar.

The inguinal.

12. 13. 14. 15.

THE THORAX.

Fig. 2.

Diagram of the back of the thorax. The letters refer to the named regions.

A. The supraspinous.

B. The infraspinous.

C. The infrascapular.

D, E. The interscapular.

The Methods of Examination.

In our examination of the chest we use the senses of sight, touch, and hearing, and we arrange our observations accordingly, under the three heads of :

1. Inspection, i.e. what we can see.

2. Palpation, i.e. what we can feel.

3. Auscultation and Percussion, i.e. what we can hear.

These methods are applicable to all parts of the body, though, not in an equal degree, but they are of chief importance in the examination of the chest.

Any other methods which may be available in certain cases will be referred to and described as occasion arises to make use of them.

It is desirable, so far as possible, to represent in a graphic form all the information we obtain. Ways of doing this will be suggested as opportunity offers.

We shall commence with the systematic examination of the lungs, then proceed to the examination of the heart, and lastly, of the mediastinum.

Our observations will be arranged in order under the heads of Inspection, Palpation, Percussion, Auscultation.