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RM2ANFCF1–Transactions . d to the dorsum. The pleuritic fric-tion sounds excited near the apex and over thedorsum are easily distinguished from the heartsfriction sounds. The dulness on percussion thatoften exists in pleuritis, prevents the pericardialeffusion from being accurately mapped out. Veryoften pleuritis prevents the inspiratory motion ofthe chest. ENLARGEMENT OF THE HEART WITHOUT PERI-CARDIAL ADHESION. When the heart is enlarged, its surface beingfree from attachments, the lungs on each side, thediaphragm below, and the costal cartilages and ribsin front, are displaced. The whole volume of the
RM2AG2TCP–. Medical diagnosis for the student and practitioner. Fig. 134.—Emphy-sema. Attitude fre-quently assumed inmarked cases, conceal-ing barrel form ofchest. DISEASES OF THE LUNGS AND PLEURA 353. Fig. 135.—Emphysema (barrel chest). Samechest, patient in dorsal recumbent posture. inspection and reveals an enfeebled vocal fremitus; a weak or wholly obscuredapex beat, and some downward displacement of the liver. The author has seldom or never seen a well-marked case lacking somedegree of arteriosclerosis. Percussion.—Percussion develops hyperresonance; low position of the lungborder, impaired, moveme
RM2AKHW8N–Albany medical annals . The right apex is contracted and the expansion is diminished at theleft base. Examination of December 23, 1912. 86 PNEUMOTHORAX, WITH A REPORT OF THREE CASES. MALCOLM DOUGLAS 87 Examination of his chest showed (see Fig. I) on percussion, a dullnote anteriorly on both sides of his chest extending down to the secondinterspace with corresponding increase of vocal resonance and bronchialbreathing. In the back the same condition existed down as far as thesixth vertebral spine on both sides. There were many rales on quietbreathing especially on the left side and posteriorly o
RM2ANFY89–Diseases of the chest and the principles of physical diagnosis . ^ occur. Cardiac dul-ness extends further to the left beyond the apex impulse than is the casein hypertrophied hearts. Dulness in the fifth right intercostal spacenear the sternum (Rotchs sign) is sometimes demonstrable quite earlyin the effusion stage. Stress is sometimes laid upon the fact that the HEART MURMURS 259 heart dulness in pericardial effusions tends to be pyriform, but this iscertainly not always the case. An area of percussion dulness at theangle of the left scapula together with bronchial breathing, etc., fre-quent
RM2AJE6T1–A treatise on orthopedic surgery . Marked lateral deviation ofthe spine with rotation. De-formity at the eighth dorsalvertebra. TUBEBCULOUS DISEASE OF THE SPINE. 55 sis of Potts disease and its differential diagnosis are consideredin more detail elsewhere. Abscess as a complication of disease of the thoracic regioncannot be demonstrated by palpation unless it has found anoutlet between the ribs, but percussion will often show an areaof dulness or flatness extending from the diseased vertebraetoward the lateral aspect of the chest. This is due in part. Fig. 23.. Double psoas contraction of an e
RM2ANDT46–Diseases of the chest and the principles of physical diagnosis . dition seemed toindicate a chronic inflammatory condition of the left base with dilatationof the bronchi at the root of the lung. The X-raj^ examination showed apartial pneumothorax with the lung adherent at a point lateralh^ and atthe base. Ten days later the foregoing signs had disappeared. Thebreath sounds were perfectly clear except at the extreme base where thedulness on percussion and distant breathing pointed to a small effusion.A second X-ray examination confirmed these findings. DISEASES OF THE PLEURA 627 In the majority
RM2AWGNMX–The Practitioner . Respiration 28 per minute, not laboured.He has a frequent cough, which is somewhat paroxysmal and isnot suppressed to any extent. He brings up small quantitiesof slightly frothy mucopurulent sputum. Examination of chest shows it to be rather flat but fairlywell formed. Expansion is equal on the two sides. Vocalfremitus is well marked everywhere, except over the left baseposteriorly, where it is slightly lessened. Percussion shows slight impairment of note over the leftbase posteriorly, and also a rather high-pitched note over theleft apex posteriorly. Palpation reveals the p
RM2AWD5BF–Diseases of the chest and the principles of physical diagnosis . ., right subclavian vein; L.I.V., left innominate vein. If one lung becomes infiltrated, its percussion note becomes higher in pitch, notby virtue of any nevi^ sound element added, but on account of the loss of the deepertones. The note of consolidation is, therefore, to speak accurately, not actuallyhigher but relatively less low. It is the prominence of the low-pitched notes whichcauses what we know as resonance. The difference between a resonant and a dullnote lies, however, not only in the rate of the vibrations (pitch) but a
RM2AX6Y74–A manual of auscultation and percussion; . The longitudinal and vertical lines indicate the regional divisions onthe posterior aspect of the chest. ab, lower boundary of lungs; cd, lower limit of expansion of lungs:ef, interlobar fissures; h, spleen; /.lower boundary of liver: k. leftkirlney; /, right kidney. REGIONAL DIVISIONS OF THE CHEST. 37 the clavicle. The infra-clavicular region embraces thespace between the clavicle and the third rib. Themammary region is bounded above by the third and. The horizontal line indicates the regional division of the lateralaspect of the chest. ab, lower bou
RM2AN2P69–Organic and functional nervous diseases; a text-book of neurology . ork.Examination in January, 1897,showed a very marked condition ofatrophy with corresponding paral-ysis in the muscles of both upper ex-tremities, chest, scapulae, and back,as shown in the picture. (Fig.144.) No muscle was entirely para-lyzed, but all the muscles were ex-tremely weak, presented fibrillarycontractions on exposure to cold oron percussion, but did not showany reaction of degeneration. Theatrophy was most extreme aboutthe muscles of the scapulae and inthe deltoids and upper part of the arms. The muscles of the tho
RM2ANCC20–Diseases of the chest and the principles of physical diagnosis . pplyingthe palm of the hand firmly over the manubrium. A systoHc thiill local-ized over the aortic area and a diastolic shock in the same region are not 816 DISEASES OF THE PERICARDIUM, HEART, AND AORTA infrequent. If aortic insufficiency is present, there may be a diastolic thi-ill.Except in those cases in which dilatation has been produced by arterialhypertension the blood-pressure is, as a rule, low. Percussion.—Dulness over the manubrium above the level of thesecond ribs may be caused by extension of the aorta upward; this is
RM2AFTA6E–. Diseases of the heart and thoracic aorta. tory murmur was audible over the usual position ofthe heart, but the heart sounds could not be heard. Very distinct pulsation could be seen and felt in the third, fourth,and fifth right interspaces (see fig. 25) ; there was marked dulness overthe area of pulsation; and the heart sounds were loudly heard over thesame part of the chest. The percussion note over the outer part of theright infra-clavicular region was impaired, but the right lung, both ante-riorly and posteriorly, seemed normal. The liver was situated on theright side; and the stomach in
RM2ANJB8Y–Diseases of the chest and the principles of physical diagnosis . nin adults (see vocal resonance). The apex heat is in the fourth interspace,just within or even to the left of the left mid-clavicular line. 1 For assistance in the preparation of the following paragraphs, we are indebted toDr. J. C. Gittings. 138 PHYSICAL FINDINGS IN INFANTS AND YOUNG CHILDREN 139 Percussion.—Percussion must be extremely light—finger percussion isoften necessary. If a forcible stroke be employed the whole lung as wellas the neighboring abdominal viscera will be thrown into vibration andtopographic percussion wil
RM2AWY6HE–Clinical tuberculosis . phere of vibration causedby percussion; e-d, the shadow area, is wiiolly within the lung and does not reach theheart; /, is partly in lung tissue and partly in the heart, consequently it gives informa-tion. (Sahli.) As explained throughout these pages, this conception is erroneous. Thedeep borders of the heart may be outlined by a touch or I)y a stroke so light tliat it isbarely audible. is of special iiiiportaiice in all chest coiiditidus. There are manyiiictliods of percussion but there are niiiie superior to finger-fin-ger percussion if the examiner is skilled in its
RM2AG966X–. The diseases of children : medical and surgical. nsohdated lung can be detected by percussion, the presence of consonantintensely ringing rales with a temperature of 103° or 104° points almost cer-tainly to pneumonia. A A 2 j:) Diseases of the Respiratory Apparatus In the early stages the respiratory murmur is weak, later there is mostlywell-marked bronchial breathing over the dull area. If a fatal result isabout to occur, the respirations become more hurried, the distress greater,and the pulse weaker and weaker ; rales and rhonchus are heard o^?er thewhole chest, the heart flags, and the ch
RM2AWD7CY–Diseases of the chest and the principles of physical diagnosis . Fig, 72.—1, Plexor or percussion hammer; 2, ivory pleximeter; 3 and 4, Hirschfelderspleximeter; 5, Sansoms pleximeter.. Fig. 75. Fig. 74. Figs. 73 and 74.—The method of percussion. The percussion blow is struck from thewrist only, the forearm being practically stationary. The impact, which is delivered justbehind the nail of the middle finger, should be quick and brief in duration, the force of theblow should fall as vertically as possible. Fig. 73 shows the beginning, Fig. 74 the endof the percussion stroke. In order to delive
RM2AWD657–Diseases of the chest and the principles of physical diagnosis . hboringsolid organs upon those filled with air. Such a dulling influence does notexist (Sahli). The strength of percussion must vary with the size andcharacter of the organs and neighboring tissues: e.g., in children (thinchest walls, superficial organs) light percussion is necessary; in corpulentadults (thick chest walls, deeply placed organs) heavier percussion isrequired. 1 Moritz and Rihl: Deul. Arch. f. kl. Med., 1909. METHODS AND RESULTS OF PERCUSSION 85 As has been stated, the percussion note obtained over the lung is acom
RM2AX6XHT–A manual of auscultation and percussion; . The horizontal line indicates the regional division of the lateralaspect of the chest. ab, lower boundary of right lung; cd, lower boundary of hepaticflatness ; cj upper boundary of hepatic dulness; g, border of kidney. 38 INTRODUCTION below by the sixth rib, and the infra-mammary regionis the portion of the chest below the sixth rib. Posteriorly the divisions are into the scapular, theinfra-scapular, and inter-scapular regions. The scapular Fig. 4.. ab, boundary of hepatic flatness; <•-. lower boundary of left lung:(../. </. h, i, k. 1. bounda
RM2AKHRB7–Albany medical annals . Patient in right lateral position. A. Percussion note is hyperresonant from 2nd rib to area of liverdulness. except over fluid (B).Left side of chest posteriorly not examined.Examination of March 30th, 1912. at this time (see Fig. IV) gives a combined picture of pulmonary tuber-culosis and shock; a somewhat lower temperature with very markedvariations and a very noticeable increased rate of pulse and respiration. The points of particular interest in this case were:1. He had no recollection of any acute onset of the trouble.The leakage of air into his pleural cavity had
RM2ANH1Y2–Diseases of the chest and the principles of physical diagnosis . Fig. 167.—^The anterior chest wall viewed from behind. This, the first of a series ofsections, shows the anterior wall of the heart viewed from within, surrounded by the lungs-R.V., anterior wall of right ventricle; S, stomach; D, diaphragm. point is indicated by a diminution of pulmonary resonance and willgenerally correspond to the upper border of the third rib. (2) Percussfrom the left mid-axillary line toward the heart and note the point atwhich, over different ribs or interspaces the percussion sound becomes 206 PERCUSSION o
RM2AX6YKN–A manual of auscultation and percussion; . The horizontal lines indicate the boundaries of the regional divisionson the anterior aspect of the chest. The vertical line is the linea mam-illaris. The oblique dotted lines indicate the interlobar fissures. ab,ac,cd, and bd, boundaries of superficial cardiac space, pouterboundary of deep cardiac space; ce, lower boundary of right lung; df,lower boundary of left lung; gh, upper boundary of right and left lung ;Im, lower boundary of hepatic flatness; pq, upper boundary of hepaticdulness; no, lower boundary of the stomach moderately distended. 36 INTR
RM2AWD6KM–Diseases of the chest and the principles of physical diagnosis . ed was to the eflfect that percussion -v-ibrations penetrated only 5to 7 cm., thus only -t to 5 cm. into the lung itseK. This beUef was founded on the factthat liver dulness could not be demonstrated when more than 4 to 5 cm. of lung tissueoverlay it. The following experiments show that even light percussion has a deeppenetration. I. Moritz and Rihl beat up into a spongy froth, a solution of stiflfening gelatin towhich formalin and carbohc acid had been added, this closeh* resembling lung tissue in METHODS AND RESULTS OF PERCUSSI
RM2ANE7X0–Diseases of the chest and the principles of physical diagnosis . Fig. 339.-Showin, area .kodaic tympany (Garlands triangle).. r,^. 340.-Upper and lower Umits of dulness in a massive effusion. In massive effusions the highest point of cMness^^^^^^^spine (see Fig. 340) and ^^^^fZ^^J^^^^^^ character but lapsed portion of the lung the ^^^^^^^^J^^^^^^^ devoid of air the if?the king has been so completely compiesseci as lo je 584 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAG.M note will be dull. In massive effusions the flat or dull percussion noteanteriorly may be elicited some distance to t
RM2AG6W60–. The diseases of infancy and childhood : designed for the use of students and practitioners of medicine. Fig. 162.—Interlobar empyema of the left .side. (Roentgen ray.). Fig. 163.—Effusion over the left side rpm|wor,mi /^^n^ ^fiy ) DISEASES OF THE PLEURA 639 this quality over the whole diseased side of the chest behind, or thetubular sound may be conducted to the healthy side. The voice maybe normal above and heard faintly below, toward the base of the lung.Diagnosis before exploratory puncture rests mainly on (a) com-plete absence of fremitus; (b) absolute flatness on percussion withresistan
RM2AWDHJP–Diseases of the chest and the principles of physical diagnosis . tines are more elastic, vibrate more readily and more complexly, furnish moreovertones which produce a clearer, louder, longer, higher pitched, more intense andmore musical sound (tympany). Solid organs on the other hand—hver, spleen,thigh—yield but few overtones, hence the sound is shorter, weaker and more mufHed.Percussion of normal lung produces a larger wave amplitude—louder sound—thanthat of airless structures. 68 THE EXAMIXATIOX OF THE LUNGS The dull note obtained by percussing pulmonary consolidation ischaracterized by the
RM2AN823W–The medical examination for life insurance and its associated clinical methods : with chapters on the insurance of substandard lives and accident insurance . Fig. 6i.—Pleural Effusion.Especial attention should be directed to the compressed lung in the larger effusion. THE l Wll I I OF THE l I 111 CHEST l i ? i.( noN. Fig. 62. -Lobar Pneumonia (Left); Central Pneumonia (Rigb The lobar consolidation on the right side would present the 1 lassie signs olplete solidification with patent bronchi. ntral ana of consolidation would yield no percussion signs, and be chieflydenoted by distant tubu
RM2ANF9RD–Diseases of the chest and the principles of physical diagnosis . re obtained: Per.Cent Whispering pectoriloquy 53 out of 58 (91.3) Tympany (on percussion) 39 out of 58 (67.4) Cavernous or amphoric breathing 38 out of 58 (65.5) Gurghng or consonating rales 33 out of 58 (58.6) 362 DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM Although none of the above signs are pathognomic of a cavity thepresence of anj^ one of them is suggestive and the probabihty of its exist-ence is increased by combinations of any two or more of them. Twosources of error are to be borne in mind: (1) Consohdated pulm
RM2ANJARN–Diseases of the chest and the principles of physical diagnosis . .yield a cracked-potsound (p. 69). Percussion is generally less satisfactory than auscultation.The sense of resistance is often a valuable criterion in deciding betweenconsolidation and liquid effusion. The heart is large, lies higher in the thorax, as well as more horizon-tally. Cardiac dulness, therefore, normally extends relatively further tothe left than in adults. It may normally extend >^ inch beyond the mid-clavicular line. Dulness due to the right auricle, however, rarely extendsbeyond the sternal line. The great vesse
RM2AG6W1F–. The diseases of infancy and childhood : designed for the use of students and practitioners of medicine. Fig. 163.—Effusion over the left side rpm|wor,mi /^^n^ ^fiy ) DISEASES OF THE PLEURA 639 this quality over the whole diseased side of the chest behind, or thetubular sound may be conducted to the healthy side. The voice maybe normal above and heard faintly below, toward the base of the lung.Diagnosis before exploratory puncture rests mainly on (a) com-plete absence of fremitus; (b) absolute flatness on percussion withresistance to percussion; (r) bronchial voice and breathing over thewhole
RM2AG3A09–. Medical diagnosis for the student and practitioner. Absolute liverdulness. Tracing theborder. Normallytympanitic. Clinical value. 28o MEDICAL DIAGNOSIS. Fig. 93.—Percussion areas, normal chest(anterior surface). Lungs—red. Liver—horizontal black lines. Relative cardiacdulness—vertical black lines. Absolutecardiac dulness—cross-hatching. Stomachtympany—oblique red lines. This repre-sents the incomplete cardiac area obtain-able by flat-finger percussion in the normalheart. The more modern methods closelyapproximate the x-ray outline and shouldbe used^exclusively. Fig. 94.—Percussion areas (nor
RM2ANGXHB–Diseases of the chest and the principles of physical diagnosis . dilatation and pulsation are demonstrable.^ 1 Pesci, G. : Laugmento di volume della brecchietta sinistra del cuore nel quadroradiologico. Radiologia med., I, 1914, 106. Wt^* ^<^^ QQJiUB^^ ...ViB SHY PERCUSSION OF THE HE 213 Increased dulness at the base is generally due to dilatation or aneur-ism of the aorta (Figs. 409, 412); it may in rare instances be due to apatulous ductus arteriosus. This lesion produces a quadrilateral area ofdulness to the left in the second (and first) interspace. Accurate outliningby percussion of t
RM2AG39GB–. Medical diagnosis for the student and practitioner. Fig. 93.—Percussion areas, normal chest(anterior surface). Lungs—red. Liver—horizontal black lines. Relative cardiacdulness—vertical black lines. Absolutecardiac dulness—cross-hatching. Stomachtympany—oblique red lines. This repre-sents the incomplete cardiac area obtain-able by flat-finger percussion in the normalheart. The more modern methods closelyapproximate the x-ray outline and shouldbe used^exclusively. Fig. 94.—Percussion areas (normalchest, posterior surface), a, a. Lungs.b, b. Pleural space, c. Spleen, c. Liver.d, d. Kidneys. Are
RM2AFT789–. Diseases of the heart and thoracic aorta. Fig. 33.—Stiperfuial vieiu of the organs of the chest and abdojnen from the front,shozoing the part of tlie heart uncovered by hmg. {Enlargedfrom Sibson.) 124 Diseases of the Heart.. Fig. 34.—The area ofprcecordialdtilness in middle age. (After Weil.) ABCD, area of superficial or absolute cardiac dulness ; AIK, area of im-paired percussion or deep dulness; CE, lower border of right lung; DF, lowerborder of left lung; G and H, upper borders of lungs; PQ, upper border of hepaticdulness ; LM, lower border of hepatic dulness ; NO, lower border of stomach
RM2CE5BEX–. A manual of auscultation and percussion : embracing the physical diagnosis of diseases of the lungs and heart, and of thoracic aneurism . spar-agement to physical diagnosis that its reliability dependson other facts than those which belong exclusively to it.To repeat a statement already made more than once,the significance of the signs, as regards the conditionswhich they severally represent, is based on the constancyof their association with the latter, our knowledge ofthis association being derived from examinations duringlife and after death. Regional Divisions of the Chest. Before enteri
RM2CDAEH6–. Physical diagnosis . Germany instruments are still used to a considerable extent. (a) Mediate and Immediate Percussion. Percussion may be either mediate or immediate, the lat-ter term referring to blows struck directly upon the chest with theflat of the hand, or upon the clavicles with the tip of the secondringer. Methods. Mediate percussion (which is used ninety-nine hundredths of thetime) is performed as follows: The patient should either lie down or sit with his back againstsome support. The reason of this is that for good percussion oneneeds to press very firmly with the middle finger of
RM2CJ4M1D–. Physical diagnosis . Area of cardiacdulness. Fig. 171,-Small Pleural Effusion Accumulating (in part) near the Right Border of the Heart. could have been suspected from the percussion outlines; on the otherhand, the dulness may be extensive and intense on account of greatinflammatory thickening of the costal pleura, by the accumulation 340 PHYSICAL DIAGNOSIS. of layer after layer of fibrinous exudate and its organization intofibrous plates, while very little fluid remains within. The amount of dulness depends also upon the thickness and elasti-city of the chest wall and the degree of collapse
RM2CEWX7W–. Diseases of the heart and arterial system; Designed to be a practical presentation of the subject for the use of students and practitioners of medicine. rdiacdulness may be due to an associated or antecedent cardiac or pul-monary affection. Vesicular emphysema, chronic pleuritic effu-sion or hydrothorax, and cirrhosis of the right lung, may renderunavailing any attempt to determine by percussion the accuratesize of the right heart. In vesicular emphysema the borders ofthe lungs are distended, pushing the heart away from the chest-wall and occasioning such a?degree of hyperresonance thatthe l
RM2CDANWA–. Physical diagnosis . nes and divisions such as are frequently forced upon the 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 referenceto the bones of the chest. 2. The position of certain points which experience has taught ushave a certain value in physical diagnosis. I mean (a) the so-calledvalve areas of the heart, which do not correspond to the actualposition of the valves, for reasons to be explained later on, and (6) INTRODUCTION 63 the percussion outlines of the heart, liver, and spleen. These outl
RM2CE5B68–. A manual of auscultation and percussion : embracing the physical diagnosis of diseases of the lungs and heart, and of thoracic aneurism . should be applied to the chest, with pressure sufficientto condense the soft structures, and the blows are given Fig. 7.. Flints Percussor. with one or more of the fingers of the right hand bentat the second phalangeal joint so as to form a rightangle. In giving the blows, the movements should be NORMAL RESONANCE. 45 limited to the wrist-joint, the ends, not the pulp, of thepercussing fingers being brought into contact with thedorsal surface of the finger
RM2CDA40Y–. Physical diagnosis . icinity of the second right intercostal spacenear the sternum. Previous to perforating the thoracic parietes, thegrowth of the aneurism may give rise to pain, pulsation, and dulnessand thrill in this region. (b) Aneurism of the transverse arch or diffuse dilatation of theaorta, which is the most common of all types of aortic aneurism, maynot give rise to any visible pulsation of the chest wall, and, if deep- 270 PHYSICAL DIAGNOSIS seated, need not produce any abnormal dulness on percussion. Insuch cases an aneurism is to be recognized, if at all, by evidences ofpressure
RM2CRRJX9–. A practical treatise on medical diagnosis for students and physicians . rom themedian line. The percussion-dulness is at the base of the chest andquite extensive. Arterial murmurs are not present. The pulsation is influ-enced by pressure and by respiratory movements. In mediastinal cancer we are aided by the discovery of enlargement ofthe glands in the axilla, neck, or elsewhere, or by a history of the growthin some other area. Aneurism must not be confounded with phthisis. The diseased vesselmay occlude a bronchus and cause collapse and bronchial dilatation; hem-orrhage may occur; bronchorr
RM2CJ7902–. Physical diagnosis . Fig. 76.—The Wrong Way to Percuss—i. e., From the Elbow. for which the percussion is used—that is, upon what organ we arepercussing—and also upon the thickness of the muscles coveringthat part of the chest. For example, it is necessary to percussvery strongly when examining the back of a muscular man, wherean inch or two of muscle intervenes between the finger on which PERCUSSION. 123 we strike and the lung from which we desire to elicit a sound.Over the front of the chest and in the axillae the muscular coveringis much thinner, and hence a lighter blow suffices. In chil
RM2CRK5DB–. A practical treatise on medical diagnosis for students and physicians . Flints plessor.. Percussion—showing method of delivering the blow. stoop forward with his arms folded. While this renders the musclesmore tense, it has the advantage of exposing a larger portion of the 384 METHODS OF PHYSICAL DIAGNOSIS. chest. When the patient is confined to bed, if not too ill, he shouldbe allowed to sit up during percussion, as contact with the bed-clothes orwith the pillows deadens the sounds elicited. This fact should be bornein mind when from any cause it is not desirable to have the patient sit up.
RM2CJ6HE2–. Physical diagnosis . percussion, and uponthe condition of the pulmonary and peripheral circulation, asshown in the other symptoms and signs of the cases (dropsy, cough,etc.). (4) Intensity of Murmurs.—Sometimes murmurs are so loudthat they are audible to the patient himself or even at some dis-tance from the chest. In one case I was able to hear a murmureight feet from the patient. Such cases are rare and usually notserious, for the gravity of the lesion is not at all proportional to AUSCULTATION OF THE HEART. 191 the loudness of the murmur; indeed, other things being equal,loud murmurs are
RM2CJ5BGX–. Physical diagnosis . so slight that the sphygmograph has to be employedto demonstrate differences in the shape of the wave not perceptibleto the fingers. Examination of the heart itself may show some dislocation ofthe organ to the left and downward, owing to the direct nressureof the aneurismal sac, but no enlargement. II. Percussion. If the aneurism is deep-seated, the results of percussion arenegative. If? on the other hand, it be situated immediately be* THORACIC ANEURISM. 285 neath the sternum or close under the thoracic wall, an area of dull-ness, not present in the normal chest, may be
RM2CE5BA9–. A manual of auscultation and percussion : embracing the physical diagnosis of diseases of the lungs and heart, and of thoracic aneurism . The horizontal line indicates the regional division of the lateralaspect of the chest. ab, lower boundary of right lung; cd, lower boundary of hepaticflatness ; ef, upper boundary of hepatic dulness ; g, border of kidney. 3 38 INTRODUCTION. below by the sixth rib, and the infra-mammary regionis the portion of the chest below the sixth rib. Posteriorly the divisions are into the scapular, theinfra-scapular, and inter-scapular regions. The scapular Fig. 4..
RM2CRPJ60–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent : designed for the use of practitioners and students . d. The following cases, and cases given on pages 285 and 286, illustratethis point: — Mary F. D. Entered my service at the Boston City HospitalMay 7, 1898. The right chest contained fluid which pushed the heartto the left; this displacement was recognized by the X-rays, but not bypercussion. It may be that displacements are sometimes not readilyrecognized by percussion because the heart is pushed into the body ofthe lung rather than along or near
RM2CRKF79–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent; designed for the use of practitioners and students . d. The following cases, and cases given on pages 285 and 286, illustratethis point: — Mary F. D. Entered my service at the Boston City HospitalMay 7, 1898. The right chest contained fluid which pushed the heartto the left; this displacement was recognized by the X-rays, but not bypercussion. It may be that displacements are sometimes not readilyrecognized by percussion because the heart is pushed into the body ofthe lung rather than along or near t
RM2CDAE5T–. Physical diagnosis . Fig. 96.—Position of the Hands When Percussing the Left Apex.. Fig. 97.—The Right Way to Percuss—i.e., From the Wrist. PERCUSSION 123 chest with the second finger of the left hand1 on the dorsum of whichthe blow is to be struck. Raise the other fingers of the left hand fromthe chest so as not to interfere with its vibrations. (2) Strike a quick, perpendicular, rebounding blow with the tipof the second finger2 of the right hand upon the second finger of theleft just behind the nail, imitating as far as possible with the right
RM2CRPJ4T–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent : designed for the use of practitioners and students . heart is often difficult to place by percus-sion, because it lies away from the chest wall. The thickness of thiswall is another important factor to be taken into account when consid-ering the accuracy of percussion. That is, varying distances of theborder of the heart from the chest wall and variations in the thicknessof this wall would affect the results obtained by percussion. In a word, percussion as a rule indicates what hes near the innersid
RM2CRHM7N–. A practical treatise on medical diagnosis for students and physicians . line. The percussion-dulness is at the base of the chest andquite extensive. Arterial murmurs are not present. The pulsation is influ-enced by pressure and by respiratory movements. In mediastival cancer we are aided by the discovery of enlargement ofthe glands in the axilla, neck, or elsewhere, or by a history of the growthin some other area. Aneurism must not be confounded with phthisis. The diseased vesselmay occlude a bronchus and cause collapse and bronchial dilatation ; hem-orrhage may occur; bronchorrhoea and coug
RM2CRKEGK–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent; designed for the use of practitioners and students . heart is often difficult to place by percus-sion, because it lies away from the chest wall. The thickness of thiswall is another important factor to be taken into account when consid-ering the accuracy of percussion. That is, varying distances of theborder of the heart from the chest wall and variations in the thicknessof this wall would affect the results obtained by percussion. In a word, percussion as a rule indicates what Hes near the innerside
RM2CRT23T–. A practical treatise on medical diagnosis for students and physicians . ) dulness. Modifications of these typesrepresent all sounds produced under every variety of circumstances. Resonance. The term resonance, or pulmonary resonance, is appliedto the clear sound that is produced by percussion over the lungs, due tothe vibration of the chest-walls and of the air in the bronchi. Fig. 90. Relative Dulnessof Heart. Absolute Dulnessof Heart Splenic Dulness.Gastric Tympany Showing the areas of resonance, dulness, and tympany in health. Dulness. Dulness indicates the absence of air. The sound over
RM2CRK97K–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent; designed for the use of practitioners and students . and chest. Dyspnoea with cough. Dyspnoeaincreased in severity with some orthopnoea. Has vomited every daysince second day of attack, and complains of sharp pain over praecordia.Much expectoration with cough, whitish and frothy in character. Norusty sputa. PJiysical Examination. — Lungs : percussion note over right frontand upper right back slightly higher-pitched than left; respiratorysounds increased on right, diminished over left. Dulness over lo
RM2CDACH4–. Physical diagnosis . bevery lightly struck, either upon the chest itself or upon the fingerused as a pleximeter in the ordinary way. Some observers use ashort stroking or scratching touch upon the chest itself withoutemploying any pleximeter. PERCUSSION 127 This method is used especially in attempting to map out theborders of the heart and in marking the outlines of the stomach.In the hands of skilled observers it often yields valuable results,but one source of error must be especially guarded against. Theline along which we percuss, when approaching an organ whose bor-ders we desire to mark
RM2CE5BAW–. A manual of auscultation and percussion : embracing the physical diagnosis of diseases of the lungs and heart, and of thoracic aneurism . The longitudinal and vertical lines indicate the regional divisions onthe posterior aspect of the chest. ab, lower boundary of lungs; cd, lower limit of expansion of lungs:ef, interlobar fissures; h, spleen; flower boundary of liver; k, leftkidney; I, right kidney. REGIONAL DIVISIONS OF THE CHEST. 37 the clavicle. The infra-clavicular region embraces thespace between the clavicle and the third rib. Themammary region is bounded above by the third and Fig. 3
RM2CRKPCB–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent; designed for the use of practitioners and students . how a variation in the thickness of the chest wall may alterthe percussion note. This note had misled him in determining part ofthe cardiac outline. A radiograph was also taken of this patient, which shows theappearances seen from the side. (See Fig. 125.) Physical Signs of Tuberculosis hidden by Emphysema; AbnormalCondition of Lungs seen by X-Rays. — The same cause that makes itdifficult or impossible to recognize the cardiac area in pulmonary emp
RM2CRPMHK–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent : designed for the use of practitioners and students . how a variation in the thickness of the chest wall may alterthe percussion note. This note had misled him in determining part ofthe cardiac outline. A radiograph was also taken of this patient, which shows theappearances seen from the side. (See Fig. 125.) Physical Signs of Tuberculosis hidden by Emphysema; AbnormalCondition of Lungs seen by X-Rays. — The same cause that makes itdifficult or impossible to recognize the cardiac area in pulmonary em
RM2CRPFT9–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent : designed for the use of practitioners and students . ith chills.Pain throughout back and chest. Dyspnoea with cough. Dyspnoeaincreased in severity with some orthopnoea. Has vomited every daysince second day of attack, and complains of sharp pain over prsecordia.Much expectoration with cough, whitish and frothy in character. Norusty sputa. Physical Examination. — Lungs: percussion note over right frontand upper right back slightly higher-pitched than left; respiratorysounds increased on right, dimini
RM2CJ7B5X–. Physical diagnosis . Fig. 74.—Position of the Hands When Percussing the Left Apex. sit up with a military erectness. The muscular tension thus pro-duced modifies the percussion note and causes an embarrassingmultitude of muscle sounds which greatly disturb auscultation. Having placed the patient in an easy and symmetrical position,our percussion should proceed according to the following rules: (1) Always press as firmly as possible upon the surface of the PERCUSSION. 121 chest with the second finger of the left hand on the dorsum ofwhich the blow is to be struck. Eaise the other fingers of t
RM2CDAD98–. Physical diagnosis . ce a lighter blow suffices. In children oremaciated patients, or in any case in which the muscular develop-ment is slight, percussion should be as light as is sufficient to elicit aclear sound. Heavy percussion is sometimes necessary but alwaysunsatisfactory, in that the sound which it elicits comes from a rela-tively large area of the chest and does not therefore give us infor-mation about the condition of any sharply localized area. If a car- PERCUSSION 125 penter, in tapping the wall to find the position of the studs, strikestoo hard, he will fail to find the beam, be
RM2CRT24M–. A practical treatise on medical diagnosis for students and physicians . Flints plessor.. Percussion—showing method of delivering the blow. stoop forward with his arms folded. While this renders the musclesmore tense, it has the advantage of exposing a larger portion of the 184 Millions OF PHYSICAL DIAGNOSIS. chest Wlirn the patienl is confined to bed, if nol too ill, In- shouldbe allowed to sit ap during percussion, as contacl with the bed-clothes orwith the pillows deadens the sounds elicited. This fact should be bornein mind when from anj cause it is nol desirable t have the patient .-it u
RM2CE5BEH–. A manual of auscultation and percussion : embracing the physical diagnosis of diseases of the lungs and heart, and of thoracic aneurism . The horizontal lines indicate the boundaries of the regional divisionson the anterior aspect of the chest. The vertical line is the linea mam-illaris. The oblique dotted lines indicate the interlobar fissures. ab, ac, cd, and bd, boundaries of superficial cardiac space, ik, outerboundary of deep cardiac space; ce, lower boundary of right lung; df,lower boundary of left lung; gh, upper boundary of right and left lung;Im, lower boundary of hepatic flatness;
RM2CRJRA8–. A practical treatise on medical diagnosis for students and physicians . the patient, especially if the cavity be longer in one diameterthan in the others. This is due to the change in the relative positions ofthe air and the fluid contained in the cavity. Biermers Change of Sound. The percussion-note over a pueumo-hydrothorax changes in pitch with alteration of the patients position, onaccount of the change in the relative position of the air and the fluid. Bet.l Tympany. This is elicited in pneumothorax by com-j)ercussion.One person li.^tens at the back of the chest while a second person pe
RM2CDA3J6–. Physical diagnosis . he aortic second sound or produce characteristic changes in the pulse,and by the presence of some one of the symptoms above described, suchas tracheal tug, pressure symptoms, abnormal area of percussion dul-ness, x-ray shadow, etc. (c) Simple dynamic throbbing of a normal aortic arch similarto that which occurs in the abdominal aorta may lift the chest wall 272 PHYSICAL DIAGNOSIS so as to simulate aneurism. The other positive symptoms andsigns of aneurism are, however, absent. (d) Pulmonary tuberculosis or cancer of the oesophagus, producingas they may substernal pain, c
RM2CDADX7–. Physical diagnosis . Fig. 97.—The Right Way to Percuss—i.e., From the Wrist. PERCUSSION 123 chest with the second finger of the left hand1 on the dorsum of whichthe blow is to be struck. Raise the other fingers of the left hand fromthe chest so as not to interfere with its vibrations. (2) Strike a quick, perpendicular, rebounding blow with the tipof the second finger2 of the right hand upon the second finger of theleft just behind the nail, imitating as far as possible with the right. Fig. -The Wrong Way to Percuss—i.e., From the Elbow. hand the action of a piano-hammer. The quicker the perc
RM2CRPKY6–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent : designed for the use of practitioners and students . Fig. 131. Thomas R. March 12, 1897. Pleurisy with effusion. First X-ray examination withscreen. Whole of left chest dark; first and second ribs seen faintly ; heart displaced to right. (Cutone-third life size.) with diminished breathing and voice sounds; tactile fremitus muchdiminished; in the left back the same signs, most marked from belowangle of scapula to base; at base, flatness by percussion ; respiratorymurmur absent. PLEURISY WITH EFFUSION
RM2CRKN1D–. The Roentgen rays in medicine and surgery as an aid in diagnosis and as a therapeutic agent; designed for the use of practitioners and students . Fk;. 131. Thomas R. March 12, 1897. Pleurisy with effusion. First X-ray examination withscreen. Whole of left chest dark; first and second ribs seen faintly; heart displaced to right. (Curone-third life size.) with diminished breathing and voice sounds; tactile fremitus muchdiminished ; in the left back the same signs, most marked from belowangle of scapula to base; at base, flatness by percussion; respiratorymurmur absent. PLEURISY WITH EFFUSION.
RM2CGGPX5–. Physical diagnosis . „,» Upper lobe. ^, Lower lobe. , Spleen. Lower lobe.. Upperlobe. Itlirkllelobe. Fig. 38.—Position of tbe Left Lung from the Fig. 39.—Position of the Right Lung from theSides and of the Spleen. Side, and of the Liver. chest walls—will be illustrated in the section on Percussion (seepage 118). CHAPTER IV.TECHNIQUE AND GENERAL DIAGNOSIS. INSPECTION. Much may be learned by a careful inspection of all parts of thechest, but only in case the clothes are wholly removed. A goodlight is essential, and this does not always mean a direct light; forexample, when examining the fron
RM2CD9YNN–. Physical diagnosis . with great shock it is dangerous to move patients at all. The movements of breathing or coughing may bring out a metal-lic tinkle (see above, p. 165). At the base of the chest, over an 1 Osiers Modern Medicine, Vol. Ill, p. 881. 2 Emerson: Pneumothorax, Johns Hopkins Hospital Reports, 1903, Vol. XI. DISEASES AFFECTING THE PLEURAL CAVITY 311 area corresponding to the position of the fluid, an area of dulness maybe easily marked out by percussion, and this area shifts very markedlywith change of position. The shifting dulness of pneumohydrothoraxis strongly in contrast wit
RM2CDACAF–. Physical diagnosis . semilunar tympanitic space. Liver flatness. Fig. 103.—Percussion Outlines in the Normal Chest. II. Percussion Resonance of the Normal Chest. The note obtained by percussing the normal chest varies a greatdeal in different areas. In Fig. 103, the parts shaded darkest arethose that normally give least sound when percussed in the mannerdescribed above, while from the lightest areas the loudest and clear-est sound may be elicited. (a) Vesicular Resonance. The sound elicited in the latter areas is known as normal orvesicular resonance, and is due to the presence of a normal a
RM2CJ4NRY–. Physical diagnosis . ght track, I shall take up first DISEASES AFFECTING THE PLEURAL CAVITY. 339 Percussion. 1. A small effusion first shows as an area of dulness (a) Just below the angle of the scapula. (b) In the left axilla between the fifth and the eighth rib. (c) Obliterating Traubes semilunar area of tympany; or (d) In the right front near the angle made by the cardiac andhepatic lines of dulness (see Fig. 171). In the routine percussion of the chest, therefore, one shouldnever leave out these areas. A small effusion is most easily de-tected in children or in adults with thin chest wal
RMREYK10–. The pathology and differential diagnosis of infectious diseases of animals. Veterinary medicine -- Diagnosis; Communicable diseases in animals. 336 PNEUMONOMVCOSIS not eat, was weak and depressed, respiration labored and from 40 to go per minute. Pulse rapid. Percussion of the chest walls gave a sound that if anything was clearer and louder. Fig. 87. Composite drazving of section of lung through nodule of aspergillus origin. F, fibrin in alveoli. S, fruit hyphae and spores of fungus (Ravenel). than the normal percussion sound. Upon auscultation it was found that the vesicular and bronchial m
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