Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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respirations per minute in grown people at from twelve to twenty ;
in young persons, from fourteen to twenty-four ; in children, about
twenty -six, and in infants about forty- four. But there are other con-
ditions which may materially modify the frequency of respirations —
such as mental excitement, bodily exertions, digestion, temperature,
and other conditions of the air. As a rule, however, if compared
with the pulsations of the heart, it may be said, that durnig one res-
piratory act there are three or four beats of the heart; but these
respiratory motions of the lungs and pulsations of the heart never
correspond in rhythm, as you may easily ascertain by counting your
pulse, and observing your breathing at the 'same time, the pulse
being a little too fast or a little too slow to make up an even count
between respiration and pulsation. This is a very interesting fact,
which it is well to bear in mind. When respiration and pulsation
become synchronous — that is, when upon each act of respiration for a
length of time fall precisely two, three, four, five, or six pulsations—
we may be pretty sure that death is near. My attention was first
drawn to this interesting fact by Dr. Hering. Since then I have
found it verified many times. Its explanation is another matter.
We might, perhaps, explain it, if we remember that the heart's
action is governed mainly by the sympathetic nerve, whilst the lungs
are under the control of the vagus, though each of them sends branches
to the other organ, the sympathetic to the lungs, and the vagus to
the heart. The sympatheticus is the great nerve of organic life, and



138 THORAX.

under its direction all tlie functions of the body are performed, wliicli
are entirely out of the reach of the will. It arises from a series of
ganglia, extending along each side of the vertebral column from the
head to the coccyx. The vagus has its origin in the brain, and its
fibres may be traced through the fasciculi of the corpus restiforme
into the gray substance of the floor of the fourth ventricle, and there-
fore the parts to which it is distributed are more or less under the
control of the will. When death approaches, or, in other words,
when the separation of soul and body commences, those functions
which are more or less under the control of the wall are most
probably the first to cease. The vagus losing its influence upon
the luns-s, their action is now continued under the sole direction of
the sympatheticus as long as organic or vegetative life stfll continues ;
thus respiration and pulsation act in full harmony — become perfectly
synchronous.

" The respiratory motion of the chest itself in ordinary health ia
comparatively slight, in consequence of the thoracic cavity being
enlarged in every direction nearly simultaneously. It resembles
the easy ebb and flood of a soft wave. When, however, a deep res-
piration is taken, it is observed that the sternum is slightly but
steadily projected forward, the abdominal parietes gently dilated.
The lower ribs are first and most considerably raised, and the eleva-
tion of each separate rib takes place gradually, evenly, and regularly
upwards, notwithstanding which, each and all appear to move at the
same time. Every part acts separately, but each in perfect harmony
with the other." Hughes.

The form of the thorax must also be taken into consideration, and
this must always be done by comparing one side with the other. In
this way, if we bear in mind the natural motion and the natural
shape of the thorax, ocular inspection will reveal the following
noticeable facts :

1. The upper ribs sink away from the clavicle, become flattened
and motionless, while, in many cases, the movement of the lower
ones is not interfered with, and, as a general rule, the change is more
evident on one side than on the other. This is a sign of advanced
phthisis. Barclay.

2. The chest is full and rounded ; the ribs stand out, but have a
very slight range of movement, and the inspiratory effort is marked
by powerful traction of the muscles of the neck ; the movement of
the lower part of the chest is very often inward in place of outward,
during inspiration. (Barclay.) These are some of the physical signs



PALPATION — MANUAL EXAMINATION. 139

of em-pliysema of tlie lungs, that morbid state in which the volume
of the organ is increased in consequence either of the dilatation of
the air-cells or, what is of rarer occurrence, of the escape of air into
the space between the lobules or beneath the pleura.

8. Only one side bulges, the intercostal spaces are obliterated and
the respiratory motion is annihilated. This is a sign of hydrothorax —
a collection of serous effusion — or a sign of •pneumothorax — a collec-
tion of gas or air into the pleural sac.

" But in many advanced cases of pleuritic effusion, of empyema
(collection of pus) and of pneumothorax, with effusion, not only, as
before stated, is the side not enlarged, but it is, on the contrary, con-
tracted ; and not only are the intercostal spaces not widened and
prominent, but they are actually much narrowed. Herein exists a
notable example of that which is so necessary to bear constantly in
mind, that the results of one mode should be carefully compared with
"those deduced from other modes of physical examination, and the
whole weighed together with the observations derived from the history
and the constitutional symptoms of the case under examination. Be-
cause the side is contracted, and the intercostal spaces narrowed, as
observed upou inspection, it might be hastily assumed that there was
no fluid in the chest, while in truth the contracted side might be
actually filled with pus or serum, and the other, supposed from its
greater size to be the one diseased, might be quite healthy." Hughes.

4. A general fulness or roundness of the precordial region may be
sometimes observed. This is the case when the heart has been en-
larged for a considerable time, or when fluid effusion has long existed
in the pericardium. Nota bene : A broken rib may bulge out too !

5. Without any deviation in form, a remarkable stillness and want
of movement may be observed either of a whole side or only a part
of it. This is a sign of inflammation of the pleura in its early
stage.

6. The thoracic hreathing, when the diaphragm is not moved, is a
sign of 'peritonitis ; the abdominal breathing, when the ribs are not
moved, is a sign either of inflammation of the chest, or of paralysis
of the respiratory nerves, except the phrenic, from injury of the
upper part of the spinal cord.

II. Palpation — Manual Examination.

This is a method of using the hand with its sense of touch, for the
elimination of certain conditions of the thorax. We may merely tap
with one finger, or lay the whole hand upon the parts to be exam-
ined, press or glide gently over the surface, according to the require-



140 THORAX.

ments of the case. In this way we become cognizant of temperature,
form, resistance and m^otion of these parts.

The temperature, if raised to calor mordax^ fairly burns and stings
the examining hand, and is found on the chest in far advanced pul-
monary complaints.

The /o?'m. When it is inconvenient to expose the chest of a patient,
the appressed fingers of one hand placed flatly and pressed firmly upon
the infra-clavicular region of one side, while the other is similarly
placed and pressed upon the corresponding region of the other side,
are often capable of distinctly appreciating a flatness of one side, or a
difference in the pliability or expansibility of the two sides, even in
the early stages of phthisis.

The resistance depends upon the character of the parieties and the
contents of the thorax. The resistance of the parieties is greater, the
more convex, stiff and strong the thoracic bones, and the narrower the
intercostal spaces are. It is more yielding where the contrary con-
ditions exist. In the acromial region the resistance to pressure in-
creases when the muscles are put upon the stretch. The resistance of
the contents of the thorax increases in the ratio as they are compressed.
Whether there be much or little air, water or pus collected in the
cavity, it has no influence upon its resistance to external pressure.
But when this air, water or pus becomes compressed, and in consequence
the walls which contain it are put apon the stretch, its resistance in-
creases in the same ratio, and such swelling within the chest may feel
as hard as a stone. Hepatization of the lungs gives a considerable
resistance, but it is greater in exudations under the above-mentioned
conditions.

Palpation lastly reveals different kinds of m,otions which originate
within the cavity of the chest. The most important of them is the
vibration of voice, or the vocal fremitus, of which we become cogni-
zant by placing our hand upon the thorax of a person who is in the
act of talking or singing. Its force corresponds' with the power and
depth of the voice, so that we feel it much stronger in men of a deep
base voice than in other persons, whose voices are of a higher pitch.
Singing and screaming causes fremitus even in the highest-toned voice.
The localities in which it is perceived, arranged according to the
streno'th of the vibration, are as follows :

1. Larynx and trachea down to the sternum in front and laterally.

2. The last four cervical and first three dorsal vertehrse of the adjacent
portions between the scapulae, especially in thin persons and children.

8. The acromial and subclavian regions doivn to the liver aiid spleen,
on the right side much stronger than on the left.



PALPATION — MANUAL EXAMINATION. 141

4. The lateral regions, from the axillse down to liver and spleen; to
the fifth rib stronger on the right side : helow the fifth rib stronger on
the left side,

5. The posterior inferior regions from the edges of the shoulder-blades
doivnivards.

6. The shoulder -hlade region.

7. The manubrium sterni.

8. Where the liver or the enlarged heart or spleen lie close to the thoracic
wall, the fremitus is not felt at all.

The mammge of women decrease the vibration of the voice, but do
not suppress it altogether. In thin persons with a long thorax, the
fremitus is stronger than in persons with a broad but short thorax.
It is felt more in the horizontal than in the upright position. This is
its normal condition in health.
• In disease it may be increased or decreased.

It is increased, when the bronchial walls become thickened by chronic
inflammation; or when the lungs become hepatized, or infiltrated
with tubercles, or indurated and consolidated. It is also increased by
cavities, which lie near the periphery, contain no air and not much
fluid, and which are surrounded by walls of good conducting quality ;
in short, its increase depiends upon good conductors of vibratory motions.

The fremitus is decreased by the presence of large abscesses or gan-
grenous destruction or softening of the substance of the lungs ; it is
decreased or even suppressed when gas or serum fills the pleural sac ;
and it is decreased when the bronchial tubes are filled with mucus, pus
or blood ; in qhort, in all cases where the vibratory undulation has to
pass through different media, air, fluids and solids.

For here, too, is the physical law of the conducting of sounds appli-
cable ; the more equal the media in respect to density and elasticity, the
better do they conduct sounds; the greater their inequality of substance,
the less is their conductive poiver.

Another vibratory motion within the cavity of the chest, which
manifests itself to manual examination, is, the rhonchus vibration, caused
by tough mucus lodged in the larynx, trachea or bronchial tubes,
and brought into vibratory motion by the ingoing and outgoing cur-
rent of air. This vibration very often extends over the whole chest,
although only a little tough phlegm may be the cause of it, which can
be thrown off by a single cough.

When, however, the cause of this vibration consists of phlegm
lodged in the bronchial tubes, the rhonchus vibration is not felt in the
trachea and larynx, but may extend all the way down to the bronchial



142 THORAX.

periphery. For this reason we can never judge from the extension
of the vibration to the extension of its cause ; in other words, it does
not follow that because we feel the rhonchus fremitus all over the
chest, that there should be phlegm all through the chest. This would
be a mistake which could be made only by those who do not under-
stand the propagation of rhonchus vibration.

A third vibratory motion, recognizable by manual examination, is
the peculiar rubhing or grating feel, which occurs when the surface of
the pleura pulmonalis and costalis — which naturally glide smoothly
upon each other — are roughened by solid effusion between their con-
tiguous surfaces, as in pleurisy. It is mostly of short duration, but
may last in some cases months, and even years. The same motion
is caused by fibrous deposits within the pericardium, in consequence
of pericarditis ; it resembles very much the purring of a cat.

A fourth motion which the examining hand discovers upon the
thoracic walls is the pulsations of the heart. " While the body is erect,
the heart, when in a natural condition, is constantly felt to strike the
parietes about an inch below and to the inner side of the nipple.
While lying upon the back, its impulse is greatly decreased, and is
usually felt somewhat nearer to the sternum. When the body is
turned to the left side, the impulse is felt in a direct line with, or
often nearly an inch to the outer side of a line passing vertically
over the nipple ; while, on the contrary, when the body is turned to
the right side, it is felt between the cartilages of the ribs, close to
the sternum, or sometimes cannot be felt at all.

'' When the parietes of the heart are thickened, or hypertrophied,
and the force of its impulse is consequently increased, the hand,
placed over the precordial region, becomes at once sensible of its
abnormal force, though the pulse at the wrist may at the very same
time be small and feeble.

" When the cavities of the heart are dilated, with or without any
increase of the thickness of their walls, the impulse is often percept-
ibly extended over a larger space than natural, and may be felt not
only above, below, and around its ordinary site, but also in the scro-
biculus cordis ; and sometimes even on the right of the sternum. It
must, however, be recollected, that in nervous and excitable persons
of spare habit, the impulse of the heart is often very extensively dif-
fused, even when no disease of the heart exists; and, therefore, that
a widely -extended or diffused impulse is by no means a proof of the
existence of disease in the heart, or in any other organ.

" When the heart is removed from its natural situation by gaseous



PERCUSSION. 143

or fluid effusions into tlie pleura, by tumors, abscesses, &c., it is by
manual examination that the fact can generally be best determined.

" When obstruction exists in the valves, a trembling motion or
'purring ti-emor' is frequently communicated to the hand, and the
tumultuous action, or trembling motion, existing in the more advanced
stages of disease in the heart, can often be best appreciated by palpa-
tion." Hughes.

III. Percussion.

A casual examination of the different works on this subject is amply
sufficient to cause total confusion in the mind of the beginner, and a
loathing of the task of wading through such contradictory assertions
of the different authors. For whilst the one pretends to hear the
grass grow, and to find out every little nook and hook in the lungs, if
-wrong, by knocking, another asserts coolly, that such talk is a mere
flatulent phraseology, referring simply to the fact that the most skilled
and experienced in this knocking art themselves confess to having
made the most glorious mistakes.

What are we to do then in such a perplexing position? Shall
we throw the whole overboard, as a fashionable craziness of the
profession ? It would be a short process of getting rid of the trouble.
But then, that is not the thing. There has been so much labor and
ingenuity bestowed upon this subject, that there must be some guid-
ing truths in this heap of collected experiments and researches ; no
matter if it be mixed up with contradictory assertions.

In the following pages I shall try to state the fundamental principles,
which may easily be amplified by our own personal observations.

There is an immediate and a m,ediate m,ode of percussion. It is ini-
mediate when the finger of the examiner strikes directly upon the
parietes of the chest. It is mediate when some solid material, such as
a disc of wood or ivory, a piece of leather, or the finger of the left
hand, is interposed between the parietes and the striking body.

The striking body may be one or more fingers pressed together and
bent slightly ; or a little steel hammer, whose head or striking surface
is covered with leather or caoutchouc.

In regard to the merits of these different modes I have to say that
much depends upon what we may have got accustomed to ; still the
one or the other may be preferable under certain circumstances,
which practice will soon teach.

What does percussion reveal?

If we strike different things we receive different sounds. There is,



144 THOEAX.

however, a marked difference between those bodies which contain air
and such as do not. As extreme examples of this difference we may
cite the sounds which we obtain when we percuss the chest or stomachy
and when we percuss the thigh. In the first case we obtain a sound
which reverberates, — has resonance ; whilst in the other case we hear a
mere noise, a clap, without any resonance or tone whatever. This
latter, which we may call the didl, dead ov fleshy sound, is everywhere
the same, where we strike upon an organ not containing air; such as
the liver, the spleen, the kidneys, hepatized lung, or lung completely
deprived of air by compression and fluids; a hard liver yields the
same sound as a soft liver, a hard spleen as a soft spleen.

But it is different with such organs and bodies as contain air ; there
the sound varies quite considerably. Take for example an open jar
or bottle, and percuss it at its mouth, you will hear a sound similar to
that of a drum; this is the sound which Skoda has called the tym-
panitic sound, and which we also might call drum sound. Its varia-
tions are as follows :

1. If we percuss an open jar or bottle, this drum sound will be
deeper, the higher or longer the bottle or the column of air which it
contains ; it will be higher, the shorter the column of air is within.

2. If we percuss an open jar or bottle, we find that the wider the
mouth of the vessel, the higher is its tympanitic tone ; and, the more
we contract the mouth of the vessel, the deeper becomes this tone.

3. If we however percuss closed cavities, there comes into considera-
tion another momentum. A drum or jar, whose mouth is closed
tightly with a piece of bladder, can exemplify it. We perceive at
once that the tenser the skin is drawn over the drum or the bladder
over the jar, the higher becomes its tympanitic tone, and vice versa,
the looser, the deeper. Here, however, it must be remarked, that this
comes to pass only when the surrounding air and the air within is of
equal density and expansion. As soon as either is set out of that
equilibrium, just as soon the tympanitic sound is lost, because this
diversity hinders the regular vibrations of the membrane, which are
necessary for the tympanitic sound.

Thus we find that the tympanitic sound varies in height and depth
of its tone. It becomes higher in the ratio —

1. That the column of the percussed air is shorter ;

2. That the mouth or aperture by which the percussed air stands in
connection with the external air is wider ; and

3. That the enclosing membrane is drawn tensely over the cavity.
It becomes deeper in the same ratio —



PERCUSSION. 145

1. That the column of the percussed air is longer;

2. That the mouth or aperture by which the percussed air is in
contact with the external air is narrower ; and

8. That the membrane which closes the vessel is looser.
Applying these physical rules to the living organism we come to
the following results :

1. The tympanitic sound is heard at the larynx. The ivider the
person under examination opens his mouth the higher is its tone ; in
closing the mouth it becomes deeper and weaker, and when closing
the nostrils also it becomes still deeper and weaker.

2. The tympanitic sound is heard luliere there exist superficial cavities
in the lungs which contain air. If it happens that such cavities are
in immediate connection with the trachea, larynx, and mouth, by
means of large bronchial tubes, then we have the same phenomena
in opening and shutting the mouth, as above detailed. In opening
the mouth the tympanitic sound has a higher, and, when shutting it, a
deeper, tone. If the cavity is in no such connection, then opening or
shutting the mouth does not alter the tympanitic sound.

3. It is heard on the thorax in all those conditions of the lunqs in
which the external air presses equally strong within upon the substance
of the lungs, hy means of its air-cells and bronchial tubes^ as it does from
the outside upon the thorax ; that is, where there is a perfect equilibrium
betiveen the pressure of the internal and external air. This, however,
in a normal state is never the case. The inner pressure of the air is
like the external minus the contractility of the pulmonary tissue. But
disease may deprive the lung-tissue of this elasticity and contrac-
tility by compressing it, whereby this equilibrium becomes estab-
lished. This, we find, for example, in partial emphysema, in the
neighborhood of infiltration as happens in pneumonia, where, not
nnfrequently, the tissue around the hepatized portion, and especially
at the borders of the lung, is emphysematous. In this condition we
hear a decided tympanitic sound, whilst in pneumothorax — a collection
of air or gas in the pleural sac — we hear none. Especially is this the
case when the thorax is much distended ; although we might be
inclined to expect it more thaa under other conditions. We hear it
again distinctly and invariably at the upper portion of the chest, when
the lower portion of a hmg is entirely compressed by any pleuritic
ejfusion and its upper portion is reduced in volume.

4. The tympanitic sound is heard Ictstly in those parts of the chest in
zohose neigliborhood the stomach lies, namely, the lower part of the left
mammary, left lateral, and left infra-scapular regions, provided the

10



M6 THORAX.

storaach be not too mucli distended with air, "because otherwise a reg-
ular vibration of its walls would be impossible, and hence also the
tympanitic sound.

The same is true of the abdomen ; and thus we come directly to
the following result : The tympanitic sound on percussion is heard at
the larynx; at the collapsed or compressed lungs ; at the relaxed stomach,
and at the compressihle abdominal walls.

Quite different from this tympanitic sound is another sound elicited
by the percussion of bodies containing air : the non-tympanitic sound,
of Skoda, which we might just as well, and perhaps more intelligibly,
call the resonant sound of the hmgs, or, by abbreviation, lung-sound.
The best example of this sound is obtained by percussing a healthy
thorax ; and, in doing this, we perceive at once that there are dif-
ferent degrees of the resonance in it. It varies in clearness from a
very resonant to a mufded sound ; and, in duration, from a long reso-
nance to a short snap.

In the normal state of the lungs we find this sound very resonant in
the superior sternal, the axillary, and the upper part of the infra-scap-
ular regions ; resonant in the subclavian, the upper part of the mam-
mary, and lateral, and inter-scapular regions; muffled in the acromial,
and the lower part of the right mammary, and lateral, infra-scapular,
and scapular regions ; dull, dead, fleshy in the inner edge of the left
mammary, (where the heart lies,) the liver, spleen, and kidney regions.

Pathological altered states of the lungs alter also this natural reso-
nance of the percussion sound.

It is m,ufied, dull —

1. On any portion of the lung which is deprived of air, if it be
about the size of a half-dollar, and about half an inch in thickness.

2. In the subclavian regions from tubercalar infiltration.

3. In the inferior posterior regions, as the favorite seat of pneumo-



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 15 of 65)