George William Norris.

Diseases of the chest and the principles of physical diagnosis online

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importance is obtained in the incipient stage. The majority of patients



at the onset of the disease present well-shaped chests, which do not
present any marked abnormality. Thus Pope and Brown found 83
per cent, of well-formed chests in 193 incipient cases. The so-called
paralytic thorax, which is sometimes seen, is not uncommonly noted in
individuals with a marked hereditary taint and antedates the tubercu-
losis rather than being caused by it. The paralytic thorax is long and
narrow and apparently flattened in the antero-posterior diameter, the
clavicles and scapulae are prominent, the latter being tilted outward from
the chest and away from the spine. The ribs are oblique, forming an
acute angle with the sternum. (See Figs. 13, 24, 31, 35.)

The following points should be noted: (a) Whether the shoulders
are on a level; a very early sign is drooping of the shoulder on the affected

Fig. 251.

-Shows drooping of the right shoulder and the long line from the neck to the
point of the shoulder.

side. In this connection, however, it must be recalled that certain occu-
pations, such as clerks, predispose to a faulty sitting posture, which will
raise or lower one shoulder.

(6) The line from the neck to the point of the shoulder. This line
is normally slightly convex, but with beginning disease at one apex, it
tends to become straight and also longer than its fellow, the latter defect
being brought about by the drooping of the shoulder (Fig. 251).

(c) The degree of prominence of the clavicles. In most well-nourished
women the clavicles are scarcely, if at all, visible; in men, on the other
hand, unless unusually fat, the clavicles are more or less prominent.

Associated with undue prominence of the clavicle is an exaggeration
of the supraclavicular fossa. A noticeable amount of flattening may be
noted also beneath the clavicle.

(d) Expansion. — Deficient expansion of the chest wall overlying the
apex of the lung is one of the most valuable signs of early tuberculosis
which we possess. It is especially to be looked for toward jthe outer
border of the lung, just beneath the clavicle. In this situation the


chest wall normally balloons out quite markedly. If, however, there
exists an infiltration of tubercles at or near the apex, the underlying lung
does not expand as fully as its fellow, or if the expansion is equal on both
sides the affected side tends to lag behind slightly, especially at the
beginning of the inspiratory period.

Inspection of the apices for the purpose of determining the degree
of expansion yields the best results, if but one apex is involved. If
there exists disease at the summit of both lungs the value of comparison
is thus lost, and one may be unable to come to any definite conclusion
from this method alone. Two other methods of determining slight
amounts of retraction on the affected side are available, namely, palpation
and mensuration, both of which will be described in detail later.

Inspection of the chest posteriorly. In the early stages of tubercu-
losis the amount of information gained from the posterior view of the
chest is slight compared to what can be learned from the anterior view.
A very common occurrence in tuberculous subjects is the presence of
fine venules in the region of the nape of the neck. These small veins
may be bluish or purplish in color. They have been cited as an evidence
of the existence of pulmonary tuberculosis, but are so frequently
encountered as to be of little value as a diagnostic sign.

Owing to the interposition of the scapular muscles and the ribs little
can be noted as to expansion in the upper part of the chest. At the bases,
however, expansion can be determined in the same manner as over the
apices anteriorly. The most noticeable finding is the presence of varying
degrees of atrophy of the muscles in the supraspinous fossa. If the arms
are allowed to hang naturally at the sides, the angle of the scapula on the
affected side may tip backward slightly more than its fellow. This
tendency to " winged scapulae" becomes much more marked as the
disease progresses.

Slight degrees of scoliosis may be present. Litten's sign may be
present (see Part I, p. 28). The sign is not often employed as there is
another and easier method of determining the mobility of the lower part
of the lung, namely, by percussing the lower border of the lung during
forced expiration and inspiration. The fluoroscope may be employed

Palpation. — Tactile fremitus is a sign of comparatively little value in
incipient tuberculosis, as the amount of infiltration in the underlying
lung is usually too slight to produce much exaggeration over the normal.
The normal discrepancy between the two apices has already been alluded
to (see p. 73).

Pottenger has called attention to rigidity of the muscles over the
affected area. Recently Galecki 1 reports on finding this sign present in
93 per cent, of recent cases and not at all in cases with a healed lesion.
The sign is elicited by light touch palpation. This sign is not to be con-
fused with myoidema. The latter term is applied to a local contraction
of the muscle, produced by direct percussion, and causing a nodular swell-
ing, which arises immediately after percussion, lasts a second or two,
and then gradually disappears. It may be produced two or three times
and then cease to appear. It is best seen in the pectoralis major muscle.
Although this phenomenon is commonly encountered in tuberculosis,
it is not peculiar to the disease.

1 Beitrdge Zur Klin. d. Tuberculose, 1914, xxx, No. 3.


Palpation, however, is an invaluable method, for determining the
amount of expansion at the apices in those instances where the difference
between the two sides is slight and one is in doubt from inspection alone.
In determining the degree of expansion over the apices anteriorly by
means of palpation, one of two procedures may be followed. The
examiner sits squarely in front of the patient and places one hand in the
same relative position beneath each clavicle; he should then close his
eyes, or turn his head aside. In this way even the very slightest variation
may be noted. Or the examiner can watch his two hands and determine
which moves the most. The former is by far the more delicate method.
The value of the sign is enhanced by the readiness with which it is
elicited. Students with but a rudimentary knowledge of physical diag-
nosis can readily detect a slight difference between the two apices when
the other signs, indicative of a lesion, are too vague to be appreciated by
an untrained observer. In the incipient stage palpation is not apt to
reveal abnormalities in portions of the chest other than one or the other

Mensuration is the least used of the various procedures of physical
diagnosis. At one time a great deal of stress was laid on the degree of
expansion of the chest, good expansive power being looked upon as in-
dicating freedom from thoracic disease; and insurance companies still
insist on a record of the difference between expiration and deep inspira-
tion. In the absence of more convincing signs it is doubtful whether
any importance can be attached to a degree of expansion below the
normal (approximately 2}^ inches) , if this is the only evidence obtainable.

A more useful method of employing mensuration is by means of the
lead tape cyrtometer. This method is too little used. While it is valuable
for diagnostic purposes, its greatest usefulness is in depicting the changes
in the contour of the chest as the disease progresses, either to a favorable
or an unfavorable termination. The technique of the method is readily
acquired with a little practice. The lead cyrtometer consists of a piece
of sheet lead, ^f q inch thick, ^ inch wide and 26 inches long. It should
be covered with thin calfskin. In addition there is required a pair of
obstetrical calipers capable of opening at least 12 inches. The first step
is to obtain the antero-posterior diameter of the chest. Minor recom-
mends for the two fixed points, the middle of the sternum at the level of
the fourth costal cartilage in front, and the eighth dorsal spine posteriorly.
The latter is a little below the level of the inferior angles of the scapulae.
Having, with the calipers, ascertained the depth of the chest between
the above-mentioned points the distance is marked on a sheet of paper,
capable of receiving the tracing of a chest 12 inches in its antero-posterior
diameter and 16 inches in its lateral diameter.

Each half of the chest is taken separately. With the eighth dorsal
spine as the fixed point, one end of the tape is firmly held so that it will
not slip and is then brought around to the anterior fixed point. The tape
should be firmly applied so that it fits snugly. In crossing the axillary
space care must be taken to mould the tape to the chest wall, otherwise
this space is apt to be bridged. The anterior point can be marked by
indenting the leather with the finger nail. The tape is then carefully
removed and the two ends placed over the marks indicated on the paper
by the calipers. By means of a pencil the perimeter is then traced on the
paper. The left side is similarly taken (Figs. 252, 253 and 25-f).


By using different colored pencils at each subsequent tracing, one
obtains an excellent picture of the contour of the chest. Even in very
early cases there is a slight amount of shrinkage on the affected side, and
the greater the amount of disease present the greater, as a rule, is the
degree of retraction. As the case progresses toward recovery the

Fig. 252. — Slight retraction of right side. Lesion at right apex.


Fig. 253. — Slight retraction of left side. Lesion at left apex.



Fig. 254. — Advanced bilateral disease. Marked retraction of right side.

affected side tends to fill out so that eventually discrepancies between the
two sides disappear. In some early cases with a marked degree of
shrinkages, the reexpansion is quite rapid. On the other hand, if the
disease advances, the affected side shows an increased amount of re-
traction, and with involvement of the sound side evidences of shrinkage
will likewise appear. Minor states that the increase of the perimeter


takes place on the unaffected side first as a result of the compensatory
action of the sound lung, and that the increase of the affected side gener-
ally follows the increase of the unaffected side. The increase can be in
breadth or depth; the latter is of more significance, however, as the trac-
ing of the former may be affected by an increase in the amount of fat
and muscle, while the latter being measured between two bony points is
not so affected. Thus it can be seen that the method is a valuable diag-
nostic, as well as a prognostic aid. One precaution should be kept in
mind, namely, as to whether the individual is right-handed or left-handed.
Percussion. — Before undertaking to describe the percussion changes
in early tuberculosis, it is necessary to emphasize several important facts.

1. There is a normal discrepancy between the percussion notes of
the two apices. This has been recognized for many years, but advantage
is not always taken of the knowledge. The note on the right side is
normally a little higher in pitch and a little less resonant than the note on
the left side. Flint described the note on the right side as vesiculo-
tympanitic without, however, advancing any reason for the change.
Recently Fetterolf and Norris have given a satisfactory explanation of
the difference. Their study, from both the clinical and anatomical stand-
points, shows quite clearly that the right apex is smaller than the left
(see Figs. 62, 63, 64, 76 and 77) and that furthermore the position of the
bloocl-vsesels on the right side tend to diminish the resonance. The close
approximation of the right apex to the trachea (see Figs. 49, 75, 95 and
104), the latter giving a tympanitic note, thus tends to raise the pitch
of the percussion note; the left apex, being larger and having large blood-
vessels and areolar tissue interposed between it and the trachea, gives a
pure resonant note.

2. One of the difficulties the beginner has in percussing the apices is
that to his ear the note is frequently impaired. The real difficulty,
however, is that the note is less intense in this region owing to the small
amount of lung tissue at the apex as compared to the base, and also be-
cause of the distance of the lung from the surface over which the per-
cussion is being applied. These differences apply to the posterior aspect
of the apex, and to a less extent, the area above the clavicle. Anteriorly
beneath the clavicle the pulmonary tissue, lies immediately beneath the
chest wall so that the note is usually intense, and on the left side typically
resonant (see Figs. 260, 261, and 262).

3. Keeping in mind this normal difference, it must be remembered
again that we are dealing with comparisons, and inasmuch as the changes
are at best slight, each side must be compared carefully with the other.
If slight changes exist at the summit of both lungs it is probable that very
little definite information will be forthcoming from percussion.

Percussion of the apices in a case of suspected incipient tuberculosis
is a procedure that requires a well-trained ear, and not a little experience.
The change from the normal is usually so slight that for the beginner the
method is the least fruitful of results; and even the experienced observer
is, in doubtful cases, apt to be influenced in his interpretation by the
presence or absence of symptoms, or other associated physical signs.
The detection of slight changes at the apex is facilitated by marking with
a skin pencil the borders of what is known as " Kronig's isthnius." This
is a band of resonance which crosses the shoulder (Figs. 255 and 256).'
Its narrowest point is at the top of the shoulder, and in both front


and back it widens out to meet the extended areas of resonance beneath
the clavicle and supraspinous fossa. The value of this sign arises because
of the well-known tendency of the lung with a developing tuberculous
focus to shrink, either as the result of fibrosis, or of lessened functional

In mapping out the "isthmus" it is well to begin the percussion well
up the side of the neck and gradually come downward until a change
from non-resonance to resonance is noted. This point is marked with
the pencil and by working either forward or backward the inner line is
traced out. The outer line is mapped out similarly by approaching the
resonant area from the point of the shoulder. The inner line, except at
the inner anterior extremity, is concave and runs downward and for-
ward, ending just a little outside the sterno-clavicular joint. Posteriorly

Fig. 255. — Kronig's isthmus.
Normal anterior view.

Fig! 256. — Kronig's isthmus.
Normal posterior view.

the inner line inclines toward the spinal column; at the level of the second
dorsal vertebra it continues parallel with the spinal column, at a distance
of about }/% inch.

The outer line, anteriorly, runs downward and outward, ending
at the junction of the outer and middle third of the clavicle. Posteriorly
it runs downward to about the middle of the spine of the scapula.

The value of this procedure lies in the fact that while one may be in
doubt as to the quality of the note, if percussion is made directly over
the situation of normal resonance, one is less likely to err if the normal
area is approached from non-resonant parts, such as the neck or shoul-
der. One quickly learns to appreciate what the normal width of the
isthmus should be, and if this becomes narrower it is an indication of
trouble in the underlying apex. If but one side is diseased, the affected
side will show a much narrower "isthmus" than the healthy side (Figs.
257 and 258). As the disease becomes more extensive at the apex the
two lines of the "isthmus" tend to become closer and closer "until
finally in the advanced case no semblance of resonance remains.

Some observers have laid stress on direct percussion of the clavicles
without the intervention of a plexor, the claim being made that at times,



a small area of impairment can be detected that would otherwise escape
detection. Such instances may occur, but they are far from being

Having outlined the apices the percussion should be continued down-
ward until the base of the lung is reached. Even in incipient cases it
will usually be found that the resonance does not extend quite so low on
the affected as on the unaffected side after deep inspiration (see Fig. 259) .
It will be recalled that mensuration shows some diminution in the size
of the affected side. Furthermore, it has been shown by fluoroscopic
examinations that the descent of the diaphragm on the affected side is
usually diminished. This is known as Williams' early diaphragmatic
sign (see p. 596). These observations indicate that the lung, even when
the seat of a small amount of disease, functionates less freely than the

Fig. 257. — Kronig's isthmus Normal
on left side. Narrowed on right side due
to tuberculosis of right apex.

'Fig. 258. — Kronig's isthmus. Both sides
narrow due to bilateral tuberculosis.

unaffected lung, or that the unaffected lung is functionating more than
the diseased one. Whichever is the correct explanation, the fact remains
that the resonant note is apt to stop at a higher level on the affected,
than the unaffected side.

With ordinary quiet breathing the bases of the lungs extend to the
level of the tenth dorsal vertebra; the complementary space of the pleural
cavity, however, extends to the level of the twelfth dorsal vertebra.
On deep inspiration the lung can be made to expand for an inch or more
below the level of the tenth dorsal vertebra, providing it or the pleura
is free from disease. If, however, the lung is much diseased, or the
pleural cavity is obliterated, or the diaphragm is immobile, the base
line on the affected side remains stationary.

Having marked out the borders of the lung, the heart and viscera
in relationship to the lungs should be outlined.

Auscultation. — The fact that there normally exists a difference be-
tween the right and left apex has already been alluded to (se"e p. 73).
Nothing further need be said except to emphasize the importance of


bearing this in mind. One other fact should be mentioned, namely, the
relative importance of the different steps taken to determine whether one
or the other apex is the seat of tuberculous disease. That auscultation
is the most important means at our disposal for the detection of intra-
thoracic disease, there can be no doubt. On the other hand, it is equally
true that in those instances in which the pulmonary damage is slight aus-
cultation alone, valuable as it is, will frequently fail. The recognition of
true incipient tuberculosis cannot be accomplished except by a careful con-
sideration of the facts revealed in the history, and a proper estimation of
the slight deviation from normal as revealed by inspection, palpation, men-
suration and percussion. Even a skilled auscultator would often be in

Fig. 259. — Restriction of motion at base of left lung. Lesion at left apex.

doubt as to the presence of a slight tuberculous deposit if he relied on aus-
cultation alone. The question as to whether suspicious breath sounds
may be considered normal or abnormal not infrequently hinges on the
character of the information obtained in the history and by the other
methods of physical exploration. This digression has seemed necessary
because of the absolute reliance so many physicians place on auscultation

Granular Breathing. — This type of breathing, which owes its impor-
tance as an early diagnostic sign to Grancher, and in this country to
Minor, is now regarded as the earliest manifestation of the auscultatory
changes in pulmonary tuberculosis. While readily recognized after
one has heard it a few times, it is a sound not easily described by words.
Granular breathing is a rough or sputtering type of breathing. Turban
has likened this type of breathing to the rapid succession of minute


explosions; Minor to "a succession of very short sounds, as though small,
soft granules of fine, wet sago were being rolled over each other." Per-
haps the clearest description is that it suggests the coexistence of rales,
and yet, just as the listener fully expects to hear fine rales at the end of
inspiration, the inspiratory phase ceases. This type of breathing has
been described as being due to slight narrowing or uneven surface of the
bronchioles, or to a rapid interruption of the air entering the alveoli
about the tuberculous deposit. The following seems to us a more
plausible explanation. It should be recalled that in the early stages of
pulmonary tuberculosis there is a considerable amount of relaxation and
collapse, or partial collapse of the vesicles immediately around the tuber-
cles. As the air forces its way into these partially collapsed vesicles they
expand independently instead of synchronously. This imparts to the
inspiratory murmur a jerky sound and also gives the impression of crepi-
tation due to the separation of the slightly moistened wall of the air

Feeble Breathing. — Next in importance to granular breathing is
slight enfeeblement of the respiratory murmur. This type needs no
special description. If on comparing the two apices the breath sounds
are less intense on one side than the other, the fact is significant. It
is usually taught that enfeebled breathing to be of significance as an early
sign in tuberculosis must be limited to the apex. It has been our experi-
ence, however, that the breath sounds all over the affected lung, even
with veiy slight apical signs, are not infrequently less intense than over
the affected side. This is after all not surprising, when we recall that
mensuration shows a diminution of the affected side and the fluoroscope
a heightened diaphragm.

Prolonged Expiration. — Prolonged expiration, although not the earli-
est change from the normal in the breath sounds, is the most usual find-
ing, as the two earlier changes described above often escape detection.
The respiratory murmur in this type of breathing may be harsh or
slightly suppressed, but in either instance the characteristic feature is
the prolonged, high-pitched, bronchial quality of the expiration. Heard
at the left apex, one is rarely in doubt as to its significance; when con-
fined to the right side, there is apt to be a certain amount of question
as to whether we are dealing with normal or pathological broncho-vesi-
cular breathing. While in every normal chest there is more or less
marked broncho-vesicular breathing at the right apex, there is no definite
standard and the question of whether it is pathological or not is usually
settled by the presence or absence of collateral evidence. In children
especially there is a strong tendency towards exaggeration of the normal
signs at the right apex, and not infrequently children are said to be tuber-
culous, because of the strong transmission of both the spoken and whis-
pered voice and the prolonged blowing character of expiration.

Cog-wheel or Wavy Breathing. — Cog-wheel or wavy breathing has been
described as an evidence of incipient tuberculosis, but the best authorities
now are agreed that it can no longer be considered of importance as an
early sign. As the name indicates it is an interrupted tj^pe of breathing.
The inspiratory phase is the one commonly subject to the interruptions;
rarely the expiratorj^. It may occur in a patient suffering from the pain
of acute pleurisy, or in nervous or chilly individuals. In tuberculous
subjects it is usually heard over areas which divide healthy frofh diseased


tissue. Cog-wheel breathing is not to be confounded with the cardio-
inspiratory murmur of which we will speak presently.

Vocal Resonance. — The alterations in the voice sounds are not of great
value in early tuberculosis, as the deviation from the normal may not be
sufficient to be appreciated. The whispered voice is normally heard with

Online LibraryGeorge William NorrisDiseases of the chest and the principles of physical diagnosis → online text (page 30 of 79)