THOMAS H. HAWKINS, M.D., LL.D., EDITOR AND PUBLISHER. Henry O. Marcy, M.D., Boston. COLLABORATORS: Thaddeus A. Reamy, M.D., Cincinnati. G. Law, M.D., Greeley, Colo. S. H. Pinkerton, M.D., Salt Lake City. E. C. Gehrung, M.D., St. Louis. Graeme M. Hammond, M.D., New York. Carey K. Fleming, M.D., Denver, Colo. Subscriptions, $1.00 per Year in Advance; Single Copies, 10 Cents. Address all Communications to Denver Medical Times, 1740 Welton Street, Denver Colo. We will at all times be glad to give space to well written articles or items of interest to the profession. [Entered at the Postoffice of Denver, Colorado, as mail matter of the Second Class.] EDITORIAL DEPARTMENT. PHYSICAL SIGNS OF PULMONARY TUBERCULOSIS. It is extremely important to make the first examination of the patient very thorough, comparing both sides of the chest, with due allowance for normal variations. Of special value is the finding of abnormal physical signs in the same situation on successive, repeated examinations. The examiner should insist upon having the chest bared to the waist, using only a light sheet or blanket to protect against chilling. INSPECTION. The appearance of a subject of pulmonary tuberculosis in the early stage is suggestive though not distinctive. The face is often paler than normal, with a tendency to flush easily. The eyes are wide open; the sclera pearly and glistening. The pupils may be unequally dilated. The alæ nasi are thick and bulbous, making the rest of the nose appear somewhat pinched, with a peculiar waxy pallor that brings out the yellowish orifices of the sebaceous ducts in marked relief. The teeth are generally poor and often malformed. The gums are red in the acute forms of the disease, bluish in chronic cases, nearly white in scrofulous subjects. The tongue is coated enough at times to give a foul odor to the breath, and if coughing is troublesome may be the seat of multiple ulcers. In a more advanced stage of the malady, the facies is pinched or drawn, eyes sunken, nostrils quivering and cheeks hollow, with the "hectic flush" of capillary suffusion during the afternoon rise of temperature. Emaciation becomes universal, and the abdomen is even navicular in diarrheal cases.. The general color of the patient is anemic and slightly cyanotic. The finger nails are clubbed, brittle and incurved in very chronic cases. Persons predisposed to phthisis often show a characteristic configuration of the upper part of the trunk. The neck is long and lanky; the chest long, flat and narrow; and the scapulæ winged, that is, with angles projecting backward and outward. The intercostal spaces are apt to be wide and deep, and the ribs unduly sloping. The acromial extremity of one clavicle may be lower than its fellow. An early and significant sign is the atrophy, more or less marked, of the scapulo-thoracic muscles, resulting later in drooping of the shoulders and forward bending of the vertebral column-the so-called paralytic thorax. The chest and arms are emaciated like the remainder of the body. One also often observes a network of fine, transparent veins. under the pallid skin over one or both upper lobes. There is frequently a wide area of cardiac impulse. On watching closely the respiratory act, a generally deficient expansion is observed, particularly over the upper lobes; and one apex lags behind its fellow in time and volume, as readily shown by little flags attached to levers and placed on the chest wall. The poor expansion is partly owing to muscular weakness, but when localized it indicates deficient aeration, due to tubercular deposits with fibroid or caseous changes. When the unilateral immobility is accompanied by circumscribed retraction of the chest wall, especially in the supra-clavicular or infraclavicular region, we ordinarily have to deal with extensive fibroid changes or excavations. When the localized shrinking of the wall, however, is over the lower lobe, pleural adhesions or emphysema or pneumothorax may be suspected. A circumscribed intercostal bulging and retraction, alternating with inspiration and expiration, and usually most marked in the second or third space anteriorly, is suggestive of a recent and superficial cavity. Venous and capillary pulsations are suspicious phenomena dependent on a low circulatory tension and chloranemia. Herpes zoster is a common eruption on the chest and shoulders of tubercular patients, as are likewise chloasma and pityriasis versicolor or chromophytosis. Sudamina are abundant when sweating is excessive. Even at an early stage the hair is apt to be dry, harsh and lusterless, and transverse grooves are seen on the thumb nails. Pulmonary consolidation from any cause offers ten times the resistance of normal lung to the passage of the X-rays. Hence fluoroscopy reveals consolidated areas as dark spots, and cavities as brighter spots within dark rings. Enlarged bronchial glands and pleural thickening are also revealed by. local opacities. The method is of little value in incipient cases, but is of special service in the diagnosis of well advanced central lesions. When tubercular laryngitis complicates, laryngoscopy shows numerous bilateral eminences of pale, broad, indolent, irregular ulcers, an infiltrated epiglottis and gray mucoid secretion. PALPATION.-This method shows local defect of expansion, particularly at one apex. Vocal fremitus is sometimes perceptibly increased by very small disease areas, such as a simple congested ulcer. A marked increase of tactile fremitus in localized areas is suggestive of superficial tubercular and pneumonic infiltration or solid exudates, as well as caseous or fibroid changes, large apical cavities and thickening of pleura with adhesions. It must not be forgotten, however, that fremitus is normally more marked on the right side than on the left, owing to the larger size of the right bronchus. A distinct increase of pectoral fremitus in the suprascapular region is very suggestive of tubercular deposits. Normal or abnormal fremitus may further be greatly diminished or suppressed by pleural effusion, obstruction of a large bronchus, or by a pneumothorax. The vibration due to closure of the semilunar valves is frequently palpable when the anterior border of the lung is involved in consolidation. In estimating the degree of fremitus, differences in age, sex and thickness of chest walls must be taken into account. An increase of resistance to the finger employed as a pleximeter in percussion is significant of solidification of the underlying tissues or of firm adhesions of the pleura to the chest wall. Tenderness to digital pressure in the intercostal spaces may depend on pleuritis or on intercostal neuritis. The skin of the tubercular individual is thin and sensitive, and feels either warm, dry and harsh or cold and clammy to the touch. The irregular absorption of subcutaneous fat, which takes place in emaciation, makes the skin feel in marked cases as if small nodules were imbedded beneath it. Very chronic cervical adenitis, with periodic variations in the size of the glands, is of frequent occurrence, particularly in tubercular children and ado lescents. The spleen is often enlarged as early as the so-called pretubercular stage. The pulse is full, but feeble and irregular, ranging in frequency from 90 to 100 or more. It is accelerated upon the slightest exertion. Its low tension is a more marked feature than its rate. PERCUSSION. In the early stage of pulmonary tuberculosis this method is of little practical value, since it is able to reveal definitely only the coarser pathologic changes-say a focus of 11⁄2 inches or more in diameter. It is much more applicable with superficial than with deep-seated lesions. To get the full benefits of this method the pleximeter finger should be applied closely between the ribs, and percussion should be performed. gently, then forcibly, with an even, elastic stroke. Diminution. of resonance is most readily appreciated after full inspiration. Due allowance must be made for muscular development, adipose tissue, deformities and rigidity of the chest wall, as well as for the slightly duller sound elicited normally over the right bronchus. The reative degrees of pulmonary encroachment, as demonstrated by percussion, may be expressed as slight dullness, moderate dullness, considerable dullness and flatness. The higher pitch may be noted before force and quality are affected. An initial alveolitis causes slight hyperresonance, followed later by slight dullness when the bronchioles are occluded and the alveoli obliterated by aspirated sputa or pneumonic lesions. A tympanic quality is further noted in lung areas relaxed through serous transudation, as in diffuse miliary eruptions. At a comparatively early period deep percussion may reveal a little lowering of the upper limit of the affected lung. A more definite early sign is the impaired resonance along the vertebral border of the scapula, best appreciated when the patient folds his arms across the chest. A moderately dull note is heard most frequently over fibroid areas, with or without small cavities, and over portions of pleura much thickened by fibrinous exudations. In the latter event forcible percussion elicits a deeper, fuller note. Considerable dullness is manifest over large caseated areas and filled cavities, massive pneumonic consolidations, and especially in fibroid shrinking and induration with obliteration of alveoli. These changes may be more or less obscured by overlying vicarious emphysema. When the consolidated focus lies around a bronchus or near the trachea, the note is tympanitic. The percussion note is rarely flat in phthisis, unless the disease is complicated with large pleural exudates, which are likely to be insidious in onset. Important evidence of pulmonary and bronchiectatic cavities is furnished by circumscribed tympany, increased by inspiration, though lessened by raising internal tension through forced inspiration. The circumscribed character of the note distinguishes this form of tympany from that due to relaxed conditions, as in lobular pneumonia, pulmonary edema, miliary tuberculosis, etc. Small cavities yield a modified or dull tym pany. By Wintrich's change in tympany is understood a higher and louder tone with the patient's mouth open than with it closed. This sign is pathognomonic of a cavity, which must be in open communication with a bronchus. It is associated with metallic resonance in large, superficial cavities, with smooth, firm walls. "Cracked-pot" resonance is also indicative of a cavity, particularly one with a rather narrow opening into the bronchus. The sound is best elicited on light percussion during full, openmouthed inspiration, when the walls of the cavity are thin and not very firm. It is of special value in distinguishing a pulmonary cavity from bronchiectasis, though the sign is sometimes obtained with a dense consolidation about a large bronchus. AUSCULTATION.-This is by far the most delicate method of physical examination, and is also usually the most reliable. Like the other signs, auscultatory are most significant when heard in a limited area, particularly of the upper lobe. The examination should be conducted under quiet, then deep, respiration. Muscle murmurs and physiologic crepitus must not be mistaken for rales. The breath sounds in the affected area are very early diminished in intensity, particularly during inspiration, and the expiratory sound is prolonged. Inspiratory force is first diminished in tubercular exudation, in chronic bronchitis and emphysema. Weak respiration in one lung or portion thereof is suggestive of incipient tuberculosis. Feeble respiratory sounds on one side also accompany compression of a large bronchus by enlarged glands, tumors or aneurysm, or temporary obstruction by tenacious mucus. Weakened respiration in the lower lobes is often due to a thickened pleura and fibroplastic exudate. |