Vol. 60, 1909 - University of North Carolina at Chapel Hill

220
THE CHARLOTTE MEDICAL JOURNAl.
is to stamp a skeleton chart on the history summit. Hence the closest scrutiny should
sheet and by a system of easily remembered be directed to the supra-scapular region,
symbols fill in the findings. Thus the out- rather than to the clavicular regions, which
line of the heart as determined by inspec- are invaded secondarily as a rule. In maktion
and percussion is drawn to correspond ing the examination by far the greatest
to its relative size and position. If mur- value attaches to stethoscopic auscultation,
murs are present their location, intensity straining the ears to detect fine moist rales
and transmission are appropriately shown, at the end of inspiration, or variations from
So, for the lungs, the exact areas of dul- the normal characteristics of the oreath
ness, the location and character of rales, sounds. I would call particular attention
the character of the breath sounds, and to the value of causing the patient to cough
other data can and should always be filled just prior to a moderately deep inspiration.
in. In no other way can an accurate ex- I have frequently elicited a shower of fine
amination be recorded and at the same time crackling rales by this method when none
be so quicklv available for reference. could be heard otherwise. And the detec-
There are certain points in the techuic of tion of such rales persisting after two or
examinations which I have been led to be- three full respirations is diagnostic of a
lieve by observation, are frequently imper- tubercular deposit in the vast majority of
fectly observed or neglected. To a few of cases,
these points I beg to call brief attention. In a large majority of cases these fine
1. Examination for arterial changes as- rales will be overlooked unless sought foi
sociated with high blood pressure, hyper- with extreme diligence. By diligence I
trophy of the heart, and accentuated aortic mean having the patient stripped to the
second sound. It is loo frequently true in skin, and in the case of women stiff starched
physical examinations, especially for life underclothing removed, as I have found
insurance, that the examiner is satisfied if more than once that the distant rustling of
there are no heart murmurs, and if no these garments on deep respirations proirregularities
or increased rate of the pulse duced a sound almost exactly similar to
is apparent. It is a significant fact that rales. By diligence I also mean time-takthe
statistics of one of the largest insurance idg and painstaking systematic going over
companies show that nearly 22% of the every square inch of surface with a stetho-
first year mortality of passed applicants are scope. Regardless of what may be said to
due to cardio-vascular disease. Accuracy the contrary, I believe it to be impossible
should be insured by diligent examination for any living man to hear as perfectly,
for arterial thickening, estimation of blood locate as accurately, and make as few mispressure
by the sphygmomanometer, care- takes with his unassisted ear as with a
ful auscultation of the second sound at the stethoscope. One must remember, however,
base of the heart, and estimation of the size that the stethoscope, like other instruments
of that organ. oi precision, requires constant practice in
2. The true valuation of heart murmurs, order that proficiency in its use may be
In dealing with heart murmurs accuracy is gained. Furthermore, one gets accustomed
often difficult of attainment, and yet very to his own instrument, which yields him a
necessary for correct diagnosis, prognosis satisfaction superior to any other. One
and treatment. The first distinction to be should borrow or lend a stethoscope with
drawn is between functional and organic about the same compunction he would a
murmurs. I have been led to believe that toothbrush. It has been from the infremistakes
here are very frequent. The sec- quent use of an unsuitable or borrowed inond
point in the valuation is the accurate strument that all slander of stethoscopes
determination of the valve affected, while have arisen that I have heard.
the last to be remembered is that frequently A further point in technic which I believe
the murmur is of less value in diagnosis to be of real value is the frequent auscultathan
many other features of the examina- tion of this primary area following the
tion, such as the ascertaining of the size of hypodermic administration of Koch's old
the heart, the characteristics of the pulse tuberculin for diagnostic purposes. Even
and of the heart sounds, and variations in in the absence of marked febrile reaction a
the duration of the pauses between the beats, local hypercemia with resulting slight exu-
lt is sometimes true that the silences of the date often takes place at the focus of infecheart
are more instructive than its sounds, tion, and resulting fine moist rales occur.
3. The mode of examination fortheearli- If there is a slight rise of temperature or re-
est evidences of tuberculosis. It is import- action at the site of injection, the proof is
ant to know that the primary site of tuber- all the more convincing,
culosis deposits in adults, in the vast ma- I should like to emphasize, also, the fact
jority of cases, is in the posterior portion of that the appearance of tubercle bacilli in
the apex of the lung about an inch from its the sputum is now regarded as a late sign