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consequence of the organ being already distended, and the parietes of the chest being already considerably dilated. Hence it follows, that a full rounded form of the parietes, together with imperfect elevation of the ribs upon inspiration, is one of the physical signs of emphysema of the lung.

In very long-continued cases of general emphysema, a notable exception to what has been stated may be observed in the lower portion of the chest. The ribs of the lateral regions are then bent inwards, and are depressed instead of being elevated, or approach to, rather than diverge from, the centre of the body, during inspiration. This appears to arise from the ribs having been already elevated, and the bony parietes permanently dilated to nearly the utmost extent, so that they at length become almost motionless during the inspiration. The comparatively little air which is taken into the chest gains admission, therefore, by means of the contraction of the diaphragm, the connections of which muscle to the inferior ribs cause them to be drawn inwards and downwards during its action. After long continuance of this inward motion during inspiration, the ribs at the parts indicated become permanently depressed, as in slighter and less persistent cases of emphysema they become permanently elevated from a somewhat similar cause. This inward inclination

of the lower ribs becomes very obvious upon inspection, when emphysema has existed for a long time, and the patient is already advanced in life.

When fluid of any kind is present in the pleura in considerable quantity; if, that is to say, the complaint called hydrothorax or pneumothorax exist, the air-cells cannot be filled, the lung expanded, or the chest dilated upon inspiration, as in health. Imperfect elevation of the ribs, or total immobility of one side of the chest, therefore, become characteristic signs of these complaints.

When the heart has been enlarged for a considerable time, or when fluid effusion has long existed in the pericardium, a general fulness or roundness of the præcordial region may be sometimes observed. When aneurisms of the large vessels of the heart have caused absorption of the internal parietes, or have merely become adherent thereto, a slight or considerable elevation, according to circumstances, may be frequently noticed, which sometimes increases synchronously with the pulsation of the artery. The consequences of fractures, penetrating wounds, or of abscesses affecting the internal organs, are also commonly indicated by Inspection of the parietes.

The diseases, then, in which diagnosis may be rendered more clear by inspection of the chest, and in which, therefore, it may be advantageously employed, are pleuritis, and its consequences,

whether in the form of simple effusion, of empyema, or of contraction, pneumonia, phthisis, emphysema, hydrothorax, pneumothorax, enlargement of the heart, hydropericardium, or other pericardial effusions, aneurism of the large vessels, fractures, abscesses, &c.

In every primary examination, and in all in which an opinion is expected to be delivered as to the condition of the contained organs, Inspection should never be omitted. It should, however, be constantly borne in mind that curvatures of the spine, and congenital or acquired malformation of the skeleton, may so entirely change the configuration of the parietes as to cause them to present, upon mere Inspection, the appearances which ordinarily coexist with almost every one of the diseases which have been mentioned.

CHAPTER III.

PALPATION, OR MANUAL EXAMINATION.

THIS mode of examination, by which the sense of touch affords its aid to the other senses in the diagnosis of disease, notwithstanding what has been said concerning the " tactus eruditus," requires but little skill or experience for its exercise, so far at least as relates to the complaints of the chest.

1. Mode of employing Palpation.

Palpation is chiefly used in two ways. The first of these is by pressure of the sentient extremities of the fingers, as in the ordinary exercise of the sense of touch, and requires no comment or explanation. The other mode is by placing the palmar surface of the appressed fingers, or of the whole hand, upon the part to be examined, and using such an amount of pressure as to enable it to participate in the vibrations, or to appreciate the defective motion, of the parietes of the chest, and then comparing the impressions communicated to it with those communicated to the other hand, similarly placed upon the corresponding part of the opposite side.

2. Indications afforded by Palpation. When it is inconvenient to expose the chest of a patient—when, for example, the appearance of delicacy might be considered to be thereby sacrificed-or when there may be danger, or a liability to an increase of symptoms by the surface of the body being bared, the appressed fingers of one hand placed flatly, and pressed firmly upon the infraclavicular 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, in the early stage of phthisis.

When it is doubtful whether the eye has correctly measured a supposed slight difference in the action or mobility of the two sides, Palpation, exercised in the mode just mentioned, may be usefully employed to remove or to confirm that doubt. Any considerable deficiency of elevation of the ribs, or mobility of the parietes, or any great disparity between the two sides, is immediately detected, even without exposing the patient, by the hands placed upon the lateral regionswhether that deficiency depend upon pleuritic effusion, hydrothorax, pneumonia, pneumothorax, or any other cause. The exact nature of the complaint must be decided by farther examination of

a different kind.

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