Percussion (medicine)

“ Percussion.—On percussion there will be marked dulness over that portion of the lung which is the seat of the pneumonia, while over the healthy portion, as well as over the opposite lung, there will be exaggerated resonance. The nearer the hepatization approaches the surface of the lung, the more marked will be the dulness. There is a peculiar sense of resistance on percussion over a completely airless hepatized lung which is not present in solidification from other causes. The exact outline of an hepatized lobe can often be traced on the chest-wall. ”

“ Over the greater part of the stomach the percussion note is tympanitic, sometimes with a metallic quality. Over the most dependent part of the stomach a dull sound is produced on percussion in case a sufficient quantity of fluid or solid material is contained in the viscus. In the upright position, therefore, in percussing over the stomach from above downward, the tympanitic note gives place to a dull sound, and this zone of dulness will change with the position of the patient, so that in the recumbent posture the dulness may entirely disappear. ”

“ Wherever there is air in the chest, that is all over the healthy lungs, the sound elicited by percussion resembles that given out by a drum over which a thick woolen cloth has been placed. Over the heart, where there is no air, the sound given out, when the chest is percussed, corresponds very nearly to the sound produced when the thigh is tapped. The sound elicited by percussion of the thigh Auenbrugger took as the standard of dulness and applied to it the term Schenkel-ton, or thigh sound. ”

“ When effusion has taken place the pulse is weaker and softer, irregular or intermittent, the impulse of the heart is weaker, the friction sound is lost, and the area of dulness corresponding to the heart is increased. Percussion shows it to extend higher than three inches above the breast bone in the horse and more than two or two and a half inches transversely. ”

“ When the lungs become consolidated because of an inflammatory process such as pneumonia or tuberculosis, then the percussion note over the consolidated area resembles the sound over the leg or that found over the heart. As a rule the heart is somewhat covered by the lungs, and the sound produced by percussion over it is not quite as dull as that over the solid muscular structures of the legs. Whenever fluid finds its way into the thorax, as in pleurisy, then the sound produced on percussion is very dull. ”

“ This author, in his Treatise on the Diseases of the Heart, constantly founds much of his diagnosis on the indications afforded by percussion.
The method consists in striking the respective parts of the chest, which return a hollow kind of sound, when the contents of this cavity are in a healthy state; but give a duller sound, when, from any cause, there is impediment to the free entrance of air into the cells of the lungs. When the obstruction is considerable, the perception is very much the same as when you strike upon the thigh. ”

“ Auscultatory percussion may sometimes be advantageously employed to detect fluid in the pleura, especially in the younger subjects, for intercostal fluctuation may frequently be appreciated when we press carefully with the palm or surface of the finger between the ribs while the percussion shock is applied to another part of the same side. If we auscultate with a stethoscope, the chest extremity of which is made to fit in between the ribs, while another person percusses the chest, we can sometimes detect the fluctuation within the cavity of the chest. ”

“ Auscultation detects in the early stages in addition to a healthy respiratory murmur, a friction sound audible in inspiration only in short jerks near the close of the act and comparable to the rubbing of the palm of one hand over the other laid over the ear, but this is no longer heard when effusion of liquid has taken place into the pleuræ. Percussion in the early stages detects no change from the healthy chest resonance. ”

“ When fluid fills the chest to excess and overcomes the elasticity of the lung, it gives flatness on percussion high up, even to the clavicle, and behind to the supra-spinous fossa. The fluid filling the cavity, the line of flatness becomes nearly horizontal. Then it is that percussion reveals the displacement of the diaphragm and abdominal organs. On removing the excess of fluid by aspiration or by absorption, this curved line reappears, and continues as previously. ”

“ When an upper lobe is consolidated, forcible percussion may elicit a tympanitic sound, for the column of air in a large bronchus will vibrate under forcible percussion. The cracked-pot sound (bruit de pot fêlé) is occasionally met with over those relaxed and permeable parts of the lung in the immediate vicinity of the consolidation. When this sound is present over the consolidated portion, it is due to the sudden expulsion of air from one of the larger bronchi. It is most frequent in young persons with thin, elastic chest-walls. ”

“ They consist of movements made with the pulpy ends of the fingers and thumbs, and spiral movements with the whole hand so folded as to adapt its palm to the limb. In percussion the strokes should be from the wrist, and should be quick and short. It is probably not possible, even by long strong strokes, to affect deep muscles. ”

“ It is equally true that percussion and auscultation may be most valuable, or, on the other hand, indefinite. The degree of dulness occasioned by a morbid growth in the anterior mediastinum is dependent on its size, large growths yielding flatness; but when the tumors are small the osteal resonance of the sternum is simply hardened. Respiratory percussion is available if the growth lies anteriorly. The full, clear resonance of full-held inspiration contrasts with the increased dulness developed when the lungs are stripped from the mediastinal space by forced expiration. ”

“ Here, too, auscultation and percussion are of little assistance in establishing a diagnosis when there is a laryngeal diphtheria at the same time, for the above reasons. Where, however, the dulness on percussion is accompanied by high fever, and the long-drawn inspiration is replaced by rapid respiratory movements, the diagnosis of pneumonic complication is justified. ”

“ Personally I have found that by light percussion I can limit with much accuracy the upper, right, and left borders of the heart.
There is much to be gained by using light percussion. Strong blows set in vibration not only the underlying structures, but also more or less of the chest wall. ”

“ When the breathing is slower, it commonly indicates some affection of the nervous system; when very rapid, some important lesion within the chest.
The theory of percussion is founded upon three elementary sounds, which are produced when a solid, a liquid, or a gaseous body is struck; all others are varieties of these. The sensation of resistance which is experienced at the same time bears an exact relation to the density of these bodies—hence the resistance when a solid substance is struck is greater than when a gaseous one is under percussion. ”

“ Percussion must be regarded as a necessary part of auscultation, particularly in relation to the examination of the chest; for the physician who has made himself acquainted with the normal condition of that part of the body in reference to percussion is thus able to recognize by the ear alterations of resonance produced by disease. But percussion alone, however important in diagnosis, could manifestly convey only limited and imperfect information, for it could never indicate the nature or extent of functional disturbance. ”

“ To rouse the dormant action of cold skin and flabby muscle, percussion will be of the first importance, and will alternate with friction and manipulation. Percussion is in massage what faradization is in electricity, and will often answer the same purpose; manipulation, or deep-kneading, is to massage what the constant current is to electricity, and the ultimate effects of each are very much alike. ”

“ Percussion should then be performed with the woman upon her back, upon the right side, upon the left side, sitting up, and upon the hands and knees. An encysted fluid accumulation will give practically the same result in percussion in all positions, while free fluid will gravitate to the most dependent portion. ”

“ In any case, the force should not be sufficient to bruise the tissues. The physiologic results of percussion are stimulation for functions of the skin and a marked effect upon the underlying structures, muscles, nerves, and blood-vessels. It is useful in such conditions as sciatica, inactivity of the liver, chronic constipation, poor circulation from various causes, and to produce reaction after a cold bath, etc. ”

“ The percussion sounds yielded by the chest during what has been aptly called the pre-tubercular stage do not differ from those elicited in health, because it is only when some morbid matter exists in the lungs that the percussion note is altered, therefore negative results only are obtained in the real first stage by this mode of examination. ”

“ But there can be no percussion without movement, and sound is not produced by the percussion of any kind of substance, as we have said, (since wool, however percussed, does not, while brass and smooth and hollow bodies—brass because it is smooth—do give out sound,) and hollow bodies create, by reflexion, many percussions after the first, owing to the medium within them having been set in motion and being unable to make its escape. ”

“ Instruments of concussion and percussion, like drums and cymbals, and also wind instruments of shell or horn, and rude forms of bagpipes, are inventions of most savage races; but the production of even the most elementary form of stringed instrument is a distinct advance, showing an understanding, however faint, of the use of vibration in developing and strengthening an original note. ”

“ But the percussion produced in us when we, by the utterance of a voice, cause a disengagement of certain particles, constitutes a current resembling a light whisper, and prepares an acoustic feeling for us. ”

“ The effects of percussion not to be compared with those of weight. 15. In percussion, therefore, when one hard body is in some small part of it stricken by another with great force, it is not necessary that the whole body should yield to the stroke with the same celerity with which the stricken part yields. For the rest of the parts receive their motion from the motion of the part stricken and yielding, which motion is less propagated every way towards the sides, than it is directly forwards. ”

“ The toothed bow of the left wing-case is the motor; the friction-nervure of the right wing-case is the point of concussion; the stretched membrane of the mirror is the resonator, to which vibration is communicated by the shaking of the surrounding frame. Our own music has many vibrating membranes; but these are always affected by direct percussion. Bolder than [263] our makers of musical instruments, the Decticus combines the bow with the drum. ”

“ When the pericardial fluid becomes much increased, the friction sound ceases, as does also the impulse of the heart, which at first usually palpitates, then becomes fluttering, feeble, and intermittent, and at last can with difficulty be heard. Percussion gives a dull sound in the region of the heart, but just behind it, as well as in other parts of the lungs; if there is no disease in them, or Hydrothorax, the resonance in those parts will serve to distinguish Hydrops Pericardii from Hydrothorax. ”

“ What we must endeavor to learn is the actual size of the heart as nearly as our crude means will permit.
Light, very light, almost inaudible percussion, what Goldscheider called "Schwellungsperkussion," must be practiced. Use the middle finger of the right (left) hand as the hammer and the last joint of the middle finger of the left (right) hand pressed firmly against the chest, as pleximeter. I believe it is better to place the pleximeter finger parallel to the boundary to be limited although some place the finger perpendicularly, that is, pointing toward the boundary. ”

“ The stroke of a cannon ball is attended with a flash. If the world were suddenly stopped in its course, heat enough would be generated to set it on fire. Nitro-glycerine and dynamite are exploded by percussion. Familiar illustrations of this scientific truth meet us in everyday life. It has even passed into a proverb with a moral application, that “hard cracks make the sparks fly.” A novel effect of percussion may have been noticed when a fall upon the ice has resulted in a mechanical disturbance of the optic nerve which revealed whole constellations of stars never yet catalogued. ”

“ Percussion is of valuable service in this affection. After effusion occurs the sound produced by percussing over the lower part of the chest is dull. By striking different parts one may come to a spot of greater or less extent where the blows cause much pain to be evinced. The animal may grunt or groan every time it is struck. Another method of detecting the affected part is to press the fingers between the ribs, each space in succession, beginning behind the elbow, until a place where the pressure causes more flinching than at any other part is reached. Auscultation is also useful. ”

“ The percussion treatment that I have suggested consists in alternate tapping or striking this region of the body with both hands. A chopping movement, using the outside edge of the hands, is very effective, and if you are very vigorous, the closed fist may be used. Striking repeatedly and alternately with the two fists, go over the entire region of the stomach and abdomen. This can be done gently or vigorously, according to your condition, and it is an invaluable and effective means of stimulating peristalsis and functional vigor. ”