Medical diagnosis : a manual of clinical diagnosis / J.J. Graham Brown.

  • Brown, J. J. Graham (John James Graham), 1853-1925.
Date:
1897
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Licence: Public Domain Mark

Credit: Medical diagnosis : a manual of clinical diagnosis / J.J. Graham Brown. Source: Wellcome Collection.

    120/454 page 98
    Flattening of the praecordia may only be caused by retraction of the left lung, the result of pleurisy or of fibroid phthisis. Pulsations. I. The Cardiac Impulse.—In health the apex-beat of the heart is found in the fifth left interspace, about an inch and a half or two inches from the left margin of the sternum, and its area does not exceed a square inch in extent. In childhood, however, and in persons who have a short and wide thorax, it may stand somewhat higher, and may be thrown farther to the left; whilst in old age, and in individuals whose thorax is very long and narrow, the cardiac impulse is lower than normal. While natural breathing does not affect its position, deep inspiration and expiration cause respectively depression and elevation of the apex-beat. When the patient lies on either side, the apex-beat is deflected in a corresponding direction. This alteration is more marked towards the left. The cardiac impulse does not always make itself visible on the chest wall. This is usually due to great development of fat or muscle, and in such cases we can by palpation almost always fix the position of the apex-beat. It may be noted that in certain rare cases there is a congenital transposition of the viscera, the heart lying then on the right side of the thorax. [Pathological changes in the position of the apex-beat will be considered under the head of Palpation.] Systolic indraiving of the thoracic wall is of two varieties —(i) a recession, which is exactly synchronous with each ven- tricular systole ; and (2) one which immediately succeeds the retirement of the apex of the heart from the chest wall. The former variety is sometimes met with in healthy persons (particularly children) in whom the chest walls are unusually thin. It occurs in the third and fourth interspaces, and is simply the result of that recession of the base of the heart which is synchronous with the forward movement of the ventricles.
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