EXAMINATION OF THE CHEST - the ordinary course of inquiry, we have next to examine the condition of the organs contained in the chest ; and in order to insure habits of accuracy in diagnosis, the student should make a rule under no circumstances to omit it; in practice, he may subsequently limit himself to a few general questions with regard to cough, dyspncea, or palpitation, and the existence of pain or expectoration. If the answers to such queries be unsatisfactory, further inquiry is evidently called for : but even when they fail to elicit any statement indicating the presence of disease, the ex amination of the chest may be attended with the most important results: it is scarcely too much to say that diagnosis would be less frequently at fault, and treatment more uniformly beneficial, if it were our constant practice to ascertain the leading characters of the respiration and the heart's action in all classes of disease, just as we are accustomed to look at the tongue and feel the pulse. A cursory examination at least serves to assure us that there is or is not disease of much amount, while a more careful investi gation may bring to light some fact which will in great measure serve to explain circumstances previously unintelligible.
§ 1. History and General Symptoms.—The history of the case sometimes affords but little information, while in other instances it may almost alone serve as the basis for correct diagnosis. The duration of the attack at once separates cases of recent origin from those which, by their continuance or repetition, are shown to be more or less chronic : from the date of the first deviation from health and the order of sequence among the phenomena, we learn whether pain or febrile symptoms, coryza or expectora tion, attended its commencement, or the cough came on gradu ally ; and we are also enabled to place by themselves cases in which the very important fact can be elicited that blood has been occasionally mixed with the sputa. Any past illness, directly or indirectly bearing. on disease of the chest, should be noted, be cause it would show either that the symptoms were secondary on disease in other organs, or that the present attack was one of a succession of similar character, or that it had sprung out of the organic changes wrought by the previous illness.
In the present condition of the patient we have to consider whether the general symptoms indicate inflammatory fever or hectic, or freedom from any febrile disturbance ; the pulse must be especially noticed, as it is one of the more direct signs of dis ease of the heart. The appearance may be one of health and strength, or of weakness and emaciation; the aspect may betray signs of anxiety, as caused by pain or breathlessness • the color of the face may have the dusky hue of ill-ventilated blood, or • the brilliancy of hectic. We have to pay regard to the posture which disease may oblige the patient to assume for the relief of labored respiration • and while listening to complaints of pain or discomfort, we watch the character of the breathing and cough, with regard to frequency and force, comparing the former espe cially with the quickness and power of the pulse ; it is also im portant to ascertain the character of the expectoration.
These circumstances may point either to disease of the heart or of the lungs. The history of the former is generally obscure, the origin unknown to the patient himself and the duration extremely uncertain ; and it is per haps only when the pain of pericarditis marks the commencement of that dis ease, that any definite information is gained.
The duration of the different affections of the chest varies in a very re markable degree ; the only important points connected with this inquiry are the recent occurrence of an acute attack, the continuous illness of some weeks or months which especially characterize rapid phthisis and the yearly return of cough in chronic bronchitis, emphysema. and the more tardy forms of tubercular disease. In organic changes of the heart's structure shortness of breath is sometimes spoken of as a symptom of many years' standing; at the same time it will constantly be experienced in practice that very serious disorganization must have been proceeding for years, without any conscious ness of its existence on the part of the sufferer.