Relation to surface.

dorsal spine to the middle of the sixth costal cartilage divides the lung into its upper and lower lobes. On the right side a second line drawn from the middle of the first line to the fourth chondrosternal joint marks the upper boundary of the middle lobe. The front of the chest, therefore, represents the upper, the back the lower, lobe, the apex being accessible both anteriorly and posteriorly, and the middle lobe on the right occupying a portion of the axilla and the anterior surface.

Movements of the Lungs.-There is normally a well-defined respiratory excursion of the upper and lower borders of the

Bounded by the lung, spleen, and liver, and the costal margin. Shows region of pleural sinus in which movable dullness may appear in left-sided pleural effusion.

lungs most marked in the axillary region. This will be further described under Inspection and Percussion.

Position of the Heart.-The anatomic position of the heart, its valves, and its tributary vessels is, in a general way, important, but to this must be added a special knowledge of percussion outlines and auscultation areas. A reference to figure 18 shows that the heart is placed between the lungs, and presents

(a) A base, lying at the level of the upper border of the third costal cartilage.

(b) A right border, curving from the right base downward to

the sixth chondrosternal articulation, and attaining a distance of one or one and one-half inches from the right sternal border under the fourth cartilage.

(c) A left border, which curves outward to the nipple line, and then inward to a point one inch within that line in the fifth interspace.

(d) A lower border, connecting the lower extremities of the lines representing the right and left borders.

The Aorta. From the base the aorta sweeps upward and to the right, its right border projecting slightly beyond the sternal

FIG. 17-LUNG BOUNDARIES (ANTERIOR SURFACE). (Modified Pansch-Fowler.) margin; it then passes backward and toward the left in such a manner as to leave the manubrium of the sternum resonant under normal conditions.

Range of Movement.-By means of the attachments of the blood-vessels entering its base, the heart is suspended freely within the pericardial sac, and is thus adapted to a considerable range of movement.

Manubrium normally reso

nant.

anterior.

It should be remembered that the heart presents anteriorly its Right heart right chambers, and chiefly the right ventricle, the left ventricle being represented, under normal conditions, by a mere strip of heart-muscle along the left border.

The four valves are so near together as to permit their being The valves.

almost covered by the mouthpiece of a large stethoscope, and their exact position is a matter of comparative indifference to the examiner. The heart is nearly covered by the lungs, save that Incisura cardi- the border of the left lung is so notched when it reaches the fourth rib as to leave a portion of the right ventricle uncovered and in close proximity to the chest.

aca.

area.

Superficial Cardiac Area. This uncovered portion gives us the area of percussion dullness known as the superficial cardiac In actual practice this is a somewhat triangular space of marked percussion dullness, having its base at the left sternal margin from the fourth to the sixth chondrosternal articulation,

Normal location.

Sibson.)

and its apex at or just within the apex-beat, the triangle being completed by lines drawn to connect these points. (See Fig. 14.)

Relative Dullness.-It is so difficult to outline the normal heart as a whole that modern diagnosticians are content to use two percussion areas as representing the normal and serving to determine and measure any change in the boundaries of the enveloping lung or in the size of the heart. That known as the area of relative or deep dullness is well shown in figure 14.

Apex-Beat. The apex-beat, or visible and palpable heart impulse, is normally found at a point an inch within and one and one-half inches below the male nipple, or, better stated, in the fifth interspace, an inch within the nipple line.

THE EXAMINATION OF THE CHEST (Continued).

HEART AND BLOOD-VESSELS.

The examination of the heart should be completed before that of the lungs is commenced.

THE PULSE.

Pulse-taking should precede even the mention of a physical examination.

Technic.-A correct technic is of the first importance if one expects to obtain information of value. The pulse should in every case be taken simultaneously in the two radials. Three fingers should be applied to the vessel. The applicant's arms should be similarly placed, and the position assumed should be free from restraint and allow no flexion or muscular compression of the vessels, or in any way obstruct the direct or return circulation.

In insurance examinations even more than in private practice due allowance must be made for the nervousness incident to examination and for the effects of physical exertion.

It is possible and always best to take the pulse in a casual manner while talking of other things. As before stated, it should always be taken before the chest is examined, as it is invariably accelerated during that procedure.

Points to be Determined.-(1) Abnormal thickening of the artery. (2) The size of the artery. (3) Its tension. (4) Whether or not the beats are equal and their rhythm regular and uniform. (5) Their frequency or rate. (6) The question of correspondence of the pulse of one side with that of the other.

When the examiner's fingers are applied to the artery, several questions are decided almost simultaneously; these are the size of the pulse or rather of the artery, its fullness, and the force of the beat.

The vessel is rolled under the finger and its outline noted. Pressure is made with the upper finger, and the force necessary

Tension.

Arteriosclerosis.

Causes of tachycardia.

Bradycardia.

to cut off the pulse below carefully noted.* This determines "tension." What constitutes high, moderate, or low tension is only to be learned by experience.

While the artery is thus compressed above, it is rolled under the finger to determine the question of arterial thickening (arteriosclerosis). Under these conditions the normal vessel can not be felt as a distinct tube. If so felt, it is the seat of sclerosis, and this may vary from mere palpability to a rigidity like that of a fine quill. Indeed, in senile atheroma one may distinctly. feel the placques formed by the deposit of lime-salts.

When to Take the Pulse.-The best time to take the pulse is just before the review of the questions is completed, and while the applicant's mind is given over to some point in the family or personal history. The worst times are: (a) At the beginning of an examination. (b) After forced breathing and chest examination. (c) At the end of an examination.

Tachycardia and Bradycardia.-A pulse that runs above 85 calls for the use of a temperature thermometer, and any persistently high pulse should during its continuance make ordinary life insurance unattainable.

Aside from organic heart disease, sexual neurasthenia, incipient tuberculosis, tobacco, the overuse of stimulants, and overwork, physical and mental, are the commonest causes of tachycardia, and if after several attempts the pulse still remains rapid, the case should be postponed pending further instructions from the home office. Both the very rapid and the very slow pulse are said to be in rare instances physiologic, but such cases are so rare as not to justify an insurance company in accepting at ordinary rates the ninety-nine bad risks to secure one good one.

A pulse as low as 20 to the minute has been reported in an apparently healthy man, and one of six to the minute just before death, but the later record shows that in the former case the man died suddenly only a few months after the observation was made. An abnormally slow pulse should always suggest disease of the heart with or without valvular lesion or associated renal disease. In these modern days we do not regard the pulse with that

* Recurrent Pulse.-Not infrequently a free anastomosis makes it necessary to shut off the ulnar as well as the radial artery.