PERCUSSION (percussio prostukivaniye) — one of the main objective methods of inspection of the patient consisting in percussion of body parts and definition on character of the sound of the physical properties located under the percussed place of bodies and fabrics arising at the same time (hl. obr. their density, lightness and elasticity).
Attempts to apply P. arose in an extreme antiquity. Believe that Hippocrates by a prostukivaniye of a stomach defined accumulation in it of liquid or gases. The item as a method of physical diagnosis it was developed by the Vienna doctor L. Auenbrugger who described it in 1761. The method gained general distribution only after Zh. Korvizar in 1808 translated A. Auen-brugger's work into fr. language. In the 20th 19 century were offered plessimetr and a hammer for percussion. Y. Skoda (1831) developed scientific bases of P., explained an origin and features of a percussion sound, proceeding from laws of acoustics and physical condition of the percussed fabrics. In Russia P. began to apply at the end of 18 century, and at the beginning of 19 century its implementation in broad practice was promoted by F. U of den (1817), P. A. Charukovsky (1825), K. K. Zeydlits (1836) and especially G. I. Sokolsky (1835), vnesnshy the contribution to improvement of a method, just as afterwards V.P. Obraztsov and F. G. Yanovsky.
Physical bases of percussion
At percussion on a body part arise fluctuations of the subject environments. A part these * fluctuations has the frequency and amplitude sufficient for acoustical perception of a sound. Attenuation of the caused fluctuations is characterized by a certain duration and uniformity. Frequency of fluctuations determines height of a sound; the more frequency, the is higher a sound. According to it distinguish high-pitched and low percussion sounds. Height of a sound is directly proportional to density of the subject environments. So, at P. of sites of a thorax in the place of a prileganiye of low-dense air pulmonary fabric low sounds, and in the field of an arrangement of dense tissue of heart — high are formed. Force, or loudness, a sound depends on amplitude of fluctuations: the more amplitude, the is louder a percussion sound. Amplitude of fluctuations of a body, on the one hand, is defined by force of percussion blow, and on the other hand, it is inversely proportional density of the fluctuating body (the density of the percussed fabrics, the more amplitude of their fluctuations is less and the percussion sound is louder).
Duration of a percussion sound is characterized by time of fading of fluctuations, a cut is in direct dependence on the initial amplitude of fluctuations and in the return — from density of the fluctuating body: the body is more dense, the percussion sound is shorter, the density is less, the it is longer.
Character of a percussion sound depends on uniformity of the environment. At P. of bodies, homogeneous on structure, there are periodic vibrations of a certain frequency, to-rye are perceived as tone. At P. Wednesday of fluctuation, heterogeneous on density, have different frequency that is perceived as noise. From environments of a human body a homogeneous structure only the air which is contained in cavities or hollow body organs (the stomach or a loop of a gut filled with air or gas, accumulation of air in a pleural cavity) possesses. At P. of such bodies and cavities there is a harmonious musical sound, in Krom the main tone dominates. This sound is similar to a sound at drum beat (grech, tympanon a drum) therefore it is called a tympanites or a tympanic percussion sound. Characteristic property of a tympanic sound — ability to change height of the main tone with change of tension of walls of a cavity or air in it. This phenomenon is observed at spontaneous pheumothorax: with increase in pressure in a pleural cavity (at valve pheumothorax) the tympanites disappears and the percussion sound accepts tupotimpanicheskiya in the beginning, and then not tympanic character.
Tissues of a human body are heterogeneous on density. Big density bones, muscles, liquids in cavities have, such bodies as a liver, heart, a spleen. The item in the field of an arrangement of these bodies gives a low, short or stupid percussion sound. Those treat fabrics or bodies of small density, to-rye contain a lot of air: the pulmonary fabric, hollow bodies containing air (a stomach, intestines). The item of lungs with normal lightness gives rather long or clear and loud percussion sound. At reduction of lightness of pulmonary fabric (an atelectasis, inflammatory infiltration) its density increases and the percussion sound becomes stupid, silent.
Thus, at P. of different body parts of the healthy person it is possible to receive three main characteristics of a percussion sound: clear, stupid and tympanic (tab. 1).
Table 1. The CHARACTERISTIC of MAIN TYPES of the PERCUSSION SOUND ON FORCE, DURATION AND FREQUENCY
The clear percussion sound arises at P. of normal pulmonary fabric. The stupid percussion sound (or dulled) is observed at P. of areas under which there are dense, airless bodies and fabrics — heart, a liver, a spleen, massive groups of muscles (on a hip — «femoral dullness»). The tympanic sound arises at P. of areas to which air-vessels adjoin. At the healthy person it comes to light over the place of a prileganiye to a thorax of the stomach filled with air (so-called space of Traube).
Methods of percussion
Depending on a way of a prostukivaniye distinguish a straight line, or direct, and mediocre P. Neposredstvennaya P. is made by blows of finger-tips to a surface of the studied body, at mediocre P. blows by a finger or a hammer are put on other finger imposed on a body or a plessimetra (Greek plexis blow + metreo to measure, measure) — a special plate from metal, a tree, plastic or a bone.
Among methods direct Item. Auenbrugger, Obraztsov, Yanovsky's ways are known. L. Auenbrugger covered the percussed place with a shirt or put on a glove a hand and tapped on a thorax with tips of the extended fingers, striking slow weak blows (fig. 1). V. P. Obraztsov used an index finger of the right hand (a nail phalanx) at P. and to increase force of blow, fixed an ulnarny part for a radial surface of a long finger and then during the sliding of an index finger from an average struck them percussion blow. The left hand at the same time straighten skin folds of the percussed area and limit distribution of a sound (fig. 2, and, b). F. G. Yanovsky applied one-manual P. at which percussion blows were struck with the minimum force pulp of two trailer phalanxes of a long finger of the right hand. Direct P. is used for delimitation of a liver, a spleen, absolute dullness of heart, especially in children's practice and at the exhausted patients.
Treat mediocre P.'s methods percussion by a finger on a plessimetra, a hammer on a plessimetra and so-called manual bimanual P. Prioritet of manual bimanual P.'s introduction belongs to G. I. Sokolsky who struck blows with tips of two — three fingers of the right hand put together to one or two fingers of the left hand. Gerhardt (S. of Gerhardt) offered P. a finger on a finger; it was generally recognized. Advantage of this method is that the doctor along with sound perception receives a finger-plessimetrom tactile feeling of force of resistance of the percussed fabrics.
At P. a finger on a finger the long finger of the left hand (serves plessimetry) is densely put flatwise to the explored place, other fingers of this hand are divorced and hardly touch a body surface. Hit with a trailer phalanx of the long finger of the right hand (carries out a role of a hammer) bent in the first joint almost at right angle on an average phalanx of a finger-plessimetra (fig. 3). For receiving an accurate sound strike the uniform, abrupt, short blows directed vertically to the surface of a finger-plessimetra. During P. the right hand is bent in an elbow joint at right angle and given by a shoulder to a side surface of a thorax, she remains motionless in humeral and elbow joints and makes only bending and extension in a radiocarpal joint.
Auskultatorny P.'s method consists in listening of a percussion sound a stethoscope (see. Auscultation ), which is installed on side of a thorax opposite to the percussed body (at a research of lungs) or over the percussed body (at a research of a liver, stomach, heart) in the place of its prileganiye to an abdominal or chest wall. Light percussion blows or the shaped pal-patorny movements (an auskultator-ny palpation) put on a body from the place of contact of a stethoscope with it in the direction to edge of the studied body. While percussion blows make within body, the percussion sound is heard clearly as soon as P. goes beyond body, the sound is sharply muffled or disappears (fig. 4.).
Depending on force of the struck blow distinguish strong (loud, deep), weak (silent, superficial) and average by P. Silna P. is determined by deeply located bodies and fabrics (consolidations or a cavity in a lung at distance of 5 — 7 cm from a chest wall). Average P. is applied during the definition of relative dullness of heart and liver.
Use silent P. for finding of limits of absolute dullness of heart and a liver, a lung and a spleen, small pleural exudates and superficially located consolidations of lungs. So-called quietest (minimum), otgranichitelny P. is made so light blows that the sound arising at the same time is in «a threshold of perception» an ear — threshold the Item. It is applied to more exact definition of absolute dullness of heart; at the same time percussion is made in the direction from heart to lungs.
Clinical use of percussion
Supraclavicular and subclavial areas percuss across Plesh: the finger-plessimetr is bent at right angle in the first interphalangeal joint and press it to skin only the end of a nail phalanx, blows put with a finger hammer on the main phalanx (fig. 5). Depending on appointment allocate two types of P.: topographical (restrictive) and comparative. At topographical P. define borders and the sizes of body (heart, lungs, a liver, a spleen), existence of a cavity or the center of consolidation in lungs, liquid or air — in an abdominal cavity or a pleural cavity. With its help establish border of transition of one sound in another. So, about the right relative border of heart judge by transition of a clear pulmonary sound in dulled, and about absolute — by transition of the dulled sound in stupid. At P. percussions make usually from a clear percussion sound to stupid, striking weak or average force blows.
Comparative Items make, using percussion blows of different force depending on localization patol, the center. Strong P. can reveal deeply located center, and superficial — average or silent. Percussion blows put on (strictly symmetric sites. They shall be on both sides identical on force. In each point usually make two blows for the best perception.
At percussion of heart define its borders. Distinguish limits of relative and absolute dullness hearts (see). In a zone of relative dullness the dulled percussion sound, and in a zone of absolute dullness — stupid is defined. To the true sizes of heart there correspond limits of relative dullness, and the part of heart which is not covered with lungs — a zone of absolute dullness.
Distinguish the right, upper and left borders of heart (in such sequence and carry out P.). In the beginning define the right limit of relative dullness of heart. Previously find limit of hepatic dullness. For this purpose the finger-plessimetr is established horizontally y P. conduct on mezhreberye from top to down on the right median and clavicular line. The place of change of a percussion sound from clear to stupid corresponds to limit of hepatic dullness, usually it is located on the VI edge. Further P. conduct in the fourth mezhreberye from right to left (the finger-plessimetr is located vertically).
The right limit of relative dullness of heart normal is on the right edge of a breast, and absolute dullness — on the left edge of a breast.
The upper bound is percussed in the direction from top to down, slightly otstupya from the left edge of a breast (between sternal and parasternal lines). Palets-plessimetr is located slantwise, parallel to required border. The upper bound of relative dullness of heart is on the III edge, absolute — on IV. During the definition of the left limit of cordial dullness of P. begin knaruzh from its apical beat. If the apical beat is absent, then find the fifth mezhreberye at the left and percuss, since the front axillary line, a knutra. Palets-plessimetr is located vertically, percussion blows put in the sagittal plane.
The left limit of absolute dullness usually matches limit of relative cordial dullness and is defined normal on 1 — 1,5 cm of a knutra from the left median and clavicular line in the fifth mezhreberye.
The item of the vascular bundle formed by an aorta and a pulmonary artery carry out in the second mezhreberye consistently on the right and to the left of a breast in the direction of outside knutra. Width of a vascular bundle (a zone of a dullness) normal does not go beyond a breast.
Percussion of lungs it is made in those places of a thorax where normal pulmonary fabric directly prilezhit to a chest wall and causes a clear pulmonary sound at P.
Apply comparative and topographical the Item. lungs (see). At comparative P. establish existence patol, changes in lungs or a pleura by comparison of a percussion sound on symmetric sites of the right and left half of a thorax. At topographical P. find borders of lungs, define mobility of the bottom pulmonary edge. Begin a research with comparative percussion. At P. of lungs of the patient holds a vertical or sitting position, percussing at a research of a lobby and sidewalls is before the patient, and at P. of a back surface — behind the patient. At P. costs to a front surface of the patient with the lowered hands, side surfaces — with the brushes put for the head, a back surface — with the hung head, having slightly bent kpered, with the crossed hands, having put brushes on shoulders.
Palets-plessimetr in supraclavicular areas put parallel to a clavicle, in front below clavicles and in axillary areas — in intercostal spaces parallel to edges, in nadlopatochny area — it is horizontal, in interscapular spaces — vertically, parallel to a backbone, and below a vane angle — it is horizontal, parallel to edges. Strike with a finger hammer identical percussion blows, usually average force.
Comparative P. is carried out in front in supraclavicular poles, directly on clavicles, below clavicles — in the first and second mezhreberye (the dullness from adjacent heart therefore in the third below the located mezhreberye in front comparative P. is not carried out begins with the third mezhreberye at the left). In side areas of a thorax percuss in an axillary pole and on the fourth and fifth mezhreberye (below obtusion of a sound from an adjacent liver begins on the right, and at the left the sound gets a tympanic shade from proximity of space of Traube). Behind P. conduct in nadlopatochny areas, in upper, average and lower parts of interscapular spaces and under shovels — in the eighth and ninth mezhreberye.
Patol, changes in lungs or in a pleural cavity determine by changes of a percussion sound. The stupid sound appears at accumulation of liquid in a pleural cavity (exudative pleurisy, a hydrothorax, a hemothorax, a pyothorax), massive consolidation of pulmonary fabric (a lung fever, an extensive atelectasis). Shortening and dullness demonstrates reduction of lightness of pulmonary fabric that takes place at its focal consolidation.
If reduction of lightness of pulmonary fabric is combined with decrease in its elastic tension, the percussion sound becomes prituplenno-tympanic (melkoochagovy infiltration, an initial stage of a lung fever, a small air-vessel in a lung with the pulmonary fabric condensed around, an incomplete atelectasis of a lung).
The tympanic sound comes to light at sharply increased lightness of pulmonary fabric, in the presence in it the cavity filled with air (abscess, a cavity, bronchiectasias) and at accumulation of air in pleural cavities (pheumothorax). Kind of a tympanic sound is the bandbox percussion sound which is defined at the emphysema of lungs which is followed by increase in lightness and decrease in elastic tension of pulmonary fabric. In the presence of a big smooth-bore cavity, adjacent to a chest wall, the tympanic sound gets a metal shade and if at the same time the cavity connects the narrow slotted opening to a bronchial tube, air at P. through a narrow opening comes out tolchkoobrazno in stages and there is a peculiar discontinuous jingling noise — the sound of the burst pot described by R. Laennek.
In the presence of a big cavity or another patol, the cavity which is reported with a bronchial tube, height of a tympanic sound changes during the opening of a mouth (Vintrikh's symptom), at a deep breath and an exhalation (Fridreykh's symptom) and if a cavity of an oval form, then and at change of position of a body (Gerhardt's phenomenon).
At topographical P. define borders of lungs in the beginning: the finger-plessimetr is established in mezhreberye parallel to edges and, moving it from top to down, strike silent percussion blows. Then define mobility of bottom edge of lungs and their upper bound.
The arrangement of the lower bound of lungs at people of a different constitution is not absolutely identical. At typical hypersthenics it is one edge higher, and at astenik — is one edge lower. The arrangement of the lower bound of a lung at a normostenik is given in table 2.
Table 2. The PROVISION of the LOWER BOUND of LUNGS At NORMOSTENIKA
The lower bounds fall at increase in lung volume at the expense of emphysema or acute swelling (an attack of bronchial asthma).
The lower bound rises at fluid accumulation in a pleural cavity (vypotny pleurisy, a hydrothorax), at development of a pneumosclerosis, at high standing of a diaphragm at patients with obesity, ascites, a meteorism.
At a research of mobility of bottom edges of lungs define the lower bound separately at height of a deep breath and after a full exhalation. The distance between position of edge of a lung on a breath and an exhalation characterizes the general mobility of pulmonary edge which on axillary lines normal makes 6 — 8 cm. Immobilization of pulmonary edges is observed at emphysema, an inflammation and a fluid lungs, formation of pleural commissures, accumulation in a pleural cavity of air or liquid, dysfunction of a diaphragm.
At P. of the upper bound of lungs determine height of standing of tops and their width — so-called fields Kreniga (see. fields Kreniga ).
Percussion of a stomach it is applied to size discrimination of hepatic and splenic dullness, identification in an abdominal cavity of liquid and gas, and also to establishment of painful sites of an abdominal wall (see. Stomach ). The last reveal drawing easy abrupt blows to different sites of an abdominal wall — in epigastric area, at a xiphoidal shoot (a projection of cardial department of a stomach), to the right of a midline to the right hypochondrium (a projection of a duodenum and gall bladder), on a midline and in left hypochondrium (an ulcer of small curvature of a stomach, damage of a pancreas). The pain developing at height of a breath at P. in a gall bladder is characteristic of cholecystitis (Vasilenko's symptom).
Sizes liver (see) determine perkutorno by M. G. Kurloyeu, establishing limits of hepatic dullness on three lines: the first size — on the right median and clavicular line from the upper bound of hepatic dullness to its lower bound (it is normal of 8 — 10 cm), the second — on a midline from the level of the upper bound of a liver on a breast to the lower percussion bound of a liver (7 — 9 cm), the third — on edge of the left costal arch (6 — 8 cm). The greatest practical value has the first size (on the median and clavicular line).
Reduction of the extent of hepatic dullness is observed at an atrophy of hepatic fabric and at cover of liver edges by emphysematous pulmonary fabric. Disappearance of hepatic dullness is an important symptom of a perforation of the stomach or a gut with an exit in an abdominal cavity of gas.
Item. spleens (see) make in right diagonal position of the patient, applying silent percussion. The upper bound is percussed on the average axillary line from the V edge down. Emergence of the first muting of a sound corresponds to the upper bound. The lower bound is percussed, going from the free end of the XII edge slantwise up to the average axillary line. At the healthy person the upper bound is on IX, lower — on the XI edge, and width of obtusion makes 4 — 7 cm. The rear edge of a spleen is percussed from a backbone in the horizontal direction at the level below the found upper bound, normal it is on the scapular line, but perkutorno its definition is complicated by existence of obtusion from muscle bulk. During the definition of a first line percuss from a navel to a costal arch at the level slightly below than the line which is continuation of the found upper bound. The distance from back to a first line characterizes length of a spleen (normal apprx. 12 cm). If the increased spleen leaves from under edge of a costal arch, then this part it is measured in centimeters. The sizes of a spleen express in centimeters as fraction: in numerator — length, in a denominator — width, and before fraction the size of the costal arch acting from under edge 22 parts (e.g. — the spleen supports edge of edges on 5 cm, its length of 22 cm, width of 12 cm).
Item. stomach (see) it is used for definition of its lower bound by percussion concussion of area of a stomach and receiving capotement. Capotement arises only at simultaneous existence in a stomach of liquid and air. On an empty stomach the patient drinks a glass of water and holds horizontal position on spin. Investigating elbow edge of the left brush presses down area of a xiphoidal shoot for formation of a nappe and the gas which is located over it. Strikes with four halfbent fingers of the right hand bystry percussion blows from above inside and down, causing capotement.
Features of percussion at children
Percussion inspection of children, especially early age, demands from the doctor of special care and ability because of the small sizes of bodies, a subtlety of walls and tenderness of covers.
At P. of lungs it is important to pay attention to the correct position of the child providing symmetric position of a thorax. At the senior children apply mediocre P., at younger — direct.
Mediocre P. is carried out, as a rule, by weak blows to mezhreberye or edges. The direction shall go from obviously clear sound to stupid. Direct P. is run a long finger of the right hand bent in an elbow joint. The finger shall be bent slightly dugoobrazno in metacarpophalangeal and interphalanx joints. At P. the forearm remains at rest. The movement of a brush is made in a radiocarpal joint and slightly in metacarpophalangeal that provides elasticity of blow. The item should be carried out so that it was possible to catch transition from vozdukhsoderzhashchy sites to airless. At the same time sound feelings are combined with tactile.
At comparative P. compare anatomically equally located sites on both sides: in front — over and under clavicles, from sides — on axillary lines, behind — on scapular and juxtaspinal to lines. Palets-plessimetr on all sites of a thorax, except for interscapular and axillary areas, is located on mezhreberye; in interscapular area — parallel to a backbone, in axillary area — perpendicularly, then parallel to edges. At the healthy child the percussion sound on symmetric places is identical.
At P. of lungs it is possible to receive the following sounds: the clear sound of a healthy lung dulled or absolutely stupid (femoral) on places, free of air, a tympanic sound of various shades.
At children it is accepted to define scale of sonority since at comparative P. of lungs of the healthy child the percussion sound not over all surface has the identical force, duration and height that depends on thickness of a pulmonary layer and on influence on it of the next bodies. Normal clarity of a percussion sound decreases in the following sequence: in front — the second mezhreberye, the first mezhreberye, a morengeymov a pole, a clavicle; behind — infrascapular space, interscapular space, area of shovels. Scale of sonority of the right and left lung is checked separately.
At topographical percussion the finger-plessimyotr is put parallel to required border; Items carry out from top to down on mezhreberye, on mamillar, axillary, scapular lines. The lower bounds of lungs define in the beginning on the right, then at the left. The lower bound of lungs on the right normal is determined by the mamillar line on the V edge. Other borders of lungs on both sides: on average axillary — on IX, on the scapular line — at the level of an acantha of X or XI chest vertebras.
At the senior children mobility of pulmonary edges which at the healthy child makes 4 — 6 cm is defined.
In the presence patol, process in easy P. at children gives the same data, as at adults.
At P. limf, nodes in the field of a root of a lung several symptoms are defined. The symptom of Koranyi is revealed direct P. on acanthas, since the VII—VIII chest vertebrae from below up. Normal the dullness begins on the II chest vertebra at children of early age, on IV — at the senior children. In this case the symptom of Koranyi is considered negative. In the presence of obtusion is lower than the specified vertebrae the symptom is considered positive. The symptom of a bowl of Filosofov is defined by loud P. in the first and second mezhreberye on both sides towards a breast (the finger is located parallel to a breast). At the healthy child obtusion is noted on a breast, and the symptom is considered negative. In the presence of obtusion to achievement of edge of a breast the symptom is considered positive. For detection of a symptom the Arch wine is carried out percussion on front axillary lines from below up the direction to axillary hollows. At healthy children shortening of a sound is not observed. At increase limf, nodes of a root of a lung shortening of a percussion sound is noted and the symptom is considered positive.
It is the best of all for item of heart to carry out in position of the patient lying, but it is possible also in vertical position. It is less limit of cordial dullness in vertical position, than in horizontal. At delimitation of relative cordial dullness Items use mediocre or direct. At mediocre P. the finger-plessimetr is densely put to a thorax, parallel to the defined border in the direction from a clear sound to stupid; Item of average force and the quietest. The mark of border of heart is made on the outer edge of a finger-plessimetra. P.'s order: the right, left, upper borders of heart, to-rye are defined as well as at adults. Direct P. of limits of relative cordial dullness is carried out on the same lines, as at mediocre P.; results interpret taking into account age of the child (tab. 3 and 4).
Table 3. PERCUSSION LIMITS of RELATIVE CORDIAL DULLNESS AT CHILDREN (according to V. I. Molchanov)
Table 4. PERCUSSION LIMITS of ABSOLUTE CORDIAL DULLNESS AT CHILDREN
See also Inspection of the patient .
Bibliography: Dombrovskaya Yu. F., Lebedev D. D. and M about l of the h and N about in V. I. Propedevtik of children's diseases, page 230, M., 1970; M. G. Perkussiya's Hens fishings of heart and its measurement, Tomsk, 1923; L and with t about in A. F. Bases of percussion and its feature at children, M. — L., 1940; V.P Is model. Chosen works, page 119, Kiev, 1950; Propaedeutics of internal diseases, under the editorship of V. of X. Vasilenko, etc., page 43, etc., M., 1974; Skoda Y. The doctrine about percussion and listening as means to distinguish diseases, the lane with it., M., 1852; H about 1 1 d and with k K. Lehrbuch der Auskultation und Perkus-sion, Stuttgart, 1974; P i about of at P. A. Traite de plessimetrisme et d’orga-nographisme, P., 1866.
G. I. Alekseev; V. P. Bisyarina (ped.).