. Physical diagnosis . litated states, thelungs are often not adequately expanded owing to the superficialityof the respiration, and accordingly their margins do not cover asmuch of the surface of the heart as they do in healthy results in rendering visible, in the second, third, or fourth leftinterspace near the sternum, pulsations transmitted from the conusarteriosus or from the right ventricle. Less commonly, similar pul-sations may be seen on the right side of the sternum. (b) A rarer cause of retraction of the lungs is fibroid phthisisor chronic interstitial pneumonia. In thes
. Physical diagnosis . litated states, thelungs are often not adequately expanded owing to the superficialityof the respiration, and accordingly their margins do not cover asmuch of the surface of the heart as they do in healthy results in rendering visible, in the second, third, or fourth leftinterspace near the sternum, pulsations transmitted from the conusarteriosus or from the right ventricle. Less commonly, similar pul-sations may be seen on the right side of the sternum. (b) A rarer cause of retraction of the lungs is fibroid phthisisor chronic interstitial pneumonia. In these diseases a very large 86 PHYSICAL DIAGNOSIS. area of pulsation may be seen in the precordial region owing to theentire uncovering of the heart by the retracted lung, even when theheart is not drawn out of its normal position. VIII. Aneurism and Other Causes of Abnormal Thoracic Pulsation. So far I have spoken altogether of pulsations transmitted di-rectly to the thorax by the heart itself, but we have also to bear in. IIG. 59.—Position When Looking for Slight Aneurysmal Pulsation. mind that a dilated aorta may transmit to the chest wall pulsationswhich it is exceedingly important for us to recognize and properly tointerpret. No disease is easier to recognize than aneurism when thegrowth has perforated the chest wall and appears as a tumor exter-nally, but it is much more important as well as much more difficultto recognize the disease while it is confined within the thorax. Insuch cases, the movements transmitted from the aorta to the chestwall may be so slight that only the keenest and most thorough in-spection controlled by palpation will detect them. When slightpulsations are searched for, the patient should be put in a position INSPECTION. 87 shown in Fig. 59, and the observer should place himself so that hiseye is as nearly as possible on a level with the chest and looksacross it so that he sees it in profile. In this position, or in a sittingposition with tangential l
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