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Chest Percussion Eur Respir J, 1995, 8, 1756–1760 Copyright ERS Journals Ltd 1995 DOI: 10.1183/09031936.95.08101756 European Respiratory Journal Printed in UK - all rights reserved ISSN 0903 - 1936 SERIES 'CHEST PHYSICAL EXAMINATION' Edited by J.C. Yernault Chest percussion J.C. Yernault*, A.B. Bohadana** Chest Percussion. J.C. Yernault, A.B. Bohadana. ©ERS Journals Ltd 1995. *Service de Pneumologie, Cliniques Uni- ABSTRACT: The direct method of chest percussion, first described by Auenbrugger versitaires de Bruxelles, Hôpital Erasme, but disseminated by Corvisart, has rapidly been replaced by the indirect or digi- Brussels. **Service de Pneumologie, Centre todigital method. Hospitalier Universitaire de Nancy-Brabois Chest percussion has not been evaluated by modern acoustic means, so that our et Institut National de la Santé et de la Recherche Médicale, INSERM - Unité present knowledge of the method does not consistently differ from the 19th cen- 115, Santé au Travail et Santé Publique, tury approach. Auscultatory percussion is not superior to conventional percussion. Vandoeuvre-les-Nancy, France. Eur Respir J., 1995, 8, 1756–1760 Correspondence: J.C. Yernault, Service de Pneumologie, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Route de Lennik, B–1070 Bruxelles Keywords: Percussion, physical exami- nation Received: March 25 1995 Accepted for publication March 31 1995 Historical background Although Auenbrugger found a supporter in Maximilian Stoll, who was professor of the medical clinic in Vienna Although percussion of the abdomen seems to date from 1778 to 1787, percussion did not meet with great back to antiquity [1], chest percussion was first described success until it was propagated by CORVISART [5] wor- in 1761 [2] by Leopold Auenbrugger, who was born in king in Paris. He used the palmar surface of the extended 1722 in Graz (Austria) in the inn called "Zum schwarzen and approximated fingers to percuss the chest. Convin- Mohren" [3]. It was there that Auenbrugger saw his ced that "sense organs, education and exercise are man- father striking barrels in order to determine the level of datory for physicians to become commendable at the liquid inside. This observation induced him to start per- patient's bedside", Corvisart employed percussion as the cussing the chest when he was working in the Vienna main method to discover the nature and the localization Spanish military hospital, with the aim of tapping and of several diseases. Extending and further evaluating draining pleural effusions. Relying on anatomoclinical Auenbrugger's initial observations, he communicated his confrontations, he developed the method of direct or enthusiasm to his students, including René Théophile immediate percussion for 7 years before his first publi- Hyacinthe Laënnec. That Laënnec, before his discovery cation. Striking the clothed chest with the tips of all the of mediate auscultation, was regularly percussing his fingers held together firmly (or using a leather glove to patients is testified by GRANDVILLE [6], who wrote: "It was strike the bare skin), he made the basic observation that, Laënnec's habit, when examining a newly admitted patient, when percussed, a healthy man's thorax is resonant: laboring under pectoral disorder, to percute him in every "Thorax sani homini sonat si percutitur". Auenbrugger part of the chest, both in front and at the back, as well as recognized three categories of sounds: a "sonus altior" on either side. After which he would apply the ear to (tympanic), a "sonus carnis" (dull) and a "sonus obscu- any part which resounded badly or imperfectly". Ack- rior" of indistinct quality. nowledging that percussion was unquestionably one of Although a first French translation of Auenbrugger's the main discoveries in medicine, LAENNEC [7] realized, work was published in 1770 by Rozière de la Chassagne however, that it was not a sensitive tool in pulmonary from Montpellier, percussion was not immediately accep- phthisis. He insisted on the value of adding percussion ted as a valuable tool. In 1782, TISSOT [4] wrote: "Accor- to auscultation with the cylinder for the diagnosis of ding to a German physician, if the chest covered with a emphysema, pneumothorax and pleural effusion. It was simple shirt is struck with the hand, it gives back a dull a book by FORBES [8] which introduced the techniques sound on the side where vomica is, as if one was strik- of percussion and auscultation into the English literature. ing a flesh piece, whereas if the chest opposite side is PIORRY [9] developed the indirect or mediate percus- struck, it gives back a resonant sound, as if one was strik- sion: "mediate percussion consists in an impulse given ing a drum. However, I still doubt that this observation to a resonant and solid body, applied on an organ or a is generally correct". cavity, in order to obtain a sound related to the physical CHEST PERCUSSION 1757 state of these parts". Piorry described several circum- suggestive. In the subclavicular region the attention is stances in which direct percussion was inadequate or not often aroused at once by a tympanitic note, the so-called feasible [10]: 1) it can be painful in cases of inflam- Skoda's resonance... it shades insensibly into a flat note mation of the pleura; 2) a thick subcutaneous tissue in the lower regions. Skoda's resonance may be obtained hinders the useful auditory sensations obtained; and 3) also behind, just above the limit of effusion". He fur- sounds obtained with the palm of the hand set a large ther stated "the dullness has a peculiarly resistant, wooden area into vibration, and may miss small circumscribed quality, differing from that of pneumonia and readily lesions. recognized by skilled fingers", so insisting on the role The solid body, called a plessimeter, was struck with of the tactile sense in percussion. However, the role of the tip of the right index finger, sometimes together with the tactile sense in percussion was not confirmed by other the middle finger. The ideal plessimeter was found to authors, like SERGENT [16], because resistance to the fin- be a circular ivory sheet, 5 cm in diameter and 2.5 mm ger usually follows the dullness. in thickness, that could be screwed onto the end of a According to LETULLE [17], in 1876 Noël Guéneau de Laënnec stethoscope. Some physicians replaced the strik- Mussy started studying the transonance of the lung apex ing finger by a percussion hammer, whereas others, such by striking the clavicle whilst simultaneously auscultat- as William Stokes and James Hope, who assisted in ing the corresponding supraspinous fossa. Also used by Piorry's lessons, tried to further simplify the method by NAESSENS [18] in order to detect enlarged hilar nodes, using their left middle finger as a plessimeter [11]. Al- the combination of auscultation and percussion was given though Piorry disliked this simplification, it was adop- a second youth by GUARINO [19] under the name "aus- ted by well-known clinicians, such as SKODA [12] who cultatory percussion". became the advocate of percussion in Europe. Skoda attempted to replace the imprecise flowery terms used by his French predecessors, by describing four types The physics of percussion of percussion notes [13]: 1) full-empty; 2) clear-dull; 3) tympanic-nontympanic; and 4) high-low. The physics of chest percussion is dominated by the According to BARTH and ROGER [14], in 1855 Woilliez transmission properties of the respiratory system, a mat- also described three fundamental characteristics of per- ter previously discussed by RICE [20]. From a physical cussion notes: 1) the intensity, which can be normal, standpoint, the respiratory system can be considered as low or high; 2) the tone, which can be normal, low or a coupled system, composed of the chest wall and the high; and 3) the thoracic elasticity, which is perceived lung placed in series. Under the influence of an exter- by the percussing finger. nal shock, the chest wall tends to vibrate and "ring", as One of the reasons for BARTH and ROGER [14] to pre- a resonant cavity partially damped by the thoracic con- fer digitodigital percussion over the original plessimeter tents. method was that "the finger is always available to the In normal conditions, the vibrations of percussion are physician, who might be embarrassed by the loss of his underdamped, as a consequence of the large acoustic plessimeter"!! They described the technique of digi- mismatch observed between the chest wall and the under- todigital percussion as follows: "the whole left hand, lying lung parenchyma. Such mismatch is due to the applied on the region whose sonority has to be known, fact that the acoustic impedance of the semi-rigid chest is kept fixed; then the middle finger is isolated from the wall is quite dissimilar to that of the lung parenchyma, other fingers. Movements of the right hand which is a structure that behaves like homogeneous mixture of striking must originate neither from the shoulder nor from gas and tissue. (The acoustic impedance (Z) of a medi- the elbow, but exclusively from the wrist". The num- um, is the product of the density of the medium by the ber of striking fingers (from one to three) will vary accord- sound velocity in the medium. The proportion of sound ing to the force of the impulse which is needed; this energy transmitted across a boundary between two acoustic force must initially remain gentle, and can then increase media (T) is a function of the acoustic impedances (Z1 progressively. In pathological cases, the percussion notes and Z2) of the two media; T=4Z1Z2/(Z1+Z2)2). Therefore, may vary from tympanic (like the note which is per- a large proportion of the vibratory energy of percussion ceived over the stomach gas bubble) to flat (like the note is reflected at the gas-tissue interface, yielding a clear, perceived over the liver).
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