DIRECTIONS 
TO ACCOMPANY THE 
^finieaf (g^arfs, 
BY 
W. W. KEEN, M.D., 
Fellow of the College of Physicians of 
Philadelphia. 
PHILADELPHIA : 
TURNER HAMILTON, 
18 75. CLINICAL CHARTS. 
2 
One design of these charts or diagrams is 
to aid the surgeon, by furnishing means for 
the graphical delineation of surgical dis- 
eases and injuries. They will.be found use- 
ful, it is believed, in the army, especially 
in shortening the work of those busily en- 
gaged in practical duties. By means of 
them, the various physical signs in thoracic 
and abdominal diseases and injuries, rela- 
tive measurements, deformities, fractures, 
tumors, cutaneous diseases, and many surgi- 
cal affections can be delineated in a moment. 
Long verbal descriptions may thus be 
avoided ; the eye be used instead of the 
ear; and different cases, or the same case 
at different times, can be accurately com- 
pared. 
The following suggestions as to their use 
may be of service*:- 
Wounds, Tumors and Deformities, with any 
ulcerated points, etc., can be indicated in 
outline both surfacewise and sidewise by 
using two or more of the diagrams. 
Fractures, both in direction and extent, by 
marking the bones involved. 
X 
Measurements, from point to point, thus, I 22zz 
X 
i. e., twenty-two inches-or comparatively 
thus, 12ZZX X X14zz. The 
* These methods will, of course, be varied to suit the 
purposes of different medical men, and I would invite 
suggestions from such as a basis for future improvement. circumference of a limb at any point by a 
circle drawn on its outline, and the inches 
marked. 
Cutaneous diseases can be indicated in out- 
line as to extent, and their severity and 
character be indicated. 
Dulness on percussion-by shading, which 
can express the intensity by depth of shad- 
ing. 
Rales-by large circles § or small ones g, 
according to their character, their extent 
being shown by lines. 
The position of the apex beat of the heart, 
by a V. 
Any valvular murmur, by a X at its point 
of greatest intensity, and a side-note " X 
syst. bl." etc., i. e., systolic blowing sound, 
etc. 
Bronchial breathing, tenderness to the touch, 
etc., by outlining the limits and a side-note. 
For the sake of comparison, the following 
table of the usual position of the viscera, 
etc., is introduced :- 
Lungs-apex, in front, behind the inner 
third of the clavicle; behind, at the level 
of the lower border of the 7th cervical 
spine ; base, in line with the nipple, the 6th 
rib; in the axillary line, the 8th rib; in 
the back, the 11th rib. It varies l-l} inches 
in respiration. 
Nipple-usually in the 4th intercostal 
space. 
Heart-area of dulness, from 4th to 6th left 
cartilages, and from mid-sternum to within 
an inch of the line of the nipple. 
Aortic valve-left of mid-sternum at level 
3 of 3d cartilage ; auscult it at right 2d inter- 
costal space. 
Pulmonary valve-left border of sternum 
at level of 3d cartilage ; auscult it at left 2d 
intercostal space. 
Mitral valve-left border of sternum at 3d 
intercostal space; auscult it at apex. 
Tricuspid valve-left of mid sternum at 
level of 4th cartilage; auscult it above the 
ensiform cartilage. 
Umbilicus-opposite the body of the 3d 
lumbar vertebra. 
Liver-upper border in front at 5th rib, 
lower border about at the lower border of 
the ribs; varies with posture, respiration, 
etc. 
Sc<jmach- cardia tn Inft of median line at 
the level of the 7th rib; pylorus to right of 
median line at the level of the 9th rib; 
varies considerably in position. 
Spleen-in axillary line from 9th to 11th 
ribs, about 2g-3 inches broad. 
Pancreas-level of about 11th dorsal to 2d 
lumbar spines. 
Kidney-level of 11th dorsal to 3d lumbar 
spines, the right a little lower than the left. 
Bladder and Uterus-should not rise above 
the level of the pubes unless distended. 
Aorta-bifurcates to the left of the body 
of the 4th lumbar vertebra, i. e., below and 
to the left of the umbilicus. 
Cseliac axis, solar plexus, and superior mesen- 
teric artery-correspond to the 12th dorsal 
spine. 
4 No ...Report Date..... 
Injury 
No Report Date 
Injury 
No Report Date.. 
Injury 
sunwi 
CHABTS. 
BY 
W. W. KEEN, M.D., 
Fellow of the College of Physicians of 
Philadelphia. 
Fig-. 2. 
Fig.3. 
Fig. 1. 
PHILADELPHIA : 
TURNER HAMILTON, 
1 8 75. 
Name 
Co 
Regiment 
Post 
No Report Date 
Injury 
Name 
Co 
Regiment . 
Post 
No Report Date 
Injury 
Name 
Co 
Regiment 
Post 
No Report Date 
Injury 
Copyright, 1872. 
No Report ( Date... 
Injury | 
Fig. 5. 
Fig.6. 
Fig.7 
Fig. 8. 
Tig 4. 
Fig. 9. 
Fl g.,tO. 
Fig. 12. 
Fig.lt. 
Fig. 13. 
Name 
Co 
Regiment 
Post 
Name 
Co 
Regiment 
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Name 
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Regiment 
Post L 
Name 
Co 
Regiment 
Post