PRACTICAL TREATISE PHYSICAL EXPLORATION CHEST, DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS, AUSTIN FLINT, M.D., •PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN TQE BELLEVUE HOSPITAL MEDICAL COLLEGE, AND IN THE LONG ISLAND COLLEGE HOSPITAL ; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC. SECOND EDITION, EEVISED, PHILADELPHIA: HENKY C. LEA. 18 66. Entered according to Act of Congress, in the year 1866, BY HENRY C. LEA, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania SHERMAN & CO., PRINTERS. WF PREFACE. The first edition of this treatise was published in 1856, and the Avork has for some time been out of print. During the ten years which have elapsed, the author has continued to give special atten- tion to the diagnosis of diseases affecting the respiratory organs ; and during most of this period he has given daily lessons in auscul- tation and percussion at the bedside. Having been connected for three years with the New Orleans Charity Hospital, and for the last six years with Bellevue Hospital and the Blackwell's Island Charity Hospital of New York, and with the Long Island College Hospital, of Brooklyn, his opportunities for the clinical study and practical teaching of physical exploration have been extensive. In preparing, therefore, a second edition of the work, he has felt that he might assume a degree of assurance which would have been less warrantable when the first edition was written. A comparison of the present with the former edition, will show that the work has undergone considerable modification. While its plan and essential features are unchanged, numerous important alterations have been made ; much has been added, while, by sub- stituting brief statements for certain statistical details relating especially to the healthy chest, the volume, instead of being en- larged, has been somewhat reduced in size. The aim of the author has been to present to the student and practitioner of medicine, clearly and comprehensively, an exposition of the physical explora- tion of the chest, and of the diagnosis of diseases affecting the re- spiratory organs, striving to divest these subjects of complexity and needless refinements. Recognizing the fact that physical ex- ploration, to be made generally available in medical practice, must be simplified as much as possible without compromising its capabili- ties, he has studied to facilitate the acquisition of an adequate IV PREFACE. knowledge of signs bj avoiding an unnecessary multiplication of them, by adopting a convenient classification, by pointing out dis- tinctly their differential characters, and by the introduction of a few new names which are in themselves descriptive. The experience of the author having led to certain results which he ventures to believe enlarge somcAvhat the scope of physical ex- ploration, increasing, also, the facility and accuracy with which different signs are discriminated, it may not be considered amiss to enumerate here certain points to which the attention of the reader of the work is especially invited. The distinctive characters of the signs obtained by auscultation and percussion are derived almost exclusively from differences relating to intensity, pitch, and quality of sounds. An acquaintance with the acoustic signs, to be precise and accurate, must, in the opinion of the author, be based on characters thus derived ; whereas, without an appreciation of distinctions re- lating to intensity, pitch, and quality, the knowledge of these signs is comparatively indefinite and unreliable. The studies of the author have been directed especially to characters relating to the pitch, in conjunction with those relating to the quality, of acoustic signs, and from differences in pitch, hitherto but little considered, he has de- rived distinctions which he believes to be of much practical value. By means of difi"erences in pitch, conjoined with those of quality, the respiratory sign called bronchial or tubular breathing, may be readily distinguished from the cavernous respiration ; a prolonged expiratory sound proceeding either from vesicular emphysema or an abnormal exaggeration of the vesicular murmur, that is, not denot- ing solidification of lung, need never be confounded with the pro- longed expiration which denotes a tuberculous or some other solidi- fying deposit ; exaggerated or puerile breathing is easily recognized as distinct from what has been called rude respiration; the vocal sign called bronchophony is distinguished from a simple increase of the resonance of the voice, and the pectoriloquy arising from solidi- fied lung is discriminated from the pectoriloquy which signifies a pulmonary cavity. Attention to the pitch of the resonance ob- tained by percussion, renders sometimes apparent a slight degree of dulness which would otherwise not be perceived ; and it enables the observer to perceive, in certain cases, that a morbid disparity between the two sides, as regards intensity of resonance, is due to an exaggerated, or as the author prefers to call it, a vesiculo-tym2)a- nitie resonance on the side most resonant, and not to dulness on the PREFACE. V side yielding the lesser degree of resonance. The pitch of the mu- cous, the subcrepitant, and the crepitant rale furnishes a reliable criterion of the condition of the lung as regards the existence or the absence of solidification. To these points may be added a novel mode of auscultatory percussion, viz., applying Cammann's stethoscope near the open mouth of the patient, ■while percussion is made. In this way the amphoric and the cracked metal intonation may often be obtained in cases in which they are not other-wise appreciable. Under the name hroncho-vesicular, or vesiculo-tubular respiration, are described certain modifications of respiratory sounds represent- ing all the degrees of solidification of lung which fall short of an amount sufiicient to yield purely bronchial or tubular breathing. These modifications have heretofore been loosely embraced under the names rude and rough respiration. The names broncho-vesicular and vesiculo-tubular express the distinctive characters of the sign, and are thus in themselves descriptive. By the different grades of modification as regards the pitch and quality of the inspiratory and the expiratory sound, the amount, as well as the extent, of the solidi- fication may be ascertained. This sign is of much value, especially in the diagnosis of tuberculous disease in its early stage. The name hroncho-cavernous is also introduced as expressing the characters of a sign which represents solidification of lung and a cavity conjoined. An original feature of the work is the introduction of several signs produced by the whispered voice. These signs, as representing certain physical conditions, are generally available, and their char- acters relating to pitch and quality are highly significant. The names exaggerated bronchial whisper, tvhisjjering bronchophony/ or bronchophonic u'hisper, and caver^ious tvhisper, although, perhaps, not, intrinsically, the best which might have been devised, have the advantage of corresponding with the names commonly applied to correlative signs produced by the loud voice. The author would state, as a feature of the work, the recognition of the principle that the constancy of association of certain ab- normal sounds with certain physical conditions constitutes the only reliable proof of the validity of the former as representing the latter. It is inconsistent with this principle to undertake to determine d priori signs to which certain physical conditions should give rise, and still more, on the other hand, to infer the existence of certain physical conditions from certain abnormal sounds. As stated in the preface to the first edition, " To the mechanism of physical phe- VI PREFACE. nomena, relatively small space is accorded, recognizing, as the only safe basis of our knowledge of their significance and pathological relations, clinical facts taken in connection with morbid anatomy, and believing that deductions from the laws of physics, or analogical inferences from experiments made out of the body and even with the dead subject, are to be received with great circumspection." Having now for several years devoted considerable pains to teach- ing the principles and practice of auscultation and percussion to private classes, the author is induced to conclude this preface with a sketch of the plan which he has pursued, hoping thus to make his experience of service to some of his readers who may be led to engage in this branch of* clinical instruction. Instruction in phys- ical exploration to be effective must be in the form of familiar lessons in the wards of a hospital large enough to furnish a sufficient number of examples of all the physical signs. The classes must be small, in order that it may not be tedious for the different members to listen in succession, and also that patients shall not be fatigued. The necessity of limiting the number composing a class relates only to teaching the auscultatory signs ; the signs obtained by percussion can, of course, be illustrated to a large class. The author is accus- tomed to limit classes in auscultation to, at most, fifteen members. After explaining and illustrating the acoustic distinctions expressed by the terms intensity, pitch, and quality, together with some pre- liminary considerations, the study of percussion is entered upon. The first objects for the members of the class, are to understand and become practically acquainted with the normal vesicular resonance as regards the characters relating to intensity, pitch, and quality, and with the normal variations which pertain to the chest in dif- ferent persons and in different parts of the chest in the same person. Then the four morbid signs obtained by percussion are explained by comparison, as regards the distinctive characters of each, with those of the normal vesicular resonance, and they are afterward illustrated by means of difierent cases of disease. Entering next upon the study of auscultation, the characters of the normal respiratory and vocal sounds are first explained, compared, and illustrated by ex- aminations of persons free from any disease of the respiratory system; afterward the morbid auscultatory signs are severally explained, compared with each other, and with the normal sounds, as regards their distinctive characters, and illustrated practically by cases of disease. Taking up at each lesson a few signs, their distinctive PREFACE. Vll characters, severally, as regards intensity, pitch, and quality, are, first, to be rendered clear and familiar, and, second, they are to be verified by each member of the class, cases exemplifying the signs having been previously selected for the purpose of study. After a practical knowledge of all the signs furnished by percussion and auscultation has been acquired, several lessons are devoted to the study of cases of diflferent diseases of the chest, with reference to the manner of obtaining and combining signs derived from all the methods of physical exploration, and arriving at the diagnosis. By pursuing this plan, an acquaintance with the signs, and the princi- ples of diagnosis sufficient for engaging in the practice of physical exploration may, with due capacity and attention on the part of the student, be obtained in a few lessons ; the author's course of prac- tical instruction, embracing the physical diagnosis of diseases of the heart, consists of tAventy lessons, from one to two hours being devoted to each lesson. It is not to be expected that after a course of twenty lessons the members of a class will be at once accomplished auscul- tators ; but, with the knowledge acquired in such a course, provided the teacher be able to command a sufficient number of cases to illus- trate the diflferent signs, the pupil is prepared to go on and make rapid progress without further aid, gradually obtaining by experi- ence that self-confidence which is desirable, and which is only to be obtained by practice. Physical exploration may be mastered by means of books and lectures together with such clinical opportunities as are offered in any hospital of considerable size, but the saving of time and labor eflfected by systematic bed-side instruction in large hospitals is im- mense ; the amount of progress made in a few weeks is greater than is possible during many months or even years without these advan- tages. It would conduce much toward a more general diflfusion of the practical knowledge of auscultation and percussion, were a larger number of competent physicians connected w^ith large hospitals to become engaged in forming classes for private instruction in these methods of physical exploration — a department of medicine which commends itself as not less attractive than important. New York, August, 1866. CONTENTS. INTEODUCTION. Section I. Preliminary Points pertaining to the Anatomy and Physiology of the Respiratory Apparatus, I. The Thoracic Parietes, II. Pulmonary Organs, . III. Trachea, Bronchi, and Larynx, Section II. Topographical Divisions of the Chest, I. Anterior Regions, II. Posterior Regions, . III. Lateral Regions, 17 18 34 46 54 56 59 60 PART L Chapter I. Definitions — Different Methods of Exploration — Soui'ces of the Distinctive Characters of Dif ferent Sounds — Genei-al Remarks, 65 II. Percussion, 76 Percussion in Health, . 79 Percussion in Disease, . 97 III. History, Auscultation, Auscultation in Health, Auscultation in Disease, 116 117 128 154 IV. Inspection, .... Summary, History, 275 289 291 CONTENTS. Chapter Y. Mensuration, Summary, History, VI. Palpation, Summary, History, . YII. Succussion, . Summary, History, . PAGE 292 300 302 303 309 309 310 311 312 PAET 11. DIAGNOSIS OF DISEASES AFFECTING THE RESPIKATORY ORGANS. Chapter I. Inflammation of the Bronchial Mucous Mem- brane, Acute Bronchitis, .... Capillary Bronchitis, Pseudo-Membranous or Plastic Bronchitis Chronic Bronchitis, .... Secondar}'- Bronchitis, II. Dilatation and Contraction of the Bronchial Tubes — Pertussis — Asthma, Dilatation of the Bronchial Tubes, . Contraction of the Bronchial Tubes, Pertussis — Whooping-Cough, . Asthma, ...... III. Pneumonitis — Imperfect Expansion (Atelec tasis) and Collapse, Acute Lobar Pneumonitis, Imperfect Expansion and Collapse of Pu monary Lobules, Chronic Pneumonitis, IV. Emphysema, ...... Vesicular Emphysema, Interlobular Emphysema, 322 323 331 337 340 345 346 346 358 361 363 368 368 398 403 406 406 418 CONTENTS. XI Chapter V. Pulmonary Tuberculosis — Bronchial Phthisis, . Acute Phthisis, Retrospective Diagnosis of Tuberculosis, . Bronchial Phthisis, . . . . . VI. Pulmonary CEdema — Gangrene of the Lungs — Pulmonary Apoplexy — Cancer of the Lungs — Cancer in the Mediastinum Pulmonary CEdema, Gangx-ene of the Lungs, Pulmonary Apoplexy, . Cancer of the Lungs, . Cancer in the Mediastinum, VII. Acute Pleuritis — Chronic Pleuritis — Empy- ema — Hydrothorax — Pneumothorax — Pneumo-Hydrothorax — Pleuralgia — Diaphragmatic Hernia, . Acute Pleuritis, ..... Chronic Pleuritis, ..... Empyema, Circumscribed Pleuritis with Liquid Effu sion, ...... Hydrothorax, Pneumothorax — Pneumo-Hydrothorax, Intercostal Neuralgia and Pleurodynia, Diaphragmatic Hernia, VIII. Diseases affecting the Trachea and Larynx, Foreign Bodies in the Air-Passages, . PAGE 421 465 468 471 474 474 477 483 487 494 501 501 527 541 545 549 551 561 565 572 582 PHYSICAL EXPLORATION. ERRATUM. P. 142, line 9 from toy), for "greater" rmd "smaller." The study of diseases affecting the respiratory apparatus involves, as a point of departure, acquaintance with the several structures, organs, and functions which this apparatus embraces. To this pre- paratory knowledge it is presumed, of course, the reader has already given more or less attention ; but it will be useful to review certain points pertaining to the anatomy and physiology of this portion of the organism, which will be found to have direct and intimate patho- logical relations. To these points this section will be mainly limited, omitting details other than those of special importance in their bear- ings on the subjects to be subsequently considered. The respiratory apparatus comprises 1st, the thoracic parietes, inclusive of the diaphragm; 2d, the pulmonary organs contained within the thoracic cavity ; 3d, the canal or tube leading from the lungs to the pharynx, consisting of the primary bronchi and their subdivisions, the trachea, and larynx. The throat, mouth, and nasal passages, although involved in respiration, are rather adjuncts of the respiratory apparatus than constituents of it, their construction having more direct reference to other functions. 2 PHYSICAL EXPLORATION. INTEODUCTION. SECTION L PRELIMINARY POINTS PERTAINING TO THE ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY APPARATUS. The study of diseases aiFecting the respiratory apparatus involves, as a point of departure, acquaintance with the several structures, organs, and functions which this apparatus embraces. To this pre- paratory knowledge it is presumed, of course, the reader has already given more or less attention ; but it will be useful to review certain points pertaining to the anatomy and physiology of this portion of the organism, which will be found to have direct and intimate patho- logical relations. To these points this section will be mainly limited, omitting details other than those of special importance in their bear- ings on the subjects to be subsequently considered. The respiratory apparatus comprises 1st, the thoracic parietes, inclusive of the diaphragm; 2d, the pulmonary organs contained within the thoracic cavity ; 3d, the canal or tube leading from the lungs to the pharynx, consisting of the primary bronchi and their subdivisions, the trachea, and larynx. The throat, mouth, and nasal passages, although involved in respiration, are rather adjuncts of the respiratory apparatus than constituents of it, their construction having more direct reference to other functions. 2 18 ANATOMY AND P H Y S 1 l- G Y. I. The Thoracic Parietes. The portion of the skeleton called the thorax is composed of the dorsal vertebrae, the ribs, and the bones of the sternum, forming by their union, together with their intervening cartilages, a truncated cone, designed to protect the organs which it contains, and to be subservient to certain movements concerned in respiration. The bony arches, the ribs, exclusive of the two last on each side (reckon- ing, as is usual, from the summit of the cone downward), are joined, either to the sternum, or to each other, by cartilages to which the walls of the chest are in a great measure indebted for their elasticity and mobility. The superior seven ribs joined to the sternum are called the true ribs^ and the remaining five on each side are dis- tinguished as i\iQ false ribs. The two lowest on each side, from the fact that their anterior extremities are disconnected from those situated above them, as well as from each other, are known as the floating ribs. The elasticity of the costal cartilages is greatest in early life; it becomes impaired, as a general rule, in proportion to age, and with advanced years may be nearly lost in consequence of ossification. Under these circumstances the alternate increase and diminution of the thoracic capacity with the two acts of respiration, so far as the successive expansion and contraction of the thoracic walls are therein involved, must of necessity be in some measure restrained. The direction of the first rib is nearly horizontal. The remainder have an oblique direction downward, the obliquity increasing with each inferior rib. Below the third rib the costal cartilages also have an oblique direction, but not corresponding to that of the ribs. At a short distance from the point of their attachment to the ends of the ribs, they pursue an upward direction to their sternal connections. Hence a line coincident with the axis of these ribs, forms with a line passing through the axis of their cartilages, an angle which is less obtuse with each inferior rib. The length of the costal cartilages also increases successively with the three lowest of the true ribs. These anatomical points, viz., the oblique downward direction of the ribs and the oblique upward direction of the costal cartilages, are provisions for the respiratory movements, so far as these movements relate to the anterior and lateral portions of the chest. AVith the act of inspiration, more especially when its force is voluntarily THE THORACIC PARIETES. 19 augmented, the lateral and antero-posterior diameters are increased. This is effected chiefly by the elevation of the ribs, by which their obliquity is diminished, causing them to approximate and even attain to a horizontal direction, tending thus to bring the ribs and the costal cartilages on a continuous line, diminishing or abolishing the angle formed by the union of the ribs and cartilages. After the cessation of the motive power which effects these changes, in other words, with the act of expiration, the elasticity of the cartilages sufiices to restore the costal angle which exists in a passive condition of the chest. These movements are abnormally increased and diminished in consequence of different forms of disease. A change, also, as regards the oblique direction of the ribs is attendant on certain thoracic affections, viz., pleurisy with a large accumulation of liquid in the pleural sac; the presence of liquid and gas in pneumo-hydro- thorax, and in some cases of dilatation of the air-cells or vesicular emphysema. In connection with these affections the same changes are mechanically produced which are effected by a forcible act of in- spiration, with the important difference, that while the enlargement of the chest in the latter case is but for an instant, in the former case it persists so long as the morbid conditions which have induced it continue. The margins of the ribs are not in contact, but separated, leaving what are termed the intercostal spaces. In consequence of the pro- gressively increasing obliquity in the direction of the ribs the inter- costal spaces are broader in front than behind. Under different morbid conditions these spaces are increased and diminished in width. The former is incident to the accumulation of a large quan- tity of liquid in the chest, the latter to contraction of the chest following the removal of this liquid by absorption or otherwise. In the female skeleton the upper ribs are more widely separated than in the male, and they possess also, relatively, a greater degree of mobility. This anatomical difference in the two sexes has relation to the greater part which the summit of the chest takes in the respiratory movements in the female. The intercostal spaces, when the thorax is invested with the soft parts, are filled with muscular substance, which is concerned in carrying on the respiratory movements. The intervening muscular layers are depressed below the level of the ribs, causing furrows, which are called the intercostal depressions* In persons with small or moderate adipose deposit, these depressions are apparent on 20 ANATOMY AND PHYSIOLOGY. the surface, feeing observable especially in front and laterally, at the lower part of the chest. They are everywhere visible, except in the portions covered by the scapulse, in cases of great ema- ciation. A change as respects this anatomical point occurs in cer- tain morbid conditions, viz., when there is an accumulation of a large quantity of liquid in certain cases of pleuritis, or an accumu- lation of liquid and air in pneumo-hydrothorax. Under these cir- cumstances the intercostal depressions are abolished, and the inter- vening integument may even project beyond the level of the ribs when a very large quantity of liquid or air is contained in the pleural sac. The scapulae and clavicles, with the soft parts, give to the thorax a shape quite different from that which it presents divested of these appendages. Compared to a truncated cone, the base is now above. These superadded bones, certain muscles investing portions of the thoracic walls, and, in the female, the mammary gland, offer obstacles in the way of exploring the chest for the physical signs of disease, which will be noticed hereafter in connection with the consideration of these signs. The partition wall separating the chest from the abdomen is the tendino-muscular septum, the diaphragm, springing from the lumbar vertebrae, from the first to the fourth inclusive, and attached to the six inferior ribs. Examined from below it forms a vaulted or arched roof of the abdominal cavity, its upper surface having a correspond- ing convexity extending into the thoracic cavity on each side. The height to which this convexity rises in the two sides is not equal, being greater in the right than in the left side. In the former it rises as high as the fourth intercostal space; in the latter to a level with the fifth rib. Thus the right chest has a vertical diameter somewhat less than that of the left. Accumulation of liquid within the pleural sac, and dilatation of the air-cells in some cases of.emphy- sema, may cause, mechanically, depression of the diaphragmatic arch ; and, on the other hand, enlargement of the liver on the right side, and, on the left side, enlargement of the spleen, or distension of the stomach, will produce an elevation above the normal height. The contraction of the muscular portion of the diaphragm di- minishes its vaulted form, depressing it to a plane, thereby extend- ing the vertical diameter of the thoracic space. In this way it becomes the most important agent in the act of inspiration, resuming its convexity with the act of expiration. These movements are liable THE THORACIC PARIETES. 21 to be restrained, or arrested by- various affections which- will be presently mentioned. Considered as divided into lateral halves, the thoracic parietes on the two sides, not only as respects the skeleton, but when invested with the soft parts, should be neaidy symmetrical, so that any con- siderable deviation in this point of view denotes either present disease, or deformity. An exception relates to the semicircular measurement at the middle and inferior portion of the chest. The right side usually, but not invariably, measures somewhat more than the left, the average difference being about half an inch. Of 133 cases of persons in good health in which measurements were made by Woillez, the right semi-circumference exceeded the left in 97 ; the left exceeded the right in 9, and both sides were equal in 27. The greater size of the right side, as determined by measurement, is usually attributed to the presence of the liver on that side. The facts presented by the author just named, however, seem to show that it depends, in a measure at least, on the greater use of the right upper extremity, which is habitual with most persons. In no instance in which the persons were right-handed did the left exceed the right side in measurement ; on the other hand, of five cases in which the persons were left-handed, in three the left side exceeded the right, and in the remaining two cases both sides were equal. In a per- fectly symmetrical chest the shoulders should be on the same level; and in the male the nipples, situated on the fourth rib or in the fourth intercostal space, should be on the same transverse line and equidistant from the centre of the sternum. The general law of sym- metry as regards correspondence in similar portions of the chest on the two sides is of importance in determining the existence of intra- thoracic diseases ; and, with reference to the application of this law, it is to be borne in mind that certain past affections are liable to leave deviations more or less permanent. The most common cause of defor- mity is spinal curvature, which may be sufficient to disturb the sym- metry of the two sides without existing to a degree to be noticed unless a careful comparison be instituted. Cases of slight lateral curvature depressing the shoulder and nipple of one side (oftener the right than the left side), approximating the margins of the ribs, and diminishing the semi-circumference, are very frequent, and liable, Avithout special attention, to be overlooked. Certain diseases within the chest lead to marked alterations in the conformation on one side. This is true especially, as will be seen hereafter, of chronic pleuritis. The chest 22 ANATOMY AND PHYSIOLOGY. on one or both sides may be deformed in various ways irrespective of spinal curvature. Thus the sternum may project unnaturally, causing the "chicken" or "pigeon breast," or it may be more or less depressed; there may be flattening on one side, produced per- haps by pressure from the arm of the nurse in early infancy; con- traction at the lower part of the chest in females, occasioned by tight lacing; distortions from fractures or other injuries, etc. These deviations from symmetry are sulficiently obvious, and will not there- fore escape notice. Practically they are of great importance in de- termining certain of the physical signs of existing disease. The greater portion of these signs, as will be seen hereafter, being based on the assumption that, irrespective of present disease, the two sides of the chest are symmetrical, it is obviously important to determine, in individual cases, to what extent the law of symmetry holds good. The researches of Woillez^ show that chests presenting in all par- ticulars complete regularity of conformation are found in only the proportion of about twenty of every hundred persons. Deviations from symmetry, either disconnected from disease (physiological), or resulting from previous morbid conditions (pathological), therefore, exist to a greater or less extent, in a large proportion of individuals. This fact would impair very materially the value of physical ex- ploration were it not practicable, as it generally is, to determine whether deviations which may be discovered are due to present disease, or existed previously. The respiratory movements involve certain points important to be premised in addition to those already noticed. A complete respiration, as is well known, comprises two acts, viz., an act of inspiration, and an act of expiration. In health, after adult age, the respirations are repeated from 14 to 20 times per minute, the habitual frequency varying considerably within healthy limits in different individuals. The frequency is somewhat greater in females than in males, and still greater in children. Deviations as regards the frequency of the respirations, exceeding the limits of health, are important symptoms of disease. In various affections compromising the function of hsematosis, the frequency of the res- pirations is considerably increased, rising for example in bronchitis affecting the smaller tubes, to 30, -10, 50, 60, or even a still greater 1 "Recherclies pratiques sur I'inspection et la mensuration de la poitrine, con- siderees comme moyens diagnostiques complementaires de la percussion et de I'auseultation." Paris, 1837. Archives G^n^rales de MMecine, Seme S4rie, tome i, p. 73. THE THORACIC PARIETES. 23 number, per minute. On the other hand, an abnormal diminution in frequency accompanies certain morbid conditions of the nervous system which affect indirectly the respiration. Thus, the respirations are morbidly infrequent, or slow, in apoplexy, and in coma however induced. The immediate object of the act of inspiration is the enlargement of the thoracic space, the air rushing in to fill the vacuum thus created within the air-cells and tubes of the lungs. This enlargement is effected by means of muscles attached to the thoracic walls, on the one hand, and, on the other hand, by the depression of the diaphragm. The immediate object of expiration is to restore the chest to the dimensions it naturally assumes when not acted on by the dilating muscles, and to contract it sometimes beyond that point, thus causing expulsion of the air received by the act of inspiration. The simple restoration of the chest is due mainly to the elasticity of the dilated parts, but contraction beyond the dimensions which it naturally assumes, is effected by expiratory muscles. The movements incident to the tw^o acts, respectively, in ordinary or tranquil respiration ; the modifications exhibited when the breathing is exaggerated or forced; the normal difi"erences to be observed in different persons; the variations due to age, sex, etc., are physiological points, not only interesting in themselves, but of utility in order to appreciate the aberrations associated with diseases of the respiratory apparatus. In bestowing some consideration on these points I shall not detain the reader with minute descriptions, still less engage in discussions relative to the mechanism of respira- tion, which, however much of interest they may possess for one desirous of investigating the subject fully, are not of special im- portance as preparatory to entering on the study of the physical exploration of the chest. In ordinary breathing, in the male, the diaphragm is usually the more important, and indeed sometimes almost the sole efficient agent. The diaphragmatic movements are indicated by a percep- tible rising and falling of the abdomen. But in certain diseases these movements are to a greater or less extent restrained, and they may even be completely arrested. They are notably diminished in acute peritonitis, being unconsciously repressed in consequence of the pain which they occasion ; and they are mechanically pre- vented by a great quantity of liquid within the peritoneal sac, by enormous distension of the stomach or intestines with gas, by ab- dominal tumors, and by pregnancy. Under these circumstances 24 ANATOMY AND PHYSIOLOGY. the thoracic muscles take on a supplementary activity, which is rendered sufficiently obvious by the increased movements of the thoracic walls. The breathing is then said to be tlioracic or costal. On the other hand, the movements of the ribs are voluntarily re- pressed in consequence of the pain incident thereto in acute pleurisy, or in intercostal neuralgia, and they are mechanically limited by rigidity and ossification of the costal cartilages. The diaphragm, in this case, takes on an increased action. The breathing is then distinguished as diaphragmatic or abdominal, the latter term de- noting the fact that this supplementary activity is manifested by a corresponding increase in the visible rising and falling of the ab- dominal walls. The deviations from normal respiration known as thoracic or costal, and diajjhragmatio or abdominal, thus not only indicate the existence of disease, but point to its situation. By certain intra-thoracic affections the movements of the chest are diminished or suspended on one side, and, by way of compensation, abnormally increased on the other side. This obtains in cases of copious liquid effusion within one of the pleural sacs. Paralysis of the muscles of a lateral half of the body (hemiplegia) may also be attended by diminished thoracic movements of the affected side. Analysis of the movements of the thoracic walls develops other circumstances which are to be noted. The enlargement of the chest, exclusive of the diaphragm, in inspiration, is effected by the action of the thoracic muscles elevating the ribs, the latter, as has been seen, pursuing an oblique direction and forming an angular con- nection with the costal cartilages. In proportion as the ribs are thus raised, the costal angles become more obtuse, and the ribs ap- proach to a horizontal direction, the ribs and cartilages together approximating to a continuous line. At the same time the sternum is raised upward and projected forward. The ribs, also, are rotated backward at their spinal junction. The result is, the cavity of the chest becomes enlarged in every direction. Owing to the greater length of the lower true ribs as well as of their cartilages, and the less degree of obtuseness of the angle formed by the union of the former with the lattei', these elevation and expansion movements, in the male, are much more marked in the lower, than the upper part of the chest; and they are greater during the middle, than either at the beginning or the end of the inspiratory act. In ordi- nary breathing, the ribs at the summit of the male chest appear to have little or no part in the thoracic movements. Accurate measure- THE THORACIC PARIETES. 25 ment shows that thej do not remain quiescent, but the motion is usually so slight as scarcely to be perceived. The movements are mainly confined to the lower part of the chest and the abdomen, frequently appearing to be limited to the latter. This, it is to be borne in mind, is true of ordinary breathing in the male sex. In exaggerated or forced breathing, and in the female, the respiratory movements present important modifications. It will facilitate the description of these modifications to adopt a subdivision of the thoracic movements made by Beau and Maissiat,^ which I am satisfied from my own observations is founded in nature. From an examination of a large number of individuals these observers resolve normal differences of breathing in the two sexes, as denoted by obvious movements, into three kinds, or as styled by them, types. In many persons, as already stated, ordinary breathing is carried on almost exclusively by the diaphragm. In these persons the chief visible evidences of alternate enlargement and diminution of the thoracic space, with the two respiratory acts, consist in the rising and fall- ing of the abdomen. This is called the abdominal type of respira- tion. In other persons, of the male sex, movements of the lower part of the chest, from the seventh rib, inclusive, are involved in a greater or less degree. The type, then, is called inferior costal. This type is very rarely, if ever, presented alone. It is associated with the abdominal. Both types, in other words, are represented frequently in the male sex, different persons differing considerably as respects the predominance of one or the other type. The third type is called superior costal, and, as the title signifies, is character- ized by the respiratory movements being especially manifest at the summit of the chest. This type, as will be seen presently, is peculiar to females. Now, a change in the type of respiration generally characterizes exaggerated or forced, as contrasted with ordinary, breathing. The abdominal type becomes less marked, and the inferior costal appears to take its place. This is demonstrated by the ingenious researches of John Hutchinson,^ the correctness of which may be easily verified by an examination of the nude chest in a living male subject. The respiratory movements, examined when the respiration is tranquil, and, afterward, when voluntarily increased, present, in the first instance, an abdominal motion more ^ Recherches sur le mecanisme des mouvements respiratoires. Archives G^n- ^rales de Medecine, Decembre, 1842. 2 Medico-Chirurgical Transactions, vol. xxix, 1846. 26 ANATOMY AND PHYSIOLOGY. or less marked, with or without a certain degree of inferior costal motion ; and, in the second instance, the abdominal motion, instead of being increased, is diminished, while the inferior costal motion is notably increased, a superior costal motion being sometimes super- added. Hutchinson was led to think that, with this change, the diaphragmatic movements almost ceased. This, however, is not the fact, as shown conclusively by Dr. F. Sibson. The expansion of the inferior ribs, which is measureably due to the diaphragm, pre- vents the rising and falling of the abdominal walls from being ap- parent. Nevertheless, it takes place, as may be satisfactorily proved by percussing the lower part of the chest before and after a deep inspiration. The intercostal spaces at the lower part of the chest are some- what widened with the act of inspiration, and conversely contracted with expiration. At the summit of the chest, however, the reverse of this is the case. The ribs approximate very slightly in inspira- tion, in consequence of each rib being raised slightly more than the one above it. The intercostal depressions which are apparent at the inferior portion of the chest laterally and anteriorly, in thin persons, are most conspicuous in the act of inspiration, and are increased in pro- portion to the extent of the inspiratory movements. This is the rule, but, according to Beau and Maissiat, exceptions are occasion- ally to be observed. The respiratory movements in the adult female differ in a re- markable manner from those which have been described as belong- ing to the male sex. In the adult female the superior portion of the chest presents, in the act of inspiration, an expansion notably greater than in males, the movements of the inferior portion of the chest, and of the abdomen, being proportionably less prominent. The contrast in this respect between the two sexes is striking. "The adult male," to quote the language of "Walshe, "seems to the eye to breathe with the abdomen and the lower ribs, from about the tenth to the sixth; the adult female, Avith the upper third of the chest alone." In other words, the breathing peculiar to females is the superior costal type, whereas in males it is chiefly the abdomi- nal, generally combined, more or less, with the inferior costal type. To observe this difference in the two sexes, it is only necessary that the attention be directed to the subject when in the presence of ladies; but it is especially conspicuous when the breathing is con- THE THOKACIC PARIETES. 27 vulsively affected by strong mental emotions, or when these emotions are simulated in histrionic performances. Hypothetically, two reasons suggest themselves, and have been offered to account for these dif- ferences in the two sexes — differences which it is of importance should be borne in mind with reference to the study of diseases of the respiratory apparatus. One of these reasons is, that nature has in this way provided for the due performance of respiration during the period of gestation, when the diaphragmatic movements are mechanically impeded. Boerhaave and Haller, who had observed this point of difference (which appears to have been lost sight of by more modern writers up to a period quite recent), considered it in that light. This, however, is simply adducing a final cause. An- other reason, more entitled to be called an explanation, is, that the movements of the diaphragm and lower part of the chest become per- manently impaired in females by modes of dressing which involve compression of the inferior ribs ; and, as a consequence, the superior thoracic movements are unnaturally developed. The validity of the latter explanation, it is evident, hinges on the question whether the differences be natural or acquired; and this question is to be decided by examining girls and adult females whose Avaists have not been in- cased in any restraining or contracting apparatus. With respect to this point, Walshe states that he has examined a considerable num- ber of female children, aged between four and ten years, who had never worn stays, or any substitute therefor, who presented, never- theless, the predominant action at the summit of the chest ob- servable in adult females, the peculiarity, however, being less than in later years. He states, also, that the female agricultural laborer breathes more like a male than the town female ; and that during sleep the difference between the sexes is less conspicuous. Beau and Maissiat affirm that they have observed this peculiarity marked in young girls, and in females from the country who had never worn corsets. But, according to their researches, the peculiarity does not become apparent till the third year of life. Prior to the age just mentioned the type of breathing in female as in male children is usually abdominal. Hutchinson, in his valuable paper already referred to, says he "examined 24 girls between the ages of 11 and 14 who did not wear any tight dress, and found in them the same peculiarity in ordinary breathing." Sibson^ attributes the peculiarity 1 On the Movements of Respiration in Disease, and on the Use of a Chest-meas- urer. Med.-Chir. Trans.of Royal Med. andChir. Society of London, vol. xxxi, 1848. 28 ANATOMY AND PHYSIOLOGY. to modifications of the chest induced by tight lacing. He states that "the form of the chest and the respiratory movements do not differ perceptibly in girls and boys below the age of ten." Still, he re- marks, "it is probable that in females, even if they wore no stays, the thoracic respiration would be relatively greater, and the diaphrag- matic less, than in man." Judging from the foregoing statements by those Avho, within the past few years, have made the respiratory movements the subject of extensive investigations, it would seem that, although a certain amount of influence may be attributable to dress, the difference which has been pointed out is not Avholly derived from that source. The respiratory movements are modified by age. This is owing, in a great measure, to the differences as regards the flexibility and elasticity of the costal cartilages which belong to different periods of life. In boys, the costal expansion is greater than adults, for the reason just stated; and in old men, when the cartilages become ossified, forming with the ribs one unyielding piece, the diaphrag- matic movements are increased, and the costal movements propor- tionably diminished. Between the two extremes of life, the charac- ter of the respiration will be likely to approximate to that belong- ing to the one or the other, according to the proximity of the indi- vidual to boyhood or old age. In aged persons, whose costal carti- lages are ossified, the action of the muscles elevating the ribs tells exclusively on their sternal ends; hence the motion of the sternum is marked, and owing to the greater length and obliquity of the inferior true ribs, the lower portion of the sternum is raised and projected more than the upper portion. An effect somewhat similar is produced in cases of permanent expansion of the chest from dila- tation of the air-cells in cases of emphysema. The costal cartilages, although not rendered comparatively non-elastic by ossification, are kept on the stretch by the abnormally increased volume of the lung, and the ribs and sternum move upward in the act of inspiration "as if in one piece." Infants present this modification : the abdominal movements are less, and the thoracic movements proportionably greater than in youth after the period of infancy is passed. To determine with exactitude the amount of the alternate expan- sion and contraction of different parts of the chest with the two acts of respiration, some method of accurate measurement must, of course, be employed. An apparatus for this end has been devised by Sibson, THE THORACIC PARIETES. 29 whicli he calls the chest-measurer. It consists of several parts, as follows: 1, a brass plate, covered with silk, on which the patient lies; 2, an upright rod, divided into inches and tenths, to indicate the diameter of the chest; 3, a horizontal rod, moving by a slide on the upright rod, which can be lengthened bj being drawn out like a telescope ; 4, at the extremity of the latter a dial and rack. The rack, when raised by the moving walls of the chest, moves, by means of a pinion, the index on the dial. A revolution of the index indi- cates an inch of motion in the chest, and each division indicates the 100th of an inch. By means of an instrument of this description the extent of mo- tion of different parts of the chest may be ascertained with minute accuracy. It indicates, also, very correctly the relative duration of each of the two respiratory acts, and in the latter point of view is especially useful. In the valuable paper already referred to, Sibson has given the results of a large number of observations on the movements of res- piration in health and disease. The more important of these re- sults, relating to healthy movements, are embraced in the following summary: In the healthy, robust male, the movement of the ster- num, and of the ribs from the first to the seventh, is from .02 to .07 of an inch during an ordinary inspiration, and from .5 or .7 to 2 in. during a deep inspiration. The ordinary abdominal movement (diaphragmatic), is from .25 to .3 in. ; the extreme from .6 to ^ in. As regards the two sides of the chest compared, the expansion of the second rib is alike on the two sides ; but below, the inspiratory movements, both in ordinary and forced breathing, are somewhat less on the left than on the right side, especially over the heart. In females, when stays are on, the thoracic movement at the second ribs, is from .06 to .2 in. ; the abdominal, from .06 to .11 in. When the stays are off, the thoracic movement is from .03 to .1 in., and the abdominal from .08 to .2 in. The latter observations, as Dr. S. remarks, render it certain that the wearing of stays materially in- fluences the respiratory movements, lessening the movement of the diaphragmatic ribs, and exaggerating that of the thoracic. They do not, however, disprove the fact that a natural difference exists in the two sexes, which other observations appear to establish. The reader, desirous of farther details, will find them in the paper from which the above summary is taken. The chest-measurer of Sibson, and other contrivances to deter- 30 ANATOMY AND PHYSIOLOGY. mine the amount of motion with the same exactness, have the dis- advantage of being more or less complicated and cumbersome. A simple graduated tape will suffice to determine, with tolerable accuracy, differences of size, both lateral and antero-posterior, be- tween a full inspiration and a forced expiration. But to ascertain by this mode the precise degree of motion in ordinary breathing is very difficult, the results varying very considerably according to the degree of tension with which the tape is held. This difficulty will be at once apparent to any one who attempts to employ this more simple instrument for that end. The results are only remote ap- proximations to accuracy. Dr. Quain has endeavored to obviate the difficulty attending the use of the simple tape, without impairing much its simplicity, in the instrument contrived by him, which he calls a stethometer. It consists of a cord connected by an axle with an index which moves over a graduated dial. The cord being ex- tended from a fixed point on the chest to another, the extent of the respiratory movement will be manifested by the tension made on the cord being communicated to the index, and shown in figures on the dial, from which it can be read off in fractions of an inch. Practically, however, it is not of much importance to determine with mathematical accuracy the extent of the thoracic and abdominal movements with reference to the phenomena of disease. The eye will answer for an estimation somewhat rough, but sufficiently exact for clinical purposes. Intra-thoracic disease may be evidenced by marked diminution of the movement of a portion of the chest. This is often observed in tuberculosis of the lungs, at the superior part of the chest on one side ; oftener in females than in males, in consequence of the greater mobility in them naturally in that situation. Local emphysema of the lungs may also produce a similar effect, accompanied by an ab- normal protrusion or bulging of a portion of the chest. The respiratory movements, as has been seen, are abnormally in- creased in pregnancy, and in various affections which compromise the function of htematosis. AVhen this increase is but moderate, it is stated by Beau and Maissiat that the movements in one individual will differ from those in another, according to the type of breathing natural to the individual. Thus, if the type be purely abdominal, the abdominal movements alone will be increased ; but if it be in- ferior costal, as well as abdominal, the movements of the lower ribs will be conspicuous; and if, as in females, it be superior costal, the THE THORACIC PAKIETES. 31 exaggeration "will be found to affect chiefly the superior portion of the chest. In cases, however, in which the sense of the want of respiration, or dyspnoea, is intense, and the breathing exceedingly labored, the three types may be simultaneously represented. But, under these circumstances, the thoracic muscles more especially are brought into active requisition, and in order to effect the utmost possible enlargement of the chest, various auxiliary muscles are employed which are capable of aiding in respiration. An erect or sitting posture, being most favorable for the action of these mus- cles, is also selected. These changes will claim attention in con- nection with the symptomatology of the diseases in which they are exemplified. The rhythmical succession of the tw'O acts of respiration, in other words the order of their alternation, relative duration, etc., and the degree of power belonging to each act, involve certain points of in- terest, which have also important relations to the study of diseases. Of the two acts, inspiration, in ordinary breathing, is accomplished by the active exertion of muscular power. An ordinary expiration follows as a consequence of the suspension of the muscular force which has occasioned the preceding inspiration, being due chiefly to the weight of the abdominal organs, which, with the elasticity of the abdominal walls, press upward the diaphragm ; together with the elasticity of the ribs, costal cartilages, and the contained pulmonary organs. It is only when the expiration is voluntarily increased or prolonged, or when it is spasmodically exerted, as in coughing or sneezing, that a notable degree of muscular power is exerted in this act. But the co-operation of the muscles with the several circum- stances that have been mentioned, determined either by volition or spasmodic action, renders the act more forcible than that of inspira- tion. Hutchinson,^ by a series of experiments, showing the force of the two acts, respectively, as indicated by the elevation of a column of mercury, arrived at the result, that the expiratory, with muscular co-operation, exceeds the inspiratory by one-third. This excess of force he thinks is about equal to the elasticity which is brought to bear on the former act. The greater power of expiration when aided by the will, is manifest in the application of this respira- tory act to various uses, such as singing, coughing, playing on wind instruments, glass-blowing, etc. 1 Op. cit. 32 ANATOMY AND PHYSIOLOaY. From the facts which have heen stated relative to ordinary breath- ing, it follows that the expiratory movement commences at the in- stant the inspiratory ceases. The latter is merged into the former, with scarcely any appreciable interval between the two. So far as the expiratory movement is readily appreciable, it appears to be considerably shorter than the inspiratory, and an interval of some duration seems to elapse, after the completion of an expiratory act, before the next inspiration commences. This interval, however, is more apparent than real. After the expiratory movement ceases to be obvious, the pulmonary organs probably continue to contract, in a manner not readily appreciable, nearly if not quite to the recur- rence of the act of inspiration, unless restrained by a voluntary effort. The latter part of this movement is due, not to primary contraction of the thoracic parietes, but to continued collapse of the lung, together with the pressure of the abdominal viscera. Walshe estimates the interval between the end of one expiration and the beginning of the next inspiration, at one-tenth of the period occu- pied by both acts. But if we were to be guided by the cessation of the obvious abdominal and thoracic movements, the interval would be considerably greater. Judging from a cursory examination, or from attention to one's own respiration, the act of expiration appears shorter in duration than that of inspiration. The two acts, however, as determined by the chest-measurer of Sibson, in ordinary respiration, are generally equal in duration. When a difference exists, the expiration is oftener prolonged. This is apt to be the case in the tranquil breathing of. women and children. It characterizes also the respiration in old age. In hurried breathing, in females especially, the expiratory act becomes relatively lengthened. Neither the inspiratory nor the expiratory act is performed with a uniform degree of rapidity. The inspiration is at first slow, be- comes gradually quicker, and again is retarded toward its close. The expiratory act is performed more quickly at first, and during the latter part more slowly than the inspiratory. These facts will in a measure account for certain differences which distinguish the expiratory from the inspiratory sound, as determined by ausculta- tion in health and disease. Deviations from the natural rhythm of the respiratory movements will be found to furnish characteristics of some forms of disease. In cases of obstruction seated in the larynx, or other parts of the air- THE THORACIC PARIETES. 33 passages, the expiration is morbidly prolonged. In emphysema involving an abnormal dilatation of the air-cells, and diminished elasticity of the lungs, the expiration becomes obviously much longer than the inspiration. On the other hand, a shortened and quickened, or spasmodic inspiration, is a significant symptom of some affection of the nervous system, occurring in some cases of hysteria, and also under circumstances in which it is of a much more serious import, denoting a morbid condition of great gravity affecting that portion of the nervous centre (medulla oblongata) which presides over the involuntary acts of respiration. The writer has called attention to the importance of this change in the rhythm of respiration in cases of continued fever, as often foreshadowing the occurrence of coma.^ Finally, the size of the chest is a point remaining to be noticed. This may be estimated by circular measurement with a graduated tape. Persons differ considerably in this regard. The limits of variation in 994 cases, in which the circumference was ascertained by Hutchinson, were from 30 to 40| inches. Walshe fixes the aver- age size at about 33 inches ; but the normal deviations being so great, it is of little practical utility to determine a standard by taking the mean of a series of examinations. This point, clinically, is not of much importance, especially, as the researches of Hutchinson show that the breathing capacity of the lungs, as dependent on the movements of the chest, bears no constant proportion to its size. Formerly it was supposed that contracted dimensions of the chest denoted a predisposition to diseases of the respiratory apparatus, more especially tuberculosis of the lungs ; but it is now pretty well ascertained that little or no tendency to that, or other forms of dis- ease, is derived from this source. In determining variations in the size of the chest, either by measurement, or by the eye, with refer- ence to the evidences which may be thereby afforded of the existence of disease, we do not take the dimensions of the entire chest as the standard, but institute a comparison of one side with the other. This being the case, the capacity of the thorax proper to the indi- vidual is a matter of minor importance. 1 Clinical Reports on Continued Fever, etc., 1852. 34 ANATOMY AND PIIVSIOLOGY. ir. Pulmonary Organs. The lungs are the light spongy bodies contained within the chest, in which are effected the blood-changes constituting the function of hfematosis. These organs are double, consisting of the right and left lung, each occupying a lateral half of the thorax. The lung on each side is provided with a distinct membranous envelope — the pleura — which, after furnishing a covering for the pulmonary surface, is reflected upon the thoracic wall, and forms a shut sac, presenting the same arrangement as the serous membranes in other situations. The two pleural sacs are in contact at the median line, forming, by their juxtaposition, the mediastinal partition, or septum, dividing the two sides of the chest. Joined directly beneath the sternum, they diverge to form the anterior mediastinum which incloses the remnant of the thymus gland ; approximating, and becoming united, they again separate, forming the middle mediastinum which contains the fibrous sac, or pericardium, inclosing the heart ; and by a third separation is formed the posterior mediastinum, through Avhich pass the descending aorta, thoracic duct, etc. The portion of this mem- brane investing the lungs is called the 'pulmonic or visceral pleura ; and that lining the walls of the chest, the costal or pan'e^aZ pleura. A third portion, forming a covering for the floor of the thoracic cav- ity — the diaphragm — is called the diaphragmatic pleura. Between the free surfaces of the two former portions in each lateral half of the chest is what is termed the cavity of the pleura — erroneously so called, inasmuch as the free surfaces being in contact, there does not exist, strictly speaking, a cavity. Between these surfaces, within the shut sac of the pleura, liquid effusion takes place in pleu- ritis, and hydrothorax, accumulating, in some cases, to the amount of several pounds, compressing the lung into a small solid mass, and producing changes in the external conformation of the chest which have been already noticed, viz., enlarging its size, pushing outward the intercostal spaces, elevating the ribs from their oblique towards a horizontal direction, widening the distance between them, and compromising more or less the mobility of the affected side. The parietal or costal portion of the pleura is thicker than the visceral or pulmonary portion, or the portion covering the diaphragm. The areolar tissue uniting the membrane to the parts which it invests, called the subserous areolar tissue, is more abundant and P U L M N A K Y R Ct A N S. 35 looser in the former situation, and, consequently, the serous mem- bi-ane is more easily detached from the walls of the chest than from the surface of the lungs. This, probably, explains a fact pertain- ing to inflammation of the pleura, viz., the inflammatory action is more intense, and the products of inflammation are more abundant, on the costal, than on the pulmonary surface. The lung on either side varies in size according to the quantity of air which it contains, and of course, its volume is alternately in- creased and diminished with the successive acts of inspiration and of expiration. Its form is conoidal, the base being downward. The portion in contact with the walls of the chest extends lower than the central portion, in consequence of the arched or vaulted form of the floor of the chest, — the diaphragm. Between the sides of the arch or vault formed by the diaphragm and the thoracic walls is a space, deeper behind than in front, which receives the inferior shelving border of the lungs. Thus at the lower part of the chest, on each side, a margin of lung intervenes between the diaphragm and the walls of the chest, more especially in the act of expiration, when the convexity of the diaphragm is greatest. Owing to the fact already stated that the vertical diameter of the right side of the chest is less than that of the left, the right lung is shorter than its fellow. Transversely, however, the diameter of the right lung exceeds that of the left. This accords with a fact already stated, viz., that the semi-circumference of the right side usually exceeds that of the left by about half an inch. The situation of the heart is such that a portion of this organ encroaches somewhat on the left thoracic cavity, at the expense of the lung on that side. An irregular quadrangular space between the fourth costal cartilage and the sixth rib, is occupied by the heart uncovered by the lung and in contact with the chest. Vertically, this space averages, in the adult, on the median line, about two inches ; and horizontally, from the centre of the sternum, it extends from two and a half to three inches to the left. Overlapped by the lung, the heart encroaches still farther on the thoracic space, viz., vertically, from the third to the sixth costal cartilages ; and, transversely, nearly to the nipple. In consequence of its lesser transverse diameter, together with the encroachment of the heart, the left lung is smaller in volume, not- withstanding, measured in a perpendicular direction, it is longer than the right lung. The right lung exceeds the left in weight by 36 ANATOMY AND PHYSIOLOGY. about two ounces. The average weight of both lungs is about forty- two ounces. When free from disease, or the effects of disease, the lung is de- void of any direct connection with the surrounding parts, excepting where it is connected with the bronchi, together with the bloodves- sels, lymphatics, and nerves which enter it to communicate, sever- ally, with corresponding structures forming portions of the pulmo- nary organs. United by areolar tissue, including lymphatic glands, and inclosed in a sheath formed by a reflection of the pleura, the parts just enumerated compose what is termed the root of the lung. By the root^ thus constituted, the lung on each side is as it were suspended or fixed within the chest, the surface of the remainder of the organ being entirely free in health ; but the pleural surface is often adherent over a greater or less space in consequence of morbid attachments. In its situation, the root of the lung is about equidis- tant between the base and apex. The upper extremity or apex of the lung forms a blunted point, extending in some persons only to the upper margin of the clavicle, but in other persons to a height from half an inch to two and a half inches above the clavicle. It rises higher generally on one side than on the other, and it is much oftener higher on the right than on the left side. It is more apt to extend above the clavicle in males than in females. These facts were ascertained by careful measure- ments in one hundred bodies, after death, by the late Dr. C. E. Isaacs. The division of the lungs into lobes is a point of considerable im- portance in the study of certain pulmonary diseases. It is made by deep fissures extending in an oblique direction from above downward. The left lung presents a single fissure ; the right has one fissure extending, like that of the left lung, around the whole circumference of the organ, and a second running from the anterior border a short distance only upward and backward. Thus divided, the left lung is said to consist of two lobes, called the upper and lower ; and the right lung of three, called the upper, lower, and middle lobes. The middle lobe of the riglit lung, however, is hardly entitled to be ranked as a separate lobe, but is " an angular piece separated from the anterior and lower part of the upper lobe." It is of importance with reference to the diseases which are to be subsequently consid- ered, to note the situation of the fissures dividing the lungs into lobes, as indicated by corresponding imaginary lines on the exterior PULMONARY ORGANS. 37 surface of the chest. Posteriorly, they commence about three inches below the apex of the lung. Indicated on the chest, the line corresponding to their direction takes its departure at a point not far from the vertebral extremity of the spinous ridge of the scapula. On the left side the boundary line between the two lobes passes from the point just named obliquely downward to the intercostal space between the fifth and sixth ribs, the anterior point of division falling a little to the right of a vertical line passing through the nipple. On the right side, the line marking the upper border of the lower lobe passes obliquely downward to the space between the fifth and sixth costal cartilages. The line dividing the middle and the upper lobe passes from the fourth cartilage in a direction upward and outward for a distance varying considerably in diiferent individuals. It follows from these statements that a small strip only of the lower lobe on each side is contained in the anterior portion of the chest, the greater portion being situated posteriorly. The physical signs, therefore, of morbid changes in the condition of the lower lobe are presented mainly in the middle and lower portions of the chest be- hind. It is very necessary to bear this in mind in examinations with reference to inflammation of the lung (pneumonitis), which, as will be seen hereafter, in a large proportion of cases is limited to the lower lobe. Inattention to this point may lead the medical practitioner to overlook that disease, his examination being limited to the anterior portion of the chest in cases in which the evidences of its existence are sufiiciently apparent posteriorly. The interlobar fissure becomes changed in its direction by emphy- sema seated in the upper lobe, tending under these circumstances to a vertical line. This is measurably true of lobar pneumonitis in the second stage. The situation of the fissure is not the same, in health, in inspiration and expiration ; it moves downward with the former and upward with the latter act. The foregoing are the more important of the circumstances per- taining to the situation of the lungs, and the relations of their several parts, which claim notice from their pathological bearings. But an analysis of the anatomical structure of these organs will develop numerous points which are to be taken into account in studying their diseases. In addition to bloodvessels, nerves, and lymphatics, Avhich are common to most of the important organs of the body, the lungs are composed of the divisions and subdivisions of the b7-07ichi or 88 ANATOMY AND PHYSIOLOGY. bronchial tubes, and the air-cells or vesicles. These, combined, give to the lungs their distinctive structural characters. The bronchi, after penetrating the lung, divide and subdivide in all directions, the divisions generally being of the kind called dichotomous, i. e. consisting of two branches, the mode of division most favorable for the speedy transmission of air. As the branches increase in number, they diminish in size, until at length they become extremely minute, and, finally, the ultimate ramifications, the capillary bronchial tubes, terminate in the vesicles or cells. The structure of the bronchial tubes, which are found to present in different situations important anatomical differences in addition to their gradations in size, and of the air-cells, the relations of the latter to the former, etc., must be understood before the student is prepared to enter on the study of diseases affecting the respiratory apparatus. But prior to directing attention to points pertaining to the struc- ture of these constituents of the lung, the pulmonary lobules should be described. What are ordinarily called the lobules of the lungs, are small portions of pulmonary substance, irregular in shape, united together, and at the same time, isolated by means of intervening areolar tissue. The latter forms what is termed the interlobular septa. If the surface of the lung be closely examined, it is found to present a great number of polygonal figures, indicated by dark lines. These lines, most marked in the adult, owe their dark color to pigmentary matter deposited in the interlobular areolar tissue. The figures are very irregular both in form and size. As regards the latter, they vary from a quarter of an inch, to an inch in diam- eter (Kolliker). These polygonal divisions are found to contain sub- divisions, which are the pulmonary lobules. Different lobules, al- thouo-h in juxtaposition, have not, as already stated, any direct com- munication with each other. This is demonstrated by the following experiment. If a blowpipe be introduced beneath the pleural cov- ering of the lung, and the subserous areolar tissue inflated, the air is forced into the interlobular partitions, the areolar tissue in the two situations being continuous. The lobules are thus surrounded by air, and rendered more conspicuous, but none gains admission into the cells or vesicles entering into the composition of the lobules. By careful dissection of lungs taken from a J^oung subject, and especially from the foetus, the different lobules may be separated from each other. They are then found to be quite distinct, being PULMONARY ORGANS. 39 connected only by the minute bronchial tubes, called the lobular bron- chial tubes, together with bloodvessels, nerves, and lymphatics. The diflferent lobules of a lobe, thus separated, but attached to the branches of the bronchial tree, are likened by Cruveilhier to grapes attached to their footstalks and hanging from a common stem. Each lobule represents, in fact, a lung in miniature, the several lobes being made up of an aggregation of these diminutive lungs. Con- sidered individually, each lobule is composed of the minute terminal branches of the lobular bronchial tube — called the bronchioles, or the capillary bronchial tubes — the air-cells, the vessels, and nerves, these several anatomical constituents being supported and united by areolar tissue. Collapse of lobules, in greater or less number, occurs as a conse- quence of obstruction of bronchial tubes, of a nature permitting the egress of air from the cells with expiration, and preventing its ingress with inspiration. This takes place in the disease peculiar to children heretofore incorrectly called lobular pneumonitis. Owing to feebleness, or other causes, in newly born children certain lobules may not undergo expansion, retaining their foetal, collapsed state. This has received the name of atelectasis, or imperfect expansion of the lungs. The embarrassment of respiration occurring at or soon after birth, which may proceed to a fatal issue, is not infre- quently due to this condition. In this connection it may be remarked that the pulmonary lobules are not equally permeable to air. Those most permeable are situ- ated at the apex of the lung. This difference is due to the distribu- tion of the larger bronchial tubes. According to Cruveilhier, "a moderate inflation of the lungs, made as much as possible within the limits of an ordinary respiration, does not perhaps dilate one-third of the pulmonary lobules." Thus, "there are some lobules which are kept in reserve, as it were, and only act in forced inspiration." These interesting points will be found to be involved in the phe- nomena of disease. The areolar tissue forming the interlobular septa is the seat of the rare form of emphysema of the lungs called interlobular emphy- sema, in which air obtains access, by rupture, between the lobules, widening the intervening spaces, and causing a projection of the septa above the pulmonary surface. A collection of air is also occasionally found after death, limited to a circumscribed space, within the areolar tissue connecting the pulmonic pleura to the 40 ANATOMY AND PHYSIOLOGY. surface of the lung, elevating the membrane in the form of a bleb. The form of emphysema, however, which exists in the vast majority of cases, consists in enlargement of the air-cells, or vesicles, either by coalescence or dilatation, or both. It remains to notice certain points pertaining to the structure, arrangement, and mutual relations of the bronchial tubes, and air- cells. The general course and distribution of the bronchial tubes in the several lobes have been already described. The branches, succes- sively, end in double divisions, and with multiplication in number there is a corresponding diminution in size, down to the minute lobular bronchial tubes, which, after penetrating the lobules, sub- divide into the terminal branches, the bronchioles, or capillary bronchial tubes, called by Rainey the intercellular passages. In referring to different sets of the bronchial tubes as the seat of dis- ease, or of physical signs, it is customary to consider them as embraced in three classes, viz., the larger, the smaller, and the capillary tubes. In designating the site of morbid appearances after death it is sometimes convenient to indicate the divisions as those of the first, second, third, and fourth diameters: that is, the series of double branches are thus enumerated in the order in which they are given off. These are the larger bronchial tubes, the smaller being the subsequent series, inclusive of those passing to the lobules. The larger bronchial tubes are composed of a fibrous membrane, containing irregularly shaped cartilaginous plates, the latter taking the place of the incomplete rings of cartilage which characterize the air-tubes exterior to the lung. These cartilaginous plates are situated especially at the bronchial divisions. They embrace, also, a layer of circular muscular fibres, of the kind called smooth or unstriped, belonging to the muscular system of organic, as distin- guished from animal life. This anatomical element is the seat of the affection known as asthma, and is sometimes involved in certain symptoms incidental to inflammation and irritation of the bronchial tubes. They are lined by mucous membrane, covered with a layer of ciliated, cylindrical, or columnar epithelium, the object of the latter being to propel, and thus assist in the removal, by expectoration, of the secretions furnished by the mucous follicles in health and disease, as well as various morbid products formed within or poured into the PULMONARY ORGANS. 41 tubes, and perhaps to aid in the tidal currents of air. This mem- brane is the seat of inflammation in ordinary bronchitis. The smaller bronchial tubes present marked changes. The fibrous membrane, forming their basis, becomes thinner as the tubes diminish in size; the cartilaginous plates are less numerous; the mucous membrane is more and more attenuated, and, at length, when the calibre of the tubes is reduced to about one-fiftieth of an inch, the cartilaginous plates have disappeared, and the mucous and fibrous layers appear to have coalesced, forming a single thin membrane. The inner surface, however, still presents ciliated epithelium. Finally, within the lobules, the ultimate bronchial tubes termi- nating in the air-cells, as respects size, are truly capillary, having a diameter varying from y-|o^^ *^ 75^^ ^^ ^^ inch. These capillary tubes present still more important changes in structure. The mem- brane constituting their walls is exceedingly thin, and its inner surface does not present epithelium, cylindrical, and ciliated, but it is that variety called squamous, tessellated, or pavement epithelium. The mucous follicles disappear. These tubes, in fact, lose the char- acters which belong to the bronchi elsewhere, and assume the struc- ture of the air-cells, with which they are immediately connected. The anatomical changes v,'hich thus characterize diiFerent divisions of the bronchial tubes, are in accordance with certain striking facts pertaining to diseases of the respiratory apparatus. A principle of conservatism is often evidenced in the history of diseases by their reluctance, so to speak, to pass from one part to another part con- tinuous, or contiguous, but presenting difi"erences of structure. The latter appear to constitute the restraining barrier. This principle is exemplified in the fact that ordinary bronchitis is limited to the larger bronchial tubes, rarely extending to the smaller, to constitute what is incorrectly styled capillary bronchitis. The latter variety of the disease, as will be seen hereafter, is vastly more severe and dangerous. Conversely, an inflammation seated in the air-cells and capillary tubes (pneumonitis), is usually limited to these parts, not extending to the branches of the bronchi, which, although in direct communi- cation, are protected by differences in structure. The air-cells, or vesicles, are the minute cavities in which the bronchial tubes are said to terminate. Their diameter varies from 200th to t^qUi of an inch. After birth they are never free from air, 42 ANATOMY AND PHYSIOLOGY. and their size will depend on their degree of distension, this being, of course, considerably greater at the end of inspiration than of ex- piration. They are attached to the extremities, and also along the sides of the terminal branches of bronchioles, or capillary bronchial tubes, with which they communicate by free openings. Microscopi- cal observers have differed as to the existence of direct lateral com- munications between the cells. According to the best authorities, they do not communicate with each other, except indirectly, through the bronchioles, or capillary bronchial tubes. Their connection, however, with the latter is such that, although not direct, the com- munication is free. A single bronchiole or terminal branch with its attached cells may be considered to form a common space, subdivided into numerous sections or alveoli. The air-cells are larger toward the surface of the lung, and also toward the edges, than in the interior. Their size increases with age, and they are smaller in females than in males. Their walls possess much strength, as shown by their not being easily ruptured by artificial inflation. The air-cells are surrounded by yellow elastic fibres, Avhich give to the lungs a considerable degree of elasticity. This is shown by the fact that they collapse, in a marked degree, when the cavity of the chest is opened. It is within the cells that the atmospheric air received by inspira- tion exerts its effects on the blood. The pulmonary artery entering the lobes in company with the bronchi, divides and subdivides, with- out anastomosing, its branches accompanying the air-tubes, until it ends in a very fine capillary network ramifying on the Avails of the cells. Here, also, commence the various radicles and branches, which, pursuing a retrograde course, like that of the arteries, col- lect the oxygenated blood and convey it to the left auricle. The blood within the capillary meshes surrounding the cells is brought into sufficient proximity to the air contained in the latter, for that interchange of gases to take place, by endosmosis and exosmosis, which is concerned in hgematosis. The air-cells and capillary tubes, together with the bloodvessels, nerves, and lymphatics, united by areolar tissue, constitute the pul- monary parenchyma, or the substance of the lungs. The cells and capillary tubes are the parts affected by inflammation in pneumoni- tis. Abnormal distension of the cells and capillary tubes, with or without atrophy and consequent destruction of more or less of the PULMONARY ORGANS. 43 cell-walls, giving rise to coalescence, constitutes the lesion in pul- monary or vesicular emphysema. It will be seen that some of the most important of the physical signs of diseases within the chest have relation to anatomical points which the foregoing description has embraced. With the enlargement of the chest in inspiration the lungs are dilated by the pressure of the atmosphere filling the bronchial tubes and air-cells. The movements of the diaphragm and walls of the chest in opposite directions in inspiration and expiration, cause a rubbing together of the pulmonic and costal pleural surfaces. This takes place especially at the inferior portion of the chest. As a provision against any injurious efi"ects of the friction incident to these movements, which involve a considerable degree of force, the free surfaces of the pleura are remarkably smooth, polished, and kept moist by the presence of a small quantity of liquid. Hence the two portions of the membrane glide over each other with the two acts of inspiration, not only without injury, but noiselessly. But it is otherwise in some cases in which these surfaces are ren- dered rough or irregular by morbid products. The rubbing move- ments are, under these circumstances, accompanied by friction sounds which become the signs of disease. These sounds, as might be expected, are most likely to be produced where the movements of the thorax and the gliding of the pleural surfaces are greatest, viz., at the lower portion of the chest. The movements upon each other of the pleural surfaces are limited by morbid adhesions, more or less extensive, of these surfaces, which are found to exist in the larger proportion of bodies examined after death; and in certain cases, in which the costal and pulmonic por- tions of the pleura are universally adherent in consequence of gene- ral pleurisy, they must, of course, be entirely arrested. The latter condition it might be presumed would interfere with the expansion of the chest. Observations, however, show that this is not the fact. Mr. Hutchinson has given an account of a case in Avhich there was not a square inch of the pleural surfaces, on one side of the chest, that was not firmly united ; nevertheless in this case the expansion of the chest was in no degree diminished. The quantity of air contained within the lungs not only varies greatly in different persons, but in the same person it is constantly fluctuating within certain limits. It is difiicult to determine these limits with exactitude, but in its pathological bearings this is not a 44 ANATOMY AND PHYSIOLOGY. matter of importance. The quantity after an inspiration is of course greater than that after an expiration, just in proportion as the amplitude of the chest is increased by the former, and diminished by the Latter of these acts. Owing to the control which the will can exert over the breathing movements, much will depend on the in- fluence of volition. Hutchinson, in a paper to which reference has already been made more than once, has given the results of a large number of experiments to determine the quantity of air expelled from the lungs by a forcible act of expiration succeeding the fullest possible inspiration. This he considers a test of what he terms the vital capacity of the lungs. By means of an instrument called the spirometer, the quantity of air which a person is able to receive into and expel from the lungs is ascertained. The results of these ex- periments it is evident do not enable us to determine the quantity of air received and expelled in habitual respiration, in other words, the ordinary breathing capacity of the lungs. Nor do they assist us in determining the absolute quantity of air which the lungs are capable of containing, since a residual quantity, varying in difi'erent individuals, remains after the most forcible act of expiration. Never- theless the results obtained by Hutchinson are interesting. The vital capacity, in the sense in which this expression is used, is a constant quantity in each individual; that is, each person possesses the ability to expel a certain number of cubic inches of air from the lungs, and, assuming that he remains free from disease, each person, under circumstances equally favorable, will be found to be able to expel at different trials about the same quantity. From a very large number of observations made on persons of different occupa- tions, supposed to be in good health, Hutchinson ascertained that the quantity of expired air does not depend on the size of the chest, but sustains a fixed relation to the height of the individual. The law of this relation, deduced from an immense number of cases, is the following: "For every inch of height (from 5 ft. to 6 ft.) eight ad- ditional cubic inches of air at 60° are given out by a forced expira- tion." The reason for this relation to height he confesses his in- ability to give. The fact, of course, involves the existence of some circumstances pertaining to the conformation or movements of the chest, which enable individuals in proportion to their height to in- crease and diminish, with the alternate respiratory acts, the ampli- tude of the chest. In other words, the vital capacity is another name for the breathing capacity, dependent on the extent to which PULMONARY ORGANS. 45 the chest may be expanded with the act of inspiration, and con- tracted with the act of expiration. Hodgkin attributes it to the "increased length of the dorsal portion of the spinal column." Sib- son offers as an additional reason the greater length and obliquity of the I'ibs in proportion to the stature, a fact which gives to a nar- row-chested tall man a greater range of motion, and consequent breathing capacity, than belong to a short man with a chest of greater depth. These explanations seem probable. A relation less constant was also found to exist between the vital capacity and the weight of individuals. Hutchinson supposes that the employment of the spirometer may be made serviceable in determining the existence of thoracic disease. If the vital capacity, taken in connection with the height and weight of an individual, be considerably below the average, some morbid condition compromising the pulmonary organs may be suspected. But the evidence is only presumptive, for the vital capacity may be reduced by various- causes compromising the muscular power with which the respirations are carried on, irrespective of thoracic dis- ease. This must be the case if even slight fatigue of the respiratory muscles will affect the result, and it is stated by Mr. H. that "if more than three observations are consecutively made at one time, the number of cubic inches of air will, from fatigue generally be found to decrease." The fact is shown by some observations made with reference to this point, and reported by the late Dr. William Pepper in a communication contained in the American Journal of Medical Sciences, April, 1853. The consideration just stated, together with the fact, that the variations in different persons within healthy^ limits is very great, and also the fact, that even when presumptive evidence of thoracic disease is afforded, the spirometer gives no information respecting the nature or seat of the affection, will prevent this from becoming an important means of examination with reference to diseases of the respiratory apparatus. 1 To illustrate the wide interval between extremes in healthy persons, in a series of cases reported by Dr. Wm. Pepper (Am. Jour, of Med. Sciences, April, 1853), in one person 6 ft. in height, the vital capacity was 151 cubic inches, and in another person 6 ft. lOJ inches, it amounted to 202^ cubic inches. 46 ANATOMY AND PHYSIOLOGY. III. Trachea, Bronchi, and Larynx. The trachea, bronchi, and larj'nx, are separate portions of the canal, or tube leading from the pharynx to the lungs, traversed by the air in its passage to and from the latter organs. The larynx in addition contains the organs which chiefly compose the vocal apparatus. The three divisions require separate consideration. Trachea. — This portion of the tube extends from opposite the fifth cervical to the fifth or sixth dorsal vertebra. It pursues a vertical direction from the larynx to the point last mentioned, where it ends by dividing to form the two primary bronchi. It is slightly deflected to the right at its lower extremity. It is from four to five inches in length, varying with the movements of the head and neck; and its diameter is from three-fourths of an inch to an inch in the adult male, being somewhat smaller in the female. The calibre is generally enlarged at its lower extremity, where it bifurcates. It is composed of from fifteen to twenty cartilaginous rings, with membranous interspaces. The rings, however, are not complete, forming only about four-fifths of a circle. The deficient portion of each ring is situated posteriorly, and the connecting sub- stance is membranous. The posterior one-fifth or membranous part of the tube is flattened. The anatomical constituents of the trachea in addition to the cartilages are: 1st, a membrane of white inelastic fibres, containing also longitudinal yellow elastic fibres, most abundant posteriorly, by means of which the tube resumes its normal dimensions after having been stretched or compressed; 2d, fibres constituting the trachealis muscle, which enter into the composition of the posterior flattened portion, extending from one extremity of the incomplete cartilagi- nous rings to the other, and attached, also, to the membranous in- terspaces between the rings. By the contraction of these muscular fibres the Avails of the trachea may be rendered tense, and its calibre diminished; 3d, areolar tissue, forming here, as elsewhei-e, the medium of the union of the diff'erent structures ; 4th, mucous membrane, provided with columnar, ciliated epithelium and glandular follicles, the latter being most numerous on the posterior surface, a fact which perhaps explains the greater liability of the membrane to become ulcerated in this situation. TRACHEA — BRONCHI. 47 Surrounding the trachea, especially the thoracic portion, are lymphatic vessels and numerous lymphatic glands. The latter are liable to become enlarged by disease, and compress the air-tube so as to modify the sounds produced by the current of air to and fro with the two acts of respiration, and, in some instances, give rise to obstruction sufficient to occasion results more or less serious. The anatomical construction of the trachea is such that it conforms readily to the varied movements of the head and neck, preserving in all positions a free channel through which the lungs receive the constant supply of atmospheric air necessary to the continuance of life. The trachea is rarely attacked by disease independently of other parts of the respiratory apparatus. The mucous membrane in this situation is the seat of ulcerations in a certain proportion of cases of tuberculosis of the lungs, and in typhoid fever; it is involved in inflammation proceeding from the larynx downward to the bronchial tubes; and in that peculiar form of inflammation characterizing the infantile disease called diphtheritic laryngitis or true croup, the ex- udation of lymph often extends below the larynx, sometimes descend- ing to more or less of the bronchial subdivisions. Bronchi Exterior to the Lungs. — Certain anatomical points pertaining to the size and disposition of the bronchi exterior to the lungs possess considerable importance in their supposed relations to diff"erences between the two sides of the chest, as regards the res- piratory sounds heard in health and disease, to which reference will be made hereafter. The lower part of the trachea is contained within the chest, passing behind the upper bone of the sternum, until it reaches the fifth or sixth dorsal vertebra, when it bifurcates, forming the right and left bronchus. The right bronchus diverges from the trachea in a direc- tion nearly horizontal, forming with the latter almost a right angle. Its diameter is about half an inch. It is about an inch in length. Its form and anatomical construction is like that of the trachea, being composed of from six to eight incomplete cartilaginous rings, the posterior portion being membranous and flattened. Before pene- trating the lung, which it does at a point equidistant between the apex and the base of the organ, it divides into two branches. The first or upper division is the smaller, and is connected with the upper lobe of the lung. The second, or lower branch, after passing an inch 48 ANATOMY AND PHYSIOLOGY. downward, subdivides into two unequal branches, the small one going to the middle, and the larger to the lower lobe. The left bronchus is considerably smaller than the right, the diameter being about three-eighths of an inch. Its length is about two inches, being twice as long as the right bronchus. Its direction is obliquely downward, forming with the trachea an obtuse angle. It is formed precisely like the right bronchus, embracing from nine to twelve incomplete cartilaginous rings. It subdivides to enter the lung on a level with the fifth dorsal vertebra, about an inch lower than the point where the subdivisions of the right bronchus take place. The number of branches is two, one for each lobe, the lower, being somewhat longer than the upper. In size or calibre the two bronchi united exceed the trachea, as the aggregate of the bronchial ramifications within the lungs is greater, in this respect, than that of the bronchi ; " so that the velocity of the expired air increases as it approaches the exterior."' The bronchial divisions, like the trachea, are surrounded by numer- ous lymphatic glands, called the bronchial glands, and this is the case also with the bronchial ramifications within the lungs themselves. These glands enlarged in cases of bronchitis, typhoid fever, scrofula and tuberculosis, may cause contraction of the bronchial tubes, so as to occasion certain acoustic phenomena by modifying the sonorous vibrations incident to the current of air during the respiratory acts, and may occasion obstruction, partial or complete, to the transmis- sion of air to the bronchial subdivisions and air-cells. The bronchi exterior to the lungs are the seat of inflammation in ordinary bronchitis, the inflammation frequently aff"ecting, at the same time, the air-passages, either above or below. Foreign bodies introduced through the larynx frequently become lodged in this situation, giving rise to more or less obstruction, and, if not expelled by acts of coughing, or removed by surgical means, not infrequently causing death by sufl'ocation, or from the eff'ects of protracted irri- tation. The statistical researches of Prof. Gross show that foreign bodies become lodged much oftener in the right than in the left bronchus. This may be attributable, in part, to its larger size, but, in the opinion of Prof. Gross, it is mostly due, as was first suggested by Goodall, of Dublin, to the presence of a spur, or ridge, which Prof. G. calls the bronchial septum, projecting upward within the ' Cruveilhier. LARYNX. 49 trachea at the point of its bifurcation. The septum is situated, not in the mesial plane, but to the left of it, and therefore serves to direct any substance, especially if of considerable size, into the right bronchus.^ Larynx. — The larynx is much more complex in its anatomical construction than the other divisions of the air-passages which have been already described. This is owing to the fact that, in addition to conducting air to the lungs for respiration, it contains an appara- tus for the production of the voice. To describe the several parts entering into its composition, and their respective oiEces, would in- volve details needless so far as concerns the general object of this introduction. For these the reader is referred to treatises on anat- omy and physiology. Certain anatomical and physiological points only will be noticed which are of special importance in their bearings on the study of the diseases of the respiratory apparatus, and these will be but briefly adverted to. The more important of the parts which compose the larynx are the thyroid and cricoid cartilages, the epiglottis, and the arytenoid cartilages, the latter movable and provided with several muscles. These parts are united by sev-eral ligaments, and the internal cavity is lined by mucous membrane presenting the same characters as that found in the trachea and bronchi. The thyroid and cricoid cartilages, with their ligaments, form a solid, unyielding box, affording resistance to pressure both from without and within its cavity. In this respect the larynx differs from the other portions of the air-tube ; the latter may be compressed or dilated by a moderate amount of mechanical force. This ana- tomical point is of importance with reference to certain diseases affecting the larynx. Taken in connection with the narrowness of a portion of the laryngeal canal, the resistance to pressure from within occasions obstruction, and even occlusion, as results of the swelling of the parts, morbid deposits, or abnormal growths in the interior of the larynx. It is owing to the circumstances just stated ' A Practical Treatise on Foreign Bodies in the Air-Passages, by S. D. Gross, M.D., etc. etc., 1854. This work contains deductions based on the analysis of a collection of nearly fifty cases, embracing in addition to those coming under the observation of the author and his professional friends, all that were to be gathered from medical literature. 4 50 ANATOMY A XD PHYSIOLOGY. that some diseases of the larynx involve serious embarrassment of respiration, and frequently end fatally by inducing apnoea. Exam- ples are, exudative or true croup, acute laryngitis "vvith submucous infiltration, and oedema glottidis. Other points of special importance in their pathological relations are presented when the larynx is examined internally. Viewed from above downward, the laryngeal canal may be considered as divided into three portions, viz. : 1, the superior aperture; 2, the glottis ; 3, the inferior space. Of these three portions, the first two are chiefly important. We will notice the points pertaining to these portions respectively under distinct heads. 1. Superior Aperture of the Larynx. — This embraces the trian- gular space bounded by the epiglottis in front, the vocal chords below, and laterally by mucous folds extending from the summit of the arytenoid cartilage to the epiglottis, called the aryteno-epiglottidean folds. This portion of the larynx possesses pathological relations of great importance. It is in this situation that the submucous effusion takes place in the affection known as oedema glottidis. The areolar tissue uniting the mucous membrane to the subjacent struc- ture is more loose and extensible here than in other portions of the canal. Hence the liability to serous and puruloid submucous effusions in this situation, forming tumors which, acting like a ball-valve, close the narrow orifice of the glottis with the act of inspiration, producing obstruction to respiration manifested in the inspiratory act, and unless relieved by appropriate means, often leading to fatal suffocation. The situation of these tumors is such that they are generally within reach of the finger, and their existence may therefore be determined by the touch, rendering the diagnosis of oedema glottidis^ positive. This accessibility also renders relief practicable by resorting to incisions, or scarifications with an appro- priate surgical instrument, after the method practised with success in a number of cases by Dr. Gurdon Buck,- of New York. It is an interesting fact that the loose attachmentof the mucous mem- brane at the superior aperture of the larynx, which exists in adults, does not obtain in children. In the latter the membrane is closely 1 Incorrectly called cedema glottidis, inasmucli as the oedema is situated above, not at the glottis. 2 See Transactions of the American Medical Association, Vols. I and lY. LARYNX. 51 connected with the parts beneath. Hence oedema glottidis is not a disease affecting children, but occurs only after adult age. 2. Glottis. — The portion of the larynx called the glottis, is that bounded by the cliordce vocales, or vocal chords. The anatomical conformation of this part, and the physiological acts which here take place in connection with respiration, as well as phonation, involve certain facts, not only interesting, but important in their relations to the study of disease. The vocal chords are two in number, on each side ; the upper set, formed by folds of the mucous membrane, ex- tending from the bases of the arytenoid cartilages to the anterior inner surface of the thyroid cartilage ; the lower, containing fibres of elastic tissue, extend in the same manner from the arytenoid cartilage to the front of the larynx. The upper, or superior vocal chords, are also distinguished as the false, and the inferior as the true vocal chords. Within the small space between the upper and lower vocal chords, on each side, is a depression or cavity called the ventricle of the larynx. In this cavity foreign bodies, accidentally inhaled into the larynx, are sometimes lodged. By the vocal chords the larynx is greatly narrowed at the glottis. Viewed in the dead subject, the chords diverge from the point of their junction anteriorly, to their attachment at the arytenoid cartilages, leaving a triangular interspace, called the rima or chink of the glottis. This fissure is smaller between the lower than the superior vocal chords. In an adult male subject, the antero-posterior diameter of the glottis is ten or eleven lines ; and the greatest transverse diameter, i. e. at the base of the triangle, from three to four lines, the measurements being made at the narrowest part of the glottis, viz., on a level with the lower vocal chords. In females, the size of the entire larynx is about one-third less than that of the male. At the glottis, in the female subject, the antero-posterior diameter is about eight lines, and the transverse diameter from two to three lines. Prior to the age of puberty, in the male especially, the dimensions of the glottis are less than after the remarkable development in the size of the larynx which occurs at that epoch. The small size of the aperture of the glottis, especially in children, accounts in part for the great danger attending the exudation of coagulable lymph in this situa- tion, which occurs in croup. The foregoing description relates to the glottis in the condition in which it is observed after death. During life, the condition, as respects the size and form of the space between the chords, is con- 62 ANATOMY AND PHYSIOLOGY. stantly varying in consequence of movements connected with the use of the voice, and also with the acts of respiration. In speaking and singing, the diversities in the tones of the voice are mainly due to the different degrees of approximation and tension of the chords, produced by the action of the muscles attached to the arytenoid cartilages. The movements involved in vocalization, according to the researches of Claude Bernard,' are governed by influences transmitted exclusively through the spinal accessory nerve. Pa- ralysis of the arytenoid muscles, so far as they are concerned in phonation, is the result of destroying this nerve, the respiratory movements remaining unaffected. Thus, if the nerve be destroyed in a rabbit, the breathing continues undisturbed, but the animal is unable to utter a cry Avhen hurt. This physiological discovery is in- teresting, and important with reference to the seat and character of nervous aphonia. Local affections of the larynx, involving the vocal chords, occasion modifications of the voice, which become impor- tant diagnostic symptoms. Thus in simple inflammation, as well as in croup, the voice is hoarse and may be temporarily lost ; ulcer- ation of the chords from tuberculosis, or syphilis, renders it husky and stridulous, and even the abnormal dryness incident to epidemic cholera occasions a marked effect amounting sometimes to aphonia. Similar modifications of the sound attendant on cough, are also produced by diseases affecting the glottis, which thus in the same way become diagnostic of a morbid condition seated at this division of the air-passages. The movements of the vocal chords play an important part in respiration. The concurrence of the glottis in certain occasional respiratory acts, especially coughing and sneezing, has long been known to physiologists ; but recent physiological researches have shown that with ordinary respiration an alternate separation and approximation of the vocal chords take place, accompanying the two acts, inspiration and expiration. These movements are alto- gether automatic, and continue to go on even after a large opening has been made into the trachea admitting an abundant supply of air by the artificial orifice. The size of the rima glottidis, when dilated with the act of inspiration, may become nearly double that which it has when the vocal chords are in a state of rest; but in this respect there is considerable variation with different respirations, ' Eecherches experimentales sur les fonctions du nerf spinal, ou acccssoire de Willis, parM. Claude Bernard. Paris, 1851. LARYNX. 53 the dilatation being more marked when the breathing is hurried or forced. The respiratory movements of the glottis in ordinary and forced breathing are illustrated by vivisections in inferior animals, and they may be satisfactorily observed in man by means of the laryngoscope. The variations as respects the approximation of the vocal chords with the two respiratory acts, and with different respirations, prob- ably serve to explain, in part, the differences between the sounds of inspiration and expiration emanating from within the trachea and bronchi, and the variations in the characters of sound which each act may present with different respirations, to which reference will be hereafter made under the head of Auscultation. Abnormal movements of the glottis may become important morbid events. Spasm of the muscles approximating the chords occurs as an element of inflammation of the larynx, both in croup and simple laryngitis. It occurs also as an independent affection in the so-called laryngismus stridulus of children, and occasionally in adults, inter- fering with respiration, occasioning distress in proportion to the de- gree of obstruction from the narrowing of the orifice of the glottis, and, possibly, proving fatal. The respiratory movements of the glottis are under the control of the recurrent or inferior laryngeal nerves. When these nerves are divided in vivisections, the glottis remains immovable, neither dilating nor contracting; Under these circumstances the column of air entering the larynx with inspiration forces the chords together and obstructs the orifice, causing death, which takes place more quickly if the animal be young. 3. Inferior Sjyace. — This embraces the short space below the vocal chords included within the larynx. In size, form, etc., it resembles the trachea into which it merges, and therefore does not need a separate description. 54 ANATOMY AND PHYSIOLOGY. SECTION II. TOPOGRAPHICAL DIVISIONS OF THE CHEST. For convenience of reference, especially as regards the results of physical exploration, the exterior of the chest is divided into separate spaces, called regions. These divisions, although arbitrary and con- ventional, are convenient, and the student, before entering on the study of diseases affecting the respiratory apparatus, should make himself familiar with their boundaries, and with their anatomical relations respectively to the intra-thoracic organs. To these pre- liminary points this section will be devoted. In determining the topographical divisions, the sole end being convenience, simplicity is to be consulted as much as possible. The number of regions should not be needlessly multiplied. The boun- dary lines, to be recollected and readily ascertained, should be not entirely artificial, but based, as far as practicable, on natural ana- tomical divisions ; and there is an obvious advantage in designating them by terms derived from names already assigned to the parts which they embrace. The first division is into three surfaces, viz., an anterior, a poste- rior, and two lateral surfaces. The anterior and posterior surfaces, in fact, may be said to be double, each lateral half of the chest being considered separately. For the most part it suffices to divide these surfaces into a few fractional parts. According to this plan, the anterior and posterior surfaces are divided into three parts, and designated the upper, middle, and lower thirds, of the right or left chest; and the lateral surfaces into two equal parts. This is exceedingly simple, and will often answer for reference better than more minute divisions. It is important, therefore, to bear in mind the limits of these fractional sections. They are as follows: Anterior Surface. — The upper third extends from the superior extremity of the chest to the lower margin of the second rib. The middle third embraces the space between the latter boundary and the interspaces between the fourth and fifth ribs. The loiver third is the portion of the chest below the line just mentioned. Posterior Surface. — The iipjyer third comprises the portion TOPOGRAPHICAL DIVISIONS OF THE CHEST. 55 above the spinous ridge of the scapula and a line in the same direc- tion continued to the spinal column. The middle third is the space between the lower boundary of the upper third and a transverse line intersecting the inferior angle of the scapula. The lower third is the remainder of the chest below the middle third. Lateral Surface. — This is divided into two equal portions, called the upper and the lower lateral half of the right, or the left side of the chest. Not infrequently it is desirable to refer to spaces more circum- scribed than the foregoing divisions. Hence it becomes necessary to subdivide more minutely into regions than the fractional sections already mentioned. The regional subdivisions which are generally adopted are the following : Anterior Regions. — a. Post- clavicular, or supra-clavicular. The space above the clavicle, situated over the apex of the lung. h. Clavicular. The space occupied by the clavicle, c. Infra-clavicular. Situated between the clavicle and the lower margin of the third rib. d. Mammary. Bounded above by the third, and below by the sixth rib. e. Infra-mammary. The portion of chest below the inferior boundary of the mammary region. These regions are, of course, double, i. e., existing on both sides of the chest. In addition to these, the portion of the chest ante- riorly occupied by the sternum is divided into a, the upper, and 5, the lower, sternal region. The two regions just named are separated by a line connecting the lower margins of the third ribs. The space above the sternal notch, the trachea lying beneath, is called the supra-sternal region. Posterior Regions. — a. Scapular. The space occupied by the scapula. This space is subdivided into the upper and lower scapular regions. The former embraces the portion above, and the latter that below the spinous ridge of the scapula, h. Infra-scapular. The space between a line intersecting the lower angle of the scapula, and the inferior extremity of the chest, c. Inter-scapular. The space between the posterior margin of the scapula and the spinal column. These regions are, of course, double. Lateral Regions. — a. Axillary. Extending from the highest point in the axilla to a transverse line continuous with the lower boundary of the mammary region, h. Infra- axillary. Extending from the axillary region to the lower limit of the chest. 56 ANATOMY AND PHYSIOLOGY. The relations of these regions, severally, to the organs contained within the chest, are important to be premised. Supposing the divisions to be not confined to the surface, but extended to the centre of the chest, -what anatomical parts would each section con- tain? In answering this question, so far as is practically important, we will notice the different regions, seriatim, in the following order: 1st, those situated anteriorly ; 2d, those situated posteriorly ; and 3d, those situated laterally. I. Anterior Regions. 1. Supra- or Post-clavicular, — Beneath this region lies but a small portion of lung, viz., that part of the apex which often pro- jects above the chest, rising in most persons a little higher on the right than on the left side. The space, however, is of considerable importance in the diagnosis of certain diseases. The physical signs of tubercle are sometimes early manifested in this situation, the tuberculous deposit generally taking place first at the apex of the lung. Normally, the surface in this region is more or less depressed, forming a concavity. An abnormal increase of this depression will be found to constitute one of the signs of advanced tuberculosis; and on the other hand, the space is sometimes abnormally raised, and perhaps becomes bulging, in another affection, viz., emphysema. 2. Clavicular. — The clavicle extends over the apex of the lung, and the remark just made respecting the importance of the post- clavicular region as a site for the evidences afforded, especially by percussion, of incipient tuberculous disease is here equally applicable. 3. Infra-clavicular. — This is also an important region with reference to the physical signs of tubercle. The signs of all the stages of that disease are usually to be sought for in this region. A section carried to the centre of the chest, embracing the limits of the region, would contain an important portion of the upper lobe of the lung. The primary bronchi, after the bifurcation of the trachea, situated exterior to the pulmonary substance, are also contained in this section. The bifurcation takes place on a level with the second rib. From this point the bronchi on the two sides diverge, pursuing directions somewhat different, as already described, the right being situated beneath, and the left a little below, the costal cartilage of the second rib. The presence of the bronchi gives rise to certain modifications of the sound produced by respiration, in health, as well as disease, in this region; and owing to anatomical differences ANTERIOR REGIONS. 57 in the two primary bronchi, which have been noticed in Section I, it will be seen hereafter that a natural disparity between the two sides exists as respects these modifications of respiratory sound. Normally the infra-clavicular region is in most persons slightly convex, different persons differing considerably in this particular. This convexity abnormally increased becomes a sign of emphysema, and an abnormal depression or flattening in this situation frequently attends tuberculosis of the lungs. 4. Mammary, — Some important points pertaining to the anatomy of the intra-thoracic organs, have relation to the space occupied by this region. As respects the organs lying beneath, the two sides diflFer. A considerable portion of the heart is situated in the left side within its limits, viz., the left ventricle, and auricle, and a por- tion of the right ventricle. The site of the heart is often distin- guished as a separate region, called the cardiac, or the prsecordia. Over a quadrangular space extending from the sternum into the left mammary region, the heart is in contact with the walls of the chest. This space lies between the fourth and sixth ribs. The limits of the heart beyond this space are to be taken into account in physical exploration. They extend vertically from the upper to the lower boundary of the left mammary region, ^. e., from the third to the sixth ribs, and transversely in the line of the fourth rib nearly to the nipple. The presence of the heart, as will be seen hereafter, occasions' important modifications of the phenomena determined by percussion and auscultation, and disturbs that equality between the right and left mammary region, as respects the physical signs inci- dent to health, which generally characterizes corresponding locali- ties on the two sides. The disparity just referred to is of practical importance in its bearing on physical diagnosis. Appreciating its degree and extent prevents attributing to changes produced by disease, phenomena which are entirely normal ; and on the other hand, a morbid condition may occasion a notable diminution in the normal disparity. The latter obtains in cases of emphysema, in which the over-distended lung covers the heart entirely, and some- times crowding it from its natural situation occupies its place in the prgecordia. The impulse produced by the striking of the heart's apex against the walls of the chest falls within the left mammary region from a half inch to an inch and a half within a vertical line passing through the nipple ; this line is called the linea mammalis. Normally the impulse is seen and felt between the fifth and sixth 58 ANATOMY AND PHYSIOLOGY. ribs. The situation of this point of apex-impulse is important in connection with diseases affecting the respiratory apparatus as well as the heart. In certain pulmonary affections the heart is displaced. It is carried in some cases of chronic pleuritis to the right of the sternum, and the impulse may be felt in the right mammary, or infra-clavicular region. This transference of the heart's impulse to other situations thus becomes an important diagnostic sign of pul- monary disease. Absence of the impulse in the normal position, without its being appreciable elsewhere, may also be a valuable sign of pulmonary disease. The lines corresponding to the fissures dividing anteriorly the lobes of the lungs fall within the mammary regions. The relations of these lines to the exterior of the chest are important to be borne in mind. On the left side the interlobar fissure commences at a point a little below the nipple, between the fourth and fifth ribs, and from this point it runs obliquely upward and outward to the axillary region. On the right side the fissure dividing the upper and middle lobes commences at the fourth costal cartilage, and pursues a course obliquely upward and outward for a distance, varying in difi'erent persons. The fissure between the middle and lower lobes commences a short distance below, and extends in a similar direction. The por- tion of the lower lobe situated anteriorly below the middle lobe, is quite small, as has been already seen, and sometimes the whole of this lobe is contained in the lateral and posterior regions of the chest. A small part of the heart is contained beneath the right mam- mary region, viz., portions of the right auricle and ventricle. On the right side, the convexity of the diaphragm rises into the mammary region as high as the fourth rib. On the left side, the point to which it extends is a little lower. This fact may account for certain modifications of phenomena developed by physical ex- ploration. The presence of the mammary gland in the female, and in some instances a large development of the pectoral muscle in the male, are found to interfere, to some extent, with physical exploration in this region. 5. Infra-mammary. — This region, like the preceding, has rela- tions, on the two sides, to different organs. On the right side, extending upward, nearly or quite to the superior boundary, i. e., to the sixth rib, is the liver, covered with the diaphragm. The phenomena determined by physical exploration in health, are quite POSTERIOR REGIONS. 59 different from those in other regions including pulmonary substance. These phenomena are sometimes attributed to disease bj those who overlook the fact that, owing to the presence of the liver, they are normal in this situation. On the left side, this region embraces the anterior portion of the lower lobe of the lung together with portions of the stomach, spleen, and left lobe of the liver, but the relative proportion of the latter parts lying within the limits of the region varies considerably in different individuals, and still more at different times in the same person. This is owing to the fact that the size of the three organs mentioned is far from uniform in health, and this is true more especially of the stomach. Greater or less distension of the stomach wath gas, occasions marked diversities in the phe- nomena determined by physical exploration of the left infra-mam- mary region. Enlargement and atrophy of the liver and spleen, also occasion modifications of these phenomena. In this region, the intercostal depressions, if visible anywhere, are usually more or less marked. The signs of disease which pertain to these depressions are, therefore, to be sought for in this portion of the chest. The evidences of the presence of liquid effusion within the pleural sac, are presented especially in the infra-mammary region. 6. Supra-sternal. — No portion of the substance of the lungs lies beneath the small space occupied by this region, but the whole of the space is filled by the trachea. In this space, examination is made in studying the phenomena of the tracheal respiration. 7. Upper Sternal. — Beneath the ujDper portion of the sternum, at the centre of a line connecting the second ribs, the bifurcation of the trachea takes place. Below this point, the lungs on the two sides are nearly in contact at the mesial line, covering the primary bronchi. 8. Lower Sternal. — This part of the sternum covers a portion of the heart, viz., a large share of the right, and a little of the left ventricle. The liver encroaches somewhat on this region, and also the stomach when distended. Situated above the heart, a small portion of the left lung is contained within its limits, and to the right of the mesial line a larger portion of the lung on that side. II. Posterior Regions. 1. Scapular. — The scapula is situated over the posterior portion of the upper pulmonary lobe, covering also a portion of the upper part of the lower lobe, no other important parts lying beneath it. 60 ANATOMY AND PHYSIOLOGY. This region is subdivided into the upper and lower scapular; the former situated above, and the latter below the spinous ridge. At the upper part of the lower scapular region, terminates the fissure separating the upper and lower lobes of the lungs. From this point of termination, the interlobar fissure pursues an oblique direction downward, passing through the lower axillary and mam- mary regions to the fifth interspace on the right side, and to the space between the fourth and fifth ribs on the left side. A diagonal line drawn between the two points just mentioned, will mark the situation of the division between the lobes, a matter of interest and importance in the diagnosis of lobar pneumonitis, or inflammation of the substance of the lungs extending over a lobe. 2. Infra-scapular. — Pulmonary substance occupies the space within the chest corresponding to this region, on the right side above a transverse line drawn from the eleventh rib. The liver rises to this line. On the left side the lower part of the region contains a portion of the spleen. The lower lobe on the left, and the lower and middle lobes on the right side, fill the whole of this region above the diaphragm, and also a portion of the scapular region. In cases of inflammation a fleeting (as is usual) the lower lobe in the adult (lobar pneumo- nitis), the physical evidences of disease are here presented, and are to be sought for posteriorly, not in front, a small portion only of the lower lobe, as already stated, extending to the anterior part of the chest. 3. Inter-scapular Region. — In addition to the substance of the lungs on both sides, the trachea descends into this region, and bifur- cates. The point of bifurcation, as already stated, is at the fourth dorsal vertebra. From this point the two primary bronchi diverge, running across the region obliquely downward and outward, the direction on the two sides being somewhat different, as described in Section I. It is in this region behind, and in the infra-clavicular region near the sternum, in front, that examinations are made for the respiratory sounds developed within the primary bronchi, a matter of interest and importance, as will be seen hereafter. III. Lateral Regions. 1. Axillary. — A section corresponding to the boundaries of this region Avould contain a portion of the upper lobe of the lungs, with large bronchial tubes. LATERAL REGIONS. • 61 2. Infra-axillary. — A section here would embrace, in addition to lung substance on both sides, a portion of the spleen and stomach on the left side, and on the right side the upper part of the liver. The liver rises on a vertical line in the middle of the axillary space, or the linea axillaris, as high as the eighth rib. The topographical divisions of the chest have been described in this section, and the relations of the several regions to the organs lying beneath, stated briefly, but comprehensively enough to prepare the student to enter on the study of physical exploration. The details that have been presented are in themselves dry and uninter- esting: nevertheless, they should not only be read and compre- hended, but dwelt upon until they become perfectly familiar, as a preparatory step to the subjects which are to follow. In order to obtain a clearer knowledge of the regions, and that the mind may become so familiarized with them as to refer to them, and their important anatomical relations, with readiness, it will be found to be a useful exercise to practise mapping them out either on the patient or on the cadaver. By marking with ink or black paint the boundary lines of the different divisions, their situations, etc., will very soon become firmly impressed on the memory, and much more satisfactorily and usefully illustrated, than by means of pic- tures or diagrams. I ll PART I. PHYSICAL EXPLORATION OF THE CHEST. I PART 1. PHYSICAL EXPLORATION OF THE CHEST. CHAPTER I. DEFINITIONS— DIFFERENT METHODS OF EXPLORATION— SOURCES OF THE DISTINCTIVE CHARACTERS OF DIF- FERENT SOUNDS— GENERAL REMARKS. Physical exploration of the chest is the examination of this por- tion of the body by means of certain methods involving principles of physical science, with a view to determine the existence or non- existence, the nature, situation and progress of intra-thoracic disease. Limiting attention to the respiratory organs, various abnormal phy- sical conditions are incident to the different affections to which they are liable. Among these abnormal physical conditions are solidifi- cation, greater or less in degree and extent, of the pulmonary organs, displacement and condensation of these organs from the accumulation of liquid or air in the pleural cavity, the existence of pulmonary cavities, the presence of mucus, serum, pus or blood in the air-pas- sages, dilatation of the air-cells and bronchial tubes, etc. Owing to the conformation of the chest, the elasticity of its walls, the move- ments which they undergo, and the structure of the contained organs, air being constantly present, and in motion to and fro with the acts of respiration, these abnormal physical conditions are represented by certain phenomena appreciable by the senses, and these phenomena are distinguished as the 'physical signs of disease. The discrimination of diseases, so far as these signs are concerned, constitutes physical diagnosis. The following are the different methods of physical exploration : 1. Striking the chest with the finger, or an artificial instrument, in order to determine deviations from the sounds elicited by this process in health. This method is called percussion. 5 66 PHYSICAL EXPLORATION OF THE CHEST. 2. Listening, with the ear applied directly to the chest, or through a conducting instrument, to discover morhid sounds produced by the movements of the air in respiration, or by the acts of speaking and couffhinji. This method is called auscultation. 3. Examining the chest with the eye, to see if there be deviations in form or symmetry, and if the visible motions be unnatural. This method is called inspection. 4. Applying the hand to the chest, to ascertain whether abnormal sensations are appreciable by touch, due to the movements of respira- tion, and more especially the act of speaking. This method is called falpation. 5. Measuring the chest, or parts of the chest, by means of a tape, or graduated measure, and other instruments, to obtain accurate information of alterations in size and mobility. This method is called mensuration. 6. Shaking the body to develope sounds produced when liquid and air are contained in a cavity, which occurs, occasionally, as the result of disease. This method is called succussion. The phenomena resulting from the six methods of examination just enumerated, are called physical signs, in distinction from the ordi- nary symptoms of disease, and the latter are sometimes called rational or vital symptoms. The words signs and symptoms, are often used without any adjective, the first to denote the physical and the second the vital phenomena of disease. It is convenient thus to employ these terms, and there can be no objection to attaching to each the distinctive sense just mentioned, in conformity with conven- tional usage. The branch of physical science especially involved in the practice of physical exploration, is that which treats of the phenomena and laws of sound, viz., acoustics. An adequate knowledge of physical signs, however, requires only an acquaintance with acoustic principles sufficiently obvious, and with which almost every one is familiar. Although it may be true that a thorough acquaintance with the science of acoustics will qualify one to understand more fully and to investigate with greater success the signs based on the facts of that science, this is not necessary in order to comprehend and apply, sufficiently for all practical purposes, the rules of physical diagnosis. It is important, however, before entering on the study of the signs which are obtained by the two first named methods of exploration, viz., percussion and auscultation, to have a clear apprehension of DEFINITIONS. 67 the obvious sources whence are derived the distinctive characters of different sounds ; in other words, to understand clearly how different sounds are distinguished from each other. Sounds differ as regards intensity, pitch and quality. The discrimination of different sounds involves mainly distinctive characters derived from these three sources of difference, and, more especially, characters derived from differences relating to pitch and quality. Intensity denotes quantity of sound. A sound differs from another sound in simply being louder. Differences in pitch are expressed commonly by the terms, high and low, or acute and grave. Varia- tions in the pitch of different musical notes are readily appreciated ; but obvious differences, in this respect, obtain among sounds which are not musical notes. It will be seen hereafter that the most dis- tinctive of the differential characters .of many of the signs obtained by percussion and auscultation, are derived from differences in pitch. Attention to variations in pitch as a means of discriminating the signs which are sounds, has heretofore been too little considered. The term quality or timbre, applied to a sound, denotes a peculiar character which is independent of either intensity or pitch. The sound of any familiar musical instrument is at once recognized, although the instrument be not seen. Every one would recognize the sound of a violin, for example, were the performer in another room. The recognition, it is plain, does not depend on the loudness of the notes, nor on the pitch, for it makes no difference whether the notes be high or low ; the sound is recognized because its quality is peculiar, arising from the particular construction of that instrument. The peculiar quality of any sound can only be known by becoming practically familiar with it ; no verbal description would suffice to give a correct idea of the peculiar sound from a musical instrument, to one who had never heard it. The only way in which an approach can be made to a correct idea of the quality of a particular sound, without hearing the sound, is by means of a comparison with some other sound to which it bears a resemblance. Differences, as regards quality, among sounds, are numberless. This fact may be illus- trated by reference to the human voice in speaking. Almost every one has a peculiar quality of voice, so that a familiar friend, whose voice is well known, is at once recognized when the voice is heard. The voices of different persons show almost as many shades of varia- tion as the expression of the face. It conduces to simplicity to resolve the characters derived from 68 PHYSICAL EXPLORATION OF THE CHEST. quality of sound into as few as will suffice for the discrimination of signs. The following are names denoting the differences, in this point of view, of the sounds obtained by percussion and auscultation: vesicular, tympanitic, vesiculo-tympanitic, blowing or hollow, tubu- lar, vesiculo-tubular, crackling, bubbling, musical or amphoric, rub- bing, grating, etc. Other sources of differences among sounds relate to dryness or moisture, nearness or distance, duration, etc. Distinctive characters, however, derived from intensity, pitch, and quality, are especially involved in the discrimination of the most important of the physical signs perceived by the sense of hearing. The physical signs of disease represent abnormal physical condi- tions within the chest. Thus, certain signs represent a greater or less degree of solidification, other signs represent pulmonary cavities, others liquid in the pleural cavity or in the air-passages, etc. It is not true, however, as is sometimes supposed by those who have not given attention to physical exploration, that the different signs respectively represent different diseases; in other words, that each disease has its own special signs. The signs offer definite information of the existence of certain abnormal physical conditions; but many of these conditions are common to a greater or less number of dis- eases. The term rational, as applied to symptoms in distinction from signs, would seem to imply that the perceptive faculties only are involved in the application of the latter to diagnosis. The in- ference is, that to determine the value of signs, processes of reasoning are not required: that the signs express in themselves their full im- port, and that the ability to discriminate different diseases thereby depends mainly on manual tact and the cultivation of the senses. The student should, as soon as possible, dispossess the mind of this error. Few signs, individually, are pathognomonic. Their diag- nostic signification depends on their combination with other signs, and on their connection with symptoms. Hence, something more than delicacy of hearing and skilful manipulation is requisite. Thought and the exercise of judgment are needed, not less than in determining the nature and seat of diseases by their vital phe- nomena. In short, physical exploration develops a series of facts which are to be made the' subjects of ratiocination in their applica- tion to diagnosis, as much as facts obtained by other methods. To be convinced of the great benefit which practical medicine has derived from the introduction of physical methods of exploration, it GENERAL REMARKS. 69 is only necessary to contrast the facility of discriminating the most common pulmonary affections at the present time, with the difficulty which confessedly existed prior to the employment of these methods. If the reader will turn to the works of Cullen, or the more recent writings of Good, he will find that these authors acknowledge the in- ability of the practitioner often to distinguish, by means of symp- toms, pneumonitis, pleuritis, and bronchitis from each other, so that for practical purposes it was deemed sufficient to consider these three affections as one disease. At the present time, with the aid of signs, it is very rarely the case that the discrimination cannot be made easily. And that this improvement is mainly due to physical exploration, is shown by the fact, that to distinguish these affections by means of symptoms alone, is still nearly as difficult as heretofore. But to realize the importance of the subject it is not necessary to institute a comparison of the present with the past. It is sufficient to refer to the mistakes in diagnosis daily made by practitioners who rely exclusively on symptoms, which might be easily avoided by resorting to physical signs. Examples of confounding the three affections just named are sufficiently common. Of these affections, pneumonitis and pleuritis are not unfrequently latent, as far as dis- tinctive vital phenomena are concerned, and consequently are over- looked. Chronic pleuritis is habitually mistaken for other affections by those who do not employ physical exploration. Of a considerable number of cases, the histories of which I have collected, in a large proportion the nature and seat of the disease had not been ascer- tained.^ Yet nothing is more simple than to determine the exist- tence of this affection by an exploration of the chest. Acute pleu- ritis and pneumonitis are sometimes completely masked by the symptoms of other associated affections, and thus escape detection. This is observed in fevers, and when head symptoms become de- veloped, especially in children. Under these circumstances, the practitioner who avails himself of physical signs is alone able to arrive at a positive conclusion as to their existence. Emphysema is an af- fection which cannot be recognized by symptoms alone, and hence, they who neglect signs have no practical knowledge of it. Acute tuberculosis I have known repeatedly to be called typhoid fever ; on the other hand, I could adduce numerous examples of different affec- tions erroneously considered to be phthisis, and a still greater num- * Vide Clinical Keport on Chronic Pleurisy, hy the author. 70 PHYSICAL EXPLORATION OF THE CHEST. ber of instances in -which patients with this affection were incorrectly supposed to be affected with some other disease than tuberculosis. Were we to dwell upon these, and other mistakes which might be added, it would be easy to show that they are unfortunate, not merely in a scientific point of view, but with reference to practical consequences involving the welfare, and it may be the lives of patients. The physical exploration of the chest has certain striking advan- tages which may be briefly noticed. The phenomena thus developed are entirely objective. They have no connection with the mind of the patient. They are therefore free from the difiiculties and liabili- ties to error arising from ignorance, deception, self-delusion, dispo- sition to exaggeration, or desire of concealment, which belong to subjective symptoms. They are available in children too young to give information respecting their diseases; in cases of mental de- rangement, and in the condition of coma. The evidence which they afford of morbid conditions is more positive than that furnished by symptoms. Frequently in attempting to arrive at a diagnosis by means of the latter, we can only reach an approximation to cer- tainty. In forming conclusions Ave are obliged to balance proba- bilities. This uncertainty, of course, influences the managerpent of disease. But the information obtained by the aid of signs is often so complete and precise, as to leave nothing more to be desired. The proof of the existence of certain affections is exact and de- monstrative, leaving no room for hesitation. Physical signs are more readily and quickly available than symptoms. Diagnosis is thus more prompt, as well as more positive. Hence, diseases are recognized at an earlier period, — a point often of very great conse- quence as regards successful treatment. Their value is frequently as conspicuous negatively as positively ; that is, deductions from their absence are as important and decisive as from their presence. Finally, in view of the considerations just presented, this branch of practical medicine affords to the practitioner a sense of gratifica- tion greater than that which he derives from clinical investigations by means of symptoms. By thus directing attention to some of the points of contrast be- tween symptoms and signs, it is not to be concluded that these two classes of phenomena hold conflicting relations in the practice of medicine. Neither is to be employed in diagnosis to the exclusion of the other. They are not to be disconnected save for abstract con- GENERAL REMARKS. 71' sideration. They are always to be brought to bear conjointly in clinical investigations ; combined, they lead to conclusions which neither may be competent to establish alone. They mutually serve to correct or confirm deductions drawn from either separately. It is never to be lost sight of in the study or practice of physical ex- ploration, that to devote too exclusive attention to signs is as much a fault as to ignore their value, and rely entirely on symptoms. Notwithstanding these advantages, and the importance of physical exploration in the diagnosis of diseases affecting the respiratory ap- paratus, it is still employed by only a small proportion of medical practitioners. Some even now profess to attach but little value to signs ; a much larger number practically repudiate them. This fact, however, may be stated, viz., no one who has devoted sufficient atten- tion to the subject to apply successfully the well-established rules of physical diagnosis at the bedside, has ever denied having received great assistance therefrom, or advocated a neglect of them. They who depreciate and forego the benefits of physical methods of exami- nation have had little or no experience of their practical application. If the foregoing assertion be true, the explanation of the fact that this branch of practical medicine is properly estimated and cultivated by so few, is to be sought for in causes discouraging the pursuit, or in difficulties attending it which are not easily surmounted. Such causes and apparent difficulties exist. It is a common impression that it is useless to attempt to accomplish anything satisfactory in physical exploration unless the sense of hearing be singularly apt to distinguish nice shades of difierence in sounds ; and, in addition to this, extraordinary application and opportunities are supposed to be indispensable. These ideas do great injustice to the subject. So far as the more important diagnostic principles are concerned, both in their apprehension and application, they are exceedingly simple. The points which are abstruse or intricate, as a general remark, are those which are of the least practical consequence. Oral instruc- tion by an expert, with explanations and illustrations at the bedside, are undoubtedly of very great use, as well as the selection of cases which a large hospital affords. But these advantages, although highly desirable, are not absolutely essential ; and it is possible for an intelligent student or practitioner, solely with the aid of books, and opportunities for observation which may be enjoyed every- where, to acquire a practical knowledge of physical signs sufficient b 72 PHYSICAL EXPLORATION OF THE CHEST. for ordinary purposes of diagnosis.^ A tithe of the time so often occupied by medical students in becoming very indifferent performers on some musical instrument Avould more than answer to make them adepts in the practice of physical exploration. Acuteness of the sense of hearing, and an ear for music, are doubtless useful qualifi- cations ; but the sounds to be recognized and distinguished from each other are generally easily discriminated, and I have known tolerably good auscultators who were not only unable to appreciate musical notes, but who labored under some degree of deafness. In treating of physical signs, they are to be considered under three aspects. The first aspect relates to the distinctive characters of the physical signs, respectively, as the means by which they are to be recognized and discriminated. The sources of the distinctive characters of the signs obtained by percussion and auscultation, as has been seen, are mainly differences with respect to intensity, pitch, and quality of sound. The first step in the study of physical explo- ration is to learn to distinguish practically the different signs by means of their distinctive characters. It is not sufficient to have a general indefinite knowledge of the signs ; they must be thoroughly known, and this knowledge can only be acquired by analyzing those signs which are sounds, with reference especially to intensity, pitch, and quality. The characters of the signs must be verified, and the signs made familiar by practical illustrations, or, in other words, by direct observation ; and with reference to a practical knowledge of the signs, examinations of the healthy chest are to be premised. The results of examinations of the healthy chest constitute, of course, the point of departure for determining the characters of the signs of disease ; and by these examinations are determined the variations which exist irrespective of disease, i. e., within the limits of health. The second aspect relates to the significance and value of the signs separately and in combination. What are the abnormal con- ditions which they represent ? In a practical treatise, the facts embraced in this view of the subject are of paramount importance. How are these facts ascertained ? in other words, in what manner is 1 I would not be understood, by these remarks, to undervalue the importance of a master's instruction ; but for the encouragement of those who may not be able to avail themselves of this advantage, in connection with hospital opportu- nities, I desire to express the conviction that, without them, a proficiency suffi- cient for discrimination, in a large proportion of the cases occurring in medical practice, is attainable. GENERAL REMARKS. 73 our knowledge of signs, as the representatives of morbid physical conditions, obtained ? Physical phenomena become signs of the mor- bid changes incident to disease whenever it is established that there exists a constancy of association of these phenomena with the phy- iical changes which disease induces. Being uniformly found together, a connection between the two is logically proved, and the former may be regarded as representing the latter. This is the basis of the science of physical exploration. And this constancy of association is determined by clinical observation together with the information derived from post-mortem examinations. Certain physical phe- nomena observed during life are found uniformly present in cases in which dissection reveals certain morbid changes. Hence, whenever particular phenomena are recognized, we are authorized to infer the existence of corresponding morbid conditions ; the phenomena in this way become signs, and, conversely, w^henever certain morbid conditions exist prior to death, we may expect the physical phe- nomena, or signs, which previous observation has shown to coexist with them. In short, the evidence of the value and significance of signs rests on experience. This is a fact not to be lost sight of in the study of physical diagnosis, and especially in the endeavor to contribute additions to our knowledge of the subject. Much as has been already accomplished, there is ample scope for further re- searches in this direction. Many questions of practical interest and importance are open for investigation by means of the analysis of recorded observations in the living and dead subject. The applica- tion of the numerical method to the study of physical signs is far from having been completed. A third aspect under which physical signs are to be considered is the mechanism of their production. This is the theoretical part of the subject, and is to be pursued with great circumspection. The endeavor to account for the results of physical exploration opens a wide range for speculation. A priori conclusions as to the phe- nomena which ought to accompany certain physical changes are not admissible except as temporary hypotheses to be tested. by the results of clinical and post-mortem observations. Experiments made on the dead subject, and artificial contrivances, in order to imitate the sounds which characterize certain signs, or to prove the correctness of hypothetical explanations, are to be received with a certain amount of distrust, for it is almost impossible to ascertain and re- produce all the physical elements which are combined in the living 74 PUYSICAL EXPLORATION OF THE CHEST. « body. There is reason to believe that this attempt has given rise to false views, to which reference will be made hereafter. Desirable as it undoubtedly is to understand as fully as possible the rationale of physical signs, their importance and availability in diagnosis by no means depend on the attainment of this end. Several of the signs will aiford illustrations of the truth of this remark ; its correctness, indeed, is implied in the fact already stated, viz., that our positive knowledge of the significance and value of signs is based on ex- perience. In entering on the study of physical exploration the first object should be to become acquainted with the ascertained facts pertaining to the subject. It is sometimes advised that the student should at once commence clinical observation without previous acquaintance with the knowledge which has been acquired. This is to place him in the position of the original explorers, without, it may be pre- sumed in most instances, their genius and industry. Progress in this way must be slow, and unsatisfactory, compared with that which may be made by availing oneself at the outset of the labors of others. The facts which have been ascertained are to be understood by re- sorting to oral instruction or books, and as fast as practicable they are to be verified by actual observation. The signs developed by the different methods of exploration are to be studied singly and com- bined. Isolated from the others, the knowledge pertaining to each has relation to its distinctive characters, its significance and diag- nostic value, and the probable explanation of the mode of its pro- duction. It is, however, as already intimated, very rarely the case that the diagnosis rests on a single sign. Various signs are generally associated, and it is by their combination that we are enabled to ar- rive at positive conclusions as to the nature, seat, or stage of dis- eases. Were it necessary to rely exclusively on the special signifi- cance of individual signs, the application of physical exploration to diagnosis would be much more limited than it is. Its scope is greatly enlarged by uniting the information derived from the different methods of examination. Moreover, in determining the existence of individual signs, our observations are rendered positive, or other- wise, by reference to their combinations. The mutual relations, there- fore, of the different signs constitute a highly important branch of the subject. Separately, the signs may be compared to the words which compose a language ; the laws of their combinations are an- alogous to syntax. A knowledge of both is necessary in order to interpret correctly the physical expression of disease. GENERAL REMARKS. 75 For the successful practice of physical exploration the facts per- taining thereto must not only be understood, but they must be at command, so as to be readily available. The practitioner must be qualified to appreciate characteristic sounds, and determine the value of their combinations, without waiting to refer to authorities, or even for deliberate meditation. The signs must be made as familiar as household words. This is to be attained by practice, and preserved by constant exercise. Every one accustomed to practise physical ex- ploration, must have noticed that after an intermission in its employ- ment for some time, the usual facility and quickness in arriving at satisfactory results are temporarily somewhat impaired. For this reason, were there none other, the habit of daily examining the chest, to a greater or less extent, in all cases, is to be recommended. In treating of the principles and practice of physical exploration in the following pages, the aim will be to present facts and consid- erations which have direct practical bearings on diagnosis. Inquiries purely theoretical or relating remotely to the discrimination of dis- eases, and discussions of mooted points, will receive but little atten- tion. Such inquiries and discussions, for the most part, have refer- ence to the mechanism by which the phenomena detected by the different methods of exploration are produced. To this department of the subject I shall devote, relatively, but a small space, in part from a conviction that the advantage of the reader will thereby be consulted, and, it is but candor to add, in part, because my own studies have been chiefly confined to clinical observations. CHAPTER II. PEKCUSSION. Exploration by percussion consists in striking the chest so as to induce sonorous vibrations. In consequence of the elasticity of the thoracic walls, and the presence of air in the pulmonary cells, a cer- tain degree and kind of sonorousness are produced when strokes are made in a manner to elicit sound; and various changes as regards the physical conditions incident to disease, occasion corresponding devi- ations from the type of sonorousness pertaining to a healthy state. Percussion may be practised in different modes. As first introduced by Auenbrugger, in 1761, the blows were applied directly to the chest, without any intervening medium. This is called immediate percussion. Shortly after the naore recent discoveries by Laennec, which served at once vastly to enhance the importance of the method of exploration under present consideration, mediate percussion, as it is termed, was employed by Piorry, of Paris, and has since been generally adopted. In mediate percussion the blows are made on an intervening solid medium, applied to the chest, and styled & plex- imeter. The pleximeter used by Piorry is a thin oval disk of polished ivory, about two inches in length, and an inch in its greatest width, with an upright border at both extremities projecting about half an inch. These projections serve as handles by which the instrument is adjusted, and held in contact with the thoracic walls. On one side a scale for measurement is sometimes marked in black lines, which is useful in determining accurately spaces and distances on the chest. The pleximeter which I have used for several years has the form of Piorry's instrument, but is made of hard india-rub- ber. The auricles should be roughened on the outer surface, and sufficiently large for the instrument to be conveniently held. As it is desirable to avoid as much as possible noise from the plex- imeter in practising percussion, an improvement is to cover the upper surface with a thin layer of soft india-rubber or wash-leather. A PERCUSSION. 77 square block of india-rubber answers tolerably well as a pleximeter; but tbe resonance elicited by percussion upon it is much less than when a pleximeter of ivory or hard rubber is used. Many, however, if not most practitioners who practise physical exploration, use, for the most part, simply the first or second finger of the left hand, the palmar surface being applied, in a transverse direction to the chest. The finger, as a pleximeter, is superior, in many respects, to any artificial instrument. In size and form it is well adapted to be ap- plied over the ribs, and in the intercostal spaces. The force with which it is applied can be easily graduated. It renders the oper- ation of percussion less formidable to the patient, and in cases of children especially, this is not a small advantage. It affords infor- mation as respects the sense of resistance, which it will be seen pres- ently is a point of considerable importance. Finally, among minor recommendations, it costs nothing, and in the most literal sense is always at hand. The only disadvantage attending it is the liability to suffer injury if in constant use. This I have found, at times, a serious impediment. The dorsal surface is apt to become tender, swollen, and in fact, periostitis may be induced by the repeated blows, continued daily, especially when forcible percussion is prac- tised with a view to clinical illustrations. Other pleximeters than the finger obviate the difficulty just mentioned, but aside from this advantage it may be doubted if, for ordinary purposes, there are any reasons why they may not be dispensed with, at least in private practice. In hospital or dispensary practice, owing to the number of patients to be examined, an artificial instrument may be requisite. Percussion may be made by one or more of the fingers of the right hand, or with some kind of hammer constructed for that pur- pose. The latter is termed a jjercussor. A variety of instruments for making percussion have been contrived. The percussor which I have used for several years, consists of a hammer composed of india- rubber in the form of a double cone. This is firmly fixed, at the centre, in a metallic ring, which is attached to a handle of convenient size and length. This instrument produces as little noise as possible, exclusive of the resonance coming from within the chest, and it seems to me to leave nothing to be desired as regards weight, form, and durability. Most practitioners, however, are satisfied with one or more of the fingers of the right hand, bent in a half circle ; and percussion thus made answers all practical purposes. The mode of performing percussion is a point of practical impor- 78 PHYSICAL EXPLORATION OF THE CHEST. tancc. It is not at once an easy matter to strike so as to produce in the most satisfactory manner sonorous vibrations. Certain rules are to be observed, and tact is to be acquired by practice. Tlie fingers are to be flexed so that their ends shall fall perpendicularly on the pleximeter, and the strokes are not to be made with the pulpy portion of their extremities. The blows should be given with a certain quickness, the fingers brought into contact with the plex- imeter and withdrawn as it were instantaneously, by a movement limited almost entirely to the wrist-joint. When a light percussion is desired, the index or middle finger alone may be employed, but when greater force is requisite, two or three fingers should be used conjointly. In the latter case, it is better to percuss with the fingers on a line, without bringing forward the thumb into appo- sition. With the thumb free, the movements at the wrist are un- restrained, and the fingers do not need any additional support. The type of perfect percussion is witnessed in musical performances on a series of bells representing the different notes of the gamut. It is also seen in the manner in which the little hammers strike and rebound from the strings of a piano-forte when the keys are touched. The object in these examples is precisely the same as in percussing the chest, viz., to elicit sounds as distinct and pure as possible, and they may therefore be taken as models for imitation. It is generally easy to know at a glance, by the mode in which percussion is made, whether it be resorted to in order to develop physical signs with the import of which the practitioner is practi- cally familiar, or whether it be employed merely for form's sake, or to affect an acquaintance with the subject. Rules of manipulation, pertaining to the practice of percussion, in addition to the fore- going, will be given presently. ■ A mode of practising percussion, involving, for certain purposes, an important improvement, was proposed some time since, by Dr. G. P. Cammann,^ and Prof. A. Clark, of New York. The pecu- liarity of this mode consists in combining with percussion another of the methods of exploration, viz., auscultation. Percussion is made while the ear is applied to a cylinder of wood, or stethoscope, placed in contact with the chest. This is distinguished as auscul- tatory percussion. Its advantages consist in the better transmission of sounds than when they are communicated through the atmosphere, 1 New York .Journal of Medicine, July, 1840. PERCUSSION IN HEALTH. 79 and in the greater distinctness with which differences in pitch and quality are appreciated. It is particularly useful in determining the boundaries of the solid organs, other than the lungs, which encroach on the thoracic space, viz., the heart, liver, and spleen. Auscultatory percussion, however, is rarely resorted to, because, for ordinary purposes, the other and simpler mode suffices. In some instances, for example, when it is desirable to ascertain with exactitude the space occupied by the heart, it may be employed with advantage. In treating of the results of percussion we are to consider, firsts the phenomena pertaining to health; and, second, the physical signs of disease. Percussion in Health. Percussion made on the chest of a person in health, develops a resonance which is peculiar. The quality of sound is highly char- acteristic, and cannot be described nor illustrated by comparison. This quality, or timbre, is due to the fact that the air within the chest is contained in an immense number of minute spaces — the air- vesicles. The sonorousness denotes the presence of air, and the contrast, in this respect, is readily shown by percussing first the chest, and next a portion of the body composed of a solid mass of bone and muscle, for example the thigh. The peculiar quality of sound is appreciated by percussing successively the chest and ab- domen, provided the stomach or intestines be somewhat flatulent. In the latter situation the sonorousness arises from the presence of gas in a free space of considerable size, and in distinction from that due to the presence of air in the lungs, it is called tympanitic reso- nmice. This kind of resonance becomes, as will be seen hereafter, under certain circumstances, a physical sign of disease. Its type, as the name implies, is the sound produced by percussing the ab- domen when tympanitic. On the other hand, the sound peculiar to the chest is distinguished as the pulmonary or vesicular resonance. The term vesicular is preferable, and I shall therefore employ it. In using the term, however, it is not to be understood that the char- acter of sound would suggest a priori the existence of air-vesicles, but its appropriateness is based on the fact that the distinctive quality of the resonance is attributable to the presence of air in the air-vesicles. In addition to its peculiar quality, the vesicular reso- 80 PHYSICAL EXPLORATION OF THE CHEST. nance has a certain pitch, and in this respect, compared with all the abnormal sounds, it is low or grave. The sound also has a certain degree of intensity. As regards the normal resonance in the three aspects just men- tioned, viz., vesicular quality, pitch, and intensity, it is not identi- cal when percussion is practised in the same manner on the chests of different persons in health. This may be demonstrated by placing a number of persons in a row, and percussing them, sever- ally, in succession, in the same situations. The sound in no two of the persons, perhaps, will be exactly alike. It will present marked differences in the degree of vesicular quality, in pitch, and in in- tensity. This is owing to differences in the elasticity of the thora- cic walls, in the volume of the pulmonary organs, in the amount of muscular and adipose tissues covering the chest, and other circum- stances not so easily appreciated. Nor is the percussion-sound identical over every portion of the chest in the same person. In corresponding situations, on the two sides of the chest, however, with certain exceptions, the sounds developed by percussion are considered to be identical, or nearly so. This is a very important fact in its bearing on physical explo- ration. It is, indeed, of fundamental importance in estimating the physical signs of disease, inasmuch as the latter are determined not by reference to an ideal standard of health, but by comparison of one side of the chest with the other side. As respects normal res- onance, equality of the two halves of the chest, with some excep- tions, is assumed. Were we not warranted in doing so to an extent sufficient for most practical purposes, it would often be difficult to decide whether or not the sound developed by percussion denote disease; and the same is not less true of other methods of explo- ration than of percussion. But it is obviously important to as- certain as completely as possible the deviations from this rule of equality, which may exist within the limits of health; otherwise there is a liability that such deviations may be mistaken for the physical evidences of disease. In order to determine to what ex- tent and in what particulars disparity between corresponding por- tions on the two sides may be compatible with health, examinations are to be made of the chests of persons, selected for that purpose, who are presumed to be entirely free from pulmonary disease; the phenomena must be carefully recorded, and a collection of facts PERCUSSION IN HEALTH. 81 thus obtained subjected to analysis. I shall give the results of such an investigation as regards percussion, and the other methods of exploration. I will now proceed to a comparison of the several regions of the chest on the two sides respectively.^ 1. Post-clavicular Region.^ — Percussion in this situation gen- erally elicits a pretty clear resonance, the vesicular quality being most marked in the central portion. Toward the sternal extremity, owing to the proximity of the trachea, the quality of sound is some- what tympanitic, and this quality predominates in proportion as the direction of the percussion-strokes is toward the trachea. The res- onance in this region is greater in females than in males. It is very difficult to apply above the clavicles the finger used as a plexipaeter equally on the two sides ; and if an artificial instrument be em- ployed, an inclination toward the trachea, slightly greater on one side than on the other, modifies the sound sufficiently to produce a disparity between the two regions in the pitch and quality of the resonance. In making comparative observations in healthy subjects, I have found it almost impossible to produce uniform results with repeated percussions. This should enforce caution in regarding an apparent difference, if it be slight, as a morbid sign. To denote disease, the difference must be well marked and constant. With proper care, and making due allowance for disparity arising from inequality in the performance of percussion on the two sides, impor- tant evidence of the existence of disease is sometimes obtained by percussing in this situation, in cases of tuberculosis of the lungs. 2. Clavicular Region. — Over the clavicles the resonance is someAvhat tympanitic near the sternum, from the proximity of the trachea ; on the central portion the vesicular quality is apparent, and at the acromial extremity the intensity of the sound is dimin- ished. Equal percussion can be made on the two sides in this region without difficulty. A slight disparity, however, is not infrequently 1 The examinations of corresponding regions of the two sides, the results of which are given, were made in persons not only free from all appearances of disease, but also from any apparent deviation from the symmetrical conforma- tion of the chest. Deformities of the chest, either congenital or resulting from disease, will, of course, occasion disparity between the two sides in the phenom- ena developed by physical exploration. The results in this edition arc given as concisely as possible, omitting many details which were stated in the first edition. * For the boundaries of the regions, see Introduction, Section II, page 54, et 82 PHYSICAL EXPLORATION OF THE CHEST. appreciable in health, when the chest appears to be symmetrical, owing, probably, to some difference in the size and curves of the bone. A slight difference in these respects in well-formed chests is sometimes apparent on examination with the eye and by the touch. To be considered an evidence of disease, a disparity in the resonance should be well marked, constant, and associated with a correspond- ing variation in the percussion-sound of the two sides, either in the post-clavicular or infra-clavicular regions, or in both. 3. Infka-clavicular Region, — Percussion here elicits, gener- ally, a resonance more marked than elsewhere, save in the axillary region, and, in some persons, below the scapula, behind. In this situation examination is to be made carefully for the physical signs of the early stage of tuberculous disease ; and a slight abnormal disparity in the percussion-sound, taken in connection with other signs, and with symptoms, constitutes strong evidence of a deposit of tubercle. With reference to the diagnosis of incipient phthisis, the following deviations from the rule of equality at the summit of the chest, incident to health, is highly important to be taken into account : In the majority of persons the resonance on the left side is somewhat more intense, the vesicular quality is more marked, and the pitch lower than on the right side ; ^jer contra, the resonance and the vesicular quality are less, and the pitch higher, on the right side. These point>s of disparity are more apparent in some persons than in others. The practical bearing of the fact that there does not exist in most persons absolute equality of resonance on the two sides in the infra-clavicular region, will appear hereafter ; the fact rests on observation, and is independent of any explanation that may be offered. Theoretically, in view of the greater capacity of the right side of the chest, it would seem perhaps more reasonable that the difference between the two sides should be the reverse of that which is found to exist. The larger development of the right pectoral muscle, in consequence of the greater use of the right upper extremity, may account for the fact in some instances, but the dis- parity exists in cases in which there is no apparent difference in the muscular covering, in this situation. Possibly the different physical conditions at the base of the thorax may afford an explanation. On the right side the lungs repose, with the diaphragm intervening, on the liver, which occupies the whole of the base on that side. The presence of this solid viscus may slightly diminish the sound. On the left side below the lung is situated the stomach, frequently more PERCUSSION IN HEALTH. 83 or less distended with gas, and the effect of this, it may be sup- posed, is to increase the sonorousness on that side, even at the summit, independently of the transmission of the tympanitic gastric sound which is sometimes observed. 4. Scapular Region. — I enumerate this region next to the pre- ceding because, being at the summit of the chest, its relations in diagnosis are similar. Like the infra-clavicular, it is an important region with reference to the physical signs of phthisis. The normal degree of resonance over the scapula is much less than at the sum- mit in front, for sufficiently obvious reasons. The vesicular quality of resonance is less apparent. A distinct sonorousness, however, exists here, notwithstanding the percussion has to be made on a layer of bone, and a mass of muscle placed upon it. These circum- stances do not deaden the sound sufficiently to render the region nearly or even quite unimportant in physical exploration, as stated in a work on diseases of the chest. ^ On the contrary, percussion in this situation is often of great utility in the diagnosis of tubercle. The region is subdivided into the supra and infra spinous portions. The sonorousness is greater over the latter. Disparity between the two sides is less frequent at the summit behind than in front. When present, however, the general rule is the same, viz., less sonorousness, and a higher pitch on the right side. 5. Interscapular Region. — In this region a certain amount of sonorousness exists, notwithstanding the mass of muscular substance. The vesicular quality of sound is feeble. The degree of sonorous- ness is less, and the pitch higher on the right side in some persons. 6. Mammary Region, — The mammary region offers marked dif- ferences on the two sides, owing to the upper convex extremity of the liver, in the right, and the situation of the heart in the left side of the chest. From the fourth rib, on the right side, diminished resonance is appreciable, which increases as percussion is made downward to the point where the pulmonary sound ceases. This point marks what maybe called the liyie of hepatic flatness, i. e., the lower border of the lung. This point, which is somewhat variable in different persons, usually falls a little below the lower boundary of the mammary region, or the sixth rib. Next to the sternum, on this side, between the third and fifth ribs, the presence of a portion of ' Swett on Diseases of the Chest. 84 PHYSICAL EXPLORATION OF THE CHEST. the right auricle and ventricle occasions diminished sonorousness over a space extending about a finger's breadth from the right margin of the sternum. On the left side, diminished resonance exists in the praecordial space, and over a portion of this space, in which the heart is in con- tact with the thoracic walls, there is notable diminution of sonorous- ness. Percussing in a vertical direction from above downward, mid- Avay between an imaginary line passing through the nipple, and another line coincident with the left margin of the sternum, dimin- ished resonance exists at the upper border of the mammary region, viz., the third rib. At the fourth rib, on a horizontal line passing through the nipple, the resonance is much diminished, in consequence of a portion of the heart in this situation being uncovered by lung. From the fourth to the sixth rib the absence of resonance continues, and extends more and more to the left of the sternum, the inner border of the left lung receding, so as to leave the heart in contact with the wall of the chest over a space, the widest part of which is indicated by a horizontal line touching the fifth rib at a point a little within the nipple. Percussing horizontally from the sternum out- ward, on a line passing through the nipple, resonance is notably diminished to within about a finger's breadth of the nipple. Dimin- ished resonance, however, is appreciable nearly or quite to the nipple, owing to the fact that the heart extends thus far covered by lung. The presence of the heart in the left side thus gives rise to alterations in the percussion-sounds which are twofold. First, nota- ble diminution of vesicular resonance. This is the case over the space in which the left lung fails to cover the organ. /Second, slightly or moderately diminished resonance over an area extending a certain distance beyond the boundaries of that space. The precise limits of these two areas are important in connection with the study of diseases of the heart. Variations in the degree of resonance in the praecordia are also involved in the diagnosis of pulmonary affec- tions. In health, the degree of resonance is different with the two acts of respiration, and may be affected voluntarily by increasing the extent of inspiration and expiration. By inspiration a larger portion of the heart is covered by lung than in expiration ; on the one hand, the space covered by means of the former, and, on the other hand, that uncovered by means of the latter act, other things being equal, are proportioned to the forced expansion of the lung in inspiration, and the contraction in expiration. A morbid con- PERCUSSION IN HEALTH. 85 dition of the lung, consisting in permanent distension of the air-cells (which obtains in emphysema), Avill, of course, diminish the space over which, in health, resonance is notably diminished. Abnormal resonance in the pr^ecordia, hence, becomes a physical sign of that affection. On the other hand, atrophy of the lung has a contrary effect. There are considerable differences as respect the degree of diminution of resonance, and also the limits of the two areas in dif- ferent persons in whom the lungs are perfectly healthy. In other words, the lung overlies the heart more in some individuals than in others, of which fact percussion furnishes physical evidence. The mode of performing percussion in order to develop, first, the notable dulness due to the contact of the heart with the thoracic wall, and second, the lesser degree of dulness occasioned by the pres- ence of that portion of the organ which is covered by the lung, is somewhat different ; and this difference, which involves a rule appli- cable to the practice of percussion in other situations, both in health and disease, may be here stated. In determining the space which the heart occupies, uncovered by lung, percussion should be lightly made ; but to fix the boundaries to which the organ extends covered by lung, beyond this space, greater force of percussion is requisite. The difference in the practical results of these two methods of per- cussing was first pointed out by Piorry. In general, a light per- cussion reveals physical conditions pertaining to parts situated directly beneath the thoracic walls ; while a more forcible percussion, the blows being made to bear on parts more deeply seated, is neces- sary to obtain information of the physical condition of parts situated more or less beneath the surface of the lung. To the first mode, Piorry gives the name superficial percussion ; and the second mode he calls deep percussion. Forcible or deep percussion is necessary to determine the existence and the size of indurations of lung from pneumonitis, pulmonary apoplexy, or tuberculous deposit, which are removed, to a greater or less distance, from the surface of the lung. The mammary region affords a degree of resonance considerably less than the region situated above it, viz., the infra-clavicular, for rea- sons other than those already mentioned. The pectoral muscle dimin- ishes the sonorousness ; and the difference in the bulk of this muscle, in different persons, is a cause of the differences in the degree of resonance observed in this region within the> limits of health. In the female, the mammary gland tends still more to deaden the sound, 86 PHYSICAL EXPLORATION OF THE CHEST. and in the size of this gland, it is well known different females present a very wide range of difference. It is an error, however, to say that, on this account, the mammary region in females " is of no value in percussion."^ Even when the mamma is unusually large, an abnormal degree or kind of resonance may be determined in this situation sufficiently for the practical objects of diagnosis. In making percus- sion over the mammary gland, the ivory or hard india-rubber plex- imeter may be used with advantage. With its broad, smooth sur- face, the soft parts may be compressed more firmly, and the strokes brought to bear more efficiently on the thoracic walls. The left mammary region frequently yields a tympanitic sound on percussion, due to the presence of gas within the stomach. 7. Infra-mammary Region. — In this region, as well as in the pre- ceding, the two sides present a marked disparity. Over nearly, and in some persons quite, the entire region on the right side, there is absence of resonance, owing to the situation of the liver. This fact is not infrequently overlooked by persons but little accustomed to physical exploration, and the want of resonance attributed to intra- thoracic disease. Instances of this error have often fallen under my observation. The line marking the lower anterior extremity of the right lung, in other words the line of hepatic jiatness^ varies consid- erably within healthy limits. Determined by percussing downward on a vertical line passing through the nipple (the persons standing or sitting), the point at which resonance ceases, in the majority of instances, will be found over the seventh rib. Kot unfrequently, however, it is over the sixth, and occasionally, as low as the eighth rib. The line of hepatic flatness now referred to, is that existing with ordinary respiration. Even with ordinary respiration, the line is not fixed, OAving to the play of the diaphragm with the two respi- ratory acts. This may be thus shown : the finger employed as a pleximeter may be placed at a certain point, where, continuing for some time repeated percussions, with some of the strokes a resonance will be observed, and with others none whatever. But forced acts of inspiration and expiration, in consequence of the convexity of the diaphragm with the latter, and its depression with the former act, affect considerably the point at which resonance ceases. If the line of flatness in ordinary respiration be over the sixth rib, the effect of 1 Swett on Diseases of the Chest. PERCUSSION IN HEALTH. 87 a deep inspiration is to lower it to the seventh rib ; and if, in ordinary respiration, the line is on the seventh, it is depressed to the eighth rib. In an instance in which the line with ordinary respiration lay on the eighth rib, it was depressed to the ninth. The distance to "which it may thus be voluntarily carried downward, is pretty uni- formly about IJ inches. On the other hand, by forced expiration the line of flatness is elevated to an extent less uniform in different persons. It is carried upward to the sixth, fifth, and fourth ribs, the distance varying from 2J to 5J inches. The distance from the line of hepatic flatness after a deep inspiration to that after a forced expiration, in different persons, varies from 4 to 7 inches. This distance is a pretty good criterion of the breathing capacity of the individual. Above the line of flatness, on making forcible percussion, diminished vesicular resonance extends upward for one or two inches. This is caused by the convex upper surface of the liver, covered by the thin extremity of the right lung. A tympanitic resonance is sometimes produced by percussing over the liver, due to the presence of gas in the transverse colon. In the left infra-mammary region the percussion-sound not only varies in different persons but in the same person at different times ; and also in different portions of the region at the same time. These variations depend on the different organs below the diaphragm which encroach on the lower division of the thorax. Into the right portion of the region, the left lobe of the liver enters to an extent somewhat variable, generally about two inches to the left of the median line. Light percussion over this portion elicits a flat sound, or absence of resonance. The left boundary of the liver may generally be de- fined by the percussion-sound. Beneath the left portion of the re- gion lies the spleen, an organ, the volume of which, as is well known, varies considerably within the limits of health, and in certain diseases (typhoid and intermittent fever), becomes enlarged to a greater or less extent. Its average dimensions, according to the observations of Piorry, are about four inches in length, and three inches in width. The stomach is situated between the two solid organs just named, and this organ is constantly fluctuating as regards degree of disten- sion, and the nature of its contents. Enlarged by the presence of gas, it occasions a tympanitic resonance frequently pervading the ■whole infra-mammary region, and sometimes extending to the mam- mary. The sound is characteristic, and may be distinguished as the 88 PHYSICAL EXPLORATION OF THE CHEST. gastric tympanitic resonance. It is high in pitch, and often has a ringing metallic tone. These characters are rendered obvious by comparing it with the tympanitic resonance elicited by percussion over the intestines. The percussion-sound over the lower part of the left side of the chest is frequently more or less modified by the presence of gastric tympanitic resonance. On the other hand, when the stomach is filled with solid or liquid alimentary substances, the percussion-sound is flat. 8. Sternal Regions. — These regions are single ; that is, they do not, like the regions already referred to, consist of corresponding divisions of the thorax situated on either side of the mesial line. On this account, and in consequence of the sternum forming a contin- uous bony covering, devoid of the elasticity belonging to the ribs, and, moreover, over the greater part of its extent other organs than the lungs lying beneath, it is rarely the case that much important information respecting pulmonary disease is here obtained by means of percussion. Over the greater portion of the upper sternal region, viz., above the lower margin of the second rib, there is more or less sonorousness, which is non-vesicular in character, being due to the air contained in the trachea above the point of bifurcation. From the character of the sound it is sometimes distinguished as tubular sonorousness^ but for all practical purposes it suffices to consider it as tympanitic. Below the point of bifurcation, ^. e. from the second to the lower margin of the third rib, the inner border of the lungs on the two sides approximate, and the resonance has more or less of the vesicular quality. The remnant of the thymus gland, and the deposit of adipose substance, however, sometimes render the percus- sion-sound dull in this situation. The presence of the large vessels leading from the heart conduces to the same result. Over the lower sternal region, i. e. from the lower margin of the third rib, the combination of several difierent organs occasions vari- ous modifications of resonance. Beneath the region are, 1, a portion of the right lung, lying to the right of the mesial line; 2, the greater part of the right ventricle of the heart, and a portion of the left ; 3, at the lower part a portion of the liver ; and 4, occasionally, where distended, a portion of the stomach. It is obvious that the percussion-sound must vary in different parts of the region, and present often a mixed character. By care and tact in percussion, however, it is practicable frequently, if not generally, to define the boundaries of the several organs which are embraced in a section of PERCUSSION IN UEALTH. 89 this region, by means of the distinctive sounds pertaining to them respectively. This, which, according to Walshe, " is one of the most difficult practical problems in the art of percussion," involves a question of some interest and importance in its bearing on physical exploration, to which reference has not yet been made, and which may be briefly noticed in the present connection. The question is. Do the different solid organs of the body, the liver, heart, spleen, kidney, etc., yield, on percussion, sounds distinctive in character? Piorry, assuming the affirmative of this question to be true, has described a series of sounds, each of which he regarded as charac- teristic of the organ lying beneath the point percussed. Thus, ac- cording to him, there is a liver-sound, a spleen-sound, etc., and each of these distinctive sounds is supposed to depend on the molecular arrangement belonging to the structure of the particular organ. The correctness of the opinion just stated is denied by Skoda.* According to this author, " there is no difference in the percussion- sound by which we can distinguish between organs not containing air, such as the liver, the spleen, the kidneys, hepatized lung, or lung completely deprived of air by compression, and fluids; a hard liver yields the same sound as a soft liver, a hard spleen as a soft spleen, and blood the same sound as pus, water, etc. We may readily con- vince ourselves of the fact, by placing these different organs on a non-resonant support, and percussing them one after the other, either with or without a pleximeter ; fluids, similarly supported and in suf- ficient quantity, may also be percussed by aid of a pleximeter, care- fully applied to their surface."^ "Walshe makes a similar statement.^ Others have arrived at an opposite conclusion by means of the very experiments cited by Skoda, and contend that of the different solid organs, and different fluids, each has its peculiar sound, as the wood of various species of trees may be distinguished from each other by percussion, or as bone and cartilage differ in this respect, according to Skoda* himself. This point of physics is of less consequence than may at first appear, inasmuch as the question whether the several organs named have not peculiarities of sound in situ by no means hinges upon it. Skoda and Walshe do not deny distinction 1 A Treatise on Auscultation and Percussion, by Dr. Joseph Skoda. 2 Translation, by W. C. Markham, M.D., London edition, page 5. 3 Op. cit. * See note to French translation of Dr. Skoda's treatise, hy the translator, Dr. F. A. Aran, page 6. 90 PHYSICAL EXPLORATION OF THE CHEST. of percussion-sound pertaining to these organs as they are situated in the body, but they account for the difference from the relations, of the organs to neighboring parts Avhich contain air, viz., the lungs, stomach, and intestines. The question, therefore, may be settled by the result of examinations practised on living and dead subjects. Facts thus obtained undoubtedly establish the existence of a differ- ence in sound by which the sites of the different organs may be determined and their boundary lines often mapped out. For exam- ple, the sound produced by percussing over the liver differs obviously from that elicited over the heart, and the boundary line is generally determinable. It is highly probable that this difference is due to the disparity in size of the two organs, and the parts in juxtaposition, rather than to intrinsic peculiarities of the organs alone. The fact of the difference, however, exists irrespective of the explanation. The peculiarities of sound emanating from solid organs are more sharply defined, and appreciated with greater facility, by employing " auscultatory percussion,''^ than by percussing in the ordinary mode. The practice of ordinary percussion, which is more simple, and therefore more readily available, with a view to determine and mark out the boundaries of the different solid organs encroaching on the chest, is an exercise to be highly recommended, not only as a means of becoming familiar with the characteristic sounds of each, but as tending to impress on the mind the relative situations of these organs, and, at the same time, conducing to practical skill in the use of the method of physical exploration under present consideration. 9. Infra-scapular Regions. — Percussion posteriorly, below the scapula, generally yields a marked degree of vesicular resonance. The larger portion of the inferior lobe being embraced in this region, and a very small portion only of this lobe extending into the ante- rior part of the chest, it is here especially that exploration is made for the physical signs of inflammation of the lungs or pneumonitis, the lower lobe being the one affected in the great majority of cases of that disease. The point to which the lower extremity of the pulmonary substance extends is over the eleventh rib. On the right side the line of hepatic flatness commences at or near this point, varying somewhat, as in front, in different persons. This line, as in front, is depressed from one to two inches by a deep inspiration, and elevated to a greater or less extent by a forced expiration. Here, 1 See Essay by Dr. Cammann and Clark, previously referred to. PERCUSSION IN HEALTH. 91 too, as in the right infra-mammary region, above the line of flatness in ordinary respiration, a marked degree of dulness on percussion is appreciable for a distance of from one and a half to two inches. On the left side the resonance may be more or less tympanitic, from the presence of gas in the stomach. Below the eleventh rib there may be tympanitic resonance from intestinal gas; and near the spine the limits of the left kidney, which is here situated, may be indicated by the percussion-sound; at the outer side of the lower part of the region, the space occupied by the spleen is in some in- stances determinable. 10. Lateral Regions. — The axillary region on both sides is highly sonorous on percussion, the vesicular quality usually being strongly marked. The infra-axillary region generally presents more or less disparity on comparison of the two sides. On the right side, near the eighth rib, the absence of resonance denotes the line of hepatic flatness, the situation of the line being subject to the same depression and elevation, with inspiration and expiration voluntarily increased, as in front and behind. Dulness for a short distance above this line is also here marked. On the left side the percus- sion-sound may be rendered more or less dull by the presence of the spleen; but it is much oftener rendered tympanitic by the presence of gas within the stomach. Crossing the infra-axillary region diago- nally is the interlobar fissure, which, although not determinable in health, may be traced by means of percussion in disease (pneumo- nitis), a fact of importance in diagnosis. Reviewing the regions which have just been considered in connec- tion with the phenomena developed by percussion in a state of health, it will be seen that the following, as regards the intra-tho- racic organs embraced within their limits respectively, are nearly similar or symmetrical on the two sides of the chest : anteriorly, the supra-clavicular, clavicular, and infra-clavicular regions; posteriorly, the scapular and inter-scapular regions ; laterally, the axillary region. The remainder, viz., the mammary and the infra-mammary, the infra-axillary and the infra-scapular, present anatomical points of dissimilarity attended by a want of correspondence in the physical phenomena produced by the method of exploration under consid- eration, as well as the other methods remaining to be considered. The regions, however, which in an anatomical point of view are similar, or nearly so, do not invariably, as has been seen, yield 92 PHYSICAL EXPLORATION OF THE CHEST. identical percussion-sounds, but to a certain extent deviations occur entirely compatible with health. In instituting comparisons of the corresponding regions of the two sides, hitherto, it has been assumed that the chest is free from disparity resulting from deformity or previous disease ; in other words, that the two sides are symmetrical in conformation. But in- stances presenting deviations from anatomical symmetry, as has been seen (Introduction, Sect. I), are of frequent occurrence. In the practice of percussion, and other methods of exploration, it is necessary to take cognizance of the points of dissimilarity which are determined by the method of inspection. This is a rule of funda- mental importance in physical diagnosis. The most prominent causes of visible alterations in the symmetry of the two sides of the chest, as already stated, are spinal curvature, rachitis, fractures, prolonged pressure on the thorax in infancy, tight lacing, and con- traction after chronic pleurisy. The existence or non-existence of alterations from the operation of these or other causes is always to be ascertained, and taken into account in drawing inferences from points of contrast which the physical phenomena, pertaining to the two sides, may offer. Allusion has been made to various circumstances occasioning in different healthy persons wide differences in the intensity and other characters of the resonance on percussion, viz., the greater volume of the lungs in some individuals than in others, greater elasticity of the thoracic walls, varying amount of muscular development as well as adipose deposit, etc. Age has a certain influence. Other things being equal, in consequence of the greater elasticity of the costal cartilages in early life, the degree of resonance is greater than at a later period, when the cartilages become stiffened, or rigid from ossification. As a rule, the pitch is lower and the sense of resistance is less in early life. In old age, the vesicular quality of the resonance is impaired by the atrophied condition of the lung inci- dent to advanced years, and the sound assumes somewhat a tympani- tic character. The percussion-sound may also be found to vary at different periods of an act of respiration in the same individual. The quantity of air contained within the air-cells, and consequently the relative pro- portion of air and solids, are not the same after a full inspiration and after a forced expiration. This difference in lung-expansion may occasion an appreciable disparity in resonance, according as the PERCUSSION IN HEALTH. 93 percussion is made at the conclusion of a full inspiration or a forced expiration. The disparity is not appreciable uniformly in different persons. "When it is apparent, it usually consists, contrary to what might perhaps have been anticipated, and the reverse of what is usually stated in works on physical exploration, in diminished reso- nance and elevation of pitch at the conclusion of inspiration. This is probably to be explained by the greater degree of tension of the lungs and thoracic walls produced by inspiration voluntarily pro- longed and maintained — a condition presenting physical obstacles to sonorous vibrations more than suiSicient to counterbalance the in- creased proportion of air within the cells. It is a curious fact, worthy of notice, that the two sides of the chest are not always found to be affected equally as regards the percussion-sound, at the conclusion of a full inspiration, contrasted with that after a forced expiration. I have observed the contrast to be more striking on the right than on the left side; and in one instance on the left side, the resonance was less intense and somewhat tympanitic at the end of a full inspiration, while on the right side, the opposite effect was pro- duced, and the sound became quite dull at the end of a forced expi- ration. In view of these variations in a certain proportion of in- stances, incident to different periods of a single respiration, in some cases of disease in which it is desirable to observe great delicacy in comparing the two sides, pains should be taken to percuss cor- responding points at a similar stage of respiration, and the close of a full inspiration is, perhaps, the period to be preferred. Ordi- narily, the liability to error from this source is obviated, either by repeating a series of strokes, first on one side and next on the other, or by percussing both sides repeatedly in quick succession, in order mentally to obtain the average intensity and other characters of the sound during the successive stages of a respiration. The in- stances of disease, however, are exceedingly rare in which such nicety of comparison is important. Certain rules pertaining to the practice of percussion, have al- ready been stated. Others important to be borne in mind remain to be mentioned. These practical rules are equally applicable to examinations of the chest in health and disease; and it Avill not, therefore, be necessary to recur to this subject in connection with the morbid signs developed by percussion. In percussing different portions of the chest it is not a matter of indifference in what position the person examined is placed. To 94 PHYSICAL EXPLORATION OF THE CHEST. explore the anterior surface of the chest the position most favorable is standing, the shoulders thrown moderately backward, and the back resting against a door or a thin partition wall ; next to this is a sitting posture, the back resting against a firm support. A re- cumbent position, although less favorable, is frequently the only one available in cases of disease, owing to the weakness of the patient. In each of these three positions the upper extremities should be equally disposed by the side of the body, the shoulders maintained on the same level, as nearly as possible, and the two sides of the chest on the same plane. Particularly in the recumbent posture, care should be taken that the bed and pillows be so arranged as to avoid any inequality affecting one side more than the other. For an examination of the posterior surface in the most satisfactory manner, the patient must assume a sitting posture, the body inclined a little forward, the arms brought forward and folded so as to render tense the muscles attached to the scapula. An imperfect exploration, but frequently sufficient for the objects of diagnosis in cases of disease precluding the sitting posture, may be made of the two sides in succession, the patient lying first on one side and then on the other ; or it may be practicable sometimes for the patient to rest on the abdomen. In percussing the lateral surfaces, the pos- ture may be standing, sitting, or recumbent, the hands, with the fingers interlocked, resting on the top of the head. The position of the explorer is also a matter of consequence. If the person examined stand, it is of course necessary to take the same position. If, however, the patient be seated, or recumbent, the examination will be most conveniently made in the sitting pos- ture. It is well to be placed as nearly as possible in front of the mesial line, in order to receive the percussion-sounds from each side of the chest, at an equal distance. If, however, a lateral situation be preferred, or necessary, with reference to the same end, pains should be taken, wherever a delicate comparison is made, to pass from one side to the other, so as to percuss on corresponding points, whilst in a similar relative position to the patient. Identical sounds reaching the ear from unequal distances may appear to differ in in- tensity, if not in other respects. The manner in which the strokes are to be made in percussing has been already described. If the finger or fingers of the left hand be the pleximeter employed, they may be placed horizontally on the chest, first on the ribs, and next in the intercostal spaces ; or PERCUSSION IN HEALTH. 95 vertically, at right angles with the ribs. Whenever careful percus- sion is required, both positions should be resorted to. In percuss- ing the acromial portion of the infra-clavicular region the most convenient disposition is to place the fingers in a diagonal direction. It is better to place the palmar surface of the fingers in apposition to the chest, and strike on the dorsal surface, although the reverse is practised by some who are distinguished in the art of physical exploration. Percussion is to be made on corresponding points of each side of the chest alternately, care being taken to strike on the ribs, or the intercostal spaces successively, and to compare the sound elicited from the two sides. As already stated, deviations from healthy sounds are determined by means of this comparison, and not by reference to any fixed standard. Hence, the diiferences natural to the chest of different persons do not affect the value of percussion in developing signs of disease. It is therefore important, that the percussion be made in every respect as equally as possible on the two sides. The same degree of force is to be given to the strokes ; they are to be made in the same direction, and, in short, so far as practicable, in precisely a similar manner. By the non-observance of due precaution on this point, it is easy to produce a disparity in the percussion-sounds, in cases in which there is in reality no differ- ence as respects the physical conditions on which the sonorousness depends. For example, suppose percussion to be made in the infra- scapular region ; and let the strokes on one side be made with the ends of the fingers, in a direction opposite to the spinal column, and the movement favorable for the production of the highest amount of resonance; then, directly afterward, on the other side, let the strokes be made with the pulpy portion of the fingers, in a direction toward the spinal column, and the movement intentionally modified so that the fullest amount of resonance shall not be pro- duced, the disparity between the two sides will be marked, and yet, if such an experiment be not watched by a critical observer, the difference in the mode of percussing will not be detected. A differ- ence in simply the force of percussion on one side, in any situation, while the muscular effort appears to be similar, and in all other respects the blows are identical, will sufiice to occasion an obvious disparity in sound. Hence, before deciding on the actual existence of a slight disparity, percussion should not only be made with great care, but repeated often enough to obviate the liability to deception 96 PHYSICAL EXPLORATION OF THE CHEST. by a failure to strike with equal force, and in all respects equally, on corresponding points. That the eye may select points which correspond on the two sides, and the better to secure uniformity in the mode of percussing, it is preferable, in cases in which nicety of comparison is required, to divest the chest of all covering. In the female, this is opposed by a regard for delicacy. The end may, however, be attained without oifcnding propriety by uncovering portions of the chest at a time, and not exposing the mammge, which is rarely if every necessary. In some instances, however, the objects of physical exploration may be accomplished without the necessity of denuding any portion of the chest. In addition to the sounds produced by percussion, important in- formation may some times, at the sam time, be obtained by directing attention to the sense of resistance, felt by the fingers when struck. In proportion as the walls of the chest are deprived of their elas- ticity, or the parts contained within the thorax are unyielding to pressure, a sense of resistance will be appreciable by the finger on which percussion is made. In the healthy chest this is rendered very apparent by peixussing in the right infra-mammary region, where hepatic flatness exists, and contrasting the resistance with that felt in percussing either at the upper part of the chest on the same side, or on the lower portion of the left side of the chest. A disparity in this respect between corresponding points in which an equality should naturally exist, becomes a physical sign of disease. Finally, the following rule may be repeated, viz., to ascertain the physical condition of the superficial portion of the intra-thoracic organs, the percussion-blows should be light; but to determine a disparity dependent on deep-seated alterations, forcible percussion is requisite. In connection with this rule, it is to be stated that or- dinarily in the practice of percussion, delicate strokes, which do not occasion pain, nor present an appearance of roughness, answer every practical purpose. The facts and rules which have thus been given under the head of Percussion in Health are commended to the attentive consider- ation of the student before entering on the study of Percussion in Disease. After becoming familiar with all that has already been presented relative to percussion, and practically expert by resorting to examinations of healthy chests, the knowledge of the morbid signs developed by this method, and its application in the diagnosis PERCUSSION IN DISEASE. 97 of thoracic aiFections, are easily attained. In fact, to so great an extent may the physical phenomena of disease be studied in health, that, after such a preparation, the subject offers few difficulties. Percussion in Disease. The various physical changes incident to diseases affecting the in- tra-thoracic organs, occasion corresponding modifications of the sound elicited by percussion, and hence, the latter become the sig7is of the former. The more important of the physical changes inci- dent to different forms of disease, are the following : over-distension of the pulmonary vesicles, involving abnormal expansion of the chest, and a greater degree of tension than belongs to health ; undue reduction in the quantity of air, associated with more or less increased density of lung, from the deposit of effused blood, serum, and the inflammatory, tuberculous, or other morbid products; the presence of air or liquid, or both, in excavations or cavities formed at the expense of the pulmonary substance; liquid of different kinds in the pleural sac, compressing the lung, and sometimes supplanting it entirely ; and air or gas contained between the surfaces of the pleura, generally with, at the same time, a greater or less propor- tion of liquid. Certain physical phenomena, ascertained by per- cussion, as well as the other methods of exploration, are found by clinical observation to accompany the foregoing morbid conditions, and on the constancy of the connection between these phenomena and the morbid conditions, establishing the relation of cause and effect, depend the signifiicance and value of the former as representing the latter. Resonance of the healthy chest has been seen to involve the following elements, viz., a certain amount of intensity, or loud- ness ; relatively lowness of pitch, and a peculiar quality or timbre characterized as vesicular. Morbid deviations from healthy reso- nance are to be analyzed, and studied under the same general aspects. It is by attention to the characters derived mainly from intensity, pitch, and quality of sound, that the signs developed by percussion are recognized, and discriminated from each other. Abnormal sounds, then, I repeat, are distinguished from healthy resonance, and from each other, by variations in intensity, in pitch, and in quality. Proceeding to a description of the physical signs of disease devel- 7 98 PHYSICAL EXPLORATION OF THE CHEST. oped bj percussion, the question at once arises, what arrangement and what terms shall be adopted ? Authors differ upon this point. The following classification appears to me sufficiently comprehensive and minute for practical purposes. 1. A bsence of resonance, commonly known as flatness. The type of this sign is produced when the thigh is percussed. Flatness is not a sound, but the absence of sound ; what is heard is a noise produced by the instruments used in percussion. It has, therefore, neither pitch nor quality, since these belong only to resonance. 2. Diminished resonance. Diminution of resonance, the vesicular quality being more or less preserved, is called didness. The characters of this sign are lessened intensity and elevation of pitch ; diminution of resonance invariably involves a higher pitch than that of the normal vesicular resonance of the person examined. 3. Tympanitic reso- nance. Under this name, I embrace all kinds of sonorousness in which the vesicular quality is absent. It includes the varieties called by some, metallic, tubular, amphoric, and the cracked metal sound. The essential, distinctive character of this sign relates to quality of sound : the tympanitic takes the place of the vesicular quality. Intensity does not enter into its characters ; it may be more or less intense than the normal vesicular resonance in the per- son examined. The pitch of tympanitic resonance is always higher than that of the normal vesicular resonance, but the pitch is by no means uniform. 4. Exaggerated, or vesieido-tympanitic resonance. The characters of this sign are increased intensity of sound, the pitch always greater than that of the normal vesicular resonance ; and the quality is a combination of the vesicular and tympanitic. It seems to me that all the phenomena developed by percussion in disease, may be arranged in the foregoing divisions ; in other words, that the signs of disease which this method of exploration furnishes, are resolvable into the four just named. It remains to consider the phenomena falling under the foregoing classes severally, and their relations to the different morbid condi- tions of which they are the signs. 1. Absence of Resonance, or Flatness. — Complete abolition of sound, or flatness, is obtained especially when the pleural sac is filled with liquid effusion, either serum, sero-lymph, or pus. The flat- ness then extends over the whole of the affected side. If the chest be partially filled, flatness may exist below the level of the liquid ; if, however, the amount of liquid be quite small, there is a greater PERCUSSION IN DISEASE. 99 or less degree of dulness below its level, not complete absence of resonance. An effusion of liquid into the air-vesicles of a consid- erable portion of lung, constituting pulmonary oedema, may give rise to flatness. Flatness may be due to complete solidification of lung from inflammation or tuberculous deposit, but it is rarely the case that the solidification is so complete as to abolish all sound. Hence, instead of flatness, there is dulness, which may approximate closely to flatness. Moreover, the presence of air in the trachea and in the bronchial tubes, exterior to and within the lungs, and the proximity of the solidified portion (if the whole lung be not solidi- fied) to another portion in which the vesicles contain air, occasion a slight degree of resonance, although, perhaps, so slight as not to be appreciable without comparison with the effect of percussion on a part which yields absolute flatness. Finally, a tumor within the chest may give rise to flatness. If flatness exist over the whole of one side of the chest, and the affection be not acute, the chances are nine to ten that the pleural sac is filled with liquid. For if the flatness be not due to this con- dition, excluding a tumor filling one side of the chest, the entire lung is completely solidified by either inflammatory or tuberculous deposit. Now, if the deposit be inflammatory, and the disease be not acute, chronic pneumonitis exists, a disease of very great infre- quency ; and a deposit of tubercle is almost never so great and extensive as to abolish all resonance over an entire lung. The presence of liquid filling the chest, however, is established by other signs coexistino; with flatness. In cases in which flatness exists over a portion of the chest, the discrimination lies between liquid effusion, solidification of lung, and a tumor or morbid growth. Displacement of the lung by the accumulation of liquid, or a solid tumor, may occasion absence of all resonance, while over lung, be it ever so much solidified, there is usually only an extreme of dulness. But in making this discrimination, important informa- tion is derived from the situation of the flatness, and, in certain cases, the effect of variations in the position of the patient. If the flatness be situated at the superior portion of the chest, the prob- abilities are vastly opposed to its being due to the presence of liquid, for, excepting in some very rare instances in which liquid effusion is confined to the upper part by adhesion of the pleural surfaces below, it will fall to the bottom of the sac, and the flatness 100 PHYSICAL EXPLORATION OF THE CHEST. Tvill extend upward for a distance proportionate to the amount of the effusion. Flatness, due to solidification of the lower or upper lobe in pneumonitis, may be ascertained by delineating on the chest its boundary, and finding that the line pursues the direction of the interlobar fissure. This is a point pertaining to the physical diag- nosis of pneumonitis, to which writers on the subject have not suiBB- ciently adverted. Moreover, the limit of the flatness incident to that disease remains unaltered in every position of the patient. The same remark will apply to tumors, unless, as may happen, and an instance is given by Walshe, they are not attached except by a small pedicle. But in a certain proportion of cases in which liquid is contained within the pleural sac, the level of the surface of the liquid varies with different positions of the body, and may be ascer- tained without difficulty by percussion. If the level be ascertained by determining the line of flatness, and marked on the chest when the body of the patient is in an upright position, it will be found to encircle the chest nearly in a horizontal direction, the liquid obey- ing the same law of gravity within the chest, as if it were contained in a vessel out of the body. If now the patient take a recumbent posture, the level of the liquid in front will be found to have de- scended, and a line denoting the upper boundary of the flatness, pursues from this point a diagonal direction intersecting obliquely the horizontal line previously made. Or, without taking pains to demonstrate the variation of level so elaborately, which is not al- ways convenient in practice, let the upper limit of the flatness in front be ascertained by percussion, while the trunk is in a vertical position; then cause the patient to lie down, and ascertain if the resonance do not extend an inch or more below the point at which, in the previous position, the upper limit of flatness was found to exist. A few ounces of fluid in the pleural cavity may, in some in- stances, be detected in the manner just described. The physical explanation of these changes is sufficiently obvious. This mode of determining, by percussion, the presence of liquid is not applicable to all cases, but only to those in which the quantity is not so great as to fill the pleural sac, compressing the lung into a small space, and to those in which the movement of the liquid is not prevented by adhesions of the pleural surfaces. Both these conditions may be wanting in pleurisy, and hence the test is not so constantly available in that affection as in hydrothorax. The discrimination, however, of flatness occasioned by liquid effusion, from that which PERCUSSION IN DISEASE. 101 may be due to solidification of lung, does not depend exclusively on the evidence obtained by percussion. The physical signs derived from other methods of exploration, combined with those afforded by percussion, generally warrant a positive diagnosis. The employ- ment of percussion after the rules just given enables the practi- tioner to determine from day to day, or from week to week, the changes which take place in the quantity of liquid effusion. The progress of the disease and the effects of remedies may thus be ac- curately observed. This is a practical consideration of no small importance. With a view to note the increase or diminution of the fluid, the line of flatness, denoting the level of the liquid, while the body is in a vertical position, may be permanently marked on the chest by means of a stick of the nitrate of silver. The series of lines thus made during the course of pleurisy or hydrothorax, form a kind of diagram illustrating its past history. The physical conditions producing absence of resonance, or flat- ness, occasion at the same time, and usually in a notable degree, a sense of increased resistance ; in other words, the ribs are less yield- ing to pressure from without. This sign, cccteris paribus, will be marked in proportion to the elasticity of the costal cartilages, and hence be more obvious in early life than after the thoracic walls become unyielding from the stiffening and ossification incident to advanced years. 2. Diminished Resonance or Dulness. — This sign exists when- ever the intensity of the resonance is less than in health, provided the vesicular quality be not lost. The diminution of resonance may have every degree of gradation, from the least appreciable dul- ness to a degree falling just short of absence of resonance; the sound is dull unless there be flatness. It sufiices to express differ- ent degrees of dulness by adjectives of quantity, such as slight, moderate, considerable, great, etc. This sign occurs in a large proportion of thoracic diseases. The physical conditions which it represents are, in general terms, those in which the relative propor- tion of solids or liquid to air in the pulmonary vesicles is morbidly increased. Generally the disproportion is due to an increase of solids or liquid; but sometimes it arises from the air being decreased without any actual increase of solids or liquid. An exception to the general fact just stated with respect to the relative diminution of air in the air-cells to solids or liquid within the chest when dulness exists, is afforded by some cases of emphysema. In this 102 PHYSICAL EXPLORATION OF THE CHEST. affection the air is increased without increase of solids or liquid. Generally the resonance is exaggerated in this affection, but excep- tionally it causes dulness, owing probably to extreme tension of the pulmonary organs and the walls of the chest. Dulness always raises the pitch of sound. Bearing in mind this fact will prevent the error of considering the normal resonance on one side of the chest as dull when the resonance on the other side is morbidly ex- aggerated. Morever, attention to the pitch of the sound is of aid in appreciating a slight degree of dulness. The sense of resistance on percussion is also increased, as a rule, in proportion to the degree of dulness. The more important of the abnormal conditions giving rise to a greater or less degree of dulness irrespective of certain cases of emphysema, which have been referred to, are as follows : a. In some rare instances a disproportion between the solid struc- tures and the air takes place as the result of the reduction in the quantity of the latter, the former not being increased. An obstruc- tion may exist from the presence of a morbid product or a foreign body within the bronchial tubes, which resists the ingress of air to the cells with inspiration, but permits its egress with expiration. Collapse of more or less of the pulmonary lobules, under these cir- cumstances, may follow. The effect on the percussion-sound is to diminish the normal resonance, which depends, cceteris paribus, on the quantity of air contained in the pulmonary vesicles. b. A stratum of liquid between the pleural surfaces, either serum in hydrothorax or sero-lymph in pleuritis, may occasion more or less dulness on percussion. Liquid effusion is an infrequent cause, the quantity generally being sufficient to occasion total loss of reso- nance, or flatness, over a greater or less distance from the base of the chest upward. Instances, however, occur, in which, from ad- hesions of the pleural surfaces, a small quantity of these products may be confined within circumscribed limits, removing the lungs from the walls of the chest sufficiently to diminish but not abolish vesicular resonance. In cases in which a large quantity of liquid is contained within the pleural sac, the lung, of necessity, undergoes compression and condensation. Over the portion of the chest beneath which the condensed lung lies, the resonance is diminished, the reduction of the lung in volume increasing the proportion of solids to the quantity of air within the cells. At the summit of the chest, therefore, PERCUSSION IN DISEASE. 103 the percussion-sound is dull. With a less amount of liquid, an in- creased sonorousness frequently exists, modified in quality, which will be noticed under the head of Exaggerated or Vesiculo-tym- panitic Resonance. c. A very large accumulation of morbid products within the bron- chial tubes may be attended by slight dulness. This also is ex- tremely rare. Unless the quantity be so great as not only to fill the tubes, but distend them, and thus encroach upon the air-cells, the resonance on percussion is not appreciably lessened ; hence, as will be seen hereafter, in cases of bronchitis attended with very abun- dant expectoration, the normal resonance is not sensibly impaired. Skoda denies that appreciable dulness ever exists in cases of bronch- itis. This assertion is too positive, and does not accord with the observations of others. d. Congestion of the pulmonary vessels may exist to such an ex- tent that the blood, occupying space at the expense of the normal capacity of the air-cells, the resonance is diminished. Moderate or even considerable congestion does not produce this effect ; the engorgement must be great. A sufiicient degree obtains in some cases at least of pneumonitis, during the first stage, or stage of en- gorgement,* and in the hypostatic congestion of the dependent por- tion of the lungs taking place towards the close of life in various diseases. e. Inflammatory exudation within the air-cells which characterizes the second stage of pneumonitis, or the stage of solidification, occa- sions notable dulness. Here the cells themselves are to a greater or less extent filled with solid matter, supplanting, in proportion to its abundance, the air. The dulness will, cceteris paribus, be pro- portionate to the quantity of exudation, occasionally merging into flatness. When an entire lobe is partially, not completely, solidi- fied in pneumonitis, the dulness will be bounded by an oblique line 1 This appears to be denied by Skoda ; and since death rarely occurs from pneumonitis during the stage of engorgement, opportunities to demonstrate the correctness of the statement which has been made are not often obtained. In a case under my observation, in which a patient died with enormous dilatation of the heart shortly after an attack of pneumonitis, the limits of the lower lobe of the right lung had been marked on the chest by a line of obvious dulness on percussion ; and this lobe after death was found in the first stage of inflamma- tion, no solid exudation having taken place. The denial by Skoda is not in ac- cordance with the observations of others. 104 PHYSICAL EXPLORATION OF THE CHEST. pursuing the direction of the interlobar fissure, as in the case of flatness when a lobe is completely solidified. /. Effusion of serum within the air-vesicles of the lungs, is an- other morbid condition attended by dulness, provided the effusion be not sufficient to occasion flatness. g. Deposit of tuberculous matter within the cells is the most fre- quent in its occurrence of the morbid conditions giving rise to dulness. h. Carcinomatous infiltration of the pulmonary parenchyma, hap- pily extremely rare, occasions dulness, in the same manner as tuber- culous matter. i. Extravasation of blood, constituting pulmonary apoplexy, is another rare form of disease, producing the same effect in the same way. k. Tumors, morbid growths, aneurisms, and enlarged bronchial glands, are occasional forms of disease, which, according to the extent of encroachment on the thoracic space, lead either to diminu- tion or absence of resonance. In these various affections, percussion alone develops nothing be- yond the simple fact of the existence of some physical alteration giving rise to dulness. It affords no information in particular cases as to which one of the different morbid conditions exists. To determine this point the co-operation of other methods of exploration is requisite, taken in connection with symptoms, and the known laws of diseases. In certain cases, however, the situation of the dulness, irrespective of other signs, or of symptoms, is a sufficient ground for a strong presumption as to the nature of the disease. If the dulness extend over the space occupied by the lower lobe, especially of the right lung, it probably arises from pneumonitis, this affection being seated, in the great majority of cases, in the lower lobe, oftener of the right than the left side. If, on the other hand, the dulness exist at the summit of the chest on one side, the chances are greatly in favor of its proceeding from a tuberculous deposit, in view of the frequency of that disease, taken in connection with the fact that the deposit first takes place, almost invariably, at or near the apex of the lung on one side. But it is rarely, if ever, necessary to rely on the evi- dence afforded by one only of the methods of exploration, or to depend on signs to the exclusion of syraptons. And it is one of the great advantages pertaining to physical diagnosis that phenomena developed by different modes of examination may be brought to- PERCUSSION IN DISEASE. 105 gether, mutually serving to supply deficiencies, obviate liabilities to error, and combining to render positive the conclusions therefrom deduced. Diminished vesicular resonance, in different forms of disease, is ascertained by contrasting the two sides of the chest ; for, happily, the laws governing the pulmonary affections do not conflict with making one side a standard of comparison by Avhich to estimate the deviations from health on the other side. With very few exceptions, in cases of pulmonary diseases attended by deviations from the nor- mal resonance on percussion, either the affection is confined to one side, or it is more advanced on one side than on the other. This ■would almost seem to be an express provision for facility of diagnosis. In by far the greater proportion of cases in which the resonance on one side is diminished from a morbid cause, the fact is determined without difficulty : the disparity between corresponding points on the two sides is sufficiently obvious to be easily recognized. Occasion- ally, a delicate comparison is necessary. This is sometimes the case in the early stage of tuberculosis, when the morbid deposit is in the form of small disseminated tubercles. To appreciate a slight dul- ness which may be significant of the small physical change that has as yet taken place, observing all the precautions that have been pointed out, and repeating on corresponding points at the summit of the chest a succession of strokes as equal in every respect as possi- ble, the sound elicited on the two sides is to be compared as respects intensity, vesicular quality, and pitch. My observations have led me to regard attention to pitch as particularly useful in cases in which delicacy of discrimination is required.' A variation in pitch is more easily recognized than a slight disparity in the amount of resonance ; and in some instances the former may be distinguishable without difficulty, when the latter is inappreciable. The importance of attention to the pitch of percussion-sounds with a view to greater nicety and accuracy of discrimination, seems to me not to have been sufficiently appreciated by most writers on the subject of physical exploration. A late writer, indeed, whose views have attracted much attention, declares that variations in this respect are of little value in practice.^ It is worthy of remark, that in the classification of percussion-sounds by Auenbrugger, variations in this respect occupied the first rank, although with reference to this point, he was 1 See Prize Essay bj' author. 2 Skoda. 106 PHYSICAL EXPLORATION OF THE CHEST. misapprehended by his transLator and commentator, Corvisart/ a fact which may, perhaps serve to account for its having been subse- quently overlooked by others. In estimating the diagnostic value of a slight disparity in the sounds elicited by percussion on the summit of the chest, the fact that in but a small proportion of instances is there perfect corre- spondence in persons presumed to be in perfect health, and whose chests do not exhibit any apparent deviation from symmetry, is to be borne in mind. The rule found by observation to govern the differences compatible with health and good conformation, also has a very important practical bearing in diagnosis, viz., in the great majority of instances in which such differences exist, slight relative dulness is found on the right side. From this fact it follows that slight dulness, situated on the right side, is very likely to be due to a natural- disparity between the two sides; but situated on the left side, it proceeds from a morbid condition. In instituting a close comparison, as already remarked, care should be taken to make percussion on each side when the chest is equally expanded. This is to be done by requesting the patient to hold his breath after a full or moderate inspiration, until the com- parison is made. It is stated^ that in some cases of slight solidifi- cation from disseminated tubercles, the two sides may present a marked difference in the contrast between the sound elicited on the same side by percussing first after a full inspiration, and next after a forced expiration. The pathological significance of a disparity in this respect is impaired by the fact that it is sometimes observed in examinations of the healthy chest. In every instance in which a slight disparity between the tAvo sides of the chest is discovered, before concluding it to be a sign of present disease, it is to be ascertained whether it be not due to a want of symmetry in conformation, which may be so slight as to escape observation unless attention be directed to the point. Im- portant errors will be likely to be committed without the observance of this precaution. A slight deviation of symmetry arising from the position of the patient, will occasion a disparity of the reso- nance on the two sides of the chest. 3. Tympanitic Resonance. — Agreeably to the definition already 1 Notes to French edition of Skoda by the translator, Dr. Aran 2 Dr. Walshe and Dr. J. Husrhes Bennett. PERCUSSION IN DISEASE. 107 given, under the name tympanitic resonance are embraced all kinds of sonorousness which lack the special quality due to air in the air- vesicles; in other words, the resonance is tympanitic whenever it is devoid of the vesicular quality. It is proper to state that the term tympanitic resonance is not always used in so comprehensive a sense. By some writers the term is applied to an exaggerated res- onance without regard to its quality. It simplifies the subject and obviates confusion, to call all percussion-sounds tympanitic, which, however they may differ among themselves, agree in this, viz., they are non-vesicular. The most distinctive feature, thus, of tympanitic resonance, pertains to its quality. It may have any degree of in- tensity so long as it has the negative feature just named. It may be more or less intense than the normal vesicular resonance. The pitch of tympanitic resonance is always higher than that of the normal vesicular resonance in the person under examination. The variation of pitch in different cases is considerable; but to the statement just made there are no exceptions. Tympanitic resonance occurs in different forms of disease, and presents certain modifications, which, to some extent, are significant of particular morbid conditions. These modifications, which may be considered as forming varieties of this sign, will be noticed in connection with the different affections giving rise to the quality of resonance under consideration. Existing in a marked degree of intensity, exceeding that of nor- mal resonance, it becomes, combined with other circumstances, a sign quite distinctive of the presence of air or gas within the pleu- ral sac. This physical condition characterizes the disease called pneumothorax, or as air and liquid are usually combined in variable proportions, pneumo-hydrotJiorax. In this affection percussion over the space occupied by air, elicits a sonorousness totally devoid of vesicular quality, and which gives to the mind an impression of a hollow space of considerable size filled with air. So far as an idea of size is conveyed, it is what Skoda calls SifuU, in distinction from an empty sound. When the chest is greatly distended by a large accumulation of liquid and air, the degree of sonorousness is less than when the distension is but moderate ; the sound may become quite dull. This fact is probably due to the extreme tension of the thoracic walls. A similar phenomenon, as remarked by Walshe, is observed in a drum. "If a drum be tightened to the extreme 108 PHYSICAL EXPLORATION OF THE CHEST. point possible, and all escape of air from its cavity prevented, its sound, when struck, becomes muffled, toneless, almost null." The tympanitic resonance in pneumo-hydrothorax sometimes has a ringing metallic tone, resembling the sound produced by tapping lightly the back of the hand when the palm is applied firmly over the ear. This character of resonance is more apparent if percussion be made while the ear is applied to the chest. The presence of liquid effusion in cases of pneumo-hydrothorax may give rise to flatness on percussion below the inferior boundary of tympanitic resonance, and the relative portions of the surface of the chest over which resonance or flatness are found will serve to determine the relative quantity of liquid and of air. If the pleural surfaces be free from adhesions, the tympanitic resonance will, of course, exist at the superior portion of the chest, the body being in a vertical position. But inasmuch as pneumo-hydrothorax occurs oftener as an accidental complication of phthisis than otherwise, and since in the latter afi"ection adhesions generally take place to a greater or less extent, the air may be prevented from distending the upper part of the pleural sac. Under these circumstances, there may be a liability of attributing the tympanitic sonorousness due to air between the pleural surfaces, to presence of gas within the stomach. The situation of the space occupied by air will be found to vary with the position of the patient. Thus, if when the trunk is inclined far backward the space on the surface of the chest, within which the resonance is tympanitic, be marked on the chest in front, it may be considerably lessened by repeating the examina- tion when the trunk is inclined far forward. The same is true, of course, of the posterior surface. The level of the surface of the liquid may be ascertained as in ordinary pleurisy, or in hydrotho- rax, and this will be found to vary with different positions of the body, as in the diseases just named. The diagnosis of pneumo-hydrothorax does not rest exclusively on percussion, although the evidence afforded by this method is generally in itself quite conclusive. With an imperfect knowledge of the subject, however, there are liabilities to deception. Emphy- sema gives rise to exaggerated sonorousness, and a quality of reso- nance approximating to the tympanitic. It does not, however, lose entirely the vesicular quality. It is unaccompanied by the physi- cal signs of liquid effusion, and is distinguished by signs obtained by other methods. The whole of the left side is sometimes rendered PERCUSSION IN DISEASE. 109 highly tympanitic by distension of the stomach with gas. In such instances, aside from the distinctive circumstances which are not less applicable than in emphysema, the intensity of the tympanitic resonance is greatest at the lower part of the chest; and diminishes in proportion as percussion is made toward the summit, thus revers- ing the rule which obtains in most cases of pneumo-hydrothorax. Exaggerated and tympanitic resonance exists sometimes over the lower lobes when solidified in pneumonitis. On the left side this is not uncommon, and the explanation which at once suggests itself, refers the resonance to the transmitted gastric sound so frequently found in health at the inferior portion of the left side. On the right side it may be due to the presence of gas in the transverse colon. Tympanitic resonance, more or less intense, sometimes exists over consolidation of an upper lobe of the lung from pneumonitis or tuberculosis. Under these circumstances the resonance must come from the air in the trachea and the bronchial tubes without and perhaps within the solidified lobe. The sources of tympanitic resonance which have been named are, air or gas in the pleural cavity, air in the bronchial tubes, the upper lobe of the lung being completely solidified, and gas in the stomach, or when furnishing a resonance which may be conducted upward to a greater or less extent, especially when the lower lobe of the lung is solidified. Another source is air in pulmonary cavities. In the latter case, tympanitic resonance may be more or less marked within a circumscribed space or spaces corresponding to the situa- tion of a cavity or cavities. This will be referred to hereafter as one of the cavernous signs in pulmonary tuberculosis. Thus far tympanitic resonance has been considered as a non- vesicular sound differing in different instances only in intensity. It is occasionally presented with modifications of quality, which are significant of a special pathological condition. These modifications are araphorie resonance, and the cracked-metal sound. Amphoric resonance denotes a musical intonation, such as is sometimes elicited by percussing over the stomach, and which may be imitated by filliping the cheek Avhen the jaws are moderately separated and the integument rendered somewhat tense, as is done in the trick of imitating the pouring of liquid from a bottle. The percussion-sound occasionally assumes this intonation in pneumo- hydrothorax; and 'sometimes over the upper lobe in cases of solidi- 110 PHYSICAL EXPLORATION OF THE CHEST. fication from inflammation or tuberculous deposit. But in the great majority of the cases in which it occurs it is occasioned by a tuber- culous excavation of considerable size, and, of course, more or less empty. Although not an infallible sign of a cavity, the evidence is very nearly conclusive if it be confined within a circumscribed space, at the summit of the chest. The cracked-metal sound, as the name implies, resembles that produced by striking a cracked metallic vessel. It may be imitated by folding the palms of the hands loosely and striking the dorsal surface on the knee, in the manner frequently done to amuse chil- dren, producing a sound as if pieces of money were placed between the palms. This, like the ordinary amphoric resonance, usually denotes a cavity, but not invariably. It occurs in children at the summit of the chest in thoracic affections without excavation, and even when no pulmonary disease exists. Of this fact repeated ex- amples have fallen under my observation. The production of this sound is doubtless due to the air being suddenly and forcibly ex- pelled from a cavity communicating with the bronchi by free open- ings, precisely as the blow on the knee expels the air between the palms in the trick by which the sound may be imitated. To elicit the sound a forcible percussion is necessary, and a single blow is better than several strokes repeated in quick succession. The patient's mouth should be open. If the mouth and nostrils are completely closed the sign is not heard. This fact appears to de- monstrate the production of the sound in the manner just stated. When it occurs in children without the existence of a cavity, it is due to the air being expelled from the larger bronchial tubes as it is from an excavation. Percussion at the summit of the chest in children may be brought to bear on the bronchial tubes with greater effect than in adults, owing to the greater elasticity of the costal cartilages in early life. The sign, however, has been observed in adults in cases of consolidation of the upper lobe of the lung. I have repeatedly observed it in cases of pneumonitis in which the upper lobe was solidified. Occurring at the summit of the chest in a circumscribed space, especially if not near the sternal extremity of the infra-clavicular region, and if associated with symptoms de- noting advanced tuberculous disease, the cracked-metal resonance is almost conclusive evidence of the existence of a cavity, but the evidence may frequently be rendered complete by its association with other signs. PERCUSSION IN DISEASE. Ill It would be an error to suppose that either of the preceding varieties of tympanitic resonance is found, save in a certain propor- tion of the cases in which excavations in the lungs have taken place. For the peculiar sounds to be produced, the cavity must be of considerable size; the walls must be sufficiently rigid not to collapse when free of liquid contents ; it must be situated near the superficies of the lung, or the pulmonary substance between the cavity and the walls of the chest must be solidified; and other con- ditions may be essential, the importance of which is not so appre- ciable. Cavities resulting from circumscribed gangrene, or abscesses in connection with pneumonitis, do not embrace the necessary phys- ical conditions, and the signs are therefore chiefly significant of tuberculous excavations. They may occur in connection with pouch- like enlargement of the bronchi. Both varieties of tympanitic reso- nance may frequently be ascertained by means of Cammann's steth- oscope (percussion being made when the pectoral extremity of the stethoscope is brought near the open mouth of the patient) in cases in which it is not otherwise appreciable. By this application of auscultatory percussion, a light percussion stroke may be suffi- cient to elicit a well-marked cracked-metal or amphoric sound. Bringing the naked ear near to the open mouth of the patient assists in the recognition of this sound, when the stethoscope is not used. It has been already stated that a cavity may give rise to a well- marked tympanitic resonance on percussion, the sound being neither amphoric nor of the cracked-metal character. Under these cir- cumstances, how is a cavernous resonance to be distinguished from the resonance which in some cases of tuberculous disease is found at the summit of the chest prior to softening and excavation? Guided by the evidence which percussion alone aff"ords, it would certainly be difficult, if not impossible, to make the discrimination. If a distinct tympanitic resonance be found within a circumscribed space at the summit of the chest on one side, the sound elicited around the border of this space being dull, the evidence of the ex- istence and situation of a cavity is very strong; and the evidence becomes quite conclusive if, the disease having been of considerable duration, and attended by pretty copious expectoration, it should be found, by percussing at different periods of the day, that the tympanitic resonance is sometimes present and at other times 112 PHYSICAL EXPLORATION OF THE CHEST. absent; tlic former being observed to occur after free expectoration, and the latter when there is reason to suppose that the cavity is filled with the morbid products which are expectorated. Occasion- ally a tympanitic resonance at the summit of the chest, on one side, is found to be suddenly developed in a circumscribed space in which previous dulness had been ascertained to exist, and this occurs after a more or less copious expectoration. Under these circumstances the evidence of a cavity is quite conclusive. The physical diagnosis of excavations, however, does not rest ex- clusively on the evidence afforded by percussion. Important signs are obtained by other methods of exploration, especially ausculta- tion. 4. Exaggerated or Vesiculo-tympanitic Resonance. — The terms exaggerated and vesiculo-tympanitic resonance are applied to a sign having the following distinctive characters : The intensity greater than that of the normal resonance in the person examined, the quality a compound of the vesicular and tympanitic, and the pitch more or less raised. The term vesiculo-tympanitic is descrip- tive of the quality just stated. Increase of intensity, as compared with the normal vesicular resonance, is an essential character of the sign. Were the intensity less than that of the normal vesicular resonance, the sign could not be distinguished from dulness. Rec- ognizing increase of intensity as essential, the sign cannot, of course, be confounded with dulness; but in cases in which the res- onance is exaggerated on one side of the chest, or in which the exaggeration is greatest on one side, there is a liability to the error of considerinor the resonance as dull on the side in which it is not exaggerated, or in which the exaggeration is less than on the oppo- site side. This error may alwa^'s be avoided by a comparison of the resonance on the two sides with respect to pitch and quality. Assuming the resonance to be more intense on one side of the chest than on the other side, the disparity must be due either to exagge- rated resonance on one side or to dulness on the other side. Now, if it be due to exaggeration of resonance on one side, the resonance on the other side being unaffected, or to the exaggeration being greatest on one side, the pitch of the sound will be higher on the side on which the resonance is greater, and the quality of the reso- nance on that side will be vesiculo-tympanitic as compared with the opposite side. On the other hand, if the disparity be due to dul- ness on the side on which the intensity of resonance is less, the PERCUSSION IN DISEASE. 113 pitch of the sound will be higher on that side, and the quality more vesicular or in a less degree vesiculo-tympanitic. Whenever the resonance is morbidly exaggerated, provided the sound be not purely tympanitic, the quality is vesiculo-tympanitic and the pitch is always raised. Exaggerated or vesiculo-tympanitic resonance is an important sign as representing the condition existing in vesicular emphysema, viz., abnormal dilatation of the air-cells. In most cases of emphysema, the resonance is exaggerated; but, exceptionally, as already stated, owing, probably, to extreme tension of the pulmonary organs and the walls of the chest, the resonance is diminished, that is, there is dulness. Emphysema, excepting when it is circumscribed or con- fined to a few lobules, affects, as a rule, both lungs, the upper lobes being especially affected; but in the great majority of cases the emphysema is greater on one side. This is an important law with respect to the diagnosis. Were the emphysema equal on the two sides, it would be difficult to determine that the resonance was ex- aggerated, owing to the want of a disparity in resonance between the two sides. The greater exaggeration of the resonance on the side most affected, is easily determined; but it is to be borne in mind that relative dulness sometimes exists on this side. It is probable that wdien the lung on one side acquires an in- creased expansion in consequence of the lung on the other side being rendered useless by disease, as in cases of chronic pleuritis with large effusion, the resonance on the healthy side is exagge- rated. But this cannot be positively determined without knowledge of the degree of resonance existing prior to the disease; in other words, the standard of health, as regards resonance, is wanting in these cases. The fact of an exaggeration of resonance, under these circumstances, is of no importance in diagnosis. Exaggerated resonance is often found in cases of pleuritic effu- sion on the affected side above the level of the liquid, provided the quantity of liquid be not too great. If the liquid be not quite small, or, on the other hand, not rising much above midway from the base to the summit of the chest, the resonance above the liquid, as a rule, is more intense than in health, and the vesiculo-tympan- itic character is more or less marked. If the quantity of liquid be sufficient to rise much above the middle of the chest, the condensa- tion, by pressure, of the lung above the liquid, gives rise to dulness. The rule just stated with respect to exaggerated resonance above 114 PHYSICAL EXPLORATION OF THE CHEST. the liquid, is not invariable. It is less likely to exist when the pleural cavity has been filled and the liquid has decreased, than "when the liquid has not been sufficient to extend more than half way to the summit. Dulness in tlie former case, and in exceptional cases when the pleural cavity has not been filled, may be due to lymph coating the upper portion of the lung. The increased sono- rousness above the liquid may lead to the error of supposing that dulness exists on the healthy side; and, if the examination be limited to the summit, the disease maybe supposed to be pulmonary tuberculosis. I have known this error to be committed. It may always be avoided by attention to the pitch and quality of sound as already stated; the pitch is higher on the side which yields the most resonance, and the quality is vesiculo-tympanitic, whereas, if the disparity Avere due to dulness on the opposite side the pitch would be higher on that side and the vesicular quality less marked. In some cases of pleuritic efi"usion, the intensity of resonance above the liquid and the predominance of the tympanitic quality might lead to the suspicion of pneumothorax. This error may always be avoided by having recourse to other signs. In cases of pneumonitis affecting one lobe, the resonance over the other lobe of the same lung, as a rule, is exaggerated. The sign is more marked over the upper lobe when the lower lobe is solidified; but it exists over the lower lobe when the upper lobe is in the second stage of pneumonitis, I have repeatedly met with cases in which the upper and the lower lobe of the right lung were solidified, the middle lobe remaining unaffected; in these cases the resonance over the middle lobe is usually intense and notably vesiculo-tympan- itic. It follows from the rule just stated that, the existence of pneu- monitis affecting a lower lobe of one lung being known, the situation of the pneumonitis, that is, the side affected, may be ascertained by percussing over the upper lobe. Extensive solidification of the lower lobe from tuberculous deposit also renders the resonance over the upper lobe vesiculo-tympanitic. The rationale of the production of this sign over the healthy lobe when a lobe of the same lung; is solidified, and over lung situated above the level of liquid, has given rise to much discussion. A probable explanation is as follows: The presence of liquid and the expanded volume of the solidified lobe keep the affected side of the chest more or less expanded, and the consequence is, the proportion of air to solids, above the liquid, in pleurisy and in the TABULAR VIEW. 115 unafiected lobe in pneumonitis, is greater than in health. The con- dition, in fact, approximates to that in emphysema. Exaggerated resonance is not uncommon over an upper lobe con- taining a tuberculous deposit. Under these circumstances the sign is attributable to emphysematous lobules in the neighborhood of the tuberculous deposit. The coexistence of these two conditions is not infrequently found in autopsical examinations. TABULAR VIEW OF THE DISTINCTIVE CHARACTERS OF, AND THE PHYS- ICAL CONDITIONS REPRESENTED BY, THE SIGNS OBTAINED BY PER- CUSSION IN HEALTH AND DISEASE. Sign. Distinctive Characters. Phtsical Condition. 1. Normal vesicu- lar resonance. Variable intensity : pitch low and quality vesicular. Healthy lung. 2. Flatness or ab- sence of resonance. No sound. Liquid in pleural sac or in the air- vesicles ; complete solidification of lung ; displacement of lung by tu- mor or morbid growth. 3. Dulness, or di- minished resonance. Intensity less than in health, the lessened in- tensity varying between very great and very slight dulness, in different cases. The pitch higher than in health. Partial soliditication of lung from inflammatory, tuberculous, or other deposit; great vascular engorge- ment ; condensation due to mechani- cal pressure or collapse ; small pleu- ritic effusion and partial filling of air-cells with liquid ; accumulation of mucus in bronchial tubes ; exuda- tion of lymph on the pleuritic surface, and, exceptionally, dilatation of the air-cells in emphysema. 4. Tympanitic res- onance. Entire absence of the vesicular quality, and the pitch more or less raised. The intensity variable. Air in the pleural cavity (pneumo- thorax) ; tuberculous cavities con- taining air ; solidification of the up- per lobe, the resonance derived from air in the trachea and bronchial tubes, or the resonance conducted fropi the stomach and colon. Varieties of tym- panitic resonance : amphoric and crack- ed metal resonance. Musical intonation in the amphoric, and a chinking sound in the cracked metal variety. Generally tuberculous cavities ; sometimes obtained over the upper lobe solidified, and sometimes in health over the upper lobe. 5. Exaggerated or vesiculo - tympanitic resonance. The intensity greater than in health ; the qual- ity a compound of the vesicular and the tym- panitic, and the pitch more or less raised. Dilatation of the air-cells in em- physema ; obtained frequently over lung above liquid in the pleural cavity, and over a healthy lobe, the other lobe, or lobes, of the same lung being solidified. 116 physical exploration of the chest. History. Percussion was first proposed as a means of determining the nature and seat of diseases by Leopold Auenbrugger, born in Graetz, in Styria, in 1722. Auenbrugger was the author of two works on mad- ness, of a drama, and wrote on dysentery. His work on percussion was thus entitled: Inventum novum ex percussione thoracis Eumani, ut signo abstrusus interni pectoris morhos detergendi} The author died in 1809. The subject attracted scarcely any attention, and had fallen into oblivion, when thirty years afterward, the method was applied to the diagnosis of affections of the heart, by the distinguished French physician, Corvisart, who translated Auenbrugger's treatise into the French language in 1808. The latter was translated into English by Dr. Forbes, in 1824. The value of percussion was immeasurably enhanced by the dis- covery of auscultation. Of those who have cultivated the art of per- cussion, since the time of Corvisart, Piorry, of Paris, is the most prominent. Mediate percussion was introduced by him. He is the author of several works on the subject.^ In practice, however, he places too exclusive reliance on this method, rejecting auscultation; and he professes to achieve results with the pleximeter, to which others with equal ability, and not less conscientiousness, have failed to attain. The idea of combining auscultation with percussion may be said to have originated with Laennec. He resorted to it, however, to a very limited extent. The plan of practising the two methods, simul- taneously, with a view especially of determining accurately the situation and dimensions of the solid viscera encroaching on the thoracic space, which, although it has not come into general use, and perhaps never will, in consequence of the ordinary simpler modes being adequate to most of the objects to be obtained by percussion, originated with Drs. Cammann and Clark, of New York. 1 One cannot avoid an emotion of sorrow at the thought that Auenbrugger, who devoted seven years to researches, as he says, inter tedia et labores, could not have enjoyed during his lifetime the satisfaction of seeing the importance of percussion in some measure appreciated. In this respect the discoverer of auscultation was far more favored. 2 Trait6 de la Percussion mediate, Paris, 1828, and Du Proc^d^ operatif de la Percussion, Paris, 1831. The views of M. Piorry are also embodied in a more recent work, by one of his pupils, M. Maillot, Traite,de la Percussion mediate, etc. The latter has been translated into English, but not republished in this country. CHAPTER III. AUSCULTATION. The term auscultation is applied to the act of listening to the sounds produced within the chest, in connection with respiration, speaking, and coughing. The use of the term in this restricted sense is conventional. Properly speaking, the phenomena developed bjpercussion, involving, as they do, in their application equally an act of listening, should come within the domain of auscultation. There is, however, this distinction, viz., in percussion the sounds are pro- duced by the listener, whereas in auscultation they result from the actions, either instinctive or voluntary, of the patient. The ex- plorer, in the one case is an active agent in originating the impres- sions received through the sense of hearing ; in the other case he is little more than a passive recipient. Another point of difference is, that percussion may be practised on the dead as well as on the living body, while auscultation is available only so long as life continues. The act of listening to sounds emanating from the thorax, may be performed in two ways, viz., with the ear applied directly to the chest, or by means of a conducting medium. These two modes are distinguished by the same terms employed for an analogous purpose in percussion, viz., mediate and immediate.^ In immediate ausculta- tion, the sounds are received by the ear placed in immediate contact with the chest. 3Iediate auscultation requires an instrument which is interposed between the chest and the ear of the listener, through which the sounds are transmitted. This instrument is called the stethoscope, a term signifying chest-explorer. The question at once arises, of the two modes of practising aus- cultation, Avhich is to be preferred ? Each mode has its peculiar advantages, and neither should be adopted to the exclusion of the other. Immediate auscultation is the simpler mode ; it is in most cases practised more readily, and the exploration of the whole chest is more expeditiously made. In a large majority of cases, to one practically familiar with auscultatory phenomena, it suffices for all 1 These terms were first employed by Laennec, and subsequently borrowed and applied to percussion by Piorry. 118 PHYSICAL EXPLORATION OF THE CHEST. that is desired with respect to the diagnosis. With children, who are apt to be frightened at the appearance of an instrument, this mode is often more available. But in certain parts of the thoracic surface the ear cannot be applied, for instance, the axilla and the post-clavicular region. If the patient be so feeble as not to be able to be raised from the recumbent posture, and the bed be low, the position, on the part of the explorer, necessary to practise immediate auscultation, renders it inconvenient and difficult. The uncleanly condition of the patient is often not a trifling objection ; and with fe- males, delicacy, or, at all events, fastidiousness, may oppose a resort to this mode over the anterior surface of the chest. Mediate auscultation becomes almost necessary in some instances, in which it is important to isolate the phenomena produced at a par- ticular point from those of the surrounding parts. When the head is placed in apposition to the thoracic walls, sounds emanating from a considerable distance are brought within the focus of hearing, being conducted by the parts surrounding the ear which is in con- tact with the chest. With the stethoscope, the area whence the sounds are transmitted is more circumscribed, and this is an impor- tant advantage under some circumstances, as in seeking for the auscultatory signs of an excavation, or of tuberculous consolidation contained within a small space. In some cases in which the surface of the chest has been rendered very irregular by injuries, or deformi- ties, auscultation is available only by means of the stethoscope. Neither mediate nor immediate auscultation, then, is to be cultivated or practised to the entire neglect or exclusion of the other, but each is to be resorted to as it may be specially indicated, and frequently both employed in the same examination. The part performed by the stethoscope in auscultation was much exaggerated by the illustrious discoverer of this method of explora- tion, and is still misunderstood by many. The instrument is simply a conducting medium ; and the glory which will ever attach to the name of Laennec, as has been justly remarked, is in no measure de- rived from the invention of the stethoscope, but solely from the dis- covery of auscultation. A great variety of stethoscopes have been in use. Almost every one who has bestowed especial attention on this branch of practical medicine, seems to have felt it incumbent to originate an instrument possessing some one or more peculiarities, which frequently are of no practical importance. The material of which it is made, its size, length, form, etc., offer wide scope for AUSCULTATION. 119 diversity of construction. But the truth is, that if the sounds are conducted to the ear, the construction of the instrument is in a great measure a matter of taste or convenience. The first stethoscope con- structed by Laennec was composed of three quires of writing paper rolled compactly in the form of a cylinder and secured by paste. Afterward a cylinder of wood was substituted, and of this material the instruments employed since the time of Laennec have generally been made. Wood is not the best medium for the transmission of sound, but owing to its lightness, and some other recommendations, it is to be preferred to metal or glass, which are better conductors. Instruments have lately been constructed of gutta percha ; with these I have had no practical acquaintance. They are recommended as fulfilling all the conditions of a convenient stethoscope by com- petent authority.' It would be quite unnecessary, to say the least, to enter into a discussion of the numerous details pertaining to the length, size, form, etc., of the cylinder. It will suffice to notice, briefly, the general principles to be observed in its construction. Some (Hughes, Watson, and Blakiston) prefer solid wooden cylin- ders. Most of the instruments, however, in common use are per- forated through the centre, and the general impression is, that the sound is conveyed partly along the woody fibres, and in part by the column of air inclosed within the canal passing through the cylinder. Of the diff'erent kinds of wood, either cedar or ebony is usually selected from their lightness and straightness of fibre. The instru- ment should be of sufficient length for the head to be removed to a comfortable distance from the body of the patient ; but if it be too long, there will be difficulty in keeping it accurately adjusted to the .chest. Six to ten inches are the limits of a convenient length. The aural extremity should be broad and moderately concave, so as to receive the external ear, and admit of pressure upon the whole surface with the head, without closure of the meatus. Many stetho- scopes are faulty in these points; the aural extremity is too small, and the concavity either too great or insufficient. But the same instrument will not equally fit the ears of all persons, and, as Dr. Walshe remarks, "it is as necessary to try on a new stethoscope as a new hat." It is better that the ear-piece be of the same mate- rial as the body of the instrument. It is frequently made of ivory, which may be more pleasing to the eye, but diminishes somewhat the conducting power. The pectoral extremity should be trumpet ^ Dr. J. Hughes Bennett. 120 PUYSICAL EXPLORATION OF THE CHEST. or funnel-shaped, and not too large. A diameter of an inch or an inch and a half is sufficient. The edges should be rounded, so that the requisite amount of pressure shall not hurt the skin. For the sake of lightness, the body or stem of the instrument may be reduced in size to a cylinder of the diameter of half an inch, if the material be ebony, or an inch or so, if it be cedar. The exterior and the bore of the instrument should be smooth and polished, ^ith these data the student or practitioner might cause one to be constructed, or, imitating the example of Laennec, construct one with his own hands, without any model. Stethoscopes, however, are so common, that it is only necessary to select from a variety of specimens the one which appears best to combine the conditions just stated. Habit will be found to have much to do with the ease and facility with Avhich a particular instrument is employed ; and it is undoubtedly true that a stethoscope defective in certain points of construction will be preferred by one accustomed to its use, over another which is in reality superior, but to which he is not habituated. Flexible stethoscopes have been used to some extent, and by some preferred to the wooden cylinder. A flexible instrument several years ago was devised by Dr. Pennock, constructed of coiled me- tallic wire, covered with a silk or worsted web ; the pectoral ex- tremity consists of a metallic cone, and to the aural extremity a tube is attached, also of metal, which is introduced within the external ear. The chief recommendation of a flexible stethoscope is that it admits of application to di9"erent parts of the chest, without the necessity of much change of position on the part either of the patient or explorer. In some instances this is an important desideratum. The instrument is a sufficiently good conductor of the thoracic sounds. A disadvantage of it is, the pectoral extremity requires to be held in apposition to the chest with one hand, and the aural ex- tremity kept within the ear by the other hand. Sounds produced by the contraction of the muscles of the hands, and by friction on the instrument are apt to be commingled with those received from the chest. A little practice, however, enables the listener to dis- connect the latter and observe them separately. In this variety of stethoscope, if not indeed, in the ordinary wooden cylinder, the column of air appears to be the important conducting medium ; and, in fact, a common ear-trumpet, with a caoutchouc tube, answers the purposes of a stethoscope. M. Landouzy, of Paris, has suggested I AUSCULTATION. 121 a stethoscope ■with a number of gum-elastic tubes, by means of which several persons may auscultate simultaneously. A flexible stethoscope on a novel plan was invented about twelve years ago by the late Dr. Camraann, of Xew York. It consists of a bell-shaped pectoral extremity, made of ebony, about two inches in diameter, to which are attached two tubes of metallic wire covered with gum-elastic, and with the latter are connected two tubes of German silver, gently curved, and ending in ivory knobs, which are intended to be introduced within, and to fill accurately, the external ear on both sides. The sounds are thus received through both organs of hearing, and other sounds than those transmitted by the instrument are, in a great measure, excluded. In the construction of this instrument the agency of the column of air in conducting the thoracic sounds was established experimentally ; for it is stated that the solid media were changed many times without the conducted sound losing its intensity, and the sound was lost by making the pectoral extremity solid. Thoracic sounds are heard b}^ means of this instrument with great intensity, and they are rendered distinct when scarcely appreciable by the naked ear, or with the ordinary cylinder. In the latter respect it enlarges the application of aus- cultation by furnishing information in cases in which, by former modes of examination, the signs are not available. It also renders auscultation practicable for those whose sense of hearing is impaired. In the former edition of this work I stated that, in the conduction of thoracic sounds by Cammann's binaural stethoscope, their quality and pitch were altered, and that it was more difficult to make com- parisons of different sounds, in these respects, than with the wooden cylinder or by immediate auscultation. At that time the instrument had been quite recently invented, and I had used it for only a brief period. After having now used it almost daily for more than ten years, I am much better prepared to speak of its merits. The ob- jection on the score of the alteration of the pitch and quality of sounds I have long since found to be without foundation, and I am sure that this instrument will supplant all wooden stethoscopes as soon as it is fully appreciated. The power of conduction is greatly increased by the reception of the sounds simultaneously into both ears. Its superiority over instruments which conduct the sounds into one ear, is analoijous to that of the binocular over the mon- ocular microscope. The ease and comfort with which it is applied 122 PHYSICAL EXPLORATION OF THE CHEST. constitute not a small recommendation. The exclusion of other sounds than those conducted by the instrument is an important ad- vantage. In short, to become so much attached to it as to dispense entirely with other stethoscopes, one needs only to become accus- tomed to its use. Some practice is requisite to realize its value ; hence, many reject it after an insufficient trial, when, had they con- tinued to use it, they -would have been, after a time, unwilling to give it up. Since the first edition of this work was written, I have had several hundred private pupils in auscultation, and I have found that many, at first, are confused in using it ; but, invariably, after some practice, it is preferred, not only to other stethoscopes, but to the use of the ear applied directly to the chest, so that immediate auscultation is apt to be neglected in consequence. In the practice of auscultation it is important not to neglect the exercise of the ear without Cammann's stethoscope. It has been suggested that the use of the latter is likely to impair the sense of hearing when immediate auscultation is practised. There is no ground for apprehension on this score, provided exercise of the ear without the stethoscope be not neglected. In beginning to use the instrument the fact is to be borne in mind that it conducts all sounds as well as those which are from within the chest. Sounds produced by friction of substances upon it are to be avoided. The pectoral extremity must be applied to the naked skin to avoid extrinsic sounds. The pectoral extremity is to be held with the fingers in order to keep it firmly and equally applied to the chest. The elastic band connecting the metallic tubes should be sufficient to hold the knobs in the ear with the proper amount of force without the fingers being used for this purpose. The proper construction of the instru- ment is essential. The curves of the aural extremities, the size of the ivory knobs, the flexibility of the wire tubes which connect the metallic portion with the pectoral extremity ; the perviousness of both tubes, and the smoothness of the interior, are points which are to be properly attended to in the construction. Some of the instru- ments sold are worthless from defects in these or other points.^ This kind of stethoscope is well suited for auscultatory percussion, as pro- posed by Dr. Cammann, in connection with Prof. Clark. Dr. Alison, of London, has proposed, as a modification of Cam- 1 The instruments made by Tiemann & Co., No. 67 Chatham Street, New York, may be relied upon. AUSCULTATION. 128 mann's stethoscope, two pectoral extremities, so that sounds from two different situations may be simultaneously perceived. The object is to compare the sounds from the two situations. He calls the in- strument the differential stethoscope. The conduction of the sound into each ear is much weaker than when a sound is received into both ears ; the advantage of the binaui'al character of Cammann's in- strument is lost in the differential stethoscope. Moreover, a com- parison of sounds is not so easily made when they are heard together as when they are heard separately. Of this fact one may at once convince himself, by raising the inquiry whether notes from two diflferent musical instruments are best compared when produced simultaneously or successively. After some trial of the diflFerential stethoscope it has not seemed to me to be an improvement as regards the application of auscultation to pulmonary signs. Dr. Alison has also proposed, as an appendage to the stethoscope, the use of an india-rubber bag, filled with water, the bag being, when filled, of about the size of a large watch. This is to be applied to the chest, and the pectoral extremity of a flexible stethoscope placed upon it, the sounds being thus transmitted through the watei". Dr. A. calls the water bag the hydrophone, and claims that respira- tory sounds, healthy and morbid, are made by it more audible than when a simple flexible stethoscope, or Cammann's instrument, is used without this appendage. Other advantages are the facility with which it is applied to the chest, adapting itself to the intercostal de- pressions and other irregularities of the surface, and giving less pain if the chest be tender. It is not suited to the ordinary modern stethoscopes ; but it may be used satisfactorily with the ear applied directly upon it.^ I have lately compared with Cammann's instrument a binaural instrument, similar in all respects except that in the pectoral ex- tremity are placed two thin diaphragms of india-rubber, from two to three inches apart, the space between the diaphragms filled with water. The lower diaphragm being at the extremity of the instru- ment, the advantages of Dr. Alison's hydrophone, as regards the facility with which it is adapted to the walls of the chest, are se- cured. I am satisfied, however, that the power of conduction is impaired by this arrangement. With the diaphragms alone, that is, ' Vide Phj'sical Examination of the Chest in Pulmonary Consumption, etc. By Somerville Scott Alison, M.D., etc. London : 1861. 124 PHYSICAL EXPLORATION OF THE CHEST. without the water, the conduction is less than with the ordinary bin- aural stethoscope.^ In the performance of auscultation certain rules are to be observed, the more important of which may be here stated. Whenever prac- ticable, the person to be examined should be seated in a chair with a high back, furnishing a firm support for the shoulders, which are to be thrown moderately backward when the chest is explored in front. In examining the back a stool is preferable, or, if the patient be of the male sex, his position may be reversed, the face turned to the back of the chair ; the body should be inclined forward, and the arms folded as in practising percussion on the posterior surface of the chest. In exploring the lateral surfaces, the hands should be clasped upon the head, as when percussion is made in this situation. If the patient be confined to the bed, the chest in front may be ex- amined in the recumbent position, and afterward, if the disease be not accompanied by extreme debility, he may be raised, and sup- ported in a sitting position while the examination is made behind and laterally. It is sometimes the case that patients are too feeble to endure a sitting posture even for a short time. Inclining the body first on one side and then on the other, a partial exploration may be made under these circumstances by means of Cammann's stetho- scope. It is more satisfactory to divest the chest of all clothing, in order to judge better of corresponding points on the two sides to be explored in alternation. So far, however, as concerns the transmis- sion of sounds in immediate auscultation, this is not necessary. A single thin covering of cotton or linen offers little or no obstruction, but several thicknesses, or a thick woollen article of dress, interferes with the appreciation of auscultatory phenomena. If a covering remain, it should be soft and flexible, so as not to occasion a rustling noise from the movements of the chest, or by friction against the ear. In immediate auscultation, a soft napkin or handkerchief in- terposed between the skin and the ear, obviates the disagreeable circumstances often attendant on applying the head to the naked surface. A regard for delicacy may prevent complete exposure of the chest of the female. The portions, however, most important in 1 Dr. Charles L. Hogeboom, of this city (New York), has suggested as an im- provement of Cammann's instrument, extending across the pectoral opening a piece of parchment. The parchment should be tense, so as to be in contact with the skin and resist a certain amount of pressure. After some trial of an instru- ment thus prepared, the power of conduction seems to me to be somewhat in- creased without other change, and the source of the sounds appears to be circum- scribed by the addition of the parchment. AUSCULTATION. 125 cases in which a minute examination is most likely to be required, viz., the summit in front and behind, may, without impropriety, be divested of the dress. The temperature of the room should be prop- erly regulated, especially if the chest be exposed. This is impor- tant, not only to obviate the liability of the patient sufferino; injury from the impression of cold on the surface, but to prevent a difficulty which may interfere with the examination. The action of cold on the muscles of the chest sometimes occasions trembling movements, accompanied by a rumbling noise which obscures the intra-thoracic sounds, and without knowledge of this source of an exterior mur- mur, it might be supposed to emanate from within the chest. The position of the explorer should be one favorable for listening with attention, and which may be maintained for some time without fatigue or discomfort. If he assume a constrained posture his mind will be diverted from the object of the examination to his own sen- sations, and he will be unable to reserve his perceptions exclusively for the thoracic sounds. A stooping posture is, as much as possible, to be avoided, not only for the reason just mentioned, but because the gravitation of blood to the head induces a temporary congestion, which dulls the sense of hearing. It is not uncommon to see prac- titioners inclining their heads so low in performing auscultation that the face becomes deeply injected, and the veins largely dilated. I find it most convenient and comfortable to rest upon one knee. In this position, if the patient be sitting, the head may be placed in contact with the chest, and kept upright, or nearly so. Of course these precautions have reference to the practice either of immediate auscultation, or the use of the wooden cylinder. With Cammann's stethoscope the explorer may remain sitting by the side of the pa- tient, the latter lying, or seated, as the case may be. This is one of the recommendations of this instrument. The ear is to be pressed against the chest, in immediate ausculta- tion, with a certain amount of force. If the pressure be made too lightly the sounds are not transmitted, or an unnatural character may be communicated to them which may be mistaken for morbid phenomena. Thus the resonance of the voice by the non-observance of this rule, sometimes assumes a modification analogous to the physical sign called aegophony. On the other hand, if too great force be applied, pain may be occasioned sufficient to disturb the respiratory movements, or the expansion of the chest may even be impeded. Attention to this point, with practice, will enable the auscultator to hit the medium between the two extremes. If the 126 PHYSICAL EXPLORATION OF THE CHEST. cylinder be employed, the pectoral end should be evenly applied on the chest, and held in place with the fingers of the right hand until the ear is nicely adjusted to the aural extremity. The hand is then to be removed from the instrument, which is to be kept in place by means of pressure with the ear alone. In practising immediate auscultation it is well to accustom oneself to the use of either ear indifferently, if the sense of hearing be equally acute in both. An exploration of both surfaces of the chest can then be made without the necessity for change of position on the part of the explorer. Perfect silence in the apartment is at first necessary. The habit of mental abstraction, and the power to concentrate the attention exclusively on the thoracic sounds, are not generally acquired without more or less pains and perseverance. After a time, however, extrinsic noises are less troublesome, and an exploration may be made under unfavorable circumstances. The ability of acquiring the power to withdraw the senses and thoughts from surrounding objects is not equally possessed by all individuals, and it is owing in part to differences in this respect that some per- sons become much better auscultators than others. Every one ac- customed to physical exploration must have observed that the facility and satisfaction with which examinations are made, differ consider- ably at different times, owing to differences in the state of mental activity, preoccupation, etc. After auscultating for a time, the quickness and correctness with which thoracic sounds are perceived are liable to be impaired by fatigue. It is a useful caution, there- fore, not to continue this kind of investigation too long. From one to two hours of continuous exploration is sufficiently long without an interval of rest. The phenomena revealed by auscultation relate to the respiration, the voice, and the act of coughing, the latter being comparatively of little consequence. In listening to the respiratory sounds, the manner in which the patient breathes is a matter of importance. Mental excitement or apprehension often gives rise to more or less disturbance of the respiration. The breathing becomes hurried and irregular, and, on this account, the examination may be unsatis- factory, or even prove abortive. In persons of great nervous im- pressibility it is frequently necessary to wait until calmness is re- stored before proceeding with, or completing an exploration. As justly remarked by Fournet, the manner and bearing of the physi- cian have much to do with this point. If he wear a solemn mien, and favor by his looks or actions the idea that the examination is AUSCULTATION. 127 one of formidable import, he will be less successful than if he manage to divest it of repulsive features. It is generally desirable to cause the patient to breathe with somewhat more than ordinary force in the progress of the examination, and it is sometimes extremely difficult to effect this object satisfactorily. He accelerates the res- piration, or takes a deep inspiration and holds his breath, or in different ways alters the rhythm of the respiratory acts. The end desired is simply to render the breathing somewhat more intense without change in other respects ; and the best mode of securing the end is to breathe ourselves just as we wish the patient to do, requesting him to observe and imitate us as closely as possible. Another method is to request the patient to cough while the ear is applied to the chest, the respiration succeeding an act of coughing being deeper or fuller than ordinary. In some instances the res- piratory phenomena are not appreciable except the force of the breathing be voluntarily or involuntarily increased. It is necessary to caution the unpractised auscultator to avoid mistaking the noise frequently produced by the current of air at the mouth of the per- son examined, for sounds emanating from the thorax. The patient should be instructed to avoid making labial sounds, which tend to distract the attention, if they do not lead to the error just men- tioned. In auscultating the voice, the best plan is to cause the patient to count from one to three, repeating these numbers as often as may be requisite, with care to utter each numeral with the same tone and strength. In auscultation, as in percussion, the phenomena of disease are not, as a general remark, determined by reference to any fixed standard of health applicable alike to all individuals. It will be seen presently that auscultatory, not less than percussion sounds, differ widely within healthy limits. Here, as in the practice of per- cussion, a comparison is instituted between the two sides of the chest. The laws of disease, in a large proportion of cases, permit- ting one side of the chest to retain the phenomena of health, we are enabled to judge of morbid phenomena by means of a want of cor- respondence between the two sides. This remark does not apply to auscultation to the same extent as to percussion, for several of the phenomena revealed by the former are in themselves, irrespective of such a comparison, well-marked physical signs of disease. But in certain instances, as will be seen hereafter, a close comparison of corresponding points of the two sides is very necessary in deter- 128 PHYSICAL EXPLORATION OF THE CHEST. mining the existence of morbid phenomena. When this is the case, observance of uniformity in every particular in auscultating each side in succession is not less necessary than in practising percussion. The enunciation of this general rule will suffice, without stopping to dwell upon details. Comparison of points in exact correspondence, taking care to make an equal amount of pressure with the ear, causing the respiratory movements or the voice to be as nearly iden- tical as possible, etc., are points not to be overlooked when nicety of discrimination is involved in the diagnosis. Finally, to employ auscultation successfully, the explorer must be qualified by knowledge and practice to appreciate the sounds inci- dent to respiration and the voice, in the different aspects in which morbid deviations from health are liable to be presented: he must be prepared, in other words, to recognize the morbid signs which may exist, and to do this he must make himself conversant with their distinctive characters, first mentally, and afterwards practi- cally. Otherwise he is met by all the difficulties which the pio- neers in the cultivation of this field of research were obliged to en- counter; difficulties, thanks to the genius of the illustrious founder of auscultation, and the labors of his successors, no longer existing to retard and limit the progress of one who at this day aims to be- come a proficient in physical exploration. In the study of auscultation, as of percussion, the point of de- parture for investigating the signs of disease is an acquaintance with the phenomena pertaining to the healthy chest. The remainder of this chapter, therefore, will be divided into, 1. Auscultation in Health, and, 2. Auscultation in Disease. I. Auscultation in Health. It is essential to the application of auscultation to the diagnosis of disease, to become practically familiar with the sounds produced by respiration and the voice in health, for without this knowledge it would be impossible to determine whether sounds heard in cases of suspected disease are natural or morbid. In treating of Ausculta- tion in Health we are to consider the phenomena incident to respira- tion, to the voice, and to the act of coughing. AVe will consider these phenomena under separate heads. AUSCULTATION IN HEALTH. 129 I. PHENOMENA INCIDENT TO RESPIRATION. These phenomena are by no means the same in all parts of the respiratory apparatus. The respiratory sounds are widely different, according to. the sources whence they emanate. As distinguished by their origin, they may be arranged into two classes, viz. : 1. Those produced in the trachea and larynx; 2. Those produced in the air-vesicles. The phenomena thus incident to tracheal or laryn- geal and vesicular respiration are to be investigated separately, and contrasted with each other. 1. Tracheal or Laryngeal Respiration. — To auscultate the trachea the stethoscope is necessary, which is to be placed in front just above the sternal notch. Applied in this situation a sound is almost invariably found to accompany each respiratory act. The sound with both inspiration and expiration has a certain timbre or quality, conveying to the mind the idea of a current of air forcibly impelled through a tube of considerable size ; hence it may be dis- tinguished as a tubular sound. The respiratory and the expiratory tracheal sound present some differences, and merit separate notice. The sound with inspiration, if observed for some time, will be found to vary considerably with different respirations as regards intensity. Generally, it is intense with ordinary breathing, but it always be- comes much more so when the force of the breathing is voluntarily increased. The intensity with forced, but still more with ordinary breathing, differs considerably in different persons. Occasionally it is exceedingly feeble, almost inaudible, except when the force of the breathing is increased. Compared with the expiratory sound as re- gards intensity, it is frequently, but not generally, more intense in ordinary respiration, but almost invariably in these cases becomes less intense than the expiratory sound in forced breathing. In du- ration the inspiratory sound falls a little short of the period occu- pied by the inspiratory act. It attains its maximum of intensity quickly after the first development of sound, and maintains the same intensity to the close of the act, when the sound abruptly ends, as if suddenly cut off. As regards pitch, it may be remarked, that it is higher, i. e., more acute, or sharper, than the sound emanating from the air-vesicles. The expiratory, like the inspiratory sound, varies in intensity con- 9 130 PHYSICAL EXPLORATION OF THE CHEST. siderablj with dijOfcrent respirations, and is habitually feeble in some individuals, while it is strongly marked in others. This statement applies to ordinary respiration. When the respiration is forced, the sound almost invariably becomes intense. In tranquil breathing, its intensity is in some instances greater, and in some less, than that of the inspiratory sound ; but in forced breathing, it is almost invariably more intense. As regards pitch, it is more acute than the inspira- tory sound. Its duration, in the great proportion of instances, is somewhat longer than the inspiratory sound ; and this is more marked in forced than in ordinary respiration. Occasionally the sounds with the two acts are about equal in length. The expiratory, like the inspiratory sounds quickly attains its maximum of inten- sity, but instead of preserving the same intensity, it gradually be- comes weaker, and ends, not abruptly, but is, as it were, lost imper- ceptibly. The inspiratory and expiratory sounds are not continuous, but separated by a brief interval. The foregoing description is based on observations in forty-four healthy persons, the facts being noted at the instant of observation and afterward analyzed. The characters, then, distinctive of the tracheal respiration, taking, as a type, a respiratory act somewhat more forcible than in ordinary breathing, are as follows: A sound of inspiration and of expiration ; both having a tubular quality; both higher in pitch than the vesicular respiration ;' a short interval separating the two sounds ; the expiratory sound more intense, longer, and higher in pitch, than the inspiratory. The student should practically verify these characters, and impress them on the memory. They will be seen hereafter to have an im- portant practical bearing on the study of disease. The tracheal respiration, observed elsewhere than over the trachea, is a significant physical sign, of frequent occurrence. The laryngeal respiration is said by some writers on auscultation, to differ in a marked degree from the tracheal.^ I have recorded ' In order to appreciate this point of distinction in anticipation of the consid- eration of the vesicular respiration, the student may compare the two by listen- ing to the respiration with the ear applied to the chest after auscultating the trachea. ^ Ex. gr. Earth and Roger, "Sur le larynx meme le murmure varie encore; 11 ressemble a I'espece de souffle que determinerait I'entree de I'air dans une cavity AUSCULTATION IN HEALTH. 131 comparative observations made with care in eighteen persons, and in none of these instances were there any notable points of disparity- save in intensity. Frequently the respiratory sounds heard by placing the stethoscope on the side of the larynx were less intense than over the trachea. In other characters they were essentially identical. It is foreign to my purpose to enter into much discussion con- cerning the laws of physics by which auscultatory phenomena are to be explained. It is easy to understand why a column of air moving to and fro, with considerable velocity and force, through the trachea and larynx should give rise to a tubular sound. The sound may be imitated by blowing through a tube of uniform size, or through the larynx and trachea removed from the body.- The different characters pertaining to the inspiratory and expiratory sounds, may probably be readily accounted for, by reference to the different circumstances belonging to the two acts respectively. The force of the inspiratory movement is sustained equally to its close; hence the intensity of the inspiratory sound is maintained, and ends as abruptly as the act itself. On the other hand, the force of the expiratory movement is greatest at its beginning, and gradually diminishes; hence, a corresponding diminution in the intensity of the sound. The fact that the expiratory act involves more power, especially in forced breathing, explains the greater relative intensity of the expiratory sound; and its greater length, the corresponding longer duration of the sound. The higher pitch of the expiratory sound is due to the greater contraction of the glottis by the approxi- mation of the vocal chords in expiration, the space between the chords dilating regularly with inspiration. This approximation is greater in proportion as the respiration is forced, a fact which cor- responds with the more marked elevation of pitch under these cir- cumstances. (Introduction, pages 52 and 32.) The pitch and intensity of the tracheal respiration may be readily imitated by modulating breath-sounds with the mouth. Skoda has proposed to represent the respiratory sounds peculiar to different situations by means of whispered letters. A similar mode of estab- lishing types of cardiac bellows murmurs, was proposed by Bouillaud and Hope. Following Skoda, the letters cli^ soft, will represent a plus large; outre sa rudesse, il prend un caract^re caverneux beaucoup plus marqu6 et constitue le bruit respiratoire larynge." Op. cit. p. 36. 132 PHYSICAL EXPLORATION OF THE CHEST. tracheal sound. The pitch and loudness may be varied by gradu- ating the force with which the air is expelled when these letters are whispered, and altering somewhat the disposition of the lips. In this way may be reproduced the tubular inspiration, and the more intense, sharper sound of expiration, which characterize the respi- ratory sounds coming from the trachea and larynx. The tracheal respiration may be heard with distinctness, and sometimes with considerable intensity, when the stethoscope is placed on the neck behind, over the cervical vertebra. 2. Vesicular Respiration. — The respiratory sound heard over the chest is called the pulmonary or vesicular respiration or murmur. Both terms imply that the sound is produced within the air-cells or vesicles of the lungs. This is not strictly true. The vesicular respiration is a mixed sound, being partly due to the air entering the cells, in part to the current traversing the bronchial tubes, and to some extent, probably, in certain parts of the chest, to trans- mitted tracheal respiration. It is, however, true, that the predom- inant and distinguishing character of the vesicular respiration originates within the air-cells and bronchioles. Both terms are o therefore sufficiently appropriate, and the term vesicular is selected as the most distinctive, and the one generally adopted. In treating of the vesicular respiration, the facts of interest and importance in a practical point of view, will be found to relate mainly to 1. The characters which distinguish this variety of respi- ration from the tracheal or laryngeal ; 2. The variations within the limits of health observed in different persons, and on examinations of corresponding situations on the two sides of the chest in the same person; 3. The different modifications presented in different regions on the same side. The point first claiming attention is the first of the foregoing three divisions, viz., "The characters which distinguish this variety of respiration from the tracheal or laryngeal." In considering this point, inasmuch as the vesicular respiration in every part of the chest is not in all respects identical, some region is to be selected as furnishing a type of this species of respiration. A region con- venient for this purpose is the summit of the left lung a little below the clavicle, midway between the acromial and sternal extremities. On auscultating the summit of the left side, at the point mentioned, either immediately, or with the stethoscope, a sound more or,less AUSCULTATION IN HEALTH. 133 intense is generally found to accompany the Inspiratory act. Com- paring tliis sound with that heard over the trachea or larynx, it is found to present a striking difference in quality. Instead of being tubular, it has a quality difficult to describe, but which the student will readily appreciate on making the comparison practically. The words soft^ breezy^ expansive^ are applied to it. It is compared to the slightly audible breathing heard at a little distance from a person in deep, quiet sleep; to the sound produced by a gentle breeze among the branches and leaves of trees; to that of a pair of bellows the valve of which acts noiselessly ; to softly sipping the air with the lips, etc. These comparisons are but rudely approxi- mate, and are of little value, since it is so easy to become familiar with the sound itself by practising auscultation for a few moments on the chest and trachea, alternately, of a healthy person in whom the vesicular respiration is tolerably developed. This special quality it is convenient to designate the vesicular quality, an expression which will be frequently used in the following pages. The vesicular quality of respiration, as of percussion, is that peculiar kind of sound, not suggesting a priori the existence of cells, but due in a great measure, at least, to the cellular arrangement of the lungs. In what manner is this vesicular quality of sound generated? I shall not discuss this, more than other questions relating to the mech- anism by which auscultatory phenomena are produced. It is gene- rally attributed, after Laennec, to the friction and vibrations caused by the air expanding the cells in the inspiratory act. May not the peculiar quality be owing to the separation of the walls of the cells or bronchioles, which, to a greater or less extent, are in contact, and, owing to the moisture of the tissues, become slightly adherent during the partial collapse of the lung at the end of an expiration? We shall see hereafter that this is the most rational explanation of an important and highly distinctive physical sign of disease,^ viz., the crepitant rale. The fact that the air does not circulate freely in the air-cells and bronchioles with each inspiratory act, renders probable the explanation suggested by the foregoing inquiry. Other facts supporting this explanation are, the increase of this peculiar quality of sound in the inspiratory act which succeeds a 1 Dr. Hyde Salter appears to show conclusively that the bronchioles have more to do with the production of the murmur than the air-cells. Vide "On the Na- ture and Cause of the liespiratory Murmurs." 134 PHYSICAL EXPLORATION OF THE CHEST. forced expiration in the act of coughing; the diminution of the quality in cases of permanent dilatation of the air-cells, or emphy- sema, and the limitation of the quality to the inspiraiory sound. The inspiratory sound is some'what longer in duration than the tracheal. Like the tracheal it is continuous, augmenting in intens- ity from its commencement to its termination, and ending rather abruptly. It is notably lower in pitch than the tracheal inspira- tion. As stated by Skoda, the average pitch of the vesicular inspi- ration may be represented by the consonant v or 6, whispered. In a certain proportion of instances, an expiratory sound is ap- preciable. In this respect the vesicular respiration presents a striking point of contrast with the tracheal, the act of expiration constantly producing a sound Avithin the trachea. The difference is not less striking in other respects. The expiration, when present in the vesicular respiration, is nearly or quite continuous with the sound of inspiration ; not following a brief, but distinct interval, as in the tracheal respiration. This statement holds good, ex- cept when the person examined, increasing voluntarily the force of the respiratory movement, holds the breath for an instant after completing the act of inspiration. The duration of the expiratory sound, considered relatively to that of the inspiratory, is much shorter than in the tracheal respiration. In the latter it is as long and not infrequently longer than the sound of inspiration. In the vesicular respiration the expiratory sound is estimated by Fournet to average one-fifth the duration of the inspiratory. This estimate is perhaps not far from the truth, ^ but the relative duration varies considerably in different persons, in some being less than a fifth, in others a quarter, a half, and occasionally, but very rarely, except as an effect of disease, bearing a still larger ratio. The intensity, as compared with that of the inspiration, is much less. According to Fournet, numerically expressed, it is as much below that of the inspiration, as the duration is less, viz., one-fifth. The reverse of this rule obtains in the tracheal respiration. The pitch of the ex- piratory sound on the left side, certainly in the great majority of instances, is lower than that of the inspiratory. It is represented, according to Skoda, by a sound falling between the whispered con- 1 Barth and Roger and "Walshe make the average duration greater, viz., one- third that of the inspiration. The mean duration might be obtained with accu- racy, but it is not a matter of practical moment. AUSCULTATION IN HEALTH. 135 sonants / and Ji. Here, too, the rule is the reverse of that which governs the tracheal respiration. In the latter, the pitch of the expiratory sound is higher than that of the inspiratory. The ex- piratory sound is a simple blowing sound, being devoid of the ve- sicular quality which characterizes the sound of inspiration. To recapitulate, the distinctive characters of the tracheal respiration on the one hand, and of the vesicular respiration on the other hand, as developed by the comparison just made, arranged in parallel columns are as follows: Tracheal or Laryngeal Kespira- Vesicular Eespiratiok. TION. Inspiration. Inspiration. 1. Tubular in quality. 1. Vesicular in quality. 2. In duration falling somewhat short 2. Longer in duration, of the inspiratory act. 3. High in pitch. 3. Low in pitch. Expiration. Expiration. 1. Uniformly present in tracheal res- 1. Absent in about one-third of the piration. cases. 2. Generally more intense than the 2. Intensity much less than that of inspiration. the inspiration. 3. As long or longer than the sound 3. Much shorter than the sound of of inspiration. inspiration. 4. Higher in pitch tlian the inspira- 4. Lower in pitch than the inspira- tion, tion. 6. The inspiration and expiration sep- 5. The inspiration and expiration arated by an interval. continuous. The vesicular respiration presents marked differences in different persons, not only of the same age and sex, but apparently with chests similar in conformation. In intensity it is far from uniform. In some persons it is with diflBculty appreciable, and in some it can- not be heard even when the force of the respiration is voluntarily increased. In others it is comparatively intense. Between these extremes there is every grade of intensity. In the same person the murmur often differs considerably in intensity with different respirations, with some being perhaps loud, while with others it is feeble, and sometimes inappreciable, these fluctuations being ob- served during the few moments that the ear is applied to the chest. In pitch and quality of sound the respirations in the same person appear to be identical, whether feeble or intense; and forced respi- rations compared with tranquil breathing, do not show any change 136 PHYSICAL EXPLORATION OF THE CHEST. except in an increased intensity. It is heard with greater intensity by immediate, than by mediate auscultation, provided the ordinary cylinder be employed; but with Cammann's stethoscope, the intensi- ty is much greater than with the ear applied directly to the chest. It may be distinctly appreciated with Cammann's stethoscope, when it is not heard with the ordinary cylinder or the unaided ear. The expiratory sound, which, as has been seen, is present in some persons and absent in others, varying also in relative duration, is sometimes discovered by immediate auscultation, when it is not heard Avith the cylinder; and in some instances may be rendered distinct by Cammann's instrument, when it is inappreciable by the ordinary stethoscope or the ear alone. My recorded examinations of healthy chests contain illustrations of these facts. Sex and age exert a decided influence on the intensity of the vesicular respira- tion. In early life the intensity is marked, so that a morbidly in- tense vesicular murmur, after Laennec, is frequently distinguished as puei'ile respiration. In old age, on the other hand, the intensity is diminished, a change to be attributed to the attenuation of the walls of the air-cells which attends advanced years. At the same time the expiratory sound becomes relatively more developed and longer. The respiration thus modified by age is distinguished as senile respiration. In females, as a general remark, the respiratory sounds are more intense than in males. This is true more especially of the respiration at the summit of the chest. In other respects than intensity, differences are observed in the respiratory sounds in different persons. The degree of vesicular quality and the pitch are not uniform. Auscultating a number of persons in succession, in no two perhaps will the murmur, as regards these characters, be identical. These diversities do not impair the usefulness of auscultation more than a similar want of uniformity in the phenomena obtained by per- cussion affects the latter method of exploration ; because in both instances, deviations from health are not determined by reference to any fixed, abstract standard, as regards intensity, pitch, etc., but by a comparison of the two sides of the chest. The expiratory sound, as already intimated, differs from the inspi- ratory not only in duration, intensity, and pitch, but in quality. It is devoid of the vesicular quality which characterizes the inspiratory sound, and is feebly blowing. It remains to consider the variations in the characters of the AUSCULTATION IN HEALTH. 137 respiration observed on comparative examinations of corresponding situations on the two sides of the chest in the same person ; and the different modifications presented in different regions on the same side. I shall proceed to give the results of a series of recorded examina- tions of healthy persons with reference to a comparison of the respi- ratory phenomena, first at the summit of the chest and afterwards in the regions elsewhere, omitting many of the details contained in the former edition of this work. I have confirmed the correctness of these results by a great number of observations since the date of the publication of the former edition. Right and Left Infra-Clavicular Region. — The respiratory murmur has certain modifications in this region at and near the sterno-clavicular junction, which will be noticed after having con- sidered the murmur in the remainder of the infra-clavicular region on the two sides. Abnormal modifications of the murmur in this region are of great importance in their bearing on the diagnosis of tuberculous disease ; hence, it is highly desirable to determine the points of disparity and the variations consistent with health, in order that they may not be mistaken for morbid signs. The inspiratory sound in the majority of cases is not of equal in- tensity in this region on the two sides. The intensity is almost in- variably greater on the left side. This statement is opposed to that of some authors ;^ but the matter is purely one of observation, and as my examinations have been made with care and with no expecta- tion of such a result, I am bound to assume their correctness, I can only account for the opinion that the inspiratory sound on the right side is often more intense than on the left side, by supposing that elevation of pitch has been mistaken for increased intensity. The disparity in intensity is sometimes marked. The intensity of the inspiratory sound is sometimes notably increased by forced breathing on the left and less so on the right side. In the majority of cases, there is a disparity as regards the pitch of the inspiratory sound; the pitch is lower on the left, or, per contra^ higher on the right side. The vesicular quality is more marked on the left side. The expiratory sound is oftener wanting on the left than on the right side ; in other words, it may be heard frequently on the right and not on the left side. Not very infrequently the expiratory sound is prolonged on the right side to nearly or quite the length 1 Bartli and Roger and Gerhard. 138 PHYSICAL EXPLORATION OF THE CHEST. of the inspiratory sound. This is never observed on the left and not on the right side. The pitch of the expiratory is sometimes higher than that of the inspiratory sound on the right side; this is very rare on the left side. The sound of inspiration and of expira- tion are sometimes separated by a brief interval on the right side, and this is very rarely, if ever, observed on the left side. The foregoing points of disparity between the two sides in this region, exclusive of the sterno-clavicular portion, show that the respiratory murmur on the right side, as compared with the left, is analogous to the morbid sign which will be considered hereafter under the name broncho-vesicular respiration. In a few instances I have found in healthy persons, Cammann's stethoscope being used, a prolonged high-pitched expiratory sound over the whole of the infra-clavicular region, identical with the expiratory sound in the tracheal or laryngeal respiration, and in the morbid sign called bronchial or tubular respiration. In these instances the pitch of the expiratory sound was higher on the left than on the right side. The points of disparity presented in the account just given, may be seen at a glance by reference to the subjoined table: Comparison of Eight and Left Infra-Clavicular Kegion. Inspiratory sound. Right side. Left side. Intensity less. Greater intensity. Vesicular quality less marked. Vesicular quality more marked. Pitch higher. Pitch lower. Expiratory sound. Right side. Left side. Present on this and not on left side Never present on this side and want- in some cases. ing on the right side. Greater intensity. Intensity never greater. Not infrequently prolonged. Karely prolonged. Interval sometimes between the two The two sounds continuous, sounds. Pitch sometimes higher than that of Pitch more rarely higher than that inspiration. of inspiration. In the sterno-clavicular portion of the infra-clavicular region, the respiratory murmur is apt to be notably modified by sounds coming from the bronchial tubes exterior to the lungs and from the trachea. The intensity of the murmur in this situation is greater sometimes on the left and sometimes on the right side. The pitch AUSCULTATION IN HEALTH. 139 of the inspiratory sound is higher on the right side. The quality of the inspiratory sound on both sides differs from the normal murmur in other situations in being a compound of the vesicular and tubular, and the pitch is raised in proportion as the tubular quality predominates. The expiratory sound, in this situation, is sometimes more intense than the expiratory. In this respect there is often a disparity between the two sides, and the greater intensity of the expiratory sound is always on the right side. The pitch of the expiration is generally higher on the right side ; but to this rule there are exceptions. The respiratory murmur in the situation now referred to has been called the normal bronchial respiration. This name implies identity with the morbid sign called bronchial respiration, and in this respect it is incorrect. The inspiratory sound is not purely tubular in quality, as it is in the bronchial respiration of disease, and as it is in the normal, laryngeal, and tracheal respiration. It is a mixture, in variable proportions, of the vesicular and the tubular quality, the pitch being high in proportion as the tubular quality predomi- nates ; hence, the characters are those of the broncho-vesicular respi- ration of disease to be presently described. The same modifications extend more or less to the respiratory murmur over the remainder of the infra-clavicular region. A prolonged, intense, high-pitched expiratory sound, heard near the sterrium, and sometimes over the whole of the infra-clavicular region, doubtless comes from the tra- chea and bronchial tubes exterior to the lungs, and if this kind of expiratory sound exist on both sides, the pitch is higher on the left side. The inspiratory sound is modified in a greater or less degree, in different persons, by the combination in variable proportions of the sound emanating from the air-tubes and the sound produced in the air-cells. Without knowledge of the facts presented in the foregoing ac- count of the respiratory murmur in the infra-clavicular region, it can hardly be otherwise than that errors will be committed by mis- taking for the physical signs of disease, characters which are found in healthy persons. The normal vesiculo-tubular quality of the in- spiratory sound on the right side, as compared with the inspiratory sound on the left side, and the prolonged expiratory sound, are not infrequently considered as denoting a tuberculous deposit. The post-clavicular region may be examined by auscultation, the stethoscope being requisite in this situation. The caution inculcated 140 PHYSICAL EXPLORATION OF THE CHEST. by Laennoc, is important to be borne in mind in applying the stetho- scope above the clavicle, viz., to avoid pressing the instrument in a direction toward the trachea. The tracheal sounds are liable to be conducted to the ear if attention be not paid to this point. Pressure of the stethoscope in this region may develop an arterial murmur, which is to be distinguished from a respiratory sound by observing that it is synchronous with the pulse, and persisting when the move- ments of respiration are voluntarily arrested. The vesicular respi- ratory sound is readily discovered in the post-clavicular region if it be tolerably developed below the clavicle in the person examined. With respect to a comparison of the two sides, I have not noted ob- servations. In a single instance in which the phenomena were re- corded, care being taken not to incline the stethoscope toward the trachea, the inspiratory sound was more intense on the left side, and no sound of expiration appreciable on that side; but on the right side, after an interval, a well-marked expiratory succeeded the in- spiratory sound, and higher in pitch. Right and Left Scapular liegion. — In the upper scapular re- gion, i. e., over the scapula above the spinous ridge, the respiratory murmur is less intense than in front, but it may generally be heard, especially if Caramann's stethoscope be used. The inspiratory sound in some persons has greater intensity on the left side, and the vesicular quality is more marked on this side. The vesicular quality, however, is less appreciable over the scapular regions than in any other parts of the chest. The expiratory sound is not infrequently prolonged on the right side. In short, the murmur on the right side, as compared with the left side, may have vesiculo-tubular char- acters more or less marked. In the lower scapular region, i. e., below the spinous ridge, the respiratory murmur is heard pretty constantly'', and is more intense than in the upper scapular region, although less intense than in front, the vesicular quality being less apparent than in other parts of the chest. In this region, as above the ridge, the intensity of the inspiratory sound, in some persons, is greater on the left side, and the pitch higher on the right side; the expiratory sound on the right side may be prolonged, and it may be higher in pitch than the inspiratory sound. The vesiculo-tubular characters are thus, in some persons, more or less marked on the right side, as compared with the left side. Inter-scapular Region. — In the upper and the middle portion of AUSCULTATION IN HEALTH. 141 this region, the respiratory murmur has essentially the same char- acters as the murmur in the sterno-clavicular portion of the infra- clavicuhir region, that is, the modifications arising from the proximity to the bronchial tubes exterior to the lungs, and the trachea are more or less marked. The differences between the two sides are also essentially the same as in front. The differences between the two sides of the chest at the summit, in front and behind, compatible with a healthy condition of the thoracic organs, are generally attributed to the difference in size, length, and direction between the two primary bronchi. Fournet denies that this difference is sufficient to occasion any disparity in the auscultatory phenomena. But he also denies the fact of the existence of any disparity between the two sides as respects these phenomena. Other causes may be involved, but that the one just mentioned, if not in itself adequate to account for the disparity, is more or less concerned in its production, is rendered probable by the following experiment : The larynx, trachea, and primary bronchi, with some of the larger subdivisions of the latter extending an equal length on each side, were detached from the pulmonary organs and removed from the body. Then, by means of a large pair of bellows, the nozzle of which was inserted into the larynx and secured by a ligature, a current of air was made to traverse the bronchial tubes, first on one side and afterward on the other side, by com- pressing alternately the right and left bronchus wath the finger. Comparing the sounds thus produced, which were quite loud, it was very obvious that the sound produced by the current of air driven through the right bronchus and its subdivisions was more intense and higher in pitch than that produced within the left bronchial tubes ; care being taken to place the two bronchi as nearly as pos- sible in their natural position as regards their angular relation to the trachea. This experiment was repeated numerous times in the presence of several medical gentlemen, and also in the lecture-room before a large class of medical students. The disparity just stated was not less obvious to others than to myself. When the current was made to traverse the bronchial tubes on both sides simultaneously, it was easy to perceive a difference in intensity and pitch on bringing the ear in close proximity to the bronchial tubes, first on one side, and then on the other side. The result of this experiment may seem at first to be inconsistent with the fact that the inspiratory sound on the left side is frequently 142 PHYSICAL EXPLORATION OF THE CHEST. more intense than that on the right side. It is, however, to be borne in mind, that it is the sound produced within the vesicles on the left side which is more developed than on the right side. The respiration on the left side presents a more marked vesicular quality, at the same time that its intensity is generally greater. The latter, then, it is fair to conclude, is due to some cause connected with the air-cells, and not with the bronchial tubes. The greater intensity of the murmur from the air-vesicles at the summit of the chest on the left side, may be explained in part by the greater size of the left primary bronchus, and in part by the relatively greater descent of the diaphragm on the left side in the act of inspiration. Rigid and Left Infra- Scapular Regions. — In the infra-scap- ular region the respiratory murmur is almost uniformly appreciable. It is generally well developed, and frequently with forced breathing becomes intense. Here, as in other situations, a marked difference in intensity is often observed between the murmur developed by or- dinary and forced breathing : with the latter, in some instances, it is quite loud, when with the former it may be scarcely heard. As a rule, the intensity is greater than in the lower scapular region ; the vesicular quality is also more apparent, and the pitch somewhat lower. This rule is not without exceptions. The intensity in a small proportion of instances is about equal in the scapular and infra-scapular region ; so, also, as regards the vesicular quality and pitch. The variations between the two sides are decidedly less frequent and marked in this situation than in the regions before compared. In a few instances the intensity is greater on one side, and when this is the case, the greater intensity is almost uniformly on the left side. Occasionally the vesicular quality is more marked on the left side, and in a few instances the pitch is higher on the right side. The expiratory sound is almost uniformly lower in pitch than the sound of inspiration. I have noted an exception to this rule on the right side, and in this instance the sound was distant, an intense expiratory sound existing over the scapula on the same side. This case shows that it is possible for the tracheal or bronchial respiratory sound to be transmitted in the healthy chest to the ear applied below the scapula, — a fact important to be remembered, since this sound in that situation in the vast majority of cases is evidence of disease. Right and Left Mammary and Infra- Mammary Regions. — An in- AUSCULTATION IN HEALTH. 143 spiratorj sound is almost uniformly appreciable in these regions, but differing considerably in intensity in different individuals. The in- tensity is less than at the summit, with very few exceptions. The pitch is uniformly lower. The vesicular quality is, at the same time, more marked. In these three points of view, viz., diminished in- tensity, lowness of pitch, and more marked vesicular quality, the difference on comparison with the summit of the chest is sometimes greater on one side of the chest than on the other side. This fact is to be explained by the disparity which has been seen to exist at the summit in a certain proportion of individuals as regards inten- sity, pitch, and vesicular quality. Supposing the inspiratory sounds at the middle and lower portions of the chest to be equal, a com- parison with the sounds at the summit will, of course, not give iden- tical results if the two sides at the summit differ. Another expla- nation, applicable to a certain extent in some instances, is, the sounds over the middle and lower portions on the two sides are not equal. The latter is true but of a very small proportion of cases save with respect to intensity. An expiratory sound is rarely ap- preciable in the mammary and infra-mammary regions. Right and Left Axillary and Infra- Axillary Regions. — In the axillary and infra- axillary regions, an inspiratory sound, especially with forced breathing, is heard with as much and even more intensity than over any other part of the chest. It may be inappreciable in healthy chests, in some instances, for reasons that are apparent, as when the thorax is covered with a very thick layer of adipose de- posit; and in other instances Avhen no cause is apparent. As in other situations, the intensity differs considerably in different per- sons. The intensity is generally less in the infra-axillary than in the axillary region, and the pitch somewhat lower. Careful com- parison of the two sides, according to my observations, shows some points of disparity in the larger proportion of cases. Thus, of twelve examinations, in five no difference was apparent, and in seven there existed more or less inequality. The facts respecting the disparity in the seven cases in which it was noted, are as follows: the intensity was greater on the left side in three cases, and on the right side in three cases. The pitch was higher in four cases, all on the right side. The vesicular quality was more marked in three cases, all on the left side. An expiratory sound is heard in a much larger proportion of in- stances than over the middle and lower portions of the chest in front 144 PHYSICAL EXPLORATION OF THE CHEST. or behind. It is present in the axilla in some .instances and not in the infra-axillary region. II. PHENOMENA INCIDENT TO THE VOICE. The phenomena produced in health by the act of speaking, like those incident to respiration, differ in different portions of the res- piratory apparatus; and the vocal sounds may be arranged accord- ing to their situation, into 1st, those produced within the larynx and trachea ; 2d, those heard over the chest. The healthy phenomena in these situations incident to the voice, not less than those developed by respiration, represent sounds which, by a change of place, become the signs of disease. The more important of the vocal phenomena pertaining to morbid conditions may, in fact, be studied upon the healthy living subject. Moreover, here, as in the case of the res- piratory phenomena, variations within the limits of health exist in different individuals, and in the same individual in corresponding regions of the two sides of the chest, which, without due knowledge and care, are liable to be mistaken for the evidences of disease, giving rise, possibly, to serious errors of diagnosis. The study of the phe- nomena incident to the voice in health, therefore, merits close atten- tion, preparatory to entering on the subject of auscultation in disease. In auscultating for vocal sounds, in health and disease, the ear may be applied immediately to the chest, or the stethoscope may be employed. In general, the sounds are better appreciated and are more intense with the naked ear than with the ordinary stethoscope, and the latter is not only useless, but disadvantageous, except when it is desired to concentrate the examination upon a circumscribed space, or direct it to parts of the chest to which the ear cannot be satisfactorily applied. In listening to vocal phenomena with the ear alone, or with the cylinder, the sounds are heard better if the unoc- cupied ear be closed completely by pressure with the finger. By means of Cammann's stethoscope the sounds produced by the voice are rendered much more intense than by ordinary mediate or by immediate auscultation. Phenomena are made distinct by this in- strument, in some instances, when without it they are too feeble to be appreciated. The general rules and precautions to be observed in the practice of auscultation are alike applicable to the investiga- tion of vocal and respiratory phenomena. These need not be re- peated. We may cause the patient to speak by addressing to him AUSCULTATION IN HEALTH. 145 questions while the ear is applied to the chest; but a better mode is to request him to count, 07ie, two, three, in a distinct and tolerably loud voice, directing him to pronounce each numeral as nearly as possible with the same tone, distinctness, and degree of loudness, pausing a little between the numbers. The vocal phenomena of health and disease relate to the loud and to the whispered voice. Sounds obtained by whispered words have hitherto received but little attention. They will be found to consti- tute a highly important addition to the physical signs available for diagnosis. It will facilitate the comprehension of these signs to consider that a sound obtained with the whispered voice, always corresponds with the sound of expiration. Words are generally whispered with the expired breath ; a whispering sound, therefore, is neither more nor less than the sound produced by a forcible act of expiration. 1. Tracheal Voice — Laryngeal Voice — Tracheophony — Laryngophony. — If the stethoscope be placed over the trachea just above the sternal notch, and the person be desired to count in a moderately loud tone, the ear of the auscultator receives a com- bination of sensations. The voice occasions a strong resonance, accompanied by a concussion or shock, and, also, by a fremitus or thrill. The voice is concentrated and near the ear. The articulated words are sometimes transmitted so as to be heard almost as clearly as when received from the lips : in other instances they are conveyed with more or less indistinctness, and occasionally they are inappre- ciable. The resonance, the shock, the fremitus, and the complete or incomplete transmission of speech are the several elements which compose the phenomena embraced under the head of the tracheal voice. It will facilitate a clear apprehension of the vocal phenomena incident to the auscultation of different parts of the respiratory ap- paratus, to consider the tracheal voice as thus made up of different elements. These elements, in the great majority of instances, will be found to enter into the tracheal voice, the differences in different individuals consisting in variations in the degree, absolute and re- lative, which they present. The resonance, and shock, and fremitus, are generally strong. These three elements, as a general remark, appear to preserve a mutual relation ; that is to say, they participate about equally in the variations, as regards intensity, observed in different individuals. 10 146 PHYSICAL EXPLORATION OF THE CHEST. Yet they do not involve the same physical causes. The resonance is due to the reverberation of the voice within the tracheal space; the shock to the force given to the column of air by expiration in connection with its partial, sudden arrest by the act of speaking, and the fremitus to the vibrations of the tracheal tube, in conjunc- tion with those of the vocal chords. Collectively, they are more strongly marked in proportion to the strength of the voice and its gravity of tone. Hence, in females and children, they are com- paratively less prominent. If Cammann's stethoscope be applied over the trachea, the shock and resonance are felt with painful intensity, in some instances being quite unendurable; the articulated voice, or speech, however, is not conducted much better through this instrument than through the ordinary cylinder. The resonance of the voice and transmission of the speech are acoustic phenomena; the shock and fremitus are tactile sensations. The transmission of the speech more or less perfectly through the stethoscope is an interesting and important element of the tracheal voice, from the fact that when it occurs over the chest, as incident to disease, it constitutes the sign called Pectoriloquy. Pectoriloquy is said to be perfect when the articulated words are distinctly heard with the ear applied to the chest mediately or immediately. It is imperfect when the words are indistinctly heard. The types of perfect, and of the various grades of imperfect pectoriloquy, are fur- nished by auscultation of the trachea. Hence, by becoming prac- tically acquainted with this element of the tracheal voice, the student acquires, at the same time, an acquaintance with a morbid sign, the significance of which will be hereafter considered. The proportion of cases, however, in which perfect pectoriloquy is repre- sented by the tracheal voice is small, and the transmission of articu- lated words is quite independent of the preceding elements, viz., the resonance, shock, and thrill. This want of relation is further shown by the fact that a powerful and bass voice, which is most favorable for the elements last named, does not render the pecto- riloquous element more strongly marked. The foregoing vocal phenomena referable to the trachea are those which are occasioned by the voice when words are spoken aloud. When words are whispered there is little or no shock, nor thrill. These elements are either wanting, or comparatively slight ; but the whispered words are transmitted in some instances perfectly, and in other instances incompletely. This is identical with what is AUSCULTATION IN HEALTH. 147 called whispering pectoriloquy, when whispered words are received from any portion of the chest. The term pectoriloquy cannot of course, with strict propriety, be applied to the trachea, because its signification implies that the speech comes from the chest. From its derivation it signifies chest-talking. In connection with perfect or incomplete transmission of speech is a strongly mai'ked souffle or blowing sound. The latter follows the vocal sound, and appears as if a current of air were directed into the ear through the stethoscope. This blowing sound is also appreciable in some instances when words are spoken aloud. Its intensity is irrespective of the perfect trans- mission of the speech. It is sometimes intense when the transmis- sion of words is quite imperfect. Whispered words are oftener distinctly transmitted than Avords spoken aloud. If the stethoscope be placed on the broad surface of the thyroid cartilage, the vocal phenomena emanating directly from the larynx will be found to be resolvable into the same elements as are those proceeding from the trachea. The laryngeal voice does not present the marked differences, compared with the tracheal, which the student is led to expect from the writings of some authors; and in some in- stances the sounds in both situations are very nearly if not quite identical. As a general rule, the shock and vibration communicated to the ear are less than when auscultation is practised over the trachea. There are some exceptional instances in which they are of the same intensity, but very rarely, if ever, greater. The trans- mission of the speech is oftener perfect, and generally less incomplete. 2. Normal Thoracic Vocal Resonance — Normal Bronchial Whisper. — The resonance, over the chest, of the loud voice pre- sents important distinctive traits when contrasted with the tracheal or laryngeal voice; certain differences are frequently observed when corresponding regions on the two sides of the chest are compared, and the effect produced by the act of speaking in different portions of the same side are not identical. First, as contrasted with tracheophony, the resonance is much weaker ; in other words, it has much less intensity. It differs in not being constantly present ; not infrequently over portions of the chest no resonance is appreciable, at least with the ordinary stetho- scope and immediate auscultation, and in some persons it is absent over the entire chest. The sound is diffused, and seems farther re- moved from the ear. It is rarely accompanied by a sense of con- 148 PHYSICAL EXPLORATION OF THK CHEST. cnssion or shock. It is not always attended by fremitus or thrill, but in some instances, in certain parts of the chest, the latter con- comitant is strongly marked; and it is sometimes present in a degree which is out of proportion to the amount of resonance. Transmis- sion of the speech, in other words pectoriloquy, does not occur in connection with normal thoracic resonance, save as a very rare exception to the rule. Imperfect whispering pectoriloquy is occa- sionally observed ; and in some parts of the chest, the act of speak- ing in a whisper occasions a souffle or blowing sound, like that which attends the tracheal and the bronchial voice, but much less intense. These are the important points distinguishing the phe- nomena embraced under the appellation of the normal thoracic re- sonance as contrasted with the phenomena emanating directly from the larynx and trachea. The thoracic vocal resonance presents in different healthy persons even greater variations in degree than the vesicular respiration, due to differences in power of voice, gravity of tone, and other circum- stances not so obvious. There is not, therefore, in the one case, more than in the other, a certain normal intensity to be referred to as a standard for comparison. In both cases, equally, morbid vari- ations are not determined by reference to an abstract criterion, or to an average, but by ascertaining, as far as practicable, the degree of resonance natural to the individual ; and this is done by insti- tuting a comparison of corresponding situations on the two sides of the chest, taking advantage of pathological laws, in conformity with which, for the most part, disease is either confined to one side, or is more advanced on one side than the other. This rule of practice is based on the assumption that, in a condition of health, and pro- vided the conformation be symmetrical, the two sides of the chest furnish the same phenomena on auscultation. Measurably this may be assumed, and, as already remarked, it is a fundamental principle in physical exploration ; but we have seen that, as regards phe- nomena incident to respiration, this rule is practically not without important exceptions. The same is also true of the phenomena inci- dent to the voice. Hence, to avoid the error of mistaking normal dif- ferences for the signs of disease, it is highly important to become acquainted with the nature and extent of the deviations from equality which are within the limits of health. Fortunately, these deviations observe laws, the knowledge of which will secure against error of diagnosis, which would be unavoidable if such laws did not AUSCULTATION IN HEALTH. 149 exist. Proceeding to consider the vocal resonance in corresponding situations on the two sides of the chest, and in different parts of the same side, it will be convenient to pursue the same course as in treating of the respiratory phenomena under these points of view, taking up successively the more important of the thoracic regions, and giving the results of the analysis of a series of examinations of persons presumed to he entirely free from any disease of the res- piratory apparatus. Directing attention first to the summit of the chest, the different regions will be noticed in the same order as under the head of respiration. Infra-clavicular region. — The resonance of the loud voice is almost always appreciable in every part of this region. It varies much in different persons, being in some slight, and in others quite intense. Vocal vibration, thrill or fremitus, more or less marked, accom- panies the resonance in most persons, but is sometimes wanting ; it is sometimes more marked than the resonance. As regards a comparison of the two sides, in a very large pro- portion of persons the vocal resonance is distinctly greater in the right than in the left infra-clavicular region. This statement is op- posed to the opinion of Fournet,^ professedly based on numerous observations, viz., that a marked disparity in this region between the two sides is evidence of disease. And as regards the disparity, a law is invariable, viz., the increased resonance is always on the right side. The frequent existence of greater resonance on the right side has been well known to practical auscultators of late years. The fact was first pointed out by Stokes, and was confirmed by the researches of Louis.^ It is usually attributed to the larger size of the right primary bronchus. As regards the amount of disparity, it differs considerably in different persons. In some, a resonance is distinct on the right side, none being appreciable on the left. In some the difference is slight, in others more strongly marked, and occasionally the con- trast is striking. The thrill or fremitus is greater on the right side. It may be present on this side, and wanting on the left side. With whispered words, a souffle or blowing sound is in most per- sons heard over this region on both sides. Its intensity varies con- siderably in different persons. It is sometimes heard on the right 1 Op. cit., page 152, torn. 1. 2 Kecheiches sur la Phthisic, 1843, p. 533. 150 PHYSICAL EXPLORATION OF THE CHEST. and not on the left side. When heard on both sides, it is louder on the right side than on the left. A disparity between the two sides also exists as regards the pitch of this sound. It is higher in pitch on the left side. This whispering resonance of health may be called the normal hronchial whisper. As just stated, it is louder on the right, and higher in pitch on the left, side. These points of dis- parity correspond with differences pertaining to the expiratory sound of respiration on the two sides in this region ; this sound, when it comes from the bronchi, is louder on the right and higher in pitch on the left side. At the sterno-clavicular portion of the infra-clavicular region, the resonance of the loud voice has been called normal hronehopliony. The resonance has more intensity here than in other portions of the region, and the voice, in some persons, is concentrated, near the ear, and high in pitch ; in other words, it has, more or less marked, the characters which will be seen hereafter to distinguish the morbid sign called bronchophony. The bronchial whisper is sometimes nota- bly more intense here than elsewhere over the infra-clavicular region, and it presents the points of disparity, when the two sides are com- pared, which have been stated as pertaining to the whole of the re- gion. Whispered words are sometimes partially transmitted, con- stituting incomplete whispering pectoriloquy. Scapular region. — The resonance of the loud voice is generally more or less marked in this region. It is much less intense than at the summit of the chest in front, and is more distant and diffused. It is more intense in some persons above, and in other persons below, the spinous ridge. The intensity is uniformly greatest on the right side. The disparity in this respect varies in different persons, being sometimes slight and sometimes strongly marked. The intensity in this region, on either side, differs considerably in different persons. Vocal vibration, thrill, or fremitus, accompanies the resonance in some persons, but less frequently than in the infra-clavicular region. When present, it is most marked on the right side. It may be pres- ent on this side and wanting on the left side. The bronchial whisper is sometimes present and sometimes want- ing. It may be heard on the right and not on the left side, and ■when heard on both sides it is louder on the right side. Inter-scapular region. — The resonance of the loud voice in this region has the intensity which it has at the sterno-clavicular junc- tion in front, and in some persons it has here the characters of AUSCULTATION IN HEALTH. 151 bronchophon}'^, more or less marked. The intensity is greatest on the right side. This is true also of the bronchial "whisper. The latter is loudest on the right side, and higher in pitch on the left side. Infra'8capular region. — In a large majority of persons, the reso- nance of the loud voice in this part of the chest is greater than over the scapula. The resonance in some persons is quite as intense in the infra-scapular as in the infra-clavicular region. Here not less than elsewhere, the intensity varies in different individuals. In much the larger proportion of instances, also, there is greater res- onance on the right than on the left side. The resonance is dif- fused, distant, and the pitch low, these characters being in contrast with those of bronchophony. A thrill or fremitus frequently ac- companies the resonance. It is almost uniformly more marked on the right side, if present on both sides, and it may be present on the right and not on the left side. The bronchial whisper is often wanting in this region on both sides. When heard, it is generally slight or feeble. It may be heard on the right and not on the left side. Mammary and infra-mammary regions. — The resonance of the loud voice in these regions is uniformly less than at the summit of the chest in front, and in the inter-scapular region. It is distant, diffused, and of low pitch, in these characters contrasting with bronchophony. The intensity is greater on the right side. Vocal vibration, thrill, or fremitus, accompanies the resonance in some persons, either limited to the right side, or, if appreciable on both sides, more marked on the right side. The bronchial whisper is often wanting, and, when present, is feeble. It may be present on the right and not on the left side, and is louder on the right side if heard on both sides. Axillary and infra-axillary regions. — In these regions, the reso- nance of the loud voice is greater in intensity than over the middle and lower thirds of the chest in front, and in some persons the res- onance is quite equal to that of the infra-clavicular region. The intensity is less in the infra- axillary than in the axillary region. It is greater on the right than on the left side. The resonance is here distant, diffused, and of low pitch, in these characters con- trasting with bronchophony. Vocal vibration, thrill, or fremitus, attends the resonance in some persons, in both regions, but oftener in the axillary. This may be present on the right and absent on 152 PHYSICAL EXPLORATION OF THE ,CHEST. the left side, and, if present on both sides, is greater on the right side. The bronchial whisper is in some persons present and in other persons wanting. This may be present on the right and not on the left side, and if present on both sides it is louder on the right side. In view of the importance, with reference to the diagnosis of dis- ease, of the points of disparity between regions on the same side, and between corresponding regions on the two sides of the chest in health, the following condensed abstract of the foregoing facts per- taining to the respiration and voice is appended: Summary of the points of disparity between different regions on the same side, and between corresponding regions on the two sides of the chest, in healthy persons, as resp>ects the phenomena incident to the respiration and the voice. 1. Infra-clavieular region. — The inspiratory sound on the left side usually more intense than on the right side, and the vesicular quality more marked. The inspiratory sound on the right side, as compared with that on the left side, vesiculo-tubular in quality and higher in pitch. The expiratory sound frequently prolonged on the right side, and not infrequently higher in pitch than the sound of inspiration. In some persons the expiratory sound prolonged and high in pitch on both sides, and in these cases the sound more in- tense on the right side and higher in pitch on the left side. The characters and points of disparity just stated most marked at the sterno-clavicular junction, in consequence of the proximity to the trachea and large bronchi, constituting what has been called the normal bronchial respiration, more properly called the normal broncho-vesicular respiration. The resonance of the loud voice, as compared with the resonance over the larynx and trachea, diifused and distant, but, as a rule, more intense than in other regions, excepting the inter-scapular region. The resonance greatest on the right side, and in some persons present on this side and wanting on the left side. The resonance greatest at the sterno-clavicular junction, and in this situation, in some persons, the voice concentrated, near the ear, and high in pitch, constituting normal bronchophony. The resonance frequently accompanied by thrill or fremitus, which may be present on the right, and wanting on the left side, and, if present on both sides, most marked on the rig-ht side. AUSCULTATION IN HEALTH. 153 A souffle or blowing sound, with Avhispered words (the normal bronchial whisper) in most persons heard on both sides. Present sometimes on the right and not on the left side, and, when present on both sides, loudest on the right, and higher in pitch on the left side. 2. Scapular region. — The inspiratory sound in some persons more intense and vesicular on the left side of the chest. The ex- piratory sound, in some persons, prolonged on the right side. The resonance of the loud voice more distant and diffused than in the infra-clavicular region. The resonance greater on the right side, vocal vibration, thrill, or fremitus, if present, more marked on the right side. The bronchial whisper sometimes present and sometimes wanting; oftener present on the right side, and, if present on both sides, louder on the right side. 3. Inter-scapular region. — The characters of the respiratory murmur, and the disparity between the two sides, essentially the same as in the portion of the infra-clavicular region situated at and near the sterno-clavicular junction, that is, the murmur modified by sounds derived from the trachea and large bronchi, giving rise to what might be called the normal broncho-vesicular respiration. The resonance of the loud voice intense as compared with other regions excepting in front at the sterno-clavicular junction. The voice in some persons near the ear, and concentrated, constituting normal bronchophony. The intensity greater and the broncho- phonic characters more marked on the right side. The bronchial whisper more or less intense; the intensity greater on the right, and the pitch higher on the left side. 4. lyifra-scapular region. — The intensity and vesicular quality of the respiratory murmur sometimes more marked on the left side. The resonance of the loud voice distant and diffused, more intense than in the scapular, and less intense than in the inter-scapular region. The intensity greater on the right than on the left side. The bron- chial whisper sometimes wanting, and generally, if present, quite feeble; present on the right and not on the left side in some per- sons, and if present on both sides louder on the right side. Thrill or fremitus, if on one side only, on the right side. 5. Mammary and infra-mammary regions. — The respiratory murmur more or less intense. The intensity in some persons greater on the left side. The resonance of the loud voice more 154 PHYSICAL EXPLORATION OF THE CHEST. distant and diffused than at the summit; the intensity of the reso- nance greater on the right than on the left side. The bronchial whisper in some persons wanting, and in some persons present but feeble ; present in some persons on the right and not on the left side, and, if present on both sides, louder on the right side. Facts with respect to thrill or fremitus the same as in the infra-scapular region. 6. Axillary and infra-axillary region. — The intensity of the respiratory murmur greater than in the mammary and scapular regions. The resonance of the loud voice distant and diffused, of variable intensity in different persons, but more intense on the right side. Facts with respect to thrill, or fremitus, the same as in the infra-scapular region. III. PHENOMENA INCIDENT TO THE ACT OF COUGHING. The phenomena produced by coughing, or tussive phenomena, are comparatively of little importance in auscultation. Nevertheless, they undoubtedly possess a certain value as physical signs of dis- ease, taken in connection with those pertaining to the respiration and the voice. If the stethoscope be placed over the trachea, the act of coughing occasions a forcible shock, and a strong blowing sound. The same results, but less in degree, may be observed at the parts of the chest where the bronchial respiration and voice are sought for in health. These phenomena manifested elsewhere over the chest, constitute morbid signs. Over the chest generally, in health, the sense of impulse or shock is slight, or altogether absent, but a feeble, short, diffused sound is alone heard. The study of the tussive phenomena in different persons, and in different portions of the chest, did not enter into the examinations, the results of the analysis of which have been presented in the foregoing pages. 11. Auscultation in Disease. Having studied the phenomena which auscultation of the healthy chest discloses, we are prepared to investigate those incident to dis- ease. In prosecuting the latter investigation, the general objects are as follows: 1. To determine what are morbid sounds and in what particulars they differ from those incident to health. 2. To ascer- tain the connection between individual morbid sounds and the phys- ical conditions of which, in consequence of this connection, they AUSCULTATION IN DISEASE, 155 are the signs. 3. To explain, as far as practicable, the manner in which morbid physical conditions give rise to the phenomena em- braced under the head of Auscultation in Disease. Of these three objects I shall consider at length, in the remainder of this chapter, the first and second, devoting to the third relatively but little atten- tion. As already remarked, knowledge of physical signs, as re- gards their significance and value in diagnosis, is not dependent on our ability always to furnish a complete exposition of the mechan- ism of their production. Persons may differ in opinion as to the rationale of certain signs, and yet be entirely agreed respecting their special meaning and importance, the latter being based on the uniform relation found by observation to exist between the signs present during life, and the pathological changes ascertained after death. It is certainly very desirable to explain satisfactorily that connection subsisting between physical signs and physical condi- tions, by virtue of which the former represent the latter ; but with our present knowledge, this branch of the subject of physical ex- ploration contains many points not fully settled. In a work in- tended to be practical, it would be out of phice to discuss opinions and theories relating to questions which are as yet open for specu- lation; and I shall therefore content myself with giving, as con- cisely as possible, different views, without attempting a full consider- ation of their respective merits. In treating of auscultation in disease, as in health, the phenomena incident to respiration, the voice, and the act of coughing, are to be considered under separate heads. PHENOMENA INCIDENT TO RESPIRATION. The morbid phenomena incident to respiration admit of a natural division, which it is convenient to observe, into, First, the normal respiratory sounds more or less, and variously, modified; Second, new or adventitious sounds, i. e., sounds having no existence in the healthy chest. Of the phenomena embraced in the first of these two classes, several are represented by types existing in health ; and with these the student who has studied faithfully the normal respiratory sounds is already familiar. They are to be found in different parts of the respiratory apparatus when entirely free from disease, and they be- come signs of abnormal conditions by a change of situation. The phenomena embraced in the second class have no counterparts 156 PHYSICAL EXPLORATION OF THE CHEST. among the sounds incident to normal respiration, and pertain ex- clusively to the changes produced by disease. We will consider these two divisions separately. I. Modified Respiratory Sounds. — Limiting the attention to the vesicular murmur, exclusive of the tracheal and laryngeal res- piration, the changes which it undergoes in connection with diflFerent forms of disease, are resolvable into various kinds of aberration. Its intensity may be increased, or diminished, or it may be sup- pressed. Its quality may be altered, the vesicular character giving place, partially or completely, to tubularity of sound. The pitch may be raised or lowered. The inspiratory and expiratory sounds may be modified separately, or conjointly. The inspiratory sound may be shortened in duration, and the expiratory prolonged. Their rhythmical succession may be disturbed. It is, however, unneces- sary to treat of all these varied modifications separately. They do not, as a general remark, occur in connection with disease singly, but several are usually presented in combination. A judicious classification of the different modifications, comprising more or less of the foregoing aberrations, is important ; and for all practical pur- poses the following arrangement sufiices.' 1. Modifications of the intensity of the vesicular murmur, con- sisting of, a, increased intensity ; b, diminished intensity ; c, sup- pression of respiration. 2. Modifications of the quality of the respiratory sounds, associ- ated with alterations in pitch, duration, and rhythm. This division will consist of, a, bronchial respiration; b, broncho-vesicular, com- monly called rude respiration ; c, cavernous respiration. 3. Modifications of rhythm, consisting of, a, shortened inspiration ; J, prolonged expiration ; c, interrupted inspiration or expiration. I shall consider all those physical signs, derived by auscultation, which are modified respiratory sounds, as embraced under the fore- going divisions and subdivisions; and I shall proceed to describe them under distinct heads in conformity with this arrangement. 1. Increased Intensity of the Vesicular Murmur — Exaggerated Resjnration. — The vesicular murmur is simply increased in intensity, or exaggerated, whenever its loudness is augmented, the normal 1 This division accords with the arrangement by Barth and Roger. The sub- divisions difler from those which they adopt. AUSCULTATION IN DISEASE. 157 characters, in other respects, remaining unchanged. The sound maybe more intense than natural, with, at the same time, alteration in quality, pitch, and rhythm. The modifications will then fall under other divisions. Merely exaggerated respiration preserves the normal characters as regards vesicular quality, pitch, and rhythm. It has been seen that the intensity of the normal vesicular murmur differs greatly in different persons. How then are we to decide whether a certain loudness be normal or abnormal ? If this loudness be found over the whole chest, the presumption is that it is natural to the individual, and it is not to be regarded as a sign of disease. But if, on the other hand, it exist on one side of the chest only, it may be presumed to be a result of disease. An exaggerated vesicular murmur does not proceed from diseased lung, but from healthy lung situated either near or remote from the seat of disease. Whenever the lung on one side, or a considerable portion of it, is rendered by disease incompetent to fulfil its part in the respiratory function, the lung on the other side takes on an in- creased action to supply its place. Hence an increased intensity of the respiratory murmur, corresponding in degree to this augmented activity, the increase of intensity being most marked at the superior and anterior portion of the chest. The exaggerated respiration under these circumstances is vicarious, or supplementary, and it has been called by some writers supplementary respiration. Laennec applied to it the name puerile respiration, from its resemblance to the naturally loud respiration of early life. Hyper-vesicular respira- tion is another appellation, Any disease which compromises to much extent the respiratory function of one lung occasions an increased functional activity of the other. The physical sign of this increased activity, viz., an increased intensity of the vesicular murmur, thus, is indirect evi- dence of the existence of disease in the opposite side, but it does not afford any information as to the particular form of disease which exists. The pulmonary affections with which it is oftenest associated, and in the most marked degree, are pneumonitis and pleuritis. In the former of these affections, occurring in the adult, generally an entire lobe and sometimes an entire lung is rendered, for a time, nearly or quite incompetent to take part in hsematosis, in conse- quence of the cells being filled with inflammatory exudation ; in the latter affection, the lung on one side is more or less reduced in volume by the compression of effused fluid within the pleural sac. 158 PHYSICAL EXPLORATION OF THE CHEST. Obstruction to the entrance of air into one lung from the presence of a foreign body, pressure of an enlarged bronchial gland, etc., will also give rise in the other lung to exaggerated respiration. Considerable deposit of tubercle on one side may produce it; and also solidification from extravasated blood, carcinoma, etc. It is stated by Fournet' that exaggerated respiration ensues in healthy lung situated in the immediate vicinity of a local affection ■which compromises or abolishes the function within a limited space. For example, around a mass of tubercle he thinks the vesicular murmur is unduly intense, and, indeed, he asserts that an abnor- mally increased vesicular murmur in the surrounding healthy por- tion of lung is greater in proportion to its proximity to the point of local disease. Whether this statement be correct or otherwise, is not easily determined, nor is it of importance with reference to diagnosis ; for, assuming that the vesicular murmur does become more intense in the healthy lung surrounding a diseased portion, for example in tuberculous disease, the respiratory sound is at the same time more or less modified by the diseased portion in other respects, presenting the character of a bronchial or broncho-vesicular respira- tion. In cases of solidification of an entire lobe from pneumonitis, according to Fournet, the vesicular murmur proceeding from the other lobe or lobes of the afi'ected side is exaggerated, and in a more marked degree than that proceeding from the healthy side. I should express a different opinion, speaking from the impressions derived from my own experience. I am certain that in some cases, at least, the vesicular murmur over the healthy lobe or lobes of the affected side, is notably less intense than on the opposite side, and even below the normal intensity. When the vesicular murmur is abnormally exaggerated, the dura- tion of the inspiratory sound, as a rule, is somewhat increased. This is because the murmur is heard during the entire act of in- spiration, whereas, if the intensity be not increased, the sound is too feeble to be heard at the beginning of the act when the intensity is the least. The expiratory sound is also much oftener heard, and is comparatively longer in duration. This is due to the fact that the exaggeration affecting equally the sounds of inspiration and expira- tion, the latter becomes appreciable when, with ordinary normal breathing, it is too feeble to be heard ; and for the same reason it 1 Rechcrclios Cliniques, etc. AUSCULTATION IN DISEASE. 159 acquires a longer duration. In pitch, rhythm, and quality, the expi- ratory sustains the same relation to the inspiratory sound, as when the two are not exaggerated. This is a fact important to be borne in mind if we would not be led astray by the greater loudness and longer duration of the expiratory sound, the latter being a promi- nent feature, as will be seen hereafter, of the bronchial respiration. In simple exaggerated respiration the expiratory sound is lower in pitch than the inspiratory, and it is continuous with the sound of inspiration, these being the characters belonging to the vesicular murmur when its intensity is not increased. In each of these points it differs from the bronchial respiration. With due attention to these points of difference, the two need never be confounded, an error which Barth and Roger state is liable to be committed, and examples of which have fallen under my observation. An abnormal intensity of the vesicular murmur is attributable, as has been stated, to an increased activity of respiration, by way of compensation for suspended function in a portion of the pul- monary organs. This increased activity can only proceed from an expansion of the chest beyond the limits of ordinary normal breathing, and with greater force than is employed in health, in con- sequence of which a larger quantity of air is draAvn into the bronchial tubes, giving rise to a more powerful expansion of the lung ; and under these circumstances, a larger number of cells are dilated than in ordinary breathing. Hence the exaggeration of the respiratory sound, the intensity of which depends on the conditions just men- tioned. And the fact that in pleuritis, pneumonitis, and tuberculosis, the movements of the affected side are more or less restrained, while those of the opposite side are increased, would lead us to anticipate what (in opposition to the opinion of Fournet) I believe clinical observation shows to be true, viz., that in these affections the exag- gerated respiration is limited to the opposite side of the chest. As a physical sign of disease, exaggerated respiration does not possess great importance. Isolated 'from other signs, it would be insignificant in diagnosis. Taken in connection with other signs, it is deserving of attention. 2. Diminished Intensity of the Vesicular Murmur — Feeble or Weak Respiration. — The effect of disease is much oftener to dimin- ish than to increase the intensity of the vesicular murmur. Feeble or weak respiration is an abnormal modification of frequent occur- 160 PHYSICAL EXPLORATION OF THE CHEST. rence, and it is a physical sign incident to numerous and varied morbid conditions. This species of modification, like that just considered, consists of a greater or less diminution in loudness of the respiratory sound, the distinctive characters of the vesicular murmur, pertaining to quality, pitch, and rhythm, remaining unaffected. A respiratory sound may be lessened as well as increased in intensity, with at the same time alteration in quality, pitch, and rhythm, in which case the aberra- tion would not fall under the present head, but under those belong- ing to other divisions of abnormal sounds. In duration, the inspira- tory sound is frequently shortened when its intensity is abnormally diminished, the explanation being precisely the converse of that of the longer duration when the murmur is exaggerated. An expiratory sound may or may not be heard. In one form of disease character- ized by feeble respiration, it is frequently present and prolonged, the diminution of intensity being less marked than in the inspira- tory sound. Except in this affection (emphysema), an expiratory sound is rarely heard, and is not prolonged, provided the modifica- tion consists in a simple weakness of the murmur, exclusive of any other change. The various morbid conditions which may induce abnormal feeble- ness of the vesicular murmur produce this result by four different modes, singly or combined, viz. : 1. By obstructing the passage of air in some portion of the air-tubes ; 2. By obstructing or over-dis- tending the air-vesicles ; 3. By removing the lungs from the thoracic walls; 4. By restraining the movements of the chest. Under these several heads, I will proceed to mention the more important of the affections in which simple diminution in intensity of the vesicular murmur may be expected to occur, premising that alone, this sign, as well as exaggerated respiration, fails to furnish information re- specting tlie nature of the affection of which it is an effect. To determine the latter point, it must be taken in connection with other signs and with symptoms. In "this respect, however, it differs from exaggerated respiration, viz., it often indicates directly the seat of disease ; in other words, the diminished intensity of the murmur corresponds in its situation to the locality of the affection upon which it depends. a. An obstruction in any portion of the air-tubes lessens the loud- ness of the vesicular murmur by reducing the quantity of air which expands the cells. Laryngeal affections, for example, croup, oedema, AUSCULTATION IN DISEASE. 161 spasm of the glottis, vegetations which contract the calibre of the canal in this situation, produce this effect. These causes diminish the murmur equally on both sides of the chest. An obstruction, however, may be seated in one of the primary bronchi, and then the effect upon the respiratory murmurs will be limited to the correspond- ing side. This obtains when a foreign body is lodged in one of the bronchial divisions, which occurs oftener on the right side. A for- eign body within the air-passages sometimes changes its place, being at times thrown upward into the trachea, and occasionally trans- ferred, alternately, from one bronchus to the other. The abnormal feebleness of the vesicular murmur, under these circumstances, will be present now on one side, and now on the other side of the chest. This affords evidence that the physical sign is due to a movable body, and hence it is a point of importance in the diagnosis. The situation of the sign on one side, also, when the presence of a foreign body in the air-passages is ascertained, points to its situation in one of the bronchi, and indicates the particular bronchus (the right or left) in which it is situated. The bronchial tubes, within the pul- monary organs, are liable to be obstructed, by the swelling of their lining membrane, incident to inflammation, and from the presence of the inflammatory products, mucus, pus, and coagulable lymph. The respiratory murmur may be diminished, in consequence, on one or both sides. Inasmuch as in primary bronchitis the bronchial tubes on both sides are equally affected (this being one of the symmetri- cal diseases), when the obstruction depends on swelling of the mem- brane, the effect on the murmur is equal on the two sides. Hence; abnormal feebleness of respiration on the two sides of the chest is one of the physical signs incident to bronchitis. On the other hand, when the obstruction depends on an accumulation of the pro- ducts of inflammation, it may be limited to one side, or be greater on one side than on the other, with a corresponding effect on the re- spiratory murmur. Spasm of the bronchial muscular fibres is another morbid condition diminishing temporarily the calibre of the bronchial tubes. Permanent contraction of the tubes, or stricture, may exist as a structural lesion. An enlarged lymphatic gland, or other tu- mor, may press upon one of the bronchi exterior to the lungs, or on one of their subdivisions, and occasion a feeble vesicular murmur either over the whole, or a part of one side. The clinical discrimi- nation between these various causes is to be made, if practicable, by 11 162 PHYSICAL EXPLORATION OF THE CHEST. means of the symptoms and circumstances associated in individual cases. It is not always easy, and sometimes impracticable. h. The cause of an abnormally feeble murmur, when seated in the vesicles, may consist in a morbid deposit blocking them up to a greater or less extent, and excluding the air. Thus, in tuberculosis, pneumonitis, extravasation of blood, oedema, &c., the physical sign incident to respiration may be simple feebleness of the vesicular murmur. Generally, however, in these affections, either the respira- tory sound is suppressed, or, with or without feebleness, it is more or less changed in quality, pitch, and rhythm. Over-distension and enlargement of the vesicles constitute, virtually, an obstruction, the cells remaining filled with air, the renewal with the successive respi- ratory acts taking place imperfectly, and hence the physical condi- tions for the production of the vesicular murmur are impaired. An abnormally feeble vesicular murmur, therefore, characterizes the affection called emphysema. In this affection the expiratory sound is frequently prolonged, in consequence of the slowness with which the lungs collapse, and of the obstruction to the passage of air in the bronchial tubes which often coexists, arising from bronchitis and spasm. Prolonged expiration will be considered under a distinct head. I may remark here that, occurring under the circumstances just mentioned, it is to be distinguished from its occurrence under circumstances in which its pathological significance is quite different, by the attendant circumstances, and by its preserving the normal relation, as respects pitch, to the inspiratory sound. The physical signs derived by percussion in the two forms of ob- struction within the vesicles just noticed, viz., from morbid deposit and over-inflation, are directly opposite in character. In the former instance, whether the deposit be tubercle, coagulable lymph, etc., the percussion-sound is more or less dull. In the latter, the resonance is usually abnormally intense, vesiculo-tympanitic in quality and higher in pitch than the normal vesicular resonance. This suffices for the discrimination between these two kinds of vesicular obstruc- tion. c. If the lungs are removed at a certain distance from the thoracic walls, the intensity of the murmur is diminished. Under these cir- cumstances, the sound conveys to the mind the idea of distance ; it does not seem to be produced in close proximity to the ear, but to come from a source somewhat remote. The appreciation of distance, which undoubtedly belongs to the perception of impressions received AUSCULTATION IN DISEASE. 163 through the sense of hearing, in other instances than this, will be found to furnish a character of physical signs. The lungs must not be removed beyond a certain limit, else the respiratory murmur will fail to be transmitted. The feeble respiration produced in this way occurs when there exists a small or moderate quantity of liquid effusion, of air, or gas, within the pleural sac, and when the pleural surfaces are covered with a thick layer of coagulable lymph. When it is due to the presence of liquid, the feebleness is at the lower part of the chest, provided the position of the patient be upright, and its situation may be found to vary with the different positions which the patient assumes.^ d. The intensity of the vesicular murmur, other things being equal, depends on the extent and force of the respiratory movements. Any morbid condition, therefore, which limits these movements renders the respiratory sound abnormally feeble. For example, in a case of incomplete general paralysis, which recently came under my obser- vation, the respiratory muscles were in a measure involved. The respiratory movements were wanting in strength, and the vesicular murmur was correspondingly feeble on both sides. In some cases of hemiplegia, this effect obtains on the paralyzed side. In pleuritis, before effusion has taken place, and in intercostal neuralgia, the pain occasioned by the expansion of the chest on the affected side leads the patient instinctively to restrain the movements on that side. Hence, abnormal feebleness of the vesicular murmur belongs equally to both these affections, irrespective of the cause already mentioned as incident to pleuritis at a later period. The move- ments of the chest on one side may be restrained mechanically, in consequence of permanent contraction as the sequel of chronic pleuritis, of morbid pleuritic adhesions, of injury to the thoracic walls, and deformity from any cause. Whenever by any of the modes just named the vesicular murmur is rendered abnormally feeble on one side of the chest, the respiratory sound on the other side is likely to become exaggerated, and the conr trast between the two sides is thereby enhanced. It is needless to state that in order to judge of abnormal feeble- ness of the vesicular murmur, as of most of the physical signs, there is no ideal standard to which reference is to be made, but it is de- 1 That a thin stratum of liquid may be equally diffused over the lung, as con- tended by Woillez, may fairly be doubted. 164 PHYSICAL EXPLORATION OF THE CHEST. termined by a comparison of corresponding regions of two sides of the chest. In drawing inferences from the results of tliis comparison, it is sometimes highly important to bear in mind the fact, that in individuals in good health and with chests well formed, a natural disparity exists as regards the intensity of the vesicular murmur. This fact has appeared in the portion of this chapter devoted to auscultation in health. A natural disparity may mislead the aus- cultator, the greater relative feebleness on the one hand, or on the other hand, a normal exaggeration, being attributed incorrectly to disease existing on one or the other side. This liability to error is not to be lost sight of, especially in the diagnosis of tuber- culous disease, a disease in which slight deviations from equality of the two sides at the summit of the chest, provided they are abnormal, are justly regarded as highly significant. The results of examina- tions of the healthy chest not only enforce the caution just given, but lead to another very important consideration. In much the larger proportion of instances of relative feebleness of the vesicular murmur on one side compatible with health, it is observed on the right side. It follows from this fact that comparative feebleness on the right side is much less likely to be the result of disease than when it is found to exist on the left side. A relatively feeble murmur on the left side in the great majority of instances denotes disease; but existing on the right side, if the relative feebleness be slight, it may be due to a natural disparity. Diminished intensity of the vesicular murmur, when it is evidently attributable to a morbid condition, as already remarked, alone, gives little or no information respecting the particular condition upon which it depends. Isolated from other signs, therefore, and from symptoms, its diagnostic value would be small, but, associated with the information derived from other sources, it becomes a valuable sign. 3. Suppressed respiration. — The respiration is said to be sup- pressed when no murmur is appreciable by auscultation ; the respi- ratory acts take place without giving rise to any audible sound. This effect may be produced by each of the four modes which have been seen to occasion abnormal feebleness of the respira- tory murmur : their operation being pushed to a certain extent, the sound is abolished. Suppression is therefore liable to occur in connection Avith any of the various morbid conditions which induce feebleness of respiration. This being the case, it is only necessary AUSCULTATION IN DISEASE. 165 under this head to repeat an enumeration of the affections ■which were mentioned in connection with the sign last considered. Obstruction of the larynx from inflammatory exudation, oedema, vegetations, spasm, or the presence of a foreign body, may extin- guish all sound over the entire chest. A foreign substance lodged in one of the bronchi may produce this effect on the corresponding side, giving rise to exaggerated respiration on the other side. Ab- sence of all sound obtains in some cases of bronchitis, from the swelling of the membrane. Its temporary absence over a portion of the chest, owing to an accumulation of mucus in some of the bronchial tubes, is occasionally observed in that affection ; and under these circumstances it is sometimes abruptly restored in consequence of the removal of the obstruction by an act of coughing. Pressure of an enlarged bronchial gland, or tumor of any kind, on a bronchial tube, may be sufficient for complete absence of sound. In some cases of pneumonitis, tuberculosis, pulmonary apoplexy, pulmonary oedema, etc., the respiration is suppressed. The vesic- ular murmur is generally abolished in connection with these affec- tions over the solidified portion of the lung, but, as will be seen presently, the murmur frequently is replaced by a respiratory sound modified in quality, etc., viz., the bronchial or the broncho-vesicular respiration. In some cases of emphysema no respiratory sound is appreciable. In this affection the inspiratory sound may be sup- pressed, and the expiratory, more or less prolonged, remain. The expiratory sound is also alone appreciable under other circumstances, which will be noticed under other heads. Again, when the lungs are removed beyond a very limited space from the thoracic walls, either by the presence of liquid effusion in pleurisy and hydrothorax, of air or gas in pneumothorax, or of both conjoined in pneumo-hydrothorax, the murmur of respiration is generally extinct. Finally, from contraction, deformity, injury, or paralysis, the movements of the chest may be insufficient to produce a respira- tory sound. Suppressed respiration is a barren sign as regards special signifi- cance, disassociated from other physical, and from vital phenomena. Thus, when absence of sound exists on one side of the chest, it may be incident to pneumonitis, emphysema, pleurisy, or pneumothorax. Of course no inference can be drawn from the isolated fact of the absence of respiratory sound, as to which of these several affections 166 PHYSICAL EXPLORATION OF THE CHEST. is present. But associated with the evidence afforded by percussion, and other methods of physical exploration, in connection with symp- toms, the diagnosis is usually not attended with difficulty. In point of frequency, absence of respiratory sound oftener proceeds from liquid effusion Avithin the chest than from any other morbid condition. The respiration will be feeble or suppressed in certain cases of disease according to the acuteness of hearing of the auscultator. A person with a delicate perception of sound will sometimes appreciate a weak respiratory murmur, when another person whose auditory perceptions are more obtuse will fail to discover any sound. The mode of exploration will also aff'ect the result. A murmur may be appreciable by immediate, and not by mediate auscultation ; and with Cammann's stethoscope, the respiratory sound is distinct in some instances in which, with the ordinary cylinder, and the naked ear, it cannot be perceived. The foregoing modifications relate to deviations from healthy res- piration as respects intensity, including the abolition of sound. Those to be next considered, involve, either with or without these deviations, a change in the quality of sound, associated with abnor- mal changes in pitch, duration, and rhythm. This class of modifi- cations embraces signs of great importance in physical diagnosis. 4. Bronchial or tubular respiration. — The name bronchial respira- tion imports that the sound corresponds to that heard over the bronchi in the healthy chest. This meaning of the term, however, involves an error. The normal respiratory murmur over the bronchi is not identical with the bronchial respiration of disease, but it exemplifies a broncho-vesicular respiration. A morbid bronchial respiration may be defined to be a respiratory sound essentially identical with the normal laryngo-treacheal respiration, supplanting the vesicular murmur. With this definition, the student familiar with the characters which distinguish the tracheal and laryngeal sounds from the vesicular murmur, which have been considered fully under the head of Auscultation in Health, will have no difficulty in understanding and practically recognizing the bronchial respiration incident to disease. In describing the essential traits pertaining to morbid bronchial respiration, it is only necessary to reproduce the description already given of the tracheal and laryngeal sounds con- trasted with the vesicular murmur. The distinctive characters are as follows : an inspiratory sound, tubular, in place of the peculiar character to which reference in the foregoing pages has frequently AUSCULTATION IN DISEASE. 167 been made under the name vesicular quality; shorter in dura- tion, commencing with the beginning of the inspiratory act, and ending before the act is completed ; the pitch of the sound higher. An expiratory sound, prolonged, frequently nearly or quite as long, and sometimes even longer than the inspiratory, succeeding the in- spiratory sound after an interval, owing to the fact that the inspira- tory sound ends before the completion of the inspiratory act ; the pitch of sound higher than that of the inspiratory, and the intensity generally greater. The student is again requested to impress on the memory these several points of distinction, with reference to the discrimination of bronchial respiration, not only from the vesicular murmur, but from another modification included in this class, called the cavernous respiration. At the risk of incurring the charge of a needless repetition, in order that the points distinguishing the bronchial, may be again contrasted with the characters belonging to the normal vesicular murmur, the latter are reproduced in this con- nection. They are as follows : an inspiratory sound characterized by the vesicular quality ; lower in pitch than the tracheal or laryngeal inspiration. An expiratory sound, when present, much shorter in duration, less intense and lower in pitch than the sound of inspira- tion. These are the characters of the normal vesicular murmur, certain modifications existing at the summit of the chest which have been considered under the head of Auscultation in Health. Contrasted with the vesicular murmur, the bronchial expiration is said to be characterized by greater hai'dness and dryneas. These terms, although in vogue since the time of Laennec, do not seem to me to express properties of sound, of which, in this contrast, the mind receives a very distinct idea. The distinctions pertaining to intensity, rhythm, quality, and pitch, are much more definite, and are sufficient for the discrimination. I shall therefoi'e dispense with the use of the former terms after this allusion to them. They ap- pear to me to be rendered superfluous, especially by attention to variations in pitch, an aspect under which respiratory sounds have hitherto been but little studied. The intensity of the bronchial respiration varies greatly, not only in different aff"ections to which it is incident, but in diff"erent cases of the same disease. It is not distinguished by its intensity, but by the characters which have been named, and the latter may be present and sufficiently marked, when the sound is feeble, as well as when it is loud. The intensity, however, in certain affections, pneumonitis 168 PHYSICAL EXPLORATION OF THE CHEST. especially, is often great, being equal to and at times exceeding that of the normal tracheal respiration. In some instances of intense bronchial respiration, the sound, in addition to a strongly marked tubular quality, has a peculiar ringing tone, like that produced by blowing through a tube of metal, and hence called a metallic intona- tion. It is oftener marked in the expiratory than in the inspiratory sound. The normal tracheal respiration occasionally presents this character in forced breathing. This is an incidental feature of the bronchial respiration occurring in certain cases of pneumonitis, and not possessing special diagnostic significance. In other respects than intensity, the bronchial respiration varies. The pitch is not the same in all cases, but this difference obtains in different persons as respects the tracheal and laryngeal sounds. Both the inspiratory and the expiratory sound vary in duration, as well as in their relative intensity. Either may be present without the other. In some instances the sound appears to be produced in close proximity to the ear ; and sometimes, indeed, the air appears to enter and again emerge from the meatus. This was the ground of Laennec's division into bronchial and blowing respiration, the latter term being applied when the auscultator experiences a sensation as if the breath of the patient actually traversed the stethoscope. It suffices, however, to consider this as simply an incidental feature of the bronchial and also of the cavernous respiration. In some in- stances in which this is strongly marked, the illusion is almost com- plete, and, quoting the language of Laennec, " it is only from the absence of the feeling of titillation and of warmth or coldness which a olast of air so impelled must necessarily occasion, that we are held to doubt its reality," In other cases the sound gives the impression of emanating from a source more or less distant from the Avails of the chest. It is important to be borne in mind that not only is the bronchial respira- tion,' in different cases of disease, thus variously modified, but that all the characters which serve to distinguish it from the vesicular respiration are by no means uniformly present. The existence of an inspiratory without an expiratory sound, and vice versa, divests it of several of the distinctive traits which are associated when a sound accompanies both acts of respiration. In such instances we are to determine that the respiratory sound is bronchial by the characters which remain. The bronchial respiration, like the tracheal, differs in intensity, and in other respects, with different AUSCULTATION IN DISEASE. 169 successive respirations, always, however, preserving certain charac- teristics. Skoda contends that it is an intermittent sign, frequently ceasing for a series of respirations, and then reappearing. This does not, however, accord with the experience of others, the latter, so far as my observations go, being correct as the general rule. Its occasional cessation and reappearance after coughing and expectora- tion, is a fact which I have observed. With what physical condition of the lungs is the bronchial respi- ration associated ? This question may be explicitly answered. It represents either complete or considerable solidification of the pul- monary structure. Whenever the bronchial respiration is present it denotes this condition.^ The converse of this, however, is not true, viz., that whenever lung is solidified, it gives rise to bronchial respiration. The sign always denotes the morbid physical condition just stated, but the physical condition may exist without giving rise to the sign. Solidification of lung is incident to diseases which induce condensation by pressure. This effect follows the accumula- tion of liquid Avithin the pleural sac, within the pericardium, and the development of tumors encroaching on the thoracic space. Much oftener, however, it proceeds from a morbid deposit within the pul- monary structure. Bronchial respiration, therefore, may be a sign, on the one hand, of pleurisy, or hydrothorax, or hydro-pericardium, of aneurismal and other tumors ; and, on the other hand, of pneumo- nitis, tuberculosis, carcinoma, and pulmonary apoplexy. Of the several affections last mentioned, it is more constantly present in the two first, viz., pneumonitis and tuberculosis. On this account, and owing to the frequency of these affections, the sign is especially im- portant with reference to their diagnosis. Before directing farther attention to it in connection with these affections respectively, we will inquire how does the solidification of lung incident to different forms of disease give rise to a bronchial respiration ? To this in- quiry I shall devote brief consideration. The explanation of bronchial respiration offered by Laennec, and up to the present time generally accepted, is that the sound is in fact a normal bronchial respiration, which, owing to conditions of disease, is transmitted to the ear, disconnected from the vesicular murmur. The bronchial respiration appears in connection with physical con- 1 As an apparent exception to this statement, dilatation of the bronchial tubes might be cited. Dilatation is, however, as will be seen hereafter, always associated with in- creased density of lung. 170 PHYSICAL EXPLORATION OF THE CHEST. ditions which involve suppression of the vesicular murmur. In health, the latter, as it were, stifles sounds emanating or propagated from the bronchial tubes. Moreover, the lung, when its density is increased, has been supposed to become a much better conductor of sound than air-vesicles filled with air. These two circumstances, viz., abolition of the vesicular murmur, and the transformation of the pulmonary substance into a better conductor of sound, according to Laennec, are sufficient to account for the bronchial respiration, the source of the sound being the large and small bronchial tubes. The sufficiency of this explanation has been called in question, in consequence of the bronchial respiration being sometimes more in- tense than even the tracheal sounds ; and difi"ering from the tracheal and what has been called the normal bronchial respiration, in some cases, in quality and pitch. The fact that solidification of lung, when the bronchial tubes are free from obstruction, is not invariably associated with the bronchial respiration, but in some instances gives rise to suppression of all sound, is thought to militate against the hypothesis of Laennec. Again, when the lung is solidified, as in cases of pneumonitis, it is doubted by some whether, owing to its inability to collapse and expand with the two respiratory acts, a current of air circulates in the pulmonary bronchial tubes with suffi- cient force to give rise to sound. Finally, according to Skoda, increased density of the lung does not render it a better conductor of sound. The latter statement is based on comparative experiments, made with the pulmonary organs removed from the body in a healthy condition, and when solidified by disease. Other observers, however, from similar experiments, do not arrive at the same conclusion. Walshe states, as the results of experiments made by himself, that sound may be conducted with great intensity by solidified lung, but not invariably ; and that as regards the conducting power, when the physical conditions to all appearances are the same, differences are found to exist which it is not easy to explain. That a current of air is not received into the pulmonary bronchial tubes by the act of inspiration, and expelled by expiration with sufficient force to generate a tubular sound, is assumed rather than established. The movements of the diaphragm and walls of the chest on the affected side, in cases of pneumonitis, with solidification of one or more lobes, are not abolished ; and it seems probable that, notwithstanding the comparative incompressibility of the lung, the bronchial tubes re- maining: unobstructed undergo alternate contraction and dilatation. AUSCULTATION IN DISEASE. 171 The opinion of Andral, that the obstruction to the entrance of air into the air-cells by arresting suddenly the current, and increasing the pressure of the air upon the bronchial tubes, tends to develop an exaggerated sound therein, although repudiated by high au- thority, is not disproved, and seems rational.' With regard to the greater intensity of the bronchial than even the tracheal respiration, in some cases, and variations in pitch, it is certain that differences as respects these characters, do exist in a cer- tain proportion of cases. A morbid bronchial respiration is sometimes more intense than the sound emanating from the trachea of the same person and higher in pitch. It may also present a metallic quality, when the tracheal sound of the same person, at the same time, is devoid of this quality. Nevertheless, as respects the distinctive characters which the tracheal respiration presents in contrast with the vesicular murmur, they belong equally to the bronchial respira- tion. The latter, when strongly marked, as, for example, frequently in cases of pneumonitis, is identical with the tracheal respiration as regards tubularity, duration of the inspiratory and expiratory sounds, the rhythmical succession of the latter, and their relative intensity and pitch, these constituting, as has been seen, the traits by which the bronchial respiration is distinguished from the vesicular murmur. This being the case for the production of the bronchial respiration, the tracheal respiration, it is reasonable to infer, must either be repro- duced within the bronchial tubes, or conveyed to the ear by conduc- tion. Circumstances incidental to their manifestation in disease produce in certain cases the variations in quality, pitch, and inten- sity to which reference has been made. According to Skoda, the sounds may be reproduced. lie attributes the origin of morbid bronchial respiration in certain cases, to the principle of consonance. The air contained in the pulmonary bronchial tubes, according to this view, undergoes vibrations consonating with those caused by respiration within the trachea and large bronchi, in the same way that musical notes are repeated upon the strings of a violin or piano- forte when corresponding notes from another instrument in its vicinity are produced. This fanciful hypothesis, which appears to be readily received by many, I shall notice somewhat more fully in connection with the explanation of vocal signs. The simple fact that the loudness of the bronchial respiration of disease is often 1 This view is advocated by Dr. Gerhard. Diseases of the Chest. 1846. 172 PHYSICAL EXPLORATION OF THE CHEST. equal to and sometimes exceeds the intensity of the tracheal sounds, suffices to disprove it, for a sound reproduced by consonance is always much less intense than that which originates it. The variation in pitch, -which is sometimes observed, is also fatal to the hypothesis, for a consonating sound is always in unison with tlie primitive sound. Without denying that sonorous vibrations within the pul- monary bronchial tubes may consonate with those which take place in the trachea and larger bronchial tubes, the disparity in pitch and intensity disproves the validity of the explanation under circum- stances in which, according to Skoda, the principle of consonance is particularly applicable, viz., when the bronchial respiration inci- dental to disease is intensely developed. Regarding, then, the bronchial respiration as consisting of trans- mitted sounds, they are produced within the trachea, the primary bronchi, and probably also within the subdivisions of the latter, and are conducted by the air in the tubes and the solidified lung to the ear of the auscultator. In what proportion they are due, respec- tively, to the trachea, and the large bronchi exterior to the lungs, and to what extent sounds generated within the pulmonary bronchial subdivisions may be combined, are points not easily determined. It is not difficult to conceive that^the sounds emanating from the trachea may be conveyed with considerable intensity to different parts of the chest, after applying the stethoscope on the back of the neck, and listening; to these sounds in that situation transmitted through the vertebrae and mass of muscle which intervene between the ear and the trachea. The conduction, however, of the sounds generated within the trachea and the bronchi, as in the conditions of health, will not suffice to explain the intensification of sound which sometimes characterizes the bronchial respiration in disease, nor the disparity in pitch which is observed. These diflTerences must be owing to some agencies pertaining to the bronchial tubes within the lungs, or to the pulmonary structure. Sonorous vibrations propagated to the pulmonary bronchial tubes rendered firm and un- yielding by surrounding solidification, according to Fournet, Earth and Roger, and others, are reinforced and strengthened by rever- beration, and thus acquire an increased intensity. Other physical influences are doubtless involved, which are not, as yet, satisfacto- rily explained. The fact that frequently, in the affections to which bronchial respiration is incident, the respiratory movements are made with an abnormal quickness and force, will account for the AUSCULTATION IN DISEASE. 173 bronchial respiration being more intense than the tracheal Avith ordinary breathing in a healthy person, but not, of course, for an intensity greater than the tracheal sounds of the patient at the time of the examination. It has been seen in connection with the sub- ject of auscultation in health, that the intensit}^ of the tracheal sounds is greatly increased when the respiration is voluntarily forced. It is therefore to be borne in mind, that the intensity of the tracheal respiration with ordinary breathing in health is not a criterion by which to judge whether the bronchial respiration incident to disease is intensified by some cause or causes within the pul- monary organs, but the proper standard of comparison is the tra- cheal respiration of the patient which is incident to the same cir- cumstances under which the bronchial respiration is observed. Some of the circumstances accounting for differences in different cases, as regards the intensity of the bronchial respiration, are ob- vious. Other things being equal, the greater the degree of density the more complete is the conduction of sound. If the solidification be continuous from the larger bronchial tubes to the exterior of the lung, the intensity will be greater than if the continuity be inter- rupted by healthy structure, not only because air-vesicles containing air conduct sound more imperfectly, but also from the fact that the strength of sonorous vibrations is impaired by passing from one medium to another. AYith the same amount of solidification, the greater the proximity to the larger tubes, the louder will be the sound ; hence, the bronchial respiration is more strongly marked when the physical conditions favorable to its production are situated near the roots of the lungs, in proximity to the trachea and large bronchi, and surrounding the immediate subdivisions of the latter. In so far as the sign may be dependent on the passage to and fro of air within the bronchial tubes distributed throuo-h the lunir, and on the conduction by the air within the tubes (the latter perhaps enter- ing considerably into the mechanism), it will of course be affected by obstruction of these tubes from the accumulation of mucus or other morbid products. In addition to these circumstances, there are others which are not fully understood, and which, in some cases, occasion suppression of all respiratory sound when the conditions favorable for the bronchial respiration appear to be present. The completeness and intensity, on the other hand, with which this sign will be presented, will depend on the concurrence of all the circum- stances involved in its development and transmission. 174 PHYSICAL EXPLORATION OF THE CHEST. The affection in which the bronchial respiration is most constantly present, as Avell as oftenest intense, and, as regards the union of its distinctive characters, most complete, is pneumonitis. As this affec- tion is generally seated in the inferior lobe, and extends over the entire lobe, a well-marked bronchial respiration conjoined with dul- ness on percussion over the lower scapular and infra-scapular re- gions, and with the symptoms of intra-thoracic inflammation, is conclusive evidence of the presence of that disease, advanced to the second stage, or the stage of solidification. The transition, on the surface of the chest, from the vesicular murmur to the bronchial respiration is abrupt, and it is generally easy to determine, with the stethoscope, the line of demarcation between the two. This line, marked on the chest, will be found to pursue the direction of the interlobar fissure. If this line have been previously determined by percussion, auscultation will thus afford confirmation of its correct- ness. A sufficiently large collection of cases of pneumonitis will present every shade of intensity of the bronchial respiration, and the different variations in other characters. In some cases an in- spiratory sound Avill alone be heard, and in others the expiratory ; in pitch the sound may be more or less acute, and it may or may not possess a metallic intonation. In a small proportion of cases it is absent, and there is suppressed respiration : while, therefore, the bronchial respiration, in connection with the circumstances above mentioned, is positive proof of the existence of the second stage of pneumonitis, the abolition of all respiratory sound, in connection with the same circumstances, is not proof that pneumonitis does not exist. Next to pneumonitis, as regards the frequency with which the bronchial respiration is associated, is tuberculosis. A mass of tuber- cle, situated at the summit of the chest, in proximity to some of the large bronchial subdivisions, may give rise to a well-marked, and sometimes an intense bronchial respiration, rarely, however, so in- tense as attends the consolidation from pneumonitis. Existing at the summit of the chest on one side, over a space not extensive, conjoined with dulness on percussion, and certain symptoms, such as loss of weight, pallor, accelerated pulse, and especially haemoptysis, the diagnosis hardly admits of doubt. Often, however, in connec- tion with a tuberculous deposit, the respiratory sound, although dis- tinctly modified, is not sufficiently so to constitute a well-marked AUSCULTATION IN DISEASE. 175 bronchial respiration, and the modification -will fall under the head to be next considered. In oedema of the lungs the bronchial respiration may be present, but not strongly marked, and never presenting the intensity observed in some cases of pneumonitis. The same is true of pulmonary apo- plexy and carcinoma of the lungs. These forms of disease, more especially the two last, are extremely rare, and their diagnosis in- volves, on the one hand, the presence, and, on the other hand, the absence of signs and symptoms, to which reference will be made hereafter. In pleurisy affecting the adult, a well-marked bronchial respiration is observed in a certain proportion of cases. Of twenty-six cases, selected indiscriminately, in the wards of the hospitals Hotel Bieu and La Charite^ at Paris, Barth and Roger state that it existed in nine,^ and was absent in seventeen. It is incident to this affection much more frequently in children, its coexistence in them being the rule according to Swett.^ Occurring in pleurisy, it is due to con- densation of the lung from compression by the liquid eflFusion within the pleural sac, and is usually limited to the summit of the chest, the pressure of the fluid pushing the lung upward, except in some instances in which it is prevented from yielding to the force of the pressure, in this direction, by morbid attachment of the pleural sur- faces. In some cases, however, it is more or less diffused over the chest. Such cases are met with much oftener among children than adults. When heard below the level of the fluid it is rarely intense, and the sound seems to come from a distance. In the great majority of the cases of pleuritis, certainly among adults, the respiration is suppressed over the chest, below the level of the liquid effusion. This, in fact, is the rule, the instances in which a diffused distant bronchial respiration is appreciable, being exceptions. The physical conditions in hydrothorax are the same as in pleu- risy, so far as concerns their effect on respiratory sounds ; but inas- much as, in this affection, liquid effusion takes place in both sides of the chest, the quantity necessary to produce complete or consider- able solidification of both lungs is hardly compatible with life. Oc- casionally, however, bronchial respiration over a limited space is produced on one or both sides. As already stated, compression of the pulmonary parenchyma by ^ Diseases of the Chest, etc. 176 PHYSICAL EXPLORATION OF THE CHEST. other causes than pleuritic effusion may give rise to the bronchial respiration. Barth and Roger state that it has been observed by them in connection Avith an accumulation of fluid within the peri- cardial sac, the non-existence of liquid in the pleural cavity, and of pneumonitis, or solidification from other disease, being determined by autopsical examinations. It is evident that a tumor developed within or extending into the chest may produce the same effect. Abnornal dilatation of the bronchial tubes is, perhaps, to be added to tlie foregoing list of affections giving rise to the bronchial respi- ration. It is difficult to determine how much influence is to be at- tributed to the dilatation, since it is generally associated with more or less solidification of the pulmonary tissue surrounding the dilated tubes. From the relations which have thus been seen to exist between bronchial respiration and different pulmonary affections, pneumo- nitis and tubercle more especially, it is sufficiently apparent that it is a highly important physical sign, holding very frequently a prom- inent place among the phenomena involved in diagnosis. Practical acquaintance with its distinctive characters is therefore indispensa- ble to the exercise of the art of physical exploration; and this may be readily acquired, since, as has been already stated more than once, these characters may be studied as well by means of ausculta- tion in health as in disease. In view of the doubtful propriety of the term bronchial, as applied to this sign, the name tubular respiration is preferable, although it is less commonly used, 5. Bronclio-vesicular, vesiculo- tubular^ or rude respiration. — The abnormal modification commonly called rude respiration, I have ven- tured to designate by a new title, viz., broncho-vesicular, a name expressing both the character and the source of the sounds, while the term mde, in this application, is not only indefinite, but its cor- rectness admits of question. A bronchial respiration we have seen to be characterized, first and specially, by the absence of the vesic- ular quality, which is replaced by a tubular sound; now, in certain forms of disease, the inspiratory sound presents the tubular and the vesicular quality, combined in varied proportions ; and, at the same time, other of the characters of the bronchial respiration may be more or less associated. This modification I propose to distinguish as the broncho-vesicular or the vesiculo-tubular respiration. If the reader will take the trouble to consult different works on AUSCULTATION IN DISEASE. 177 the subject of physical exploration, he will find a singular want of clearness in the manner in which this sign is usually defined ; and it is exceedingly diflScult for the student to form a correct idea of what is intended to be indicated by the term rude respiration. All concur in saying that the rude respiration merges insensibly into the bron- chial respiration. It is, in fact, neither more or less than imper- fectly developed bronchial respiration, which in the process of certain diseases, as will be seen presently, it may both precede and follow. Analyzed it consists of elementary characters approximating to those of the bronchial respiration, an essential point of difference being that the vesicular quality, although impaired, is not lost. In describing the distinctive characters of the broncho-vesicular respiration, as contrasted with the normal vesicular murmur, the in- spiratory and the expiratory sound are to be considered separately. In determining these characters clinically, in cases of disease, of course comparison is made of corresponding regions on the two sides of the chest ; the normal vesicular murmur, or an approximation thereto, being presumed to exist on one side. This comparison is necessary in judging of a broncho-vesicular more than in determin- ing the presence of a bronchial respiration, for the distinctive char- acters in the latter are more marked. As stated under the head of Auscultation in Health, in quality and pitch, as well as in intensity of the normal respiratory sounds, marked difi'erences exist in differ- ent individuals. The natural respiration in some persons, compared with that in others, might be said to be broncho-vesicular. The intensity of the inspiratory sound in the broncho-vesicular respiration may be either greater or less than in the normal vesicular murmur. The intensity is not a distinctive feature. This sound is frequently shorter in duration than in the normal vesicular murmur, ending before the close of the inspiratory act ; in other words, being unfinished. It has less of the vesicular quality, with more or less of the tubular quality added, as the name imports. It is higher in pitch. The latter is a feature highly distinctive, easily appreciated, and which is therefore of considerable importance. It is a feature to which attention had not been called prior to the publication by the author to which reference has already been made.' I am per- suaded, however, that practical auscultators have been accustomed 1 On Variations of Pitch, &c., Prize Essay. Transactions of Am. Medical Association, 1852. 12 178 PHYSICAL EXPLORATION OF THE CHEST. to recognize, unconsciously, what they have called a rude respira- tion, in a great measure by the elevation of pitch. I say uncon- sciously, for it is evident that sounds may be discriminated practi- cally, without a full knowledge of the special characters by which they are distinguished, this knowledge being obtained only by care- ful and accurate analysis. In comparing sounds on the two sides of the chest which differ but slightly, it is easier to appreciate a va- riation in pitch than a difference in the amount of vesicular quality, although each involves the existence of the other. The expiratory sound may be present or absent. It is much oftener present than in the normal vesicular murmur. It is often prolonged, being nearly or quite as long as the sound of inspiration, and sometimes longer. From the fact that the inspiratory sound is unfinished, an interval separates the two sounds, as in the bronchial respiration. In these several points the reader will not fail to notice the approximation to the bronchial respiration. This holds good still farther. The expiratory sound is higher in pitch, and frequently more intense than the inspiratory. It was observed by Jackson (who first called attention to the importance of the expiratory sound in physical diagnosis), and the fact was confirmed by Fournet and others, that in the development of the rude respiration the morbid alteration generally first appears in the expiration. It be- comes more intense and prolonged. The fact that the pitch becomes higher than that of the inspiratory sound, reversing in this respect the condition of health, appears to have escaped observation. This fact is of considerable importance to be borne in mind ; for, under other circumstances, when the expiration is prolonged, indicating physical conditions differing from those which give rise to the bron- cho-vesicular respiration, the pitch of the expiratory sound does not become higher than that of the inspiratory. To recapitulate the characters of the broncho-vesicular respira- tion : Inspiration presenting the vesicular and the tubular quality combined; shortened in duration ; pitch raised ; intensity variable; sometimes alone present. Expiration prolonged ; occurring after an interval ; pitch higher than that of inspiration, and often the in- tensity greater. Keeping in view these distinctive characters, it is not difficult to determine clinically the existence or non-existence of the sign under consideration. It should be discriminated readily from ex- aggerated or puerile respiration, after a little experience in phys- AUSCULTATION IN DISEASE. 179 ical exploration ;^ for, in the latter sign, there is no change in the quality or pitch of the inspiration, but simply increased intensity; the expiratory is continuous with the inspiratory sound, is less intense, and lower in pitch. If an inspiratory sound be alone present, the vesiculo-tubular quality and the elevation of pitch per- taining to the broncho-vesicular inspiration suffice to mark the distinction. It may be in some instances a matter of question whether the respiration be broncho-vesicular or bronchial; but thia is a point practically of little or no consequence, since the one merges insensibly into the other, and when there is room for doubt, the bearing on diagnosis in either case is the same. The chief liability to error is connected with the question whether a broncho- vesicular respiration exists naturally, or is due to a morbid condition. To this point I shall presently advert. As regards the morbid conditions which the broncho-vesicular respiration represents, it denotes a certain amount of increased density of the lung, either- from compression or morbid deposits. The conditions, in other words, are the same in character as those which give rise to the bronchial respiration ; and the physical prin- ciples involved in its mechanism are the same, the only difference being that the vesicular quality of sound is partially, not completely suppressed. It is, therefore, met with in the same diseases which give rise to the bronchial respiration, viz., pleurisy and hydrothorax; compression of the lung by distension of the pericardial sac, and tumors; pneumonitis, tuberculosis, pulmonary apoplexy, oedema, and carcinoma. In pleural effusions (pleurisy and hydrothorax) it occurs when the quantity of liquid is sufficient to-produce condensa- tion of lung, but not complete or considerable solidification. In pneumonitis it is present at different epochs, first indicating pro- gressive exudation, and, afterward, the progress of resolution ; in the former instance giving place to, and in the latter succeeding the bronchial respiration. In short, it may be a sign of any of the several affections named, provided the condensation or solidifica- tion of lung be not sufiicient to extinguish the vesicular quality of sound, in which case either the bronchial respiration appears, or all respiratory sound is suppressed. 1 " La distinction n'est pas toujours ^vidente entre la respiration rude et les formes de la respiration dite -puerile, etc." Barth and Roger. Op. cit. Other writers make a similar statement. 180 PHYSICAL EXPLORATION OF THE CHEST. In general terms, the broncho-vesicular respiration represents all the different degrees of solidification of lung, falling short of com- plete or considerable solidification, the latter being represented by the bronchial respiration. The characters of the sign vary accord- ing to the degree of solidification, and, by means of these variations, it may be determined whether the solidification be slight, moderate, or nearly enough to furnish the bronchial respiration. For example, let it be supposed that there is a slight increase of density, such as exists in a small deposit of tubercle, the characters of the broncho- vesicular respiration denoting this condition are as follows : The inspiratory sound is a little less vesicular than in health, a little tubular quality is added, and the pitch is a little higher ; the expi- ratory sound is somewhat prolonged, the intensity somewhat greater, and the pitch higher than in health. These characters denote what may be called a slight broncho-vesicular respiration. On the other hand, let it be supposed that the solidification falls but little short of the amount sufficient to furnish bronchial respiration, the charac- ters denoting this condition are as follows : The inspiratory sound is almost purely tubular in quality, only a little vesicular quality is per- ceived, and the pitch is high; the expiratory sound is prolonged, in- tense, and high nearly to the same degree as in the bronchial respi- ration. Now, between these two extremes of the broncho-vesicular respiration, every degree of gradation may be presented in different cases. In proportion as the increase of density of lung is small, the characters of the normal vesicular murmur will predominate over the characters of the bronchial or tubular respiration; and, on the other hand, in proportion as the solidification approaches the amount re- quired to furnish bronchial respiration, the characters of the latter will predominate over those of the normal vesicular murmur. The respiration is broncho-vesicular, not purely bronchial, wherever the vesicular quality is appreciable, however slight, in the inspiratory sound ; and the respiration is broncho-vesicular, not normal vesicular, wherever there is an abnormal diminution of the vesicular, and addition of tubular quality, no matter how slight, in the inspiratory sound. In proportion as the vesicular quality pre- dominates in the inspiratory sound, the increase of density of lung is small, and the elevation of the pitch of the inspiratory sound is slight in proportion as the vesicular quality predominates. Per eontra, in proportion as the tubular quality in the inspiratory sound predominates, the density of lung is greater, and the pitch of the AUSCULTATION IN DISEASE. 181 inspiratory sound is raised in proportion as the tubular quality pre- dominates. The expiratory sound varies in correspondence with the variations of the inspiratory sound. It is less prolonged, less in- tense, and less high in proportion as the vesicular quality predomi- nates in the inspiratory sound ; and, |;er contra, it is more prolonged, more intense, and higher in proportion as the tubular quality pre- dominates in the inspiratory sound. ^ The broncho-vesicular respiration is important, as a physical sign, especially in the diagnosis of pulmonary tuberculosis in its early stage. In this relation it is a sign of great value. When the amount of tuberculous deposit is small or moderate, so far as the phenomena determinable by auscultation are concerned, this is the sign most likely to be produced; hence, in conjunction with other signs and symptoms, it is often very significant. In fact, the diagnosis may hinge upon the question whether a well-marked broncho-vesicular respiration be present or not. In this connection it is to be borne in mind (as has been stated already), that all the several characters which distinguish this sign from the healthy vesicular murmur are by no means invariably present. An inspiratory sound only may be appreciable. If this be less vesicular, higher in pitch, and shorter in duration, with a greater or less degree of intensity, than the in- spiratory sound at the summit of the chest (where the tuberculous deposit first takes place), at a corresponding point on the opposite side, the respiration is broncho-vesicular, as clearly almost as if there were added the characters pertaining to the expiratory sound. On the other hand, a prolonged expiratory sound higher in pitch than either the inspiratory or expiratory sound on the opposite side may be added. In the diagnosis of tuberculous disease, before attributing to a morbid source the sign under consideration, we are always to inquire whether it may not be incident to a healthy condition ; in other words, whether the points of disparity, which may be observed, do not belong among the variations which are frequently found in per- sons free from pulmonary disease. This question, in some instances, gives rise to more room for difficulty and doubt, than a decision as regards the reality of the characters which distinguish the broncho- * Dr. Dacosta, in his work on Diagnosis, proposes the name vesiculo-bronchial instead of broncho-vesicuhir. The two terms might be used, the first to denote a predominance of the vesicular, and the latter a predominance of the bronchial characters. 182 PHYSICAL EXPLORATION OF THE CHEST. vesicular respiration. It has been seen under the head of Auscul- tation in Health, that the several elements into which the bronchial and the broncho-vesicular respiration are resolvable, are to be found in a certain proportion of healthy persons at the summit of the chest. This fact cannot be lost sight of without the risk of grave errors in diagnosis. Errors probably often occur from the want of a proper appreciation of this fact. The results of examinations of the chest in a series of healthy persons lead to a rule which affords great as- sistance in settling the question just mentioned. If the reader will refer to the comparison of the regions at the summit of the chest in health, as respects the phenomena incident to respiration, he will Bee that comparative diminution of vesicular quality and elevation of pitch of the inspiratory sound, a more frequent presence of the sound of expiration with or without the inspiratory sound, prolonga- tion of the latter with greater intensity and elevation of pitch, are points of disparity peculiar to the right side. In other words, a rela- tive broncho-vesicular respiration is natural to the summit of the chest, in front and behind, in a certain proportion of individuals.^ This being the case, it follows that the question as to this modifica- tion of the respiratory sound being due to disease, pertains to its presence on the right side of the chest. A well-marked relative broncho-vesicular respiration on the right side may not indicate more than a natural disparity. To be considered a morbid sign on this side, it must be associated with other signs, and with symptoms pointing emphatically to the existence of tuberculous disease. As an isolated sign, reliance must not be placed upon it in that situation. Non-observance of this rule exposes the practitioner to a false diag- nosis. On the left side, however, the probabilities of the sign being due to a normal disparity are very few. In this situation, it is of itself positive evidence of a tuberculous deposit, when other circum- stances create a suspicion of the existence of phthisis; and it is of less importance, with reference to the diagnosis, that it be associated with other signs, and with symptoms denoting the existence of tuber- culous disease when it is situated on the left side. The term broncho-vesicular owes its pertinency to the use of the term bronchial as applied to the sign previously considered. Vesic- ulo-tubular respiration would be preferable, if the bronchial respi- ration be called tubular. 6. Cavernous and Amphoric respiration. — The term cavernous im- 1 By the term relative, I mean the relation of one side of the chest to the other side, in corresponding regions. AUSCULTATION IN DISEASE. 183 ports modifications of the respiratory sounds due to the presence of caverns or excavations within the chest. The formation of cavities of greater or less size belongs to the natural history of tuberculosis of the lungs; they result also from abscess, as a rare termination of pneumonitis; also from circumscribed gangrene, and from perfora- tion establishing a fistulous communication between the bronchial tubes and the pleural sac. The cavernous respiration consists of the sounds caused by the entrance, with the act of inspiration, of air into the cavities incident to the several affections just named, and its expulsion with the act of expiration. Laennec described this sound as resembling that of the bronchial respiration, but dis- tinguished by the air seeming to penetrate a larger space than that of a bronchial tube. The diiference between the cavernous and the bronchial respiration, is certainly not very clearly defined in this description; and the two sounds are now considered by many to be essentially identical. Skoda takes this view. The laryngo-tracheal sounds are frequently referred to by writers on this subject, as offer- ing equally a type of the bronchial and cavernous respiration. This view is incorrect. The cavernous respiration is a distinct phys- ical sign, and, when well marked, is discriminated from the bron- chial respiration without difficulty, by characters which are quite distinctive. These characters relate to intensity, quality, pitch, and rapidity of evolution. The intensity is variable. It may be feeble, or more or less intense, but rarely acquiring the great intensity which sometimes characterizes bronchial respiration. It is rarely the case that it presents the character of the blowing respiration of Laennec, viz., the air appearing to enter and emerge from the ear of the auscultator. The quality of sound is non-vesicular, in other words blowing, using this term as denoting a quality different from that denoted by the term tubular. The quality conveys to the ear the idea of a hollow space. The difference in this respect between the cavernous and the bronchial respiration may be illustrated by blowing, first, into a cavity formed by the two hands, and afterward through a tube formed by the fingers and palm of one hand. The pitch is low, compared with that of the tracheal or the bronchial respiration. An expiratory sound may be present, and if so, the pitch is lower than that of inspiration. Finally, the inspiratory sound is evolved more slowly than in the bronchial respiration ; in other words, it does not so promptly accompany the beginning of the respiratory act. Of the characters just mentioned, those which are specially distinctive, as contrasted with the bronchial respira- 184 PHYSICAL EXPLOKATION OF THE CHEST. tion, relate to the pitch and quality of sound. The inspiratory sound is lower in pitch than in the bronchial respiration and blowing. The sound of expiration is blowing and lower than that of inspira- tion, the reverse obtaining in the bronchial respiration. This state- ment is based on numerous observations, in which the phenomena were noted during life, and the existence of cavities in the situa- tions where these characters of the respiration had been studied, being demonstrated after death. In determining, clinically, the existence of the cavernous respira- tion, other circumstances than its intrinsic characters may be taken into account. It is heard over a circumscribed area, which corre- sponds to the size of the cavity. It is an intermittent sign, being absent when the cavity is filled with liquid morbid products, or when the tubes leading to it are obstructed. Occurring, in the vast majority of the instances in Avhich it exists, in the progress of tuberculosis, it is found at the summit of the chest ; the cavities in that affection being formed at or near the apices of the lungs. It may be associated with other cavernous signs, viz., amphoric or cracked-metal resonance, cavernous whisper, gurgling, and metallic tinkling. Frequently, the symptoms afford strong corroborative evidence of the existence of a cavity. When a cavity, or cavities, exist in the lungs in connection with either of the affections which have been named, the presence of the cavernous respiration depends on certain conditions. The cavity must be empty, or, if partially filled, the opening or openings with which it communicates with the bronchial tubes, must be situated above the level of the liquid contents. Intermittency arises from the fact that, at different periods of the twenty-four hours, a cavity may be completely filled, partially filled, and entirely empty. It is less likely to be heard at an early hour of the morning, because liquid contents usually accumulate during sleep, and are removed by efforts of expectoration more or less prolonged, or repeated, after waking. The cavity, of course, must communicate by one or more openings with the bronchial tubes. The size of these open- ings will affect the sign, in the first place, directly, the intensity of the sound, other things being equal, being proportionate to the free- dom with which the air is admitted to the cavity ; and, in the second place, indirectly by favoring the removal of the liquid contents by expectoration. The opening, or openings, are liable to become tem- porarily or permanently obstructed. Their form and size sometimes are such, that the current of air in passing to and fro, gives rise to AUSCULTATION IN DISEASE. 185 adventitious sounds, which render the cavernous respiration inap- preciable. The bronchial tubes leading to the cavity must be un- obstructed, and free from loud adventitious sounds which are fre- quently generated within them. The walls of the cavity must not be so rigid and unyielding as not to collapse and expand with the alternate acts of inspiration and expiration; otherwise, it will not be successively filled with and emptied of air. The cavity must be of a certain size, and, other things being equal, the cavernous respi- ration will be marked in proportion to its magnitude. The pres- ence of the sign will depend on the situation of the cavity. Situ- ated superficially, or near to the exterior of the lung, the sound may be appreciable when it would not have reached the ear through a layer of pulmonai'y parenchyma. The condition of the lung surrounding, or in the vicinity of, the cavity is an important circumstance. Generally there is more or less solidification, giving rise to the bronchial respiration. This sometimes assists by contrast in determining the presence of a cav- ernous respiration, but in other instances it drowns the latter and prevents it from being appreciated. In consequence of its depend- ence on so many contingencies, it is only in a certain proportion of the cases in which a cavity or cavities exist, that auscultation suc- ceeds in discovering a well-marked cavernous respiration; and fre- quently in the instances in which it is discoverable, it is found only after repeated explorations. Fortunately, as a physical sign, it is of less importance practically than other signs involved in the diag- nosis of the affections to which the formation of cavities is incident. A successful search for a cavity requires some care and patience. The object is to localize within a circumscribed space a non-vesicular inspiratory sound, blowing or non-tubular in quality, and low in pitch, evolved somewhat slowly, and an expiratory sound, blowing, and lower in pitch than the inspiratory. The lowness of the pitch of inspiration compared with the bronchial respiration is mentioned by Walshe and others ; but the relative lowness of the pitch of ex- piration compared with the inspiration, was not, to my knowledge, pointed out prior to the publication of my prize essay in 1852, This constitutes a highly distinctive characteristic of the cavernous, as distinguished from the bronchial respiration; and it is rendered especially important by the fact that other signs of a cavity, for- merly considered to be distinctive (I refer more particularly to the vocal sign, pectoriloquy), have now justly ceased to be regarded in that light. The fact of a non- vesicular sound being restricted within a 186 PHYSICAL EXPLORATION OF THE CHEST. circumscribed space, is bj no means reliable as sufficient evidence that the respiration is cavernous. They, who consider the bron- chial and cavernous respirations identical in character, are obliged to base the discrimination on that circumstance. But a bronchial respiration, at the summit of the chest, is not unfrequently circum- scribed within narrow limits; hence, errors of diagnosis are neces- sarily incident to reliance on this point. I have known mistakes arising from this source to be committed by experienced ausculta- tors. Taken, however, in connection with other points, it is of considerable importance; and in order better to circumscribe the area whence sounds are received by the ear, the stethoscope should be used in preference to immediate auscultation. To determine the non-vesicular quality of the sound at a suspected point, a compari- son may be made of the sound at this point with that heard over portions of the chest where the vesicular quality is distinctly pre- served. To determine that the pitch is lower than that of the bronchial respiration, in cases of tuberculosis, the sound at a sus- pected point may frequently be contrasted with that at other points at the summit of the chest, where, owing to the presence of crude tubercle, the bronchial respiration is well marked. Or, if this com- parison be wanting, it may be contrasted with the sounds heard over the trachea. In some instances, owing to the cavity being surrounded by solidified lung, the cavernous respiration will be pre- sented in strong contrast to the bronchial respiration, which on all sides defines the boundaries of the excavation. In a case in which I localized a cavity, the following interesting circumstance was noticed. At the beginning of the inspiratory act the sound was tubular and high in pitch, but at about the middle of the act the pitch abruptly became low, and the quality blowing.' The inspiration was followed by a feeble expiratory sound low in pitch. In this case, a post-mortem examination revealed a cavity communicating at the point where this peculiarity was observed with a bronchial tube of the size of a goose-quill.^ This instance ex- emplified a combination of the cavernous and bronchial respiration. This combination I have repeatedly noticed. The characters of the bronchial and the cavernous respiration may be intermingled in varied proportions. The combination of the two signs may be ex- pressed by the term hroncho-cavernous respiration. 1 The reader is reminded that I use the term blowing as denoting a quality which is neither tubular nor vesicular. 2 Vide Appendix to Essay on Variations in Pitch, etc. AUSCULTATION IN DISEASE. 187 Of the several affections in which a cavernous respiration may be observed, tuberculosis is the one in which it occurs in the vast ma- jority of instances. The other affections are extremely rare. In circumscribed gangrene and abscess, moreover, the conditions re- quired for the production of the sign, are much more infrequently combined than in the cavernous stage of phthisis. Skoda states that in the few instances in which an excavation results from pneu- monitis, the space is so constantly filled with pus and sanies, that it almost never gives rise to distinctive sounds, determinable either by percussion or auscultation. I have, however, observed well-marked cavernous respiration in a cavity formed by an abscess. In pneu- mo-hydrothorax the pleural sac, which may be more or less circum- scribed by morbid adhesions, constitutes a cavity in which the air may enter with inspiration, and be expelled with expiration, through the fistulous communication with the bronchial tubes. There is still another mode in Avhich a cavity may be formed within the chest, viz., by means of a pouch-like dilatation of a bronchial tube. This is very infrequent, but it is to be borne in mind as a possible con- dition giving rise to the sign under consideration. In view of the vastly greater ratio of tuberculous excavations to those incident to all other affections, when the fact of the existence of a pulmonary cavity is determined, it might be attributed to phthisis, almost by the law of probabilities alone; but the situation of the cavity affords additional evidence. A tuberculous excavation in forty-nine out of fifty cases is situated at or near one of the apices of the lung, while, on the other hand, cavities from gangrene, abscess, or perforation, are more likely to occur elsewhere. As a sign indicating the nature of the disease, in individual cases, cavernous respiration is of minor importance. It is discoverable in only a certain proportion of the cases in which cavities exist. Tuberculous excavations are very frequent. They are found after death in most subjects dead with phthisis, and the prevalence of this fatal disease in all countries is well known. Yet, in cases of ad- vanced phthisis, a well-marked cavernous respiration is by no means always discoverable, even after repeated, careful explorations. And when cavities are formed in the progress of any of the affections named, but especially in tuberculosis, occurring at a late period of the disease, the diagnosis has already been determined by other signs, together with the concomitant symptoms; hence a cavernous respi- 188 PHYSICAL EXPLORATION OF THE CHEST. ration only serves to confirm its correctness. Moreover, in each of these affections, excepting, perhaps, pouch-like dilatation of a bron- chial tube, the signs and symptoms, irrespective of cavernous respira- tion, are suiEcient to render the diagnosis easy and positive, so that the latter is redundant, and except as a matter of scientific interest, sometimes hardly compensates for the pains necessary to discover it. An abnormal modification of the respiratory sound is called am- phoric respiration. It is incident to a cavity equally with the cav- ernous respiration, and both are sometimes combined, although the mechanism of their production is not the same. It sufiices to regard the amphoric as a variety of the cavernous respiration. If a per- son blow gently upon the open mouth of an empty vial, a sound is produced which has a musical intonation. This sound is analogous to that which characterizes the amphoric respiration; in other words, whenever a respiratory sound presents a musical tone it is said to be amphoric. This sound is variable as regards intensity. It has been heard even when the ear is removed at a little distance from the chest. It is generally confined to a circumscribed space, but is sometimes diffused more or less over the chest. It may accompany either respiratory act. The mode of its production within the chest is probably the same as in the illustration mentioned. It is not caused by the free circulation of air within a cavity, but by the current of air in the bronchial tubes, acting upon the air contained within the cavity. In this respect it differs from ordinary cavernous respi- ration. The special conditions which it requires are, a cavity of considerable size, of course, partially or entirely free from liquid contents, and the walls of the cavity sufficiently firm not to undergo complete collapse and expansion with expiration and inspiration. In some instances a partial displacement of air takes place in conse- quence of a certain amount of collapse and expansion of the walls of the cavity, and then there may exist an ordinary cavernous res- piration with the amphoric sound superadded. It is rare that an excavation, except it proceed from tuberculous disease, is of sufficient size and provided with walls sufficiently firm to fulfil the requisite physical conditions. It is a rare sign in tuber- culous disease. The conditions are most likely to exist in pneumo- hydrothorax : and hence, when the sign is present it generally de- notes that affection. It is stated by Skoda that for the production of an amphoric sound, a free communication between the bronchial AUSCULTATION IN DISEASE. 189 tubes and the pleural sac or a pulmonary excavation is not necessary. He thinks that the sonorous vibrations may be communicated to the air contained within the cavity, by the column of air in the tubes, through an intervening septum of pulmonary tissue. This opinion, as remarked by Barth and Roger, is supported by the fact that the experiment of producing an analogous sound by blowing into a de- canter or water-croft, is successful when the mouth of the vessel is covered by a very thin diaphragm, for example, a single layer of letter-paper. The sound, under these circumstances, is more feeble, and more force in blowing is required. Amphoric respiration, when present, indicates very positively either pneumo-thorax, or a cavity within the lungs. Its absence, however, is not evidence that one or the other, or both morbid con- ditions, do not exist. This remark, applicable to ordinary cavern- ous respiration, is still more so to the amphoric variety. Consider- ing its infrequency, and in view of the fact that the diagnosis of the affections, in connection with which it occurs, is in nowise de- pendent upon it, the sign is interesting more as a clinical curiosity than for its practical value. The three forms of morbid respiration just considered, viz., the bronchial, the broncho-vesicular, and the cavernous, constitute signs embracing abnormal modifications in quality, pitch, etc., of the nor- mal respiratory sounds. In place of a summary of the distinctions which have been described in the preceding pages, the subjoined tabular view is appended, by means of which the reader may review, at a glance, the distinctive characters pertaining to the three forms of morbid respiration just named, and compare them with the char- acters which belong to the healthy vesicular murmur. Tabular View of the Distinctive Characters of the Bronchial, the Broncho-vesicular, and the Cavetmous Respiration. Normal Vesicular Murmur. Inspiration. Expiration. Vesicular in quality. Low in pitch. Short in duration, averaging about Longer than expiration as 5 to 1. ^th length of inspiration. Less in- tense than the inspiration. Often ab- sent. Pitch lower than that of inspira- tion. Inspiration and expiration con- tinuous. 190 PHYSICAL EXPLORATION OF THE CHEST. Bronchial Respiration. Iimpiration. Tubular in quality. Pitch raised. Shortened in duration. Rapidly evolv- ed. Occasionally present without a sound of expiration. Expiraiion. Prolonged ; frequently as long or longer than the inspiration. Gener- ally more intense than the expiration. Rarely absent. Pitch higher than that of the inspiration. An interval be- tween inspiration and expiration. Sometimes present without a sound of inspiration. Ivspiraiion. The tubular and the vesicular quality combined in varied proportions, and the pitch raised in proportion to the amount of tubular quality. Duration frequently shortened. Occasionally pre- sent without a sound of expiration. Broncho-vesicular Respiration. Expiration. Prolonged. Generally more intense than the inspiration. Usually present. Pitch somewhat higher than that of inspiration. An interval between in- spiration and expiration. Sometimes present without a sound of inspiration. Cavernous Respiration. Inspiration. Expiration. Blowing, i. e., non-vesicular and non- Quality blowing. Pitch lower than tubular in quality. Pitch low. Slowly that of inspiration. Sometimes am- evolved. Sometimes amphoric. phoric. The remaining division of the modifications in quality, etc, of respiratory sounds, comprises those relating to rhythm. The subdi- visions under this head, save one, are among the constituent ele- ments of the signs which have been considered. A brief notice of them will therefore sufiice in the present connection. The modifi- cations in rhythm which are of importance in diagnosis are three in number, viz.: 1, shortened inspiration; 2, prolonged expiration; 3, interrupted respiration. The two first have received attention in connection with exaggerated, feeble, bronchial, and broncho-vesicu- lar respiration. 7. Shortened inspiration. — iVbnormal shortening of the inspira- tory sound, occurring as one of the elements entering into signs which have been considered, is of tw^o kinds. As it is presented in the feeble respiration incident to emphysema, it forms what is called deferred inspiration. The inspiratory sound does not commence prior to the middle or toward the close of the inspiratory act. Hence the propriety of the term deferred. With the ear applied to the chest, the expansive movement is frequently felt for some AUSCULTATION IN DISEASE. 191 time before any sound is heard. The murmur is heard in health with an intensity increasing from the beginning to the end of the inspiratory act. When, therefore, the sound becomes abnormally feeble in emphysema, it is inaudible until the intensity increases to a certain point. In this way, with the progress of the disease, it is in some instances at length extinguished ; the suppression extends more and more toward the end of the act of inspiration, until the sound entirely disappears. The duration of the inspiratory sound is diminished in a different manner in the bronchial and the broncho- vesicular respiration. The sound is quickly evolved, commencing nearly at the commencement of the act of inspiration, and ends be- fore the close of the act. The inspiratory sound in this case is said to be unfinished. The difference in these two forms of shortened inspiration, it will be observed, corresponds to the difference as respects the situation in which the sound is generated. A vesicular inspiratory murmur, when shortened, is deferred ; a shortened bronchial inspiration is always unfinished. Another point of dis" tinction is involved in the foregoing, viz. : a shortened bronchial or unfinished inspiration is, at the same time, notably changed in qual- ity and pitch ; a shortened vesicular or deferred inspiration offers much less change in other respects. To treat here of the diagnostic significance of this rhythmical modification, would be to repeat what has been already fully presented. As the consequence of an unfinished inspiration, an interval occurs between the inspiratory and the expiratory sound. The duration of this interval is proportionate to the extent to which the inspiration is shortened. Regarding this as a distinct modification of rhythm, it is called divided respiration. Division of the two sounds of respiration is one of the several elements of the bronchial and the broncho-vesicular respiration. It is a change, however, en- tirely dependent on the unfinished duration of the inspiratory sound, and it suffices to notice it as incidental to the latter. 8. Prolonged expiration. — Although Laennec did not overlook the fact of the existence of an expiratory sound in health, the im- portance of its abnormal modifications escaped the attention of the illustrious discoverer of auscultation. His observations of the phe- nomena of disease referable to modified respiratory sounds were confined to those pertaining to the inspiration. The honor of having first called attention to the value of the expiration in physi- cal diagnosis belongs to an American physician, arrested by the 192 PHYSICAL EXPLORATION OF THE CHEST. hand of death at the threshold of a career of useful labor in behalf of medical science. In 1833, Dr. James Jackson, Jr., of Boston, at that time prosecuting his studies in Paris, communicated a paper to the Societe Medicale d' Observation, on the subject of a prolonged expiratory sound as an early and prominent feature of the bronchial respiration, and frequently constituting an important physical sign of the first stage of phthisis. From this epoch may be dated the commencement of observations -which have rendered the expiratory scarcely inferior to the inspiratory sound, in its relations to the dis- tinctive characters of the bronchial, the broncho-vesicular, and the cavernous respiration. The reader has only to glance at the tabu- lar view of the characters distinguishing severally the signs just mentioned, to perceive the importance of the abnormal changes in duration as well as in the intensity and pitch of the sound of ex- piration. A prolonged expiration has been also seen to enter into the characters distinguishing exaggerated respiration, and to con- stitute a striking feature of the opposite, viz., feeble respiration as exemplified in certain cases of emphysema. Differences in other particulars than duration, and especially vari- ations in pitch, are important to be considered in connection with prolongation of the inspiratory sound. Thus, in bronchial respira- tion, the expiration, while it is increased in length, is more intense and higher in pitch than the sound of inspiration. The same differ- ence holds good, to a greater or less extent, in broncho-vesicular respiration. On the other hand, in cavernous respiration, the ex- piratory sound is generally feeble and lower in pitch than the sound of inspiration. In exaggerated respiration, the expiration is less intense than the inspiration, and the relatively lower pitch which the latter has in normal respiration is preserved. The same is true of the prolonged expiration in emphysema ; at all events, it does not present the elevation of pitch which characterizes the expiratory sound in bronchial respiration.^ These variations in the pitch of the expiratory sound have hitherto been but little studied, and their significance has, therefore, not been sufficiently appreciated. They appear, from the facts just stated, to sustain relations to the differ- 1 The prolonged expiration in emphysema often assumes a high-pitched tone in consequence of coexisting bronchitis. Under these circumstances it ceases to be, properly considered, a modified respiratory sound, but becomes a r&le. This distinction is to he observed in verifying by observation the statement made above. AUSCULTATION IN DISEASE. 193 ences in the physical conditions under which the duration of the expiratory sound is increased, which it is both interesting and im- portant to note. When the pitch is raised in the bronchial and the broncho-vesicular respiration, the prolongation is due to increased density of lung ; whereas in exaggerated respiration there is no morbid change in the part of the lung Avhence the sound emanates, but simply an increased functional activity, and under these circum- stances the pitch is not raised, but continues, as in health, lower than that of the inspiration. In emphysema, owing to the dimin- ished elasticity of the lung, the cells collapse and expel their con- tents more slowly than in health. In this case the pitch is not notably, if at all raised. The same is true when the prolongation arises from any obstruction to the passage of air from the cells to the larger bronchial tubes. If these statements be correct, — and observation will confirm their correctness, — the pitch of the expira- tory sound, taken in connection with its prolongation, affords a means of determining whether the latter is an indication of tuber- culous or other morbid deposit, or only an effect of a retardation of the current of air from the cells. A prolonged expiratory sound in some instances is the sole or chief alteration of the respiration which an examination of the chest discloses, the inspiratory sound not presenting any distinct morbid change in quality, intensity, pitch or duration. Now, what is the diagnostic value of a prolonged expiration under such circum- stances ? The importance of this question relates to its practical bearing on the diagnosis of incipient phthisis. Is a prolonged ex- piration under such circumstances, to be regarded as a sign of tu- bercle? These inquiries suggest some considerations to which I will devote a little space. The earliest and most obvious of the auscultatory evidences of tubercle, in a certain proportion of cases, undoubtedly, are incident to the expiration. On this point, the ob- servations of Dr. Theophilus Thomson are interesting.^ This author states that among 2000 consumptive patients, a prolonged expira- tory murmur was the most remarkable of the physical signs in 288, or a proportion of about one to seven. In a large majority of these cases, the concomitant signs and symptoms were not such as to ren- der the diagnosis positive ; and, hence Dr. Thomson is led to con- clude that a prolonged expiratory murmur frequently takes prece- 1 Clinical Lectures on Pulmonary Consumption. 13 194 PHYSICAL EXPLORATION OF THE CHEST. dence of other characteristic signs ; an opinion according with that advanced by Jackson, in his memoir on this subject. But a pro- longed expiratory murmur is found to exist frequently in a healthy chest. This is shown by the results of a series of examinations given under the head of Auscultation in Health. A certain allow- ance is to be made for this fact, which was not ascertained when Jackson first called attention to the importance of the expiration in diagnosis, and hence, he was naturally led to overrate the intrinsic significance of the sign under consideration. There is reason to suspect that in some of the cases examined by Dr. Thomson the prolonged expiration may have been normal. The subjects were the out-patients of an hospital, and it is not stated how large a propor- tion remained under observation till the evidences of tuberculous disease were unequivocally declared. A naturally prolonged expir- ation, however, occurs only on the right side. The question whether it be normal or morbid, therefore, arises only when it is found on the right side. Existing on the left, and not on the right side, the significance is vastly greater than when the reverse is the case, or it is found on both sides. It is needless to say that its significance as a sign of tubercle depends on its situation at the summit of the chest. If it exist more or less over the entire chest on one side, still more on both sides, it is due to other causes than tuberculous disease, and, if not normal, denotes emphysema. The more circum- scribed the space over which it is heard at the summit, the greater the diagnostic evidence of tubercle. The evidence, also, is enhanced if it be found in a circumscribed space in the infra-clavicular region at some distance from the point at which a normal broncho-vesicular respiration is to be sought for, and is more marked than in the latter situation. Finally, the elevation of pitch is to be taken into ac- count. If the pitch be not raised, a prolonged expiration indicates only obstruction, which, it is true, may be incident to tubercle, but inasmuch as other causes may induce obstruction, the evidence of phthisis is less if the pitch remains unaltered. Among cases in which a tuberculous deposit actually exists, it must be exceedingly rare that the diagnosis hinges exclusively on a prolonged expiration. It would certainly be unsafe ever to base a positive diagnosis on this sign alone. In conjunction with other signs, however, and Avith symptoms, observing the cautions just stated, it is entitled to consid- erable weight. In a large proportion of cases, it is associated with more or less of the other characters of the bronchial, or the bron- AUSCULTATION IN DISEASE. 195 cho-vesicular respiration, of which modifications, when it coexists with tubercle, it is to be regarded as a constituent element. It is necessary to caution the inexperienced auscultator against mistaking for a prolonged expiratory murmur the sounds originating in the mouth, throat, or nasal passages, entering the ear not applied to the chest, and appearing to come from the chest. 9. Interrupted respiration. — This rhythmical aberration has re- ceived several names, such as jerking, wavy, cogged-wheel.^ The sound, instead of being continuous, is broken into one or more parts. It may be imitated in the mouth by drawing in the breath with a series of disconnected inspiratory efforts, instead of a single uniform act of inspiration. It is very rarely observed with expiration. The inspiratory sound may be interrupted in connection with various affections, which may be arranged into two classes, accord- ing to the mode in which they produce this sign. In one of these classes the interruption takes place in consequence of a corre- sponding want of continuousness in the expansive movements of the thoracic walls. This occurs in pleurisy, pleurodynia, and intercos- tal neuralgia, in consequence of the pain occasioned by expanding the chest. The patient instinctively, as it were, shrinks from the movements necessary to hgematosis, and hence an irregular series of efforts instead of a steady expansion. Thus produced, an inter- rupted inspiratory sound will pervade the entire chest. In the other class the cause is seated in the pulmonary organs. In the latter case the sign is limited to a part of the chest. When the cause is pulmonary, it is of a nature to oppose an obstacle to, but not to prevent, the free expansion of a portion of the lungs. Partial ob- struction of a bronchial tube, either from spasm, tuberculous deposit, or bronchitis confined within circumscribed limits, is probably com- petent to produce this effect. Adhesions of the pleura, also, may involve the necessary physical conditions. This exists as a normal peculiarity in a certain proportion of in- dividuals, who, irrespective of this sign, are apparently free from pulmonary disease. I met with it in two of twenty-four examina- tions. I have observed it on the healthy side in lobar pneumonia. Incident to health, it is sometimes a transient or intermittent pecu- liarity, but in some instances is persistent. In health or disease it 1 Called by Laennec inspiration entrecoitpee, and by French writers of the pres- ent day respiration saccadee. 196 PHYSICAL EXPLORATION OF THE CHEST. is oftener observed on the left than on the right side, and is rarely found, exclusive of the cases in which it extends over the whole chest, elsewhere than at the summit in front. The importance of this sign practically may be said to have refer- ence solely to the diagnosis of incipient phthisis. Observations show that it is present not infrequently in cases of tuberculous disease, at an early period, while the associated physical indications are slight. Under these circumstances it may, in some instances, be due to the obstruction caused either by the pressure of the tubercles on the bronchial tubes, or by circumscribed bronchitis; and in other in- stances to mechanical restraint exterior to the lungs, such as is inci- dent to pleuritic adhesions. Its significance or value as a diagnostic sign of phthisis of course depends on the frequency with which it is observed in that affection, and its infrequent occurrence in health, or in connection with other forms of disease. Dr. Theophilus Thom- son, who has made this sign the subject of special statistical re- search, recorded 105 cases in which it was found to be present.^ Of these cases, in 32 there were grounds, irrespective of this sign, for suspecting tuberculous disease. Of the remainder, many were en- tirely free from other evidences of any affection of the lungs. Dr. Thoinson adds that in several instances he has watched the persist- ency of this sign for years without its becoming complicated with any other indication of disease. In view of these facts an interrupted inspiratory sound cannot be considered to afford more than a certain amount of presumptive evi- dence of phthisis. As an isolated sign it is entitled to but little weight. Associated with other signs, such as dulness on percussion, prolonged expiration, etc., being present at the situation where the latter are observed, and this situation being a circumscribed space at the summit of the chest, it adds to the amount of collective proof of the existence of a tuberculous deposit. II. Adventitious Respiratory Sounds. — Thus far, in treating of the morbid phenomena incident to respiration, the sounds which have been considered are abnormal modifications of those which pertain to health. It remains to consider certain phenomena which have no existence in the healthy chest, and are therefore distinguished as new or adventitious sounds. The greater part of these sounds originate 1 Op. cit., p. 161. AUSCULTATION IN DISEASE. 197 either in the air-tubes, the vesicles, or within cavities formed in the lungs. Different names have been applied to these adventitious sounds. Laennec called them rdles^ a term still in vogue with the French, and also with medical writers, and in conversational lan- guage, to a considerable extent in other countries than France. Other names by which they are collectively distinguished are rlionchi and rattles. The two latter terms are not only wanting in euphony, but their signification is inappropriate when applied to some of the sounds embraced in this class. In the absence of a satisfactory sub- stitute, either of classical derivation or from our own language, it seems to me preferable to retain the title adopted by the discoverer of auscultation. I shall accordingly make use of the term rale in the sense in which it was employed by Laennec, viz., to denote any abnormal sound produced with the acts of respiration in the air- tubes and vesicles of the lungs, or within cavities formed in these organs.^ Proceeding at once to a consideration of the rales, the points to be first settled are, the number which are to be recognized as constituting individual signs ; the method of classification, and the names by which they are to be distinguished severally from each other. Laennec determined the rales by their audible charac- ters, and designated them after resemblances to other well-known sounds. Most of the rales discovered by him are still recognized, and the same names are generally retained. Andral proposed to divide the rales after their anatomical location in the air-tubes, vesi- cles, or cavities, and to distinguish them from each other by their conveying to the ear the sensation either of the presence or absence of liquid, the former being called moist, and the latter dry rales. ^ As a basis of classification this is convenient and advantageous. The names, however, in common use since the time of Laennec will con- tinue to be employed, and they are so interwoven in medical litera- ture that it would be undesirable to endeavor to substitute others, even were they in some respects preferable. Following, then, the plan of distribution according to situation, certain rales are produced within the air-tubes, the larynx, trachea, the two primary bronchi 1 If the French term rale be adopted, it should, I think, be anglicized, and I shall hereafter use it as an English word. 2 Skoda restricts the application of the term rale to the sounds produced by liquid. The dry rales he calls simply sounds. The latitude of signification ac- corded to the rales may, however, be settled fairly by conventional usage, and there is a convenience in a generic term applied to all new or adventitious sounds. 198 PHYSICAL EXPLORATION OF THE CHEST. and their subdivisions. Those produced within the larynx and trachea, may be arranged into one class, and embraced under the denomination of Tracheal Rales. Tracheal rales may be dry or moist. The latter proceed from mucus or other liquid collected in the portions of the air-tubes just named. As a general remark, they occur, excepting when they are transient, only as an effect of the movements necessary to expel morbid products from these situations becoming ineifectual, in consequence of blunted percep- tion and defective muscular power. The tracheal rales are there- fore characteristic of the moribund state, or indicate generally that this state is nigh at hand. Constituting what is popularly known as the "death-rattles," they are sufficiently loud to be heard often at a considerable distance, and indicate to the ear the presence of liquid. They are exaggerated types of certain of the moist rales produced within the pulmonary air-tubes. Dry rales may be produced within these sections of the air-passages when there exists contraction at the glottis from spasm, oedema, exudation of lymph, etc.; or when, from the pressure of a tumor, the presence of a foreign body, mor- bid deposits or growths, the calibre of the tube is diminished at a point below the glottis. They consist of wheezing, whistling, or crowing sounds, more or less intense, which may be audible at a distance, without stethoscopic examination. These sounds also repre- sent, on a large scale, the dry rales produced within the pulmonary organs, and involve similar physical conditions. Auscultation of the larynx or trachea will sometimes reveal dry rales not otherwise audible, and, in either case, maybe useful in determining the precise seat of an obstruction. Rales produced within the larynx or trachea may be propagated to the chest and heard in the latter situation. It is, therefore, necessary sometimes to auscultate the larynx and tra- chea in order to determine whether sounds heard over the chest are transmitted from these sections of the air-tubes. It is chiefly in the two points of view just named that tracheal rales are of importance in diagnosis. Adventitious sounds produced within the primary bronchi and their subdivisions are called the Bronchial Rales. These are of two kinds, the one, indicating by the character of the sound, the presence, and the other, the absence of liquid in the bronchial tubes. The former are called moist, and the latter dry rales. The dry bron- chial rales are subdivided into two varieties, called the sibilant and AUSCULTATION IN DISEASE. 199 sonorous. The distinction between the sibilant and sonorous rales consists mainly in a difference of pitch. A sibilant rale is high- pitched, and as the name imports, is a whistling or hissing sound. A sonorous rale is low or grave in tone. The former, in general, is produced in the smaller, and the latter in the larger bronchial tubes. Both are sometimes distinguished as the vibrating rales. Most of the moist bronchial rales are usually styled mucous rales, the liquid concerned in their production being generally mucus. They are, however, produced equally by other fluids, viz., pus, softened tuber- culous matter, serum, or blood. They are subdivided into coarse and fine rales. The sound in the former instance conveying to the ear, the idea of large, and in the latter of small bubbles. These variations are found to correspond to differences in size of the bron- chial tubes in which the sounds are produced. In contrast with the term vibrating^ applied to the dry rales, the moist are sometimes called bubbling rales. A moist rale produced in the minute bronchial divisions, is dis- tinguished as a sub-crepitant rale. The significance of this title is derived from resemblance to a sound produced within the vesicles, to which reference will shortly be made. The sub-crepitant is an im- portant variety of the fine moist bronchial rales. The only rale attributed to the air-vesicles is called the crepitant or crepitating ; so called from the peculiar character of the sound. This is a highly important physical sign. Crurgling is a name applied to a peculiar sound produced by bub- bling, and the agitation of liquid contained in a cavity of consider- able size. In addition to the several rales just enumerated, there are certain sounds occasionally heard, undetermined as regards their location and the mode of their production, as well as somewhat varied in character. These may be embraced under the title indeterminate rales. By reference to the subjoined tabular view, the reader will be able to see at a glance the number and names of the several pulmonary rales, which are to be subsequently considered, arranged in the order in which they have just been briefly' described. 200 PHYSICAL EXPLORATION OF THE CHEST. Table showing the Number, Names, and Anatomical Situations of the Puhnonai-y Rales. a. Dry or vibrating. 1. Bronchial. 1. Sibilant rale. 2. Sonorous rale. fl. Coarse mucous rale. 2. Fine mucous rale. 3. Sub-crepitant rale. 2. Vesicular. 1. Crepitant rale. 3. Cavernotts. 1. Gurgling rale. 4. Indeterminate. 1. Pulmonary crumpling. 2. Pulmonary crackling. 1. Sibilant rale. — Any bronchial sound, not a modification of the normal respiration, in other words, any adventitious sound or rale, which conveys to the ear the sensation of dryness, and is acute or high-pitched, falls under this denomination. Frequently the sound has a musical tone, resembling sometimes the cry of a young animal, the chirping of birds, etc. In other instances, it is a sharp, clicking sound. Occasionally it is not unlike the whistling of wind through a crevice or key-hole. Without any uniformity as respects tone, or resemblance to particular well-known sounds, a sibilant rale is char- acterized by its dryness and elevation of pitch. With this defini- tion, notwithstanding its diversities, it is appreciated without diffi- culty. The respiratory murmur may continue to be heard, the rale being superadded, or the former may be masked by the latter. It may accompany the inspiratory or the expiratory act, oftener the former when confined to one, but it sometimes attends both acts. A sibilant rale is frequently variable, occurring not with each suc- cessive respiration, but at irregular intervals, continuing perhaps for a few moments, then ceasing, and again reappearing. It is variable as regards intensity, as well as other characters. It may be often suspended by an act of coughing. It is apt to vary also in situation, being heard at one moment in a certain part of the chest, and the next moment in another part ; thus changing its seat, it may be, frequently, within a short space of time. The rale may be more or less diffused over the entire chest, or confined to one side, or, again, limited to a circumscribed space. AUSCULTATION IN DISEASE. 201 The sibilant rale is produced within the smaller bronchial tubes. This is the rule, with exceptional instances in which it originates in the larger tubes in consequence of their calibre being diminished by morbid changes. Laennec attributed its production to the space within the tubes becoming contracted at certain points by swelling of the mucous membrane. From its variability, however, and the fact that it frequently disappears after an act of coughing, it is prob- ably due, in many instances, to tenacious mucus adhering to the walls of the tubes with suflScient firmness to occasion a partial obsta- cle to the current of air, and give rise to sonorous vibrations with- out bubbling. This explanation is sustained by the fact that the rale is observed especially at the commencement of inflammation of the mucous membrane lining the smaller tubes, when the mucus secreted is small in quantity and adhesive. The swelling of the membrane, greater in some portions than in others, reducing thereby the capacity of the tubes, not uniformly, but irregularly, may also give rise to dry rales, which, under these circumstances, are more persistent. Spasm of the muscular fibres induces the requisite phys- ical condition, and the rale is louder and more diffused in asthma than in any other affection. The pressure of a tumor on the tubes, diminishing their size, and changing their direction, but not suffi- ciently to produce obstruction, may occasion this rale. In the majority of instances a sibilant rale is a sign either of asthma or of bronchitis seated in the smaller tubes. If it be heard more or less over the chest on both sides, and associated with sub- sternal soreness and febrile movement, the evidence is very strong of the early stage of bronchitis occurring as a primitive affection; for primary bronchitis is one of the symmetrical diseases, which is not true, to the same extent, of diseases in which bronchitis is liable to occur as a secondary affection. On the other hand, if it be con- fined to one side of the chest, it may be due to bronchitis occurring as a secondary affection, for example, in connection with pneumon- itis. If it be restricted to a circumscribed space at the summit of the chest on one side, taken in connection with other facts, it infer- entially points to the existence of phthisis; for bronchitis thus cir- cumscribed rarely occurs except in the immediate vicinity of a tuber- culous deposit, and it is at the summit of the chest, near the apex of the lung, that this deposit usually takes place. The sign is present in a marked degree in asthma, proceeding from spasm of the bron- 202 PHYSICAL EXPLORATION OF THE CHEST. chial tubes, generally associated with pulmonary catarrh or bron- chitis; and it is still more marked if the catarrh or bronchitis be associated with emphysema. Under the circumstances last men- tioned, it may be marked in the expiration, owing to tbe same causes which occasion a prolonged expiratory murmur, viz., im- paired elasticity of lung, and the necessity of increased muscular power to expel the air from the over-distended cells. Although, therefore, the presence of the sign generally denotes either inflam- mation or spasm affecting the smaller tubes, the diagnosis would often be incomplete were not other signs taken into account, as well as symptoms which disclose the coexistence of other affections, viz., pneumonitis, tubercle, and emphysema. It is only after excluding these several affections by the absence of their diagnostic criteria, that the sign denotes a morbid condition pertaining solely to the bronchia] tubes. 2. Sonorous rah. — This term, which the French apply to the dry bronchial rales collectively, by English writers is limited to a rale distinguished from the sibilant rale by gravity of tone. A sonorous rale may be defined to be any dry adventitious sound produced within the bronchial tubes, not acute or high in pitch. The exact line of demarcation between the sibilant and the sonorous rale cannot be de- fined in words, nor is it necessary to make the distinction with rig- orous exactitude in practice. A sonorous rale is due to the same physical conditions as the sibilant, the only difference as regards their production pertaining to location. The sonorous rale proceeds from the larger bronchial tubes. In audible characters it is not more uniform than the sibilant rale. Among the diversity of sounds to Avhich it may be compared are the snoring of a person sleeping, heard at a distance, the humming of a mosquito, the cooing of a pigeon, a note of a bass-viol or bassoon, etc., etc. The tone is oftener more distinctly musical than that of the sibilant rale. The sound is also louder and stronger, being sometimes heard at a distance, without auscultation, and producing a vibration or thrill perceived by placing the hand on the chest. The remarks in connection with the sibilant rale as to variable- ness of intensity and peculiarity of tone, change of place, cessation and reappearance, and suspension by acts of coughing, are equally, and, indeed, even more applicable to the sonorous rale. Like the sibilant, the sonorous rale may accompany either act of respiration, AUSCULTATION IN DISEASE. 203 or both acts. When confined to one, it is more apt to be produced by expiration, in this particular differing from the sibilant rale. A sonorous rale occurs in asthma and in bronchitis aflFecting the larger bronchial tubes ; the latter may be primary or a complication of other diseases, viz., pneumonitis, tubercle, emphysema, etc. The coexistence of other affections is to be determined by the associ- ated signs, in conjunction with symptoms. Occurring in connection with other affections which are limited to one side of the chest, whereas primary bronchitis is bilateral, it will be confined to the side affected; and hence, when present on both sides, it is presump- tive evidence that the bronchial affection is primary. The sonorous and the sibilant rale are often heard in combination ; that is, the sonorous existing at some parts of the chest, and the sibilant at other parts at the same moment; or the two alternate at irregular intervals with successive acts of respiration in the same situation ; or, again, both are appreciable at the same instant, some- times commingled together, and sometimes succeeding each other at difi'erent periods of a single respiration. When combined, it is evidence that the bronchial affection is seated both in the larger and smaller tubes. The sonorous, like the sibilant rale, is especially marked in paroxysms of asthma. The sounds are sometimes so in- tense as to be heard at a distance. On applying the ear to the chest during a paroxysm of asthma, frequently a great variety of musical tones are heard, which, if auscultation be continued, are found to undergo constant mutations. They are sometimes continu- ous, not only during the two acts of respiration, but uninterrupted by the intervals between successive respirations, the contraction of the lung prolonging the sounds with expiration after the visible ex- piratory movements have ceased. The discrimination of both varieties of dry rale from other sounds emanating from the chest is attended with no difiiculty. A mere description of their varied characters suffices for their recognition when heard for the first time. They are quite unlike any of the modifications of the natural respiratory sounds, and are distin- guished by points not less striking from other rales. As diagnostic signs they are important, indicating, as has been stated, in the great majority of instances, the early stage of bronchitis, or a paroxysm of asthma, afiections of frequent occurrence. As denoting these affections, their signification is almost positive; and if they are present extensively on both sides of the chest, together with the 204 PHYSICAL EXPLORATION OF THE CHEST. negative evidence afforded by the absence of the signs of other dis- eases, tlie diagnosis is complete. Bronchitis, however, not unfre- quently occurs as a complication of other pulmonary affections. Under these circumstances it is often confined to one side of the chest, or is still more circumscribed, whereas the reverse is the rule when it is idiopathic or primary. But the fact of its existence as a complication is to be established by the concomitant signs and symp- toms of the coexisting affections. 3. 3Iucous or bubbling rales. — The mucous rales are the moist bubbling sounds produced in any portion of the bronchial tree ex- cept the minute branches, the sounds in the latter situation consti- tuting the sub-crepitant rale. The term mucous is here used in a generic sense to comprehend sounds, essentially similar in character, Avhich are due to the presence of any liquid in the subdivisions of the bronchi. Mucus is the kind of liquid oftenest present ; but other kinds are pus, blood, softened tubercle, and serum. Whenever either of these liquids is contained within the bronchial tubes, the currents of air with the respiratory acts cause explosive bubbles, Avhich o;ive rise to sounds more or less intense. These sounds have a bubblino; character which is distinctive. In contrast with the rales already considered, they afford intrinsic evidence of the presence of a liquid ; in other words, the ear appreciates at once the fact that they are moist rales. Differences in the quality of the liquid, as respects viscidity, &c., doubtless affect somewhat the character of the sound. The variations, however, due to this source, are not suf- ficiently defined to serve as the basis of well-marked distinctions. So far as the audible characters are concerned, the only inference to be drawn is, that liquid of some kind, in greater or less abun- dance, is contained in the bronchial tubes. Generally, the kind of liquid is determined demonstratively by an examination of the mat- ter of expectoration. The mucous rales may be imitated by blow- ing through a tube introduced into any liquid. The character of the sounds indicates the size of the tubes in which they are produced. In the larger tubes, the bubbles appear to be of greater volume : perhaps the difference is in part owing to the space in which the explosions occur. At all events, the bub- bling sounds differ perceptibly according to the dimensions of the bronchial subdivisions in which they are produced. This has been shown by experiments in which, after death, sounds differing ac- cording to the size of the tubes are produced by injecting fluids AUSCULTATION IN DISEASE. 205 into different sections of the bronchi, and afterwards introducing currents of air by inflation.* These diflFerences are expressed by the terms coarse and fine ; and the different degrees of coarseness and fineness are expressed by words of quantity, such as very, con- siderable, moderate, etc. These expressions are suflSciently precise for practical purposes. The coarsest mucous rales, then, are pro- duced in the largest bronchial tubes ; they lose this quality gradu- ally in the subdivisions of these tubes, until, in the smaller ramifi- cations, before reaching the minute branches, they assume the quality of fineness ; and this fineness merges into the still finer sub-crepi- tant rale. It would be difficult to determine the particular locality at which the sounds cease to be coarse and become fine, and it is equally difficult to draw the line of demarcation between the two classes of sounds with exactitude ; but such precision is of no con- sequence in diagnosis. The mucous rales resemble the dry rales in variableness. They are liable to appear now here and now there, shifting their seat from one part to another part ; occurring not with each respiration, but intermittingly in the same locality, and are often removed for a time by an act of expectoration. The bubbling sounds heard at the same moment in a single spot may not be uniform. Bubbles of unequal volume appear to be commingled together. The sounds may be heard with inspiration or with expiration, or with both acts. Fi- nally, they may exist on both sides of the chest, or on one side only, or in a circumscribed space on one or both sides. Mucous rales, more or less diff"used on both sides of the chest, constitute the physical sign of bronchitis advanced to the second stage, or the stage of mucous secretion. The rales, other things being equal, will be diffused over the chest, and abundant in propor- tion to the extent to which the inflammation pervades the bronchial mucous membrane, and the abundance of the mucus secreted in con- sequence. If fine and coarse rales are intermingled, which is not infrequently the case, it is evidence that the aff"ection of the mem- brane is not confined to the larger tubes, but extends to those of smaller size. In the progress of the affection, the dry rales may gradually disappear and give place to the moist ; but it is not infre- quently the case that the former do not entirely cease, and the dif- ferent varieties of the dry and moist rales are combined in various and constantly varying proportions. ' Barth and Koger. 206 PHYSICAL EXPLORATION OF THE CHEST. In view of the fact that a primary bronchitis affects the bronchial tubes on both sides of the chest equally, if mucous rales are found on the two sides, and especially toward the lower part of the chest behind, the evidence of this affection is almost conclusive. The rales are most apt to be present, or to be more marked in the situation just mentioned, viz., at the lower part of the chest behind, on account of the greater amount of inflammation in this situation, the larger number of bronchial subdivisions, and because, from their position, the removal of their liquid contents is effected less easily than from the tubes at the superior portion of the lungs. If, on the other hand, the rales are confined to one side of the chest, they denote a bronchial affection not primitive, but secondary, occurring, for example, as a complication of pneumonitis. Or they may be produced by the presence of liquid in the bronchial tubes irrespective of any affection of the tubes themselves. Thus, pus in this situation may be derived from the pleural cavity, the liver, or an abscess formed within the pulmonary parenchyma ; the tubes may contain blood in cases of hi^moptysis, or pulmonary apoplexy, or serum in bronchorrhoea and oedema. In all such instances, the nature of the disease to which the mucous rales are incident is to be determined by other associated signs, and by symptoms. If the rales are confined to a circumscribed space at the summit of the chest, or, even if they are more marked in this situation, and especially if they are either present on one side only, or per- sistingly more marked on one side than on the other, they are sig- nificant of phthisis, because they denote a bronchitis confined to a small section of the bronchial tubes. Thus restricted, bronchitis is never primitive, but dependent on a prior local affection, which affec- tion, when the circumscribed bronchitis is situated at the summit of the chest, in the vast majority of cases, is tuberculosis. Mucous rales are apt to attend tuberculous disease in all stages of its prog- ress, being produced not alone by bronchitis occurring as a compli- cation, but by the presence of liquid derived from tuberculous exca- vations. Moreover, the bubbling of the liquid contents of small cavities occasions rales which cannot be distinguished from those produced within the large bronchial tubes. In general, mucous rales do not accompany, in a marked degree, tuberculous disease prior to the stage of softening and excavation. Definite information respecting the condition of the lung sur- rounding the bronchial tubes within which mucous rales are pro- AUSCULTATION IN DISEASE. 207 duced, is afforded by the pitch of these rales. If the bubbling sounds are produced within tubes surrounded by solidified lung, their pitch is high ; the elevation of pitch is in proportion to the degree of solidification. On the other hand, the pitch of these rales is low if the lung be not solidified. The pitch of the rales corresponds to that of the bronchial or broncho-vesicular respiration, if these signs of solidification are present. It is practicable to determine the existence of solidification, and its degree, by the pitch of these rales, in the absence of other signs ; or to determine that solidification does not exist. In this point of view, the significance of these rales is interesting, and in some cases highly important. 4. Suh-crepitant rale. — By some writers, all the moist bronchial rales are embraced under this name ;^ and, on the other hand, the sub-crepitant might with propriety be regarded as a variety of mu- cous rale. The only reason for making it a separate physical sign is, that, approximating in certain of its characters to the rale pro- duced within the air-vesicles, it is important to be discriminated from the latter. The name expresses the resemblance just referred to. The sub-crepitant rale forms an intermediate link between the mu- cous and the crepitant rales. It is distinguished from the mucous rales by its greater degree of fineness. It is produced in the minute bronchial ramifications. Its locality accounts for its being finer, — that is, for the bubblincr beinw smaller than in other bronchial rales. The bubbling character of sound is, however, preserved ; the sensa- tion conveys the idea of the presence of a liquid in tubes of small dimensions. The bubbling sounds are generally unequal ; in other words, they seem to be made up of bubbles uniformly small, but dif- fering in volume. This character is due to the fact that the subdi- visions in which the rale is produced, although minute, are not of the same calibre. It is heard in inspiration and expiration, with either act alone, or with both acts. It may continue during the whole duration of the inspiratory or the expiratory sound, or be heard only during a small portion of one or both of the respiratory acts. As regards persistence it presents somewhat of the irregularity and want of uniformity which characterize the mucous rales, but its variableness is less marked. These few points are important to be borne in mind with reference to its distinctive characters as con- trasted more particularly with the crepitant rale. 1 Barth and Rosier. 208 PHYSICAL EXPLORATION OF THE CHEST. The sub-crepitant rale attends those aifections in which a liquid is present in the minute bronchial branches. The liquid is different in different forms of disease, presenting the same varieties as in the case of the mucous rales, viz., mucus, pus, serum, softened tubercle, blood. These different liquids are present in the minute bronchial branches, in capillary bronchitis, pneumonitis, oedema of the lungs, phthisis, hiemoptysis, and pulmonary apoplexy. The sub-crepitant rale, therefore, is liable to occur in each of these diseases. So far as the characters of the rale are concerned, it is impossible to de- termine thereby the nature of the liquid giving rise to the bubbling sound. This assertion is in opposition to the views of Fournet, who described a distinct rale for each of the several affections just named. In this he has not been followed by other auscultators, who regard the rale as essentially identical in all, although by no means uniform in every respect, even in different cases, and at different periods of the same affection. The discrimination of the different affections characterized by the presence of this sign, is to be based, not on dif- ferences in the characters pertaining to sound, but on other circum- stances to which I shall briefly allude. In capillary bronchitis the membrane lining the minute bronchial branches is the seat of inflammation. The inflammation may be limited to this section of the bronchial tubes, or it may affect, at the same time, the larger subdivisions. The sub-crepitant rale in this disease is due to the presence of mucus. It succeeds, and may be more or less intermingled with, the sibilant rale, and if the affec- tion be not confined- to the minute branches, also with the sonorous and mucous rales. Capillary, as well as ordinary bronchitis, affect- ing, when primary, both sides of the chest, the rale will be present on the two sides, and especially at the base of the chest behind. This is an important diagnostic point, inasmuch as the other affec- tions to which the rale is incident, are usually confined to one side of the chest. A sub-crepitant rale at the base behind on both sides is almost conclusive evidence of capillary bronchitis, as distinguished from pneumonitis, in which the crepitant rale, in the great majority of cases, is present on one side only. But other evidence derived from physical exploration may be brought to bear on the differential diagnosis, exclusive of the characters distinguishing the crepitant from the sub-crepitant rale. In capillary bronchitis the percussion- resonance continues clear, while in pneumonitis it becomes dull. In the former the sub-crepitant rale continues, and is replaced by the AUSCULTATION IN DISEASE. 209 vesicular murmur; in the latter the crepitant rale in most cases soon diminishes or ceases entirely, and gives place to the bronchial respiration. These circumstances will aid in arriving at a positive conclusion in instances in which, judging from the intrinsic char- acters pertaining to the rale, there might be room for doubt. The sub-crepitant, however, as well as the crepitant rale, belongs to the natural history of pneumonitis. It occurs in a certain pro- portion of cases during the stage of resolution, having been preceded by the crepitant rale, and the physical signs of solidification of lung. With the latter signs it is moreover associated. Under these cir- cumstances it constitutes, in some cases, the rhonchus crepitans redux, or the returning crepitant rale of Laennec. In pulmonary oedema the sub-crepitant rale is due to the presence of serous fluid within the minute bronchial branches. Occurrincr in connection with this form of disease, it is present on the posterior surface of the chest; it is accompanied with more or less dulness on percussion, and is found in connection with the morbid condi- 'tions upon which the production of oedema depends, viz., disease of heart, or of the kidneys, and blood changes leading to stasis in the pulmonary capillaries (as in fevers), or favoring serous transudation. These circumstances, together with the absence of more or less of the physical signs of pneumonits, in addition to the characters dis- tinguishing the sub-crepitant and crepitant rales, enable us to ex- clude the latter afi"ection. In phthisis a sub-crepitant rale may be due to circumscribed ca- pillary bronchitis in the vicinity of the tuberculous deposit, or it may proceed from the presence of liquefied tubercle in the minute tubes. In the first instance, it may occur early in the disease ; in the latter, not until a later period, after softening has taken place. In either case its significance depends on conditions similar to those which render a sibilant or a mucous rale a sign of tuberculosis, viz., its situation at the summit of the chest, within a circumscribed space. With these conditions, a sub-crepitant rale is strongly indicative of the existence of phthisis. In haemoptysis and pulmonary apoplexy the presence of liquid blood in the minute bronchial branches, may give rise to a sub-crepitant rale. It is, however, by no means a sign constantly attending these affections. It is observed in but a certain proportion of cases, and is of small value in their diagnosis. Blood escaping from the pul- monary vessels either passes into the larger tubes, and is expecto- u 210 PHYSICAL EXPLORATION OF THE CHEST. rated; or it coagulates, constituting apoplectic extravasation ; both results doing away with the physical conditions necessary to develop the rale under consideration. The sub-crepitant rale is an iraportant physical sign. From the mucous rales it is distinguished chiefly by the sensation which it conveys of a finer bubbling sound. The characters which will be presently found to mark the distinction from the crepitant rale are, the sense of a liquid, inequality in volume of the bubbles, its pres- ence sometimes with expiration, as well as inspiration. In some instances the approximation is so close to the crepitant rale that, it must be confessed, judged by intrinsic characters, it is not easy to make the distinction. As regards pitch, the sub-crepitant rale has the same significance as the mucous rales. The pitch is high if the lung be solidified, and comparatively low if solidification does not exist. Thus in capil- lary bronchitis the pitch is low, and in pneumonitis, before resolution has taken place, the pitch is high. By means of the pitch of the rale the condition of the lung with respect to the existence of solid- ' ification, or otherwise, may be ascertained in cases in which the modifications of the respiration and voice which represent this con- dition are absent. 5. Crepitant rale. — The crepitant, also called the crepitating and crepitous rale, is distinguished from the rales already considered by its origin. It is a vesicular rale ; but it is not produced exclusively within the vesicles. The anatomical relations of the air-cells and the ultimate bronchial tubes, or bronchioles, are such that they can hardly be isolated from each other; and, in fact, the physical con- ditions giving rise to the crepitant rale pertain equally to both. The character of the sound is well expressed by the term crepi- tating. Laennec compared it to the noise produced by salt in a heated vessel. Earth and Roger liken it to the crackling of a moistened sponge, expanding close to the ear after being forcibly compressed. Dr. Williams has suggested an excellent imitation, viz., the sound caused by rubbing a lock of hair between the thumb and finger close to the ear. Other illustrations might be cited, but these are sufficient, and the one last mentioned is available at any moment. Opportunities for studying the rale itself are sufficiently abundant everywhere, and after a description of its characters, with the comparisons just mentioned, the student will have no difficulty in recognizing it the first time it is presented to his notice. As AUSCULTATION IN DISEASE. 211 already stated, it bears a resemblance to the sub-crepitant rale. The two rales approximate in their audible characters, but usually they are distinguished by their intrinsic differences alone, and always with the aid of collateral circumstances. The peculiar traits by which the crepitant rale is characterized may be best exhibited by contrasting it with the sub-crepitant rale. The sound in the crepi- tant rale is a true crepitation, while in the sub-crepitant rale it is a fine bubbling, approaching to a crepitating character. With the common idea that in both instances the sound is caused by minute bubbles, it is usual to say that the crepitant is a finer rale than the sub crepitant. It will presently be seen, however, that agreeably to the most rational explanation of the crepitant rale, it is not a bubbling sound. The crepitant rale, in fact, so far as the sound is concerned, belongs among the dry rales. It does not convey to the ear the sensation of the presence of a liquid. Laennec regarded it otherwise, and in conformity with the prevalent opinion respecting its mode of pro- duction, it is included in the division of moist rales. Laennec, how- ever, undoubtedly confounded the crepitant and sub-crepitant rales, the points of distinction between the two having been indicated since his time. He designated the crepitant as the moist crepitant, but in describing its characters in connection with the diagnosis of pneumonitis, he says, it " seems hardly to possess the character of humidity." Auscultators at the present day who attribute the sound to bubbles, nevertheless consider dryness as one of its distinctive features. The sound appears to be made up of a large number of minute crepitations, in all respects equal. In this point of view it differs from the sub-crepitant rale, which is composed of unequal sounds, owing to the bubbles taking place in tubes differing con- siderably in calibre. The equality of the minute sounds which combine to form the crepitant rale is due to the fact that the spaces in which they are produced are more uniform in size. The crepi- tating sounds are rapidly evolved, occurring, as it were, in puffs, resembling the noise produced by ignition of a small train of gun- powder, to which it has been aptly compared. The sub-crepitant, as well as the mucous rales, take place more slowly. In addition to the foregoing points which pertain to the audible characters, there are others not less distinctive. The crepitant rale is not variable. It continues constantly for a certain period, not changing with different respirations, save in intensity, and this is usually proportionate to the force with which respiration is per- 212 PHYSICAL EXPLORATION OF THE CHEST. formed. It is sometimes developed by forced breathing when it is not otherwise appreciable. It is not suspended by coughing and expectoration. On the contrary, after an act of coughing, the res- piratory movements immediately succeeding being more forcible, it becomes more intense. Finally it is heard with the inspiratory act exclusively. This is certainly the rule, and probably there are no exceptions. This last point, to which attention was first called by Dance, is eminently distinctive, the sub-crepitant rale, as well as the mucous rales, being present frequently in the expiratory, as well as the inspiratory act. This point, as will be seen presently, has an important bearing on the explanation of the mechanism by which the rale is produced.* Laennec regarded the crepitant rale as almost pathognomonic of pneumonitis. At the present time, its distinctive characters having been more clearly defined, it is even more significant as a diagnostic sign than heretofore. A true crepitant rale is very rarely observed except in pneumonitis. Moreover, it is rarely the case that it is absent during the career of that disease. The opinion of Skoda is in opposition to the latter statement. He declares that not only has he failed to find it present, but he has not often observed it. This is one of the extraordinary assertions enunciated by that writer. It is at variance Avith the observations of others, whose opportunities for studying this disease have been quite as extensive. For example, Grisolle, who has contributed the results of the numer- ical investigation of a large number of cases of pneumonitis, affirms that this sign was wanting in only four instances. M. Aran failed to discover it in only one of fifty cases. That it is not invariably present is undoubtedly true, but the experience of most auscultators is united on the fact of its existence being the rule in pneumonitis. Not only, therefore, is it, as originally claimed by the founder of auscultation, almost pathognomonic when present, but its constancy makes it highly valuable as a diagnostic criterion. ^ A pleural friction-sound sometimes bears a very close resemblance to the crepitant rale, so that, judged by the audible characters alone, the former may be mistaken for the latter. This I state from experience. Earth and Koger state this liability to error, as follows : " II est un autre bruit qui pourrait facilement induire en erreur une oreille peu exerc6e: \e f7'ottement pleuredque est parfois con- stitu4 par une serie de petits craquements successifs, par une espdce de crepitation inegale, que le rapprocho du veritable rhonchus crepitant. C'est sans doute cette variete de bruit qui a fait dire qu'il existait un rdle crepitant dans la pleuresie." P. 149. AUSCULTATION IN DISEASE. 213 It is usually discovered shortly after the attack of pneumonitis in adults; but this rule is less uniform than its existence at some period of the disease. In most cases of frank pneumonitis, it is strongly marked prior to the physical evidences of solidification, viz., notable dulness on percussion and the bronchial respiration. As regards its amount and intensity, however, difierent cases differ. When abundant, it is heard during nearly the whole of the inspira- tory act. If produced throughout an entire lobe, or within the cells at the exterior portion of the lung, it is loudly developed, and seems very near the ear; but when confined to a central situation, healthy lung intervening between the affected part and the thoracic walls, it is comparatively feeble and distant. In these respects every shade of diversity is presented in a sufficiently large number of cases. Frequently it continues more or less during the stage of solidification, and sometimes it does not appear prior to this stage. It is then associated generally with the bronchial respiration ; and, under these circumstances, it is observed only at the end of the in- spiratory sound. It is often developed by a forced inspiration, when it is not appreciable with ordinary breathing. The situation in which it is found in the majority of the cases of pneumonitis, is the posterior surface of the chest, especially below the scapula, the disease, as a general rule, affecting the inferior lobe. It is oftener found on the right than the left side, because the lower lobe of the right lung is more frequently attacked. Its existence on one side of the chest is an important diagnostic circumstance; for pneumon- itis, in the great majority of cases, is confined to one side. On the contrary, capillary bronchitis, as uniformly affecting both sides equally, the sub-crepitant rale is heard on both sides. This dis- tinction, aside from the distinctive characters pertaining to the crepitant and the sub-crepitant rales respectively, suffices, in gen- eral, for a differential diagnosis. A rale, concerning Avhich we may have some doubt whether to regard it as a crepitant or sub-crepitant, if it be present on the posterior surface of the chest on both sides is, in all probability, a sub-crepitant; but if confined to the posterior surface on one side, the chances are equally great, that it is a crep- itant rale. Pneumonitis may be complicated with general bronchitis. This coincidence is not frequent, but of occasional occurrence. The vesicular rale and the bronchial rales will then be likely to be variously combined. Capillary bronchitis and pneumonitis are 214 PHYSICAL EXPLORATION OF THE CHEST. sometimes associated. In a case of this description which recently came under my observation, the fact of the concurrence of the two diseases having been demonstrated after death, the sub-crepitant rale existed on both sides, but on one side the sub-crepitant and crepitant rales were distinctly appreciable during the same inspira- tion, the former during the first part, and the latter at the close of the act. The returning crepitant rale, described by Laennec as character- izing the resolution of pneumonitis, included the sub-crepitant rale. A true crepitant rale occurs not infrequently in this stage of the disease; but it is apt to be associated with the sub-crepitant, and the latter may be present without the former. The combination of the crepitant and the sub-crepitant rale has probably led to the opinion, held by some, that the crepitant rale is sometimes heard in the expiratory act. In the vast majority of cases, the crepitant rale denotes pneumo- nitis. It is not, however, true that it never occurs in any other affection. It is sometimes observed in oedema, and in pulmonary hem- orrhage. In these affections, the rale is generally a sub-crepitant, but the presence of serum, and perhaps of blood, in the air-cells, may give rise to a rale essentially similar to the true crepitant of pneumonitis. In cases of hemorrhage, the expectoration of blood settles the diagnosis. Moreover, in these cases, the rale will be found at the summit of the chest in front, and not on the posterior surface, as in the larger proportion of cases of pneumonitis, haem- optysis being generally incident to tuberculous disease. The differ- ential diagnosis of pneumonitis and oedema, is to be based on the associated circumstances, which will usually suffice for discrimination without much difficulty. CEdema occurs in certain pathological connections, and is unattended by the symptoms which usually accompany an attack of pneumonitis. A crepitant rale, at the summit of the chest on one side in front, confined within a circumscribed space, is a significant sign of phthisis. Primitive pneumonitis, in the adult, as already stated, generally invades an entire lobe, and in the majority of instances, an inferior lobe. When situated toward the apex of the lung, and ejctending over a small area, the pneumonitis is secondary, and the antecedent affection is probably tuberculosis, inflammation having been developed in the immediate vicinity of the tuberculous deposit. This rale, under the circumstances just stated, becomes a sign of AUSCULTATION IN DISEASE. 215 phthisis like the sibilant, the mucous, and the sub-crepitant rales, under similar circumstances. The explanation of the mechanism by which the crepitant rale is produced, given by Laennec, and generally received at the present time, attributes it to the formation of minute bubbles within the vesicles, and terminal bronchial tubes. According to this theory the mechanism is precisely similar to that involved in the produc- tion of the mucous and sub-crepitant rales, the diiference in the audible characters being supposed to be owing to the smaller size of the spaces in which the bubbling takes place. This explanation is unsatisfactory, in view of several facts pertaining to the characters distinctive of the crepitant rale. The absence of humidity, in other words, the dryness of the sound; the constancy of the rale during the period of its continuance, and especially its accompanying ex- clusively the act of inspiration, militate strongly against the doc- trine commonly held. To meet these objections, Dr. Walshe sug- gested that the sound may be due to the sudden pressure exerted on exudation-matter between the vesicles, by the expansion of the lung. But the exudation in pneumonitis is within the air-cells, and, hence, in so far as the sound depends on this result of inflammation, it must be intra-vesicular. The most rational theory, and the one which meets best the objections to that of Laennec, was offered several years ago, by the late Dr. Carr, of Canandaigua, N. Y. Dr. Carr attributed the production of the sound to the abrupt sepa- ration of thei walls of the cells, which had become adherent by means of the viscid exudation incident to the early stage of inflam- mation.' That this explanation accounts for the peculiar, dry, and crackling sound, as remarked by Dr. C, a simple experiment will serve to illustrate. If the thumb and finger be moistened with a little paste, or solution of gum arabic, and, while held near the ear, alternately pinched together, and separated, an imitation of the crepitant rale is produced more perfect even than rubbing a lock of hair, as proposed by Dr. Williams. A viscid exudation within the cells and bronchioles belongs among the local phenomena of the dis- ease; and as it is not readily removed by expectoration, but accumu- lates till the cells are filled, and the lung solidified, the constancy of the rale for a certain time is intelligible. Its occurrence with 1 New explanation of the crepitant rlionchus of pneumonia, by E. A. Carr, M.D. — American Journal of Medical Sciences, October, 1842. 216 PHYSICAL EXPLORATION OF THE CHEST. inspiration only, is fully accounted for by this explanation. The con- ditions for the production of the sound are only present after the lungs have collapsed with expiration, at the moment when the agglutinated walls of the vesicles and bronchioles are separated with the expan- sion of the lung by the inspiratory act. Adopting Dr. Carr's expla- nation, it would be expected that the sound would be present in the early stage of pneumonitis, the air in this stage still entering the vesicles, and subsequently cease, nearly or entirely, in proportion to the extent and completeness of the subsequent solidification. The fact that when solidification has taken place a certain number of cells are not filled with the morbid exudation, and remain in the condition which characterizes all the cells in the early stage, ex- plains the persistence of the rale in some cases during the second stage of pneumonitis, and its being developed, under these circum- stances, by forced inspirations, and especially at the end of the inspiratory act. The theory of Dr. Carr is also equally applicable to the cases of oedema and hasmoptysis, in which the crepitant rale is observed. In these affections the air-vesicles contain a glutinous liquid, although in a less marked degree than in pneumonitis ; and we can readily understand that the necessary physical conditions are present sometimes, but not constantly, on account of the greater facility with which the liquid escapes from the cells into the bron- chial tubes, giving rise to the bubbling rales — the sub-crepitant and mucous. In view of the pathognomonic character of the crepitant rale, and the uniformity with which it attends the early stage of pneumonitis, it was justly considered by Laennec to be one of the most important of the physical signs. In its diagnostic value as an isolated sign, it is entitled to the first rank among the phenomena furnished by aus- cultation. The pitch of the crepitant rale, as well as that of the sub-crepitant and the mucous rales, represents the condition of the lung as regards solidification. The pitch is comparatively low in the first stage of pneumonitis before solidification has taken place ; the pitch is raised in the second stage, if the rale continue into this stage, and the pitch of the returning crepitant rale is lowered in proportion as res- olution goes on. In feeble patients confined to the bed, a transient crepitant rale is sometimes heard when they are raised up, and the ear or stethoscope applied to the posterior and inferior portion of the chest. It may proceed, under these circumstances, from the slight agglutination of AUSCULTATION IN DISEASE. 217 air-cells and bronchioles, which from recumbency on the back and feebleness of the breathing, have been for some time unexpanded. The rale is generally heard on both sides. It disappears after a few forced respirations. Under these circumstances, it is not a sign of pneumonitis nor of any pulmonary affection. The young auscul- tator is to be cautioned against mistaking a sound caused by the movements of the pectoral extremity of the stethoscope upon the chest covered with hair, for a crepitant rale. The resemblance of the sound thus produced to the crepitant rale is sometimes striking. 6. Cavernous rale, or gurgling. — The entrance of air into a cavity partially filled with liquid, gives rise to a sound resembling a mucous rale produced within the larger of the bronchial tubes, from which it cannot always be distinguished ; and hence, according to some writers, it is needless to describe a cavernous rale as an independent physical sign. In some instances, however, the sound is sufficiently distinctive to indicate very clearly the existence of a cavity. A cavernous rale is a moist sound, conveying very distinctly the idea of a liquid. It is produced partly by bubbles, and in part by the agitation of the mass of liquid. The bubbles, in cases in which the characteristic sound is well marked, appear to be larger in size than the coarsest mucous rale, and, at the same time, fewer in number. The liquid thrown into agitation by the impulse of the air, causes a sound, of which the best idea is conveyed by the term gurgling. It may be compared to the sudden commotion which occurs from time to time, when a liquid is brought nearly to the point of ebulli- tion. The latter is an occasional variety of the cavernous rale, and is presented in the most marked degree when the communication of the cavity with a bronchial tube is sufficiently large for a column of air of considerable size to enter with force, other favorable physical conditions also coexisting. The movements of the lung, irrespective of the entrance of air into the cavity, it is probable may suffice to produce a gurgling sound, but less in degree. The impulse of the heart sometimes causes sufficient agitation of the liquid to give rise to a rale, which is determined by observing that it continues when respiration is momentarily suspended, and is synchronous with the pulse. This curious fact has been repeatedly noticed when the cav- ity was seated in the left lung, but Dr. Stokes has observed it even on the posterior surface of the right side of the chest. The bubbling and gurgling sounds may take place with inspiration and expiration, con- jointly or singly, and when with either separately oftener with the for- 218 PHYSICAL EXPLORATION OF THE CHEST. mer act. The intensity of sound is sometimes so great, that it is heard at a distance from the patient. The reverberation within the space, above the level of the liquid, occasionally gives rise to a metallic or amphoric tone. On the other hand, gurgling sounds may be low in pitch, corresponding to the low pitch of the cavernous respiration, and presenting sometimes, in this respect, a striking contrast to the high-pitched mucous rales denoting solidified lung surrounding a cavity. The cavernous rale usually exists over a circumscribed space, on one side of the chest ; and inasmuch as excavations are in the vast majority of cases of tuberculous origin, its situation in forty-nine of fifty cases, is at the summit of the chest. The physical conditions necessary for the development of the rale, when the cavity is par- tially filled, occasion the cavernous respiration when the cavity is empty. These two signs will therefore be found in certain cases to occur in alternation, and will serve mutually to confirm each other. A cavernous rale, depending as it does on several circumstances, in addition to the existence of a cavity, is by no means constant, and, in fact, is only occasionally discoverable. The cavity must contain a certain amount of liquid, neither being empty, on the one hand, nor on the other hand, completely filled. The communication with the bronchial tubes must be below the level of the liquid. This communication, and the bronchial tubes themselves, must not be obstructed by morbid products. The concurrence of these conditions can only be expected to obtain, now and then, so that we may auscultate for this sign repeatedly, in cases in which a cavity or cavities exist, without success. The value of the sign in diagnosis, therefore, is altogether positive ; negatively, it is of little or no value : that is, we are not authorized to infer the non-existence of a cavity from the absence of the sign. Other things being equal, the size of the bubbles and the loud- ness of the gurgling will be proportionate to the magnitude of the cavity. When the rale closely resembles the mucous, but retains the cavernous characters sufficiently to be distinguished from the latter, it has been called cavernulous,^ and supposed to indicate the existence of small excavations. This distinction, however, is clini- cally unimportant. As has been stated, a well-marked cavernous rale at the summit 1 This title was first applied by M. Hirtz, of Strasbourg. AUSCULTATION IN DISEASE. 219 of the chest denotes almost with certainty an excavation proceeding from tuberculous disease. But the rale may be present in cases in which cavities are otherwise formed, viz., from circumscribed gan- grene, abscess, and pouch-like dilatation of a bronchial tube. It may also exist in cases of perforation of the lung, with accumulation of liquid in the pleural sac, i. e., in pneumo-hydrothorax. The di- agnosis of each of these affections must, however, be based mainly on other signs. The infrequency with which this rale is discovered, the difficulty in many instances of discriminating between it and coarse mucous rales (the two being, moreover, frequently commin- gled), together with the fact, that it generally occurs at a period of disease and under circumstances when the diagnosis is sufficiently easy, and has probably been already made, render it a sign of minor practical consequence. 7. Indeterminate rales. — Under this head may be embraced cer- tain adventitious sounds, not clearly referable to either of the fore- going divisions, and of which the situation, as well as the manner of production, are matters of doubt. Notwithstanding this uncertainty as respects their locality and explanation, some of these sounds are by no means without value as physical signs, observation having established their pathological relations. Laennec described a distinct sound which he designated by the somewhat contradictory phrase, " Dry crepitant rale with large bubbles" [rale crepitant sec a grosses hulles). This sound, accord- ing to Laennec, "conveys the impression as of air entering and distending lungs which had been dried, and of which the cells had been very unequally dilated, and resembles the sound produced by blowing into a dried bladder." He regarded the sound thus de- scribed as characteristic of emphysema of the lungs. Most aus- cultators, since the time of Laennec, have failed to discover a rale with well-marked characters of the kind just stated ; and multiplied observations in cases of emphysema do not establish its connection with any such sign. It is probable that in instituting this rale Laennec was influenced by preconceived notions. At all events, if a rale such as Laennec described exists, in vicAV of the difficulty of appreciating it, and its indefinite signification, it is practically una- vailable in diagnosis. Pulmonary crumpling. — Under the title of froissemcnt pulmo- naire, rendered as above, Fournet^ embraced a variety of sounds 1 Op. cit. 220 PHYSICAL EXPLORATION OF THE CHEST. not bearing to each other close resemblance, save that, according to this observer, an impression is conveyed to the mind of the aus- cultator of the "pulmonary tissue forcibly struggling against some impediment to its expansion." One variety he compares to the new leather friction sound {bruit de cuir neuf) heard in pericarditis ; another is a plaintive moaning sound, with various intonations ; an- other is like the sound produced by blowing upon tissue-paper. These sounds, differing so much in their audible characters, admit of being classed together only as indeterminate rales. The bond of union stated by Fournet must be regarded as fanciful. The sound resembling the crumpling of tissue-paper, and that of new leather, may be veritable pleural friction sounds. The various moaning sounds are probably sonorous bronchial rales. Fournet endeavors to establish points of distinction between them collectively and other rales, but the chief characteristic is that by which they are placed in the same category, viz., the impression conveyed to the ear of a struggle against an obstacle. Such impressions are so apt to origi- nate within the mind, that they are to be trusted but to a limited extent in forming opinions respecting the explanation of auscultatory signs. It is chiefly with reference to the diagnosis of tuberculous disease that the sounds regarded by Fournet as dependent on pulmonary crumpling are of practical importance. And their diagnostic im- portance, in this relation, is irrespective of the question whether they are properly varieties of the same sign, and of any hypothesis as to their mode of production. Fournet states that he has observed a hruit de froissement in the proportion of about one- eighth of per- sons affected with phthisis. Occurring at the summit of the chest, frequently if not generally limited to one side, and confined within circumscribed limits, a rale resembling either of the sounds above described belongs among the varied physical signs which, from their situation and limitation, taken in connection with symptoms, point to the existence of a tuberculous deposit. According to Fournet, these sounds are observed in the early stage of phthisis, and the acute form of the disease, or tuberculous infiltration, is especially favorable for their development. This sign is not infrequent in healthy persons. If Cammann's stethoscope be used, it is not uncommon, in healthy persons, to hear pretty loud crumpling sounds at the end of a deep inspiration. They are heard particularly at the summit of the chest in front. AUSCULTATION IN DISEASE. 221 The fact of their being heai'd on both sides of the chest, taken in connection with the absence of other signs of disease, Tvill enable the auscultator to avoid the error of considering these sounds as morbid. Pulmonary crackling. — A crackling sound, presenting certain varieties [rales de craquement), like the preceding, has been particu- larly described by Fournet, and is recognized as a distinctive aus- cultatory sign by most writers on the subject of physical exploration. The varieties of this sound are arranged in two classes, viz., dry crackling and moist crackling. Like the so-called crumpling sounds, they belong among the physical signs of phthisis, and are entitled to some weight in the diagnosis of that disease. Their diagnostic significance, like that of several other signs of tubercle already mentioned, depends on their being observed at the summit of the chest within a circumscribed space on one side. Dry crepitation bears a close resemblance to the crepitant rale. Like the latter, it appears to be made up of distinct crepitations, but much fewer in number, frequently, according to Fournet, not exceed- ing two or three. Like the crepitant rale, it occurs almost exclu- sively with inspiration. The mechanism of the sound is generally considered doubtful. The most rational supposition, as it seems to me, is, that it is produced in the same way as the crepitant rale, viz., by the abrupt separation of the walls of a few cells which become adherent, when the lungs are collapsed, in consequence of the pres- ence of a small quantity of glutinous exudation.' The sound is occasionally observed during a few respirations in the healthy chest. It is a sign of rather frequent occurrence in the early stage of phthisis, and under these circumstances is usually constant during the period of its persistence. Of fifty-five cases in which it was observed by Fournet, its constancy was noted in all but nine in- stances. The crackling appears removed from the surface of the lung, not near the ear, — a point which serves to distinguish it from a pleural friction-sound. Moist crackling, according to Fournet, is developed at a later stage of the disease. The dry sometimes merges into the moist rale. Moist crackling appears to me to be neither more nor less than a sub-crepitant rale. As the title imports, it diifers from dry ' This explanation accords with the description of the character of the sound by Fournet: " II consiste dans une sensation toute particuliere de rupture," &c. 000 PHYSICAL EXPLORATION OF THE CHEST. crackling in its conveying the sensation of the presence of a liquid. It is not confined to inspiration, but occurs also in expiration. It is supposed by Fournet to indicate the transition of crude tubercle to softening, dry crackling pertaining to the period of crudity. It is probably due to the presence of fluid in the smaller branches of the bronchial tubes, and this fluid may be softened tuberculous matter, or mucous secretion from bronchitis affecting the smaller tubes within a limited area. The occurrence of the two kinds of crack- ling in regular succession, and the uniform relation of each to a dif- ferent stage of tuberculous disease, are theoretical conclusions which observation has not conclusively established. The foregoing are the adventitious sounds included within the de- nomination of rales. The subjoined table contains a recapitulation of the distinctive characters and diagnostic indications pertaining to them respectively. Table Exhibiting the Distinctive Characters and Diagnostic Import of the Different Bales. Sibilant. Dry sound, high in pitch; whistling, hissing, or clicking; sometimes musi- cal. Variable in continuance, intensity, intonation, and situation. Present with inspiration, or expira- tion, or both ; oftener with inspiration. If present on both sides, indicative Sonorous. Dry sound, grave in tone. Oftener musical than the sibilant ; louder and stronger. Variable in continuance, intensity, intonation, and situation. Present with inspiration and expira- tion, oftener the latter, and with both. If present on both sides, indicative of primitive bronchitis affecting the of primitive bronchitis, or of bronchial smaller tubes, or of bronchial spasm. spasm. Confined to one side, indicative of bronchitis complicating pneumonitis or pleurisy. Limited to a circumscribed space at the summit of the chest, indicative of tuberculosis. Often associated with the sonorous and mucous rales. Mucous. Moist, bubbling sounds. Coarse or fine, in proportion to the size of the bronchial tubes in which thej' are pro- duced. Variable in continuance, intensity, situation, and degree of coarseness. Suspended by expectoration. Confined to one side, secondary bronchitis. indicative of Limited to a circumscribed space at the summit, indicative of tuberculosis. Often associated with the sibilant and mucous rales. Cavernous. A moist sound, conveying the im- pression of very large bubbles, and the agitation of a mass of liquid (gurgling), occasionally synchronous with the heart's impulse. AUSCULTATION IN DI.SEASE. 223 Present with inspiration, or expira- tion, or both. Coarse and fine rales often com- bined. If present on both sides at the inferior posterior portion of chest, indicative of second stage of primitive bronchitis ; the coarseness or fineness denoting ex- tent of bronchial tubes affected. Confined to one side, indicative of secondary bronchitis, or the presence of pus, serum, or blood in bronchial tubes. Limited to a circumscribed space at the summit, or more marked in that situation, indicative of tuberculosis more or less advanced. May be associated with sibilant and sonorous rales. High or low in pitch, according to the existence, or otherwise, of solidifi- cation of lung. Crepitant. Dry, crepitating sound. Evolved with rapidity, in puffs. Constant, not variable. Not suspended by coughing. Present with inspiration exclusively. Very rarely existing on both sides. Almost pathognomonic of pneumoni- tis ; frequently continuing through the disease, or giving place to a sub-crepi- tant rale. Occurs occasionally in oedema and haemoptysis. Limited to a circumscribed space at the summit of the chest, indicative of tuberculosis. High or low in pitch, according to the existence, or otherwise, of solidifi- cation of lung. Present with inspiration, or expira- tion, or both, especially with inspiration. Sometimes amphoric, and, if not, the pitch low. Generally situated at the summit of the chest. Alternating or combined with cav- ernous respiration. Ceases and returns at irregular inter- vals. Indicative of tuberculous excavations ; cavities following abscess, circumscribed gangrene, and pouch-like dilatation of bronchial tubes. SUB-CREPITANT. Moist sound, giving impression of very small bubbles. Bubbles somewhat unequal. More regular and constant than mucous rales. Less likely to be suspended by expectoration. Present with inspiration, or expira- tion, or both. If present on both sides at posterior inferior part of chest, indicative of prim- itive capillary bronchitis. Occurs in pneumonitis, at period of resolution ; also in oedema, and pulmo- nary apoplexy, or haemoptysis. Limited to a circumscribed space at the summit of the chest, indicative of tuberculosis. High or low in pitch, according to the existence, or otherwise, of solidifi- cation of lung. Indeterminate. 1. Pulmonary crumpling. 2. Pulmonary crackling. Attrition, or Pleural Friction-sounds. — With the act of in- spiration the thoracic space is enlarged mainly by depression of the 224 PHYSICAL EXPLORATION OF THE CHEST. diaphragm, and the elevation of the ribs. The lung, expanding to fill the augmented capacity of the chest, moves in a vertical direc- tion downward, while the walls of the chest ascend; and hence re- sults, of necessity, a certain extent of friction of the pleural sur- faces, which is repeated with the reverse movements of expiration. Normal pleural friction takes place silently, as shown by experi- ments on inferior animals and auscultation of the healthy chest. This is undoubtedly owing to the highly polished and moistened condition of the membrane. When, however, the surfaces are ren- dered irregular and rough by morbid exudation or other causes, there exist the physical conditions for the production of adventitious sounds, to which are applied the names attrition or friction-sounds. The mechanism of their production is sufficiently intelligible ; the points of inquiry which suggest themselves are, the diversity of the sounds thus produced ; their distinctive characters, and the means by which they are to be distinguished ; the diseases to which they are incident, and the circumstances on which depends their diagnos- tic significance. The intrinsic differences of friction-sounds are such that they may be divided into several varieties. These, however, do not individu- ally sustain pathological and clinical relation so distinct and im- portant as to claim separate consideration. A delicate grazinfj is one variety, occurring when the opposing movements are not forcible, or the physical conditions are not the most favorable for the produc- tion of sound. Another variety is a more distinct rubbing, chiefly denoting greater force of attrition. A greater degree of harshness of sound, dependent on greater roughness of the pleural surfaces, constitutes the variety called r^asping or grating. A creaking, like new leather, is still another variety. These diversities of sound are due to differences which are in a certain sense accidental, and may be presented in different cases of the same affection, without furnish- ing any special indications as respects either the nature or degree of the disease. The grazing and rubbing sounds, which are the varie- ties ordinarily presented, may be exactly imitated by placing the palm of the left hand over the ear, with firm pressure, and moving slowly over the dorsal surface the pulpy portion of a finger of the right hand. A friction-sound may accompany both respiratory acts, or the act of inspiration alone. It is frequently heard with both acts, but very rarely limited to the act of expiration. When it accompanies both AUSCULTATION IX DISEASE. 225 acts, it is more distinct with inspiration. It is seldom continuous during the whole of the inspiratory or expiratory act, but it occupies a portion only of its duration. Ordinarily, it is either a single sound of brief duration, or there occurs a series of sounds succeed- ing each other with more or less rapidity, resembling, in this partic- ular, interrupted or jerking respiration. Occurring in this manner it sometimes bears a very close resemblance to the crepitant rale, and may be mistaken for it. In some instances it continues unin- terrupted through the act of inspiration, and may even be prolonged through the expiratory act, giving rise to a constant rumbling sound. In the great majority of cases, the sound is manifestly dry; but it may suggest the idea of moisture. This occurs when false mem- branes, situated on the pleural surfaces, become infiltrated with serum. Under these circumstances a sound may be produced, which Walshe characterizes as squash)/. The intensity is variable. It may be so slight as to be but just appreciable, or it may be so loud as to be heard at a distance. Several instances have fallen under my knowledge in which it was so intense as to be a source of annoyance to the patient, during convalescence from pleuritis. Between these extremes there is every degree of intensity. It is usually confined to a small space, but it may be more or less diffused, and occasion- ally is heard over the entire chest. In the latter case, it may be produced within a limited space, but its intensity causes it to be ap- preciable at a greater or less distance from its source. The situa- tions where it is heard are usually the middle and lower portions of the chest, oftener laterally, or posteriorly. As exceptions to the general rule, it is sometimes heard at the summit, and thus situated, it has a special diagnostic significance, which will be presently men- tioned. The sound always appears to be superficial, not emanating from beneath the superficies of the lung. This is a distinguishing feature. So superficial does it sometimes appear, that it seems to the auscultator to be produced upon the integument, and he is led by the apparent nearness of the sound, to suspect that a portion of the dress comes in contact with the ear or stethoscope. In some in- stances, a friction-sound is heard with each respiration, but oftener it is variable in this respect, accompanying some respirations, but absent in others. It is sometimes appreciable only with forced res- piration, and, on the other hand, it is sometimes strongest when the breathing is tranquil. The sound is sometimes increased when firm pressure is made with the stethoscope. Its continuance is varia- 15 226 PHYSICAL EXPLORATION OF THE CHEST. ble. It may be transient, or it may continue for a considerable period. In a case reported by Andral, it lasted for three months. It is observed in some instances to shift its seat, being at one time heard at a certain point, and at another time in a different situation, and these changes may take place repeatedly. Intermittency is another point of variability. It may be present, disappear, and again reappear, and these alterations may occur more than once in the progress of the same disease. I have repeatedly observed it to disappear, temporarily, after forcible respirations have been con- tinued for some time for the purpose of illustrating the sign to a number of persons in succession. Finally, if a friction-sound be strong, and especially if it be rough, a vibration or fremitus is per- ceptible to the touch, on placing the hand over the side ; and in this "way patients themselves become aware of a rubbing -within the chest. The distinctive characters of a pleural friction-sound, are such that its discrimination is not generally attended -with difficulty. The sound itself conveys the idea of its being produced by friction. In addition to this, its dryness, its accompanying frequently both re- spiratory acts, and especially its superficial situation, serve to dis- tinguish it from other adventitious sounds. As already stated, sometimes, when interrupted and limited to inspiration, it may be mistaken for a crepitant rale. The instances, however, in which this resemblance exists are rare, and the associated circumstances will generally prevent the error into which the auscultator might fall, were he to limit his attention solely to the character of the sound. In determining the existence of a friction-sound, in all cases we are aided by the coexistence of other signs, and of symp- toms involved in the diagnosis of the diseases in which it is known to occur. Dr. Stokes has called attention to the fact that a friction-sound may be due to the movements communicated to the adjacent portion of the pleura by the impulse of the heart. In this case, a friction- sound will be found to be synchronous with the beating of the heart, or the pulse, and will continue when the respiratory movements are voluntarily suspended. A pleural friction-sound was regarded by Laennec as a pathogno- monic sign of interlobular emphysema. He did not, however, profess to have established this opinion on the evidence afforded by autopsical AUSCULTATION IN DISEASE. 227 examinations, in cases in which the sound had been noted during life. Moreover, in the two instances given by him, in which he had ob- served this sign, the patients, if affected with interlobular emphy- sema, were also affected with pleurisy ; and it is remarkable that its connection with the latter affection should not have presented itself to the reflections of the discoverer of auscultation. Subsequent ob- servation has shown that in the interlobular, as well as the ordinary form of emphysema, and also in that variety in which air-blebs are formed by the elevation of a portion of the pulmonary pleura, a friction-sound is an exception to the general rule. Dr. Walshe has noted the occurrence of the sign in a few instances of the variety last named. With exceptions so infrequent that they belong among the curiosities of clinical experience, a friction-sound is indicative of pleuritis. It is, however, by no means a sign constantly or very frequently present in that affection, and, indeed, it is observed but in a small proportion of cases. It may occur in different stages of pleuritic inflammation : first., in the early stage, before the pleural surfaces are separated by liquid effusion; and second, at a later period, after absorption of the liquid has taken place, and the pleural surfaces are again brought into contact Avith each other. In the early period of the disease it is due to the presence of co- agulable lymph, with which, to a greater or less extent, the surfaces of the pleura are covered ; and according to Stokes, to abnormal dryness of the membrane, prior to the exudation of lymph. That abnormal dryness precedes, as a general rule, the exudation of lymph, is not certain, and that it is alone capable of giving rise to a friction-sound, may be doubted. But however this may be, it is certain either or both these physical conditions so seldom give rise to a friction-sound in the first stage of pleuritis, that it scarcely pos- sesses any importance as a sign to be relied upon in the diagnosis prior to the occurrence of effusion. Instances, however, are occa- sionally observed in which, notwithstanding a considerable, or even large accumulation of liquid in the pleural sac, a friction-sound is apparent. Dr. Stokes was the first to report a case of this descrip- tion, and others have been subsequently reported. The explanation of the presence of the sign under these circumstances is, the lung having become attached, not closely, but by means of bridles of false membrane, to the thoracic walls, the pleural surfaces continue to come into contact over a greater or less extent of surface. This 228 PHYSICAL EXPLORATION OF THE CHEST. may obtain anteriorly, ^vhile the whole posterior surface of the lung is separated from the walls of the chest by a large quantity of fluid; and, under these circumstances, the physical signs posteriorly show the presence of liquid, whilst, anteriorly, a friction-sound may be observed. Of the instances in which a friction-sound occurs in pleuritis, in by far the larger proportion it appears in a later stage, after absorption. The pleural surfaces coming again into contact, are roughened by dense lymph. This is so disposed in different cases as to give rise to simple rubbing, to a rougher quality of sound distinguished as grating or rasping, to creaking, or, occa- sionally, to a sound conveying the impression of a liquid. These diversities in the audible characters do not furnish any indications as to the quantity of exudation, or the gravity of the aifection, but simply denote differences pertaining to the disposition of the morbid exudation, together with variations of dryness and firmness, etc. ; and simple scarcely appreciable rubbing may occur in cases in which the lymph is more abundant and the disease more severe than in other cases in which the loudest, roughest sounds are discovered. The sounds are heard over the middle and lower portions of the chest in primary pleuritis, because, although the morbid condition may not be more marked here than at the summit of the chest, the respiratory opposing movements of ascent and descent are greater, especially in the male. The friction-sounds are not produced solely by the rubbing together of the pulmonic pleura and costal pleura, but probably oftener and with greater intensity, by the contact of the diaphragmatic pleura and costal pleura. The situation of the sign is sometimes, in fact, not over the lung, but over the diaphragm, viz., over the sixth and seventh cartilages.^ But even after absorp- tion a friction-sound is not of very frequent occurrence in pleuritis. This is probably owing to the fact that agglutination of the pleural surfaces generally takes place directly they are brought into contact. It is, however, not improbable that the sound is discoverable at some points oftener than is supposed, because, inasmuch as the diagnosis of pleuritis is sufficiently established, in the large majority of cases, long before the period arrives when the physical conditions are fa- vorable for the production of this sign, it is not always sought for with care over all parts of the chest. Occurring subsequent to absorption in the progress of pleuritis, although not of importance 1 Sibson's Medical Anatomy. AUSCULTATION IN DISEASE. 229 as respects the diagnosis, which it is to be presumed has been already made, it is useful as evidence that the surface of the lungs is in contact with the walls of the chest. As stated by Fournet, in some cases this evidence is the more valuable, because, owing to the thick- ness of the layers of morbid deposit, percussion and the auscultation of the respiratory sound may be insuiEcient to determine the fact that the liquid is absorbed. At this period of the disease the sign is of good omen, denoting progress toward restoration. A friction-sound may accompany pleuritis developed as a compli- cation, or an intercurrent affection. In pneumonitis it is occasionally observed, being due here to the pleuritic complication, and produced in the same manner as when the pleuritis is primary. It is also one of the signs which, inferentially, point to tuberculous disease. Oc- curring in connection with tuberculosis, it may originate in two ways : First, The deposit of small isolated tubercles beneath the pulmonary pleura, may occasion an irregularity of the surface sufficient to give rise to a strongly marked sound of attrition. Fournet gives an in- stance of this kind; and a striking case was reported several years ago by Prof. Lawson.^ Second, It is due to intercurrent pleuritis, confined to a circumscribed space, situated over the tuberculous de- posits. Successive attacks of pleuritis, attended by the exudation of lymph, without liquid (dry pleurisy), and followed by adhesion of the pleural surfaces over the space affected, as is well known, are so constant as to form a portion of the natural history of tuberculous disease of the lungs. A friction-sound, by no means uniformly, but occasionally, accompanies these attacks. Under these circumstances, the sign is confined to a small area at the sum- mit of the chest, and is of the grazing or rubbing variety, never presenting the rougher qualities of sound. With this character, and thus situated, i. e. at the summit of the chest, it is indicative of cir- cumscribed pleuritis, which is incidental to tubercle, and therefore it becomes a physical sign of the latter disease. It is discoverable in only a small proportion of the cases of tuberculosis, and its ab- sence is not entitled to any weight as negative evidence ; but when present, it is a sign of considerable diagnostic importance. Occur- ring in this connection it is of brief duration, usually continuing for a day or two only, being suspended by the adhesion of the surfaces over the space in which it was produced. And as this adhesion pre- 1 Western Lancet, Cincinnati, Oct., 1850. 230 PHYSICAL EXPLORATION OF THE CHEST. eludes the continuance of movements necessary for the production of the sound, it is not likely to occur, save at the first attack of pleuritis. It is probable, but I am not aware of its having been clinically established, that a friction-sound indicative of tuberculous disease is more apt to be observed in females than in males, owing to the greater part which the superior costal type of respiration performs in their respiratory movements. Finally, a friction-sound is occasionally observed in certain struc- tural affections giving rise to asperities or irregularities of the pleural surfaces, such as cancers and tumors of diff"erent kinds. These affec- tions are, however, very infrequent; and in its diagnostic relations to them the sign is of very little value. The sign here, and in all cases, merely indicates that the pleural surfaces are roughened. If, in connection with the sign, there are the symptoms, past or present, of intra- thoracic inflammation, and the sign be situated at the middle or inferior portion of the chest, it indicates, in forty-nine of fifty cases, pleuritis, either primary or secondary. If it exist at the summit of the chest within a circumscribed space, and is associated with symptoms leading to the suspicion of tuberculosis, it is highly significant of that affection. And if it be found under circumstances in which neither pleurisy nor tubercle are evinced by associated signs and symptoms, it proceeds from emphysematous tumors or other af- fections, the nature of which may not be determinable. Dr. Walshe states that intra-thoracic friction is sometimes simulated by the move- ments of the scapula in breathing. I have met with several examples of this fact. The discovery of a pleural friction-sound as a physical sign, was made by M. Honorfe, a contemporary with the discoverer of auscul- tation.^ He brought to Laennec a patient presenting the sound to which the latter applied the title of the rubbing sound of ascent and descent (bruit de frottement ascendant et descendant). Laennec, how- ever, as already stated, failed to perceive its connection with pleu- ritis, but attributed its production to interlobular emphysema. The merit of pointing out more fully its characters, and determining its true pathological significance, belongs to a French observer, M. Raynaud.* 1 Vide Treatise on Mediate Auscultation, etc., by Laennec. * Vide Earth and Kosjer. AUSCULTATION IN DISEASE. 231 PHENOMENA INCIDENT TO THE VOICE. With a previous knowledge of the vocal phenomena pertaining to different portions of the respiratory system in health, the abnormal modifications are readily apprehended. The more important of the vocal signs of disease are distinguished by characteristics of the normal tracheal or laryngeal voice, transferred to situations where they are not found in health. Two important vocal signs are called exaggerated vocal resonance and hroncJiopJiony. In the first of these two signs, the intensity of the resonance of the loud voice is mor- bidly increased without notable alteration in other respects ; in the second, with or without increase of intensity, the resonance is altered as regards apparent proximity to the ear, concentration, and pitch. Corresponding signs relate to the whispered voice. The normal bronchial whisper undergoes modifications representing the same morbid conditions; and, employing similar names to designate these signs, they may be called the exaggerated bronchial whisper^ and whispering bronchophony. The normal vocal resonance may be diminished and suppressed. Morbid changes in this direction will constitute other vocal signs, viz., diminished and suppressed vocal resonance. In treating of auscultation of the voice in health, it was seen that when the stethoscope is applied over the trachea or larynx, frequently articulate words are found to enter the ear, sometimes perfectly, and in other instances partially. This, which very rarely, if ever, occurs over the chest in health, is sometimes observed in disease, and con- stitutes a sign called pectorilocpiy . This will claim separate consid- eration, and constitutes the third of the divisions of abnormal vocal phenomena. Pectoriloquy has relation both to the loud and whis- pered voice. A modification of the pitch of the whispered voice, without transmission of the speech, constitutes an important sign of a cavity. This sign may be called the cavernous ivhisper. Another vocal sign consists of a transmission of the voice, elevated in pitch, and tremulous ; which, after Laennec, is called, from its re- semblance to the bleating of the goat, cegophony. Agreeably to the foregoing divisions, the phenomena incident to the voice in disease may be arranged under the following heads : 1. Exaggerated resonance, and bronchophony. 2. Exaggerated bronchial whisper, and whispering bronchophony. 3. Diminished 232 PHYSICAL EXPLORATION OF THE CHEST. and suppressed vocal resonance. 4. Pectoriloquy. 5. Cavernous whisper. 6. ^gophony. 1. Exaggerated Vocal Resonance, and Bronchophony. — With the ear applied to most parts of the healthy chest, — for ex- ample, the infra-clavicular region in front, or the infra-scapular behind, — the act of speaking occasions a diffused resonance, the sound appearing to come from a distance, and accompanied with more or less vibration or thrill. This is the normal vocal reso- nance. Kow, this resonance may be rendered by disease more in- tense, in other characters than intensity remaining the same as in health. The vocal resonance is then simply exaggerated. The reverberation of the voice is abnormal, and there is usually more vibration or thrill felt by the ear; but the sound is still distant, and diffused. If, however, well-marked bronchophony become de- veloped, the intensity may or may not be increased, but the voice seems concentrated and near the ear, the pitch is high, and the ac- companying vibration may be diminished. The distinction, thus, between simply exaggerated resonance and well-marked bronch- ophony is real, and the two signs may be clinically discriminated from each other without difficulty. It is not, therefore, correct to say that they are essentially identical. But it is true that both pro- ceed from similar physical and pathological conditions, differing only in degree. Moreover, exaggerated resonance not infrequently merges into bronchophony; and again, the latter, in the progress of the same disease, may give place to the former. The vibration or thrill, it is important to note, does not increase, but in general is diminished, when bronchophony exists. But with exaggerated vocal resonance, the fremitus is sometimes proportionately increased. In degree, both exaggerated vocal resonance and bronchophony present, in dif- ferent cases of disease, great variations. The intensity of the tho- racic voice may exceed that of the normal laryngeal or tracheal. These vocal signs continue, certainly in the large majority of cases, continuously, that is, they are always found on auscultation, so "long as the pathological conditions of the lung to which they are incident continue ; in other words, they are not intermitting signs, like the bronchial rales, now present and now absent, but they steadily per- sist for a certain period, in this respect resembling the crepitant rale and the bronchial respiration. This last statement is in opposition to the statement of Skoda, who maintains that the alternate absence AUSCULTATION IN DISEASE. 233 and presence of the thoracic voice is a well-known and a common occurrence, and that bronchophony may appear and disappear sev- eral times in the course of a few minutes.^ The question is one to be settled purely by observation, and the experience of others does not sustain Skoda's assertion. Intermittency is an important point in the support of certain theoretical views entertained by Skoda, which will be briefly noticed presently ; and this circumstance, it may be remarked, does not tend to enhance confidence in the accu- racy of the observations on which his opinion is professedly based, without intending by this remark to convey an imputation of want of good faith. The recognition of exaggerated vocal resonance and bronchoph- ony, practically, involves no difficulty. It is sufficiently easy to de- termine, on comparison of the two sides of the chest in corresponding situations, a disparity in the degree of resonance, and the characters pertaining to bronchophony. There is no liability of confounding these with other signs. As regards exaggerated vocal resonance, the only error to be guarded against is, attributing to disease differ- ences between the two sides which exist normally. Under the head of "Auscultation in Health," it has been seen that a normal differ- ence in intensity is observed in a large proportion of persons. The difference, however, observes a regular law, viz., the greater relative intensity is on the right side ; and this is found to be the case over all the regions on this side, but it is especially marked at the summit in front. From this fact, it follows that the resonance on the right side must be considerably greater than that on the left, to warrant the inference that it proceeds from disease ; whereas a slightly greater resonance on the left than on the right side denotes a mor- bid condition. The coexistence of other signs incident to the same physical conditions is a safeguard against the mistake of confound- ing morbid with natural variations. The physical condition of which exaggerated vocal resonance and bronchophony are the signs is increased density of the pulmonary structure. These signs occur in the different affections which give rise to the broncho-vesicular and the bronchial respiration, and are generally found in combination with the latter. The two signs, respec- tively, represent diflerent degrees of solidification. Bronchophony is the sign of either complete or considerable solidification ; exag- 1 Translation, by Markham. Am. ed., page 68. 234 PHYSICAL EXPLORATION OF THE CHEST. gerated vocal resonance denotes a greater or less amount of solidifi- cation, but an amount falling short of that requisite to produce bronchophony. With bronchophony, consequently, is associated, generally, the bronchial respiration ; but an amount of solidification suiEcient to give rise to well-marked bronchophony may be repre- sented by a broncho-vesicular respiration approximating to the bronchial ; in other words, it does not require as much solidification to cause bronchophony as it does to give rise to bronchial respira- tion. Exaggerated vocal resonance is associated with the different grades of broncho-vesicular respiration. These vocal signs of solidi- fication may be present when the respiratory signs are wanting, and vice versa. Bronchophony is generally present, and is often strongly marked, in connection with the solidification incident to the second stage of pneumonitis. In that disease, the situation in which it is observed is usually the middle and lower thirds of the posterior sur- face of the chest on one side, the seat of the inflammation, in the adult, being the inferior lobe, in the larger proportion of cases. It is in pneumonitis especially that bronchophony is strong, the voice seeming to be very near the ear, and the pitch notably higher than on the unaffected side. As respects the loudness of resonance, however, different cases of pneumonitis present great variations, dependent on differences in the degree of solidification, on more or less obstruction of the bronchial tubes, and other circumstances less obvious. The character of the voice, other things being equal, exerts an influence on the intensity of the sign. The strength of the resonance will be proportionate to the power of the voice, irrespective of its pitch or special quality. Other circumstances, such as the thickness of the muscular and adipose layers covering the chest, affect, of course, the resonance in disease as well as that incident to health. The reverberation and vibration are greater, cceteris paribus, in persons whose voices are grave or bass ; but the force or extent with which the voice penetrates the ear is greater when the pitch of the oral voice is high. Bronchophony is not present in all cases of pneumonitis, and the vocal resonance may not be exaggerated, so that absence of either or both of these signs, by no means affords positive evidence against the existence of the disease. Each, however, is present in different periods of the dis- ease in the great majority of instances. They may be present without being associated with the bronchial or broncho-vesicular AUSCULTATION IN DISEASE. 235 respiration, and in such instances they are highly important with reference to the question of solidification. Next to pneumonitis, the affection in which exaggerated vocal resonance and bronchophony are most frequent in occurrence, and most important as physical signs, is phthisis. A tuberculous deposit gives rise to either exaggerated resonance or to bronchophony, ac- cording to the quantity of tubercle, the degree of solidification which it induces, its extension to the superfices of the lung, and its prox- imity to the larger bronchial tubes. It is sufficiently intelligible that these circumstances will affect the amount of exaggeration, or the de- gree of bronchophony, in addition to the strength and character of the voice of the individual, etc. Owing to the diversity pertaining to the physical conditions favorable for the production of these signs, difierent cases of tuberculous disease diS'er greatly as respects their presence and their prominence. Even an exaggerated resonance may not be appreciable in some instances in which a considerable quantity of tubercle exists. For example, if a tuberculous mass be separated, on the one hand, from the larger bronchial tubes, and, on the other hand, from the walls of the chest, by layers of healthy lung, the vocal resonance may scarcely, if at all, exceed a normal degree of intensity. Its presence, therefore, as necessary to the diagnosis, is much legs to be counted on than in pneumonitis ; nor is the intensity with which it may be present to be considered as indicating the abundance of the deposit. Bronchophony is much oftener absent in phthisis than in pneumonitis, and it is very rarely so strongly marked in cases of the former, as it is in the larger pro- portion of the cases of the latter disease. Occurring in connection with tuberculous disease, bronchophony and exaggerated resonance are almost invariably situated at the summit of the chest, in the infra-clavicular and scapular regions, oftener the former. They do not extend over so large a space as in cases of pneumonitis affecting either a lower or upper lobe, being usually limited to a circum- scribed area ; but the history and symptoms, in conjunction with all the physical signs, rarely render it a difficult problem to decide be- tween pneumonitis and tuberculosis. It is in the diagnosis of phthisis, especially, that the normal variations in vocal resonance at the summit of the chest are important to be borne in mind. Exag- gerated resonance on the right side, contrasted with the left, is not evidence of the presence of the deposit of tubercle ; whereas a slight 236 PHYSICAL EXPLORATION OF THE CHEST. exaggeration on the left side, in itself, is sufficient ground for the presumption that the deposit exists. Increased density of the lung, in consequence of compression by the accumulation of liquid within the pleural sac, may give rise to exaggerated vocal resonance and bronchophony. Under the circum- stances the latter is rarely marked, and frequently both are absent. Excepting some instances in which the lung is retained in contact with the walls of the chest by adhesion, the effect of the accumula- tion of liquid is to remove it to the upper and posterior part of the chest. Bronchophony or exaggerated resonance, if either exists, will then be heard at the summit, in front or behind. Over the por- tion of the chest corresponding to the space occupied by the liquid the resonance is either diminished or suppressed. Serous infiltration or oedema may give rise to exaggerated reso- nance. Marked bronchophony, however, is very rarely, if ever, de- veloped in this affection ; and both signs are frequently absent. In the rare forms of disease in which a portion of the lung is solidified by carcinomatous or melanotic deposits, extravasated blood, gangrene, and also in cases of extra-pulmonic morbid growths, ex- aggerated resonance and bronchophony may or may not be present. The circumstances which should lead the diagnostician to attribute the presence of these signs to some one of these aflFections, instead of the more common morbid conditions to which they are incident, are the same that have been noticed in connection with the subject of bronchial respiration, to which the reader is referred. In general terms, if exaggerated resonance or bronchophony be circumscribed in extent, not confined to the summit, but situated in any part of the chest, and persisting (these circumstances excluding the diseases previously referred to), we may infer the existence of some one of the affections just enumerated. In determining which one of these several affections exists, we are to be guided by the circumstances associated with the physical signs ; for example, the expectoration of blood in pulmonary apoplexy, and of fetid matter in gangrene. Dilatation of the bronchial tubes is another morbid condition in which exaggerated vocal resonance and bronchophony are supposed to occur. In this rare lesion, the dilated tubes are surrounded, to a greater or less exent, with condensed or indurated lung, so that it is difficult to say what proportion of the exaggerated resonance or bronchophony is fairly attributable to the enlarged calibre of the AUSCULTATION IN DISEASE. 237 tubes. Bronchophony is not constantly associated with the lesion, and is present in different instances with variable degrees of inten- sity, sometimes being very strongly marked, when the dilatation co- exists with considerable induration of the surrounding lung. The mechanism of bronchophony, as of some other physical signs, offers scope for much discussion. In a practical point of view it is not very important ; nor is uniformity of opinion in regard to it necessary to agreement in so much of the principles and practice of auscultation as relate to the availability of the sign in the diagnosis of diseases. To this part of the subject, therefore, I shall devote but little space, referring the reader who may desire a more extended consideration of it to works which professedly treat of the physical principles involved in the production of auscultatory phenomena. Laennec attributed it to the greater conducting power of lung, when its density is increased. According to this explanation, the vibra- tions of the vocal chords, and of the air within the larynx, are prop- agated downward along the walls of the bronchial tubes, or the air contained in the tubes, or through the medium of both, and are heard in diseases attended by solidification of lung, with more inten- sity than in health, simply because solidified lung is a better con- ductor of sound than air-vesicles filled with air. This explanation has generally been accepted as satisfactory, until recently it has been thought there are certain difficulties which it does not fully meet, and it has been attempted by Skoda to disprove altogether its correctness, and to substitute another explanation, to which refer- ence has been made in treating of bronchial respiration. Skoda attributes bronchophony, as well as the bronchial respiration, to the reproduction of sonorous vibrations within the bronchial tubes, in accordance with the musical principle of consonance. The bronchial tubes, according to this author, take no direct part in the mechan- ism ; that is to say, he excludes vibration of the walls of the tubes from any participation in the resonance, regarding the column of air contained within the tubes as alone concerned in the production of the thoracic sound. In the normal condition of the lungs, the con- sonating sounds are slight, owing to the smaller bronchial tubes being membranous, and the want of firmness in the surrounding paren- chyma ; but whenever the density of the lung is increased, provided the tubes remain pervious, the physical conditions necessary for stronger consonance are present ; and hence, bronchophony is devel- 238 PHYSICAL EXPLORATION OF THE CHEST. opetU under these circumstances. In support of this theory, it is as- sumed hy Skoda that bronchophony is absent whenever the bronchial tubes are obstructed, and that it appears and disappears frequently within a brief space of time, owing to the alternate removal and accumulation of mucous secretions. This, to the extent asserted by Skoda, is at variance with common observation. That obstruction, especially of the larger tubes, may occasion a suspension of the sign, and affect its intensity, is probably true ; but the sign is certainly not so dependent on the presence or absence of mucous secretions in the smaller bronchial subdivisions, as Skoda assumes. This fact alone renders the theory of consonance inadequate, in itself, to ac- count for the phenomena of bronchophony. In disproval of Laen- nec's doctrine of conduction, Skoda declares, as the result of experi- ments on hepatized lung removed from the body, that the conducting power is less than that of healthy lung ; and that, hence, if exag- gerated resonance depended on conduction alone, it should exist in health rather than when the pulmonary structure is solidified by dis- ease. The experiments on which this opinion is based consist in listening with the stethoscope applied over a portion of solidified lung, while another person speaks through a stethoscope applied over parts of the same lung, more or less distant. It is obvious that such experiments do not fairly represent the circumstances under which bronchophony takes place in the living body, unless it be gratuitously assumed (as it is by Skoda), that the column of air in the bronchial tubes is the only agent concerned in the mechanism. Even with this assumption, the cases are hardly parallel. But, as already remarked in connection with bronchial respiration, others, in repeating the same experiments, do not arrive at the same conclusion. Walshe has found that different specimens of hepatized lung do not conduct sound equally, a fact according with the variations in the intensity of vocal resonance which are clinically observed in difi"erent cases of pneumonitis, but that, in some instances, the sound is conducted with great intensity. Again, as stated by Walshe, if a person speak through a stethoscope introduced into the trachea of a subject dead with pneumonitis, in a case in which bronchophony had been marked 1 The same explanation of bronchophony was offered many years ago by Dr. E. A. Carr, in a paper read to a medical society, but not published. Vide Buffalo Medical Journal, vol. viii, 1853. AUSCULTATION IN DISEASE. 239 during life, and another person listen to the chest, there is often nearly complete absence of sound. Here are the physical condi- tions for consonance, provided the bronchial tubes are unobstructed. Skoda endeavors to explain the non-production of sound in this ex- periment by assuming that, after death, the smaller tubes are always filled with fluid ; but, according to Walshe, close examinations showed this not to have been the case in some of the subjects on which the experiment was made. But there are other and more positive considerations which render the theory of consonance un- tenable. A consonating sound always sustains a fixed harmonic re- lation to the original sound upon which it depends. The two sounds must be in unison. Now it is a matter of observation that the sound heard over the chest, and that heard over the larynx of the same patient, are not always in harmonic relation to each other : in other words, musically speaking, they are discords. Again, air contained within a certain space is capable of being thrown into consonating vibrations, only with certain notes which correspond to, or are in unison with the fundamental note of the space. But bronchophony is produced by speaking in various tones ; some of which must be at variance with the fundamental note of the space in which the con- sonating vibrations are imagined to take place. Finally, a conso- nating sound, except under conditions which the pulmonary organs cannot furnish, is always very much more feeble than the original sound ; yet, the thoracic voice is sometimes more intense than over the trachea or larynx. The theory of consonance, therefore, is at variance with the laws of acoustics.^ The doctrine of Laennec, which, as has just been seen, is by no means disproved, nevertheless fails to account for all the phenomena of bronchophony. Simple conduction is inadequate to explain the intensification of sound which, although infrequent, does occasionally take place within the pulmonary organs ; and it is equally inade- quate to explain the variation of pitch sometimes observed between the laryngeal and the thoracic voice. The vocal sounds must be, in certain instances, at least, in some way reinforced within the bron- chial tubes, and also receive there modifications of its quality and 1 The author would express his indebtedness for the foregoing points to the ad- mirahle work of Dr. Walshe (edition for 1864) ; to which also he would refer the reader desirous of a fuller consideration of the subject. 240 PHYSICAL EXPLORATION OF THE CHEST. tone. Consonance may be one of the subsidiary agencies involved. In addition to this, and to the influences which the sound receives in passing by conduction through different media, reflection and re- verberation probably take place, constituting what is distinguished as union resonance and echo. From some of the examples employed by Skoda to illustrate his theory of consonance, it would seem that under this title he intended to comprehend the acoustic principles referred to by the terms just mentioned. With the foregoing brief discussion, which, in view of the practical character of this work, has been perhaps already too extended, I leave the consideration of the mechanism of bronchophony, repeating the remark, that the subject is one chiefly of speculative interest ; for, whether the theory of consonance be received or rejected, is a matter unimportant so far as the significance and value of the sign are concerned, our knowl- edge of the latter being based solely on clinical and autopsical ob- servations. 2. Exaggerated Bronchial Whisper and Whispering Bron- chophony. — Under the name normal bronchial lohisper, was de- scribed, in treating of Auscultation in Health, a blowing sound of vari- able intensity in different persons, heard with whispered words at the summit of the chest, in front and behind, and in some persons heard feebly over other portions of the chest. This sound, which is, in fact, identical with a forced expiratory sound, is more or less exag- gerated, raised in pitch, and becomes tubular in quality in cases of solidification of lung, and it is developed with more or less inten- sity in portions of the chest in which it may be wanting or but faintly appreciable in health. Complete or considerable solidifica- tion of lung generally causes an intense, tubular, and high-pitched whispering sound. A notable degree of intensity, tubularity, and elevation of pitch, therefore, denote complete or considerable solidification, and the significance being the same as bronchopony with the loud voice, the sign may be called wJiispering hronchopliony. This sign may often be obtained when the patient speaks in a loud voice, but it is best obtained with whispered words. The sign is sometimes available when ordinary bronchophony and the bron- chial respiration are wanting. It is a very serviceable sign in cases in which the loud voice is lost or impaired by laryngeal disease, and when from feebleness it is diflicult for the patient to speak in a loud voice. AUSCULTATION IN DISEASE. 241 A slight or moderate increase of the intensity of the normal bron- chial whisper, with a corresponding elevation of pitch and alteration of quality, denotes a slight or moderate amount of solidification, and this sign may be called exaggerated bronchial tohisper. It cor- responds, as regards its significance, with exaggerated vocal reso- nance, and hence, the propriety of giving to it a similar name. This sign is often highly useful in the diagnosis of pulmonary tuberculosis. And, with reference to this disease, the points of disparity, as re- gards the normal bronchial whisper, between the two sides at the summit of the chest, are to be borne in mind. The whispering sound is louder on the right than on the left side, and higher in pitch on the left than on the right side. A whispering sound louder on the left than on the right side, is a morbid sign — an exaggerated bronchial whisper, if the increase of intensity be slight or moderate. But on the rightside, a greater relative intensity, if slight or moderate, may not be a morbid sign ; if, however, the pitch of the sound be higher on the right side, it is a morbid sign, viz., an exaggerated bronchial whisper. These two signs are generally available, and are highly useful in determining the existence and the amount of solidification of lung. 3. Diminished and Suppressed Vocal Resonance. — An effect of certain morbid conditions is either diminution or suppression of the normal vocal resonance. If, therefore, it be apparent that the resonance proper to any part of the chest in health be lessened or absent, evidence is thereby afforded of the existence of some one of the morbid conditions which are known to produce this eff"ect. There being no fixed standard of normal vocal resonance, its diminution, as well as its increase, is determined by a comparison of the two sides of the chest. In the one case, not less than in the other, it is important to take cognizance of the normal disparity existing be- tween the two sides in a large number of individuals, and of the fact that the relatively greater degree of resonance is naturally on the right side. Without due regard to the latter fact, the less amount of resonance on the left side so frequently found in health, might be attributed to disease situated in that side, as well as vice versa. An abnormal disparity between the two sides, provided the greater resonance on one side do not exceed an amount compatible with health, may proceed from a morbid diminution on one side, or from a morbid exaggeration on the other side. In the one case, the disease is seated in the side in which the resonance is relatively less;, 16 242 PHYSICAL EXPLORATION OF THE CHEST. in the other case, the affected side is that on which the resonance is rehitivelj greater. Without the co-operation of other signs, or of symptoms, it wouhl sometimes be difficult to determine, under these circumstances, to which side the disease is to be referred ; but with the information to be derived from other sources, there can hardly be much room for doubt on this score in any instance. The morbid conditions to which diminished vocal resonance is in- cident are certain cases of solidification, obstruction of one of the large bronchi, the presence of abundant liquid effusion, or of air, in the pleural sac. Of these several conditions, in the first, viz., solidi- fication, the normal resonance is diminished, not uniformly, but in a certain proportion of cases only ; the resonance is generally increased. It is in connection with this condition, as has been seen, that exag- gerated vocal resonance and bronchophony occur in the great ma- jority of instances. As exceptions to the rule, however, an opposite effect is sometimes induced. Cavities filled with liquid products may occasion diminution of resonance within a circumscribed space cor- responding to the site of the excavation. Obstruction of one of the large bronchi diminishes the resonance in so far as the column of air within the bronchial tubes takes part in the propagation of vocal sounds, and, perhaps, also, in consequence of the changes induced in the lung in which the circulation of air is cut off. In pleuritis, hy- drothorax, and pneumo-hydrothorax, the diminution of resonance is the rule, and in these affections suppression is often observed. The presence of liquid in the two former affections, and of air together with liquid in the one last mentioned, remove the lung so far from the thoracic walls that the vocal vibrations emanating from the larynx, as well as the respiratory sounds, fail to reach the ear of the auscultator, or, if appreciated, they are feeble. Absence of vocal resonance, and its abnormal diminution, are to be embraced among the signs by which the presence of liquid, or of liquid and air, is to be determined. It is chiefly in these applications that the sign pos- sesses clinical value. 4. Pectoriloquy — Cavernous and Amphoric Voice. — The dis- tinctive characteristic of pectoriloquy, as the name imports, is the transmission, not simply of vocal sound, but speech : the articulate "words are appreciated by the ear applied to the chest. This char- acteristic is sufficient to distinguish it from bronchophony, but, as will be presently seen, in a certain proportion of cases, it may with AUSCULTATION IN DISEASE. 243 propriety be considered as a variety of bronchophony. The type of pectoriloquy is to be found among the phenomena incident to the voice in health. With the stethoscope placed over the trachea or larynx, the ear sometimes receives with distinctness the words enun- ciated by the person examined. In most instances the articulated voice is not perfectly transmitted through the instrument, but heard with more or less indistinctness. The nature of the sign, and its different degrees of completeness, may thus easily be made familiar practically by auscultating the trachea and larynx of different indi- viduals. This sign does not pertain normally to any portion of the chest, but it may be presented in connection with certain morbid conditions, and then constitutes true pectoriloquy, or chest-talking. The intensity with which the words enter the ear may even be greater than when the stethoscope is applied over the larynx or trachea. Laennec regarded pectoriloquy as a pathognomonic sign of a pul- monary cavity. He divided it into three varieties, viz., perfect, im- perfect, and doubtful. In perfect pectoriloquy the transmission of the articulated voice is complete ; in the imperfect variety, the words are indistinctly heard; and when doubtful, it is not distinguishable from bronchophony, save by circumstances other than those pertain- ing to the voice. It is evident that in giving to pectoriloquy this comprehensive scope, Laennec was influenced by the desire mani- fested in other instances to establish for each particular lesion a special physical sign. Taking his own description of doubtful and incomplete pectoriloquy, these varieties are neither more nor less than bronchophony. So far as distinctive characters are concerned, Laennec did not attempt to draw the line of demarcation. Accord- ing to him, bronchophony is, in fact, pectoriloquy, whenever, from its situation, the general symptoms, and the progress of the disease, it may be deemed to proceed from a cavity.^ Observation since the time of Laennec has abundantly disproved the hypothesis of the transmission of speech, even when most complete, being always due to the presence of a cavity; and, at the present time, pectoriloquy, be it never so perfect, has not the significance which it possessed in the estimation of the illustrious founder of auscultation. The physical condition, irrespective of excavation, to which pec- toriloquy is sometimes incident, is solidification of lung, either from 1 Vide Treatise on Diseases of the Chest, etc. Translated by Forbes, page 39, New York edition, 1830. 244 PHYSICAL EXPLORATION OF THE CHEST. inflammatory or tuberculous deposit. Under these circumstances the sign is incidental to bronchophony. The other signs indicative of solidification will be likely to be associated with it, viz., notable dulness on percussion, and the bronchial respiration. In both forms of disease, but more especially in pneumonitis, the pectoriloquy Avill be diffused, i. e., heard over a considerable space. In connection with crude tubercle, the situation in which it is found is at the sum- mit of the chest ; and it is most apt to occur in pneumonitis affect- ing the upper lobe. It is by no means frequently present in the affec- tions just named, but only in a small proportion of cases, dependent, it is probable, on a continuous and uniform density of lung between some of the larger bronchial divisions and the thoracic walls. Cavernous pectoriloquy, however, does occur; that is to say, the sign may proceed from an excavation. But it is perhaps as rarely observed in connection with cavities, as in cases in which the lung is solidified. Tuberculous excavations are sufficiently common, yet it is not often that well-marked pectoriloquy is developed in the progress of phthisis. Its occurrence cannot therefore be counted on as evidence that the disease has advanced to the stage of excava- tion. Occurring at a late period, when it is altogether probable, from our knowledge of the pathological history of phthisis, that a cavity, or cavities, have formed, how are we to determine that it is not caused by the solidification from the presence of crude tubercle which frequently exists in the vicinity of the excavations? The dis- crimination of bronchophonic from cavernous pectoriloquy may be based on a difference in character. If the pectoriloquy be incident to bronchophony, the distinctive features of the latter will be present in addition to the transmission of the speech; that is, the voice will be near the ear and raised in pitch. On the other hand, if the pec- toriloquy be cavernous the bronchophonic features are wanting; the resonance, under these circumstances, may be more or less in- tense, the intensity in some cases being extremely great, without proximity to the ear, and without notable raising of pitch. If the intensity of the resonance be increased, the pectoriloquy is incident to exaggerated vocal resonance instead of bronchophony. Other circumstances which aid in the discrimination, are the limitation of the sign to a circumscribed space, and the association with other signs indicative of excavation, viz., tympanitic or amphoric reso- nance on percussion, or the cracked metal resonance, the cavernous respiration, the cavernous whisper and gurgling. Cavernous pec- AUSCULTATION IN DISEASE. 245 toriloquy requires the conjunction of several conditions. The cavity must be of considerable size. It must communicate freely with the bronchial tubes. It must be free, or nearly so, of liquid. It must be situated near the walls of the chest, and the sign is more likely to be produced if adhesion of the pleural surfaces have taken place over the part of the lung in which it is situated, so that, in addition to the thoracic walls, a thin condensed stratum of pulmonary struc- ture alone intervenes between the exterior of the cavity and the ear of the auscultator. The walls of the cavity must be sufficiently firm not to collapse Avhen it is empty. The space within the excava- tion must not be intersected by parenchymatous bands. The infre- quency with which these several conditions are united, accounts for the absence of the sign, even when cavities exist, and for its being transient or intermittent in cases in which it may be sometimes dis- covered. In by far the greater proportion of the instances in which cav- ernous pectoriloquy occurs, the excavations are due to tuberculous dis- ease. It may, however, be incidental to the cavities resulting from circumscribed gangrene and abscess. But, in addition to the great infrequency of the latter affections, the favorable conditions are less likely to be combined than in tuberculous excavations. In that rare lesion in which a pulmonary cavity is simulated, or rather vir- tually exists, viz., pouchlike dilatation of the bronchial tubes, pec- toriloquy may be marked. The voice resounding in a cavity of considerable size, sometimes assumes a musical intonation, resembling the modification which the vocal sound receives on speaking into an empty vase or pitcher. This constitutes what is called, from the similitude just mentioned, amphoric voice. The character is analogous to that belonging to the respiratory sound to Avhich the same term is applied. It has no special significance beyond denoting the existence of a cavity, but inasmuch as, when it is strongly marked, it probably proceeds from an empty space, whereas pectoriloquy may be due to solidification, it has a positive diagnostic value in the rare instances in which it is heard. It occurs rarely in pulmonary excavations, but frequently in cases of pneurao-hydrothorax with a fistulous communication be- tween the bronchial tubes and the pleural sac. Although a sign of much value, it suffices for all practical purposes to notice it thus in- cidentally and briefly in the present connection. Pectoriloquy does not sustain any constant relation to the inten- 246 PnYSICAL EXPLORATION OF THE CHEST. sity of thoracic resonance and tlie associated thrill, nor is it depen- dent on the loudness of the oral voice. The transmission of whis- pered words is distinguished as ivJiisjyering 2y<'-c^oriloquy, which is regarded by Walshe as highly distinctive of a cavity. My own observations lead me to a diiferent conclusion. I have repeatedly found well-marked whispering pectoriloquy over solidified lung; and, without having analyzed cases with respect to this point,! should say that it is oftener met with in such cases than the transmission of words spoken aloud. This accords with the results obtained by aus- cultation of the voice in health, viz., whispered words are oftener transmitted over the trachea and larynx.^ Pectoriloquy with the whispered, as well as the loud voice, may be either cavernous or bronchophonic. The discrimination may readily be made by atten- tion to the pitch and quality of the vocal sound. If, with the trans- mitted speech, the transmitted voice be high and tubular, the pectoril- oqu}' is bronchophonic; in other words the pectoriloquy is associated with whispering bronchophony. On the other hand, if the vocal sound be low and hollow or blowing, the pectoriloquy is cavernous; that is, the pectoriloquy is incident to the cavernous whisper. The mechanism of pectoriloquy claims but a few words, inasmuch as the physical principles involved are essentially identical with those concerned in the production of bronchophony. Conducted by the air contained within the bronchial tubes and cavity, aided by the bronchial walls and solidified parenchyma, when the intensity of the transmitted speech is considerable, the sound is probably reinforced by reflection from the walls of the excavation, and possibly, also, to some extent, by consonance, according to the theory of Skoda. The amphoric modification of the vocal resonance is probably due to reverberation of sound within the cavity giving rise to a kind of echo. Skoda entertains the opinion that the development of the amphoric voice does not require a free communication betAveen the cavity and the bronchial tubes, but that the necessary sonorous vi- brations may be excited within the former, provided a thin layer of tissue only intervenes. Barth and Roger concur in this opinion. 5. Cavernous Whisper — Amphoric Whisper. — Whispered words frequently cause a sound over pulmonary cavities when the speech is not transmitted. Corresponding with the expiratory ' Vide Auscultation of the Voice in Health, page 146. AUSCULTATION IN DISEASE. 247 sound in the cavernous respiration, its quality is hollow or blowing, as contrasted with the tubular quality, and it is low in pitch. It varies in intensity in diflFerent cases, being sometimes feeble and sometimes tolerably loud. The sign may be called the cavern- ous ivlmiper. The sign occurs under the same conditions which are required for the production of the cavernous respiration, viz. : the superficial situation of the cavity, its emptiness, flaccidity of its walls, and freedom from obstruction of the bronchial tubes leading to it. But as the expiratory effort, when words are whispered, is generally greater than in- respiration, the cavernous whisper is sometimes more available than the cavernous respiration. It is heard within a circumscribed space, and, not infrequently, a cavity being surrounded by solidified lung, the cavernous whisper is ren- dered distinct and marked by its proximity to whispering bronchoph- ony, or an exaggerated bronchial whisper. I have often illustra- ted the cavernous whisper in juxtaposition to the signs of solidi- fication just named, the characters of quality and pitch belonging to the sign, being, under these circumstances, brought into strong relief. An amphoric sound, under the conditions required for the pro- duction of amphoric respiration, is sometimes heard with whispered words more distinctly and in a more marked degree than with res- piration. This may be distinguished as mnphoric whisper. The amphoric sound from pulmonary cavities, and in cases of pneumo- thorax, is more marked with the whispered than with the loud voice, the resonance of the latter and the fremitus tending to obscure the musical intonation. ■ 6. ^GOPHONY. — The modification of the thoracic voice, thus named, has given rise to much discussion respecting its pathological signifi- cance, as well as its mechanism. Limiting the attention almost ex- clusively to the former of these two aspects of the subject, I shall not devote to it extended consideration, especially, as will be admitted by all practical auscultators at the present time, clinically, the sign is among the least important of those furnished by physical explora- tion. The characters by which it is distinguished are well defined and distinctive. Its peculiarities are sufiicient to establish its indi- viduality ; and, when well marked, it is readily recognized. The inferior rank which it holds, results from the infrequency of its oc- currence, its superfluousness in certain of the instances in which it 248 PHYSICAL EXPLORATION OF THE CHEST. is observed, owing to the adcqiiateness of other signs to the diag- nosis, and, according to the opinion of some, the uncertainty which attaches to it as an expression of a particular pathological condition. The essential features which characterize segophony are a treinu- lousness or bleating character of the vocal sound, the pitch being raised above that of the oral or laryngeal voice. With these characters it frequently bears a striking resemblance to the cry of the goat, and this similarity is expressed in the etymology of the word jEo^ophony, which was employed to designate the sign by Laen- nec. In its audible characters, however, it is no by means always uniform. In some instances a sound is produced which w^as com- pared by Laennec to that of the voice transmitted through a metallic speaking-trumpet. Another variety he likens to the peculiar tone of Punch in the puppet-show, produced by speaking in a high key, ■ with the nostrils closed. Hence it is styled by the French, voix iie policliinelle. The force of the last illustration will be less gener- ally appreciated in this country than in France, performances of Punchinello being as rare in the former, as they are common in the latter. A third variety the same author compares to the sound produced when a person attempts to speak with a solid substance between the teeth and lips. It is sufficient to say that the vocal resonance becomes segophonic whenever the sound is bleating, inter- rupted*, or tremulous, and the pitch more or less acute; and that these distinctive traits may be presented in various degrees and pro- portions from strongly marked asgophony, down to the slightest modification in these particulars. The two elements which thus enter into the composition of the gegophonic voice may not be pres- ent in an equal ratio. The sound resulting from their combination is by no means uniform. It may be feeble or strong. The tremu- lousness may be strikingly marked, or just perceptible, with every intermediate shade. The pitch may be slightly or considerably raised. The bleating intonation accompanies the vocal resonance, but the two do not always occur synchronously. The former sometimes succeeds the latter, so that they may be perceived to be distinctly although slightly separated. The segophonic sound, as each word or syllable is pronounced, follows the articulation like an echo. The impression of distance is another feature belonging to segoph- ony ; the sound appears to be somewhat removed, and not produced directly beneath the ear of the auscultator. In addition to the foregoing points pertaining to the audible AUSCULTATION IN DISEASE. 249 characters, other distinctive traits relate to the situation where it is usually heard, the extent of its dijBfusion, etc. ^gophony does not occur indifferently at any part of the thorax. It is found much oftener than elsewhere at or near the inferior angle of the scapula, frequently being limited to a small space, and usually more marked at that situation, when it is more or less diffused. From the point just mentioned, when it is not thus limited, it generally extends, according .to Laennec, and other observers, to the interscapular space, and in a zone from one to three fingers broad, following the line of the ribs toward the nipple. This rule as respects situation is not without exceptions. Fournet states, as the result of numerous observations, that it may exist over the greater part of the lateral and posterior portions of the chest, but never extending to the sum- mit. It has, however, been observed in the infra-clavicular region, and also diffused over nearly the entire chest on one side. It is sometimes found to shift its seat, or to disappear when the position of the patient is changed. The explanation of these facts involves a reference to the physical conditions upon which the sign is dependent^ and will be noticed presently. Its duration is variable, but rarely extending beyond a brief period. The average time of its continu- ance is estimated from five to eight days ;^ but in a case of chronic pleuritis cited by Laennec, it lasted for several months. In the prog- ress of the same disease, viz., pleuritis, it may appear, continue only for a short time, and at a subsequent stage reappear for a brief period. This has been repeatedly observed, but is by no means an invariable rule. During the period of its continuance it is pretty constant, i. e., heard at nearly every examination ; but it is not equally manifested with each act of the voice, or ai-ticulated word. It is more intense at some moments than at others, and may be temporarily suspended by an accumulation of mucus in the bronchial tubes, being repro- duced immediately after coughing and expectoration. Laennec regarded segophony as conclusive evidence of the presence of a certain quantity of liquid within the pleural sac. He asserts that he discovered it in nearly every case of pleurisy that came under his notice during the period of five years. Subsequent obser- vations have abundantly confirmed the fact of its occurrence in con- nection with the pathological condition just mentioned, but in a pro- portion of instances less than was supposed by the founder of aus- 1 Barth and Koger. 250 PHYSICAL EXPLORATION OF THE CHEST. cultation. With the utmost veneration of the memory of Laennec, it must be presumed that, "with reference to aegophony, as in the case of pectoriloquy, a strong desire to invest each sign with a special significance, representing constantly the same anatomical condition, to some extent affected, unconsciously, the accuracy of his observa- tions. This presumption is strengthened by his confession of the difficulty, frequently, of discriminating regophony from bronchoph- ony ; and, also, by the importance which he attaches to pressing the ear very lightly against the stethoscope in seeking for this sign. This method of auscultating suffices often to give to the voice an gegophonic intonation. At all events, it is certain that well-marked jegophony, so far from being constantly or generally present in pleuritis, is a rare physical sign, and there are doubtless many who have had considerable experience in physical exploration without ever having met with a single good example of it. It may be asso- ciated with the presence of liquid of any kind between the pleural surfaces, serum, pus, or possibly even blood ; and it is therefore a sign which may be incident to ordinary pleuritis, the hemorrhagic variety of the disease, empyema, pneumonitis with liquid effusion, and hydrothorax. Even in the time of Laennec, the uniform depend- ence of regophony on the presence of liquid was doubted by some observers, who professed to have discovered it in cases of simple pneumonitis involving solidification of lung without liquid effusion. Skoda rejects entirely the special significance attached to it b}' La- ennec, and declares that he has met with it both in simple pneumon- itis and tubercular infiltration. Such instances, if they exist, are certainly exceptional. Without denying their occurrence, it may be suspected that the presence of a small quantity of liquid, sufficient to occasion this sign, but not abundant enough to give rise to other physical evidences of efi'usion, may be the explanation in some cases. The sharp tremulous character of the oral voice may also account for its occasional apparent manifestation.' Bronchoph- ony, and the normal resonance, assume frequently an regophonic character in the aged of both sexes, but especially in females. Moreover, with reference to this point, a distinction is to be made 1 Normal segophony, due to the character of the oral voice in the aged, will be likely to be present on both sides of the chest. This will serve to distinguish it from the morbid sign which, excepting some rare instances of hydrothorax, is limited to one side. But the character of the oral voice will be apparent. More- over, the other physical signs of pleuritic effusion will be wanting. AUSCULTATION IN DISEASE. 251 between distinctly marked segophony, and a slightly segophonic char- acter of the thoracic voice. The latter may occur as a normal peculiarity, or in connection with solidification of lung, without in- validating the significance which properly belongs to the former. But whether or not well-marked segophony be sometimes incident to solidification of lung alone, this fact must be admitted, viz., of the instances in which it is observed, in all save a few exceptional cases, it is due to liquid effusion. Observation also has sufficiently estab- lished that, in general, it demands for its production, a moderate amount of liquid effusion. Laennec states that he had discovered it in cases in which there did not exist above three or four ounces of fluid in the chest. A quantity sufficient to produce slight com- pression of the lung, interposing a thin stratum between the pul- monary surface of the thoracic parietes, appears to furnish the necessary physical conditions. In the progress of pleuritis, the sign, when it occurs, is found at an early period of the disease. Laennec discovered it, in some instances, within a few hours after the attack, but generally not strongly marked until the second or third day. Where the quantity of effusion increases so as to produce consider- able compression of the lung, removing it at a distance from the greater part of the thoracic walls, the sign almost invariably disap- pears. It continues, therefore, frequently but a short time, perhaps for a few hours only, rarely longer than two or three days. Its limi- tation to a particular juncture in the course of the disease, and its short duration, undoubtedly are reasons why it is not discovered in many cases in which it exists. In some instances it may have occurred and disappeared prior to patients coming under observation. At a subsequent stage of pleuritis, when the quantity of liquid is reduced by absorption to that involving the requisite physical condi- tions, it is sometimes observed a second time, or it may be discovered under these circumstances, when it had not been observed pre- viously. Returning segophony iego2Jho7iie de retour, cegoplionia 7'edux), thus furnishes evidence of the progress of the disease toward restoration. The dependence of the sign on the presence of a cer- tain quantity of liquid, has been demonstrated by its appearance in cases of empyema, in which paracentesis was resorted to, the aegoph- ony, which had not existed prior to the operation in consequence of the large quantity of liquid, becoming developed after a portion had escaped. It has been observed, during the removal of the liquid, to change its place as the quantity lessened, falling lower and lower 252 PHYSICAL EXPLORATION OF THE CHEST. on the surface of the chest, and finally disappearing after the whole of the fluid contents of the chest had been withdrawn.^ The fact of ?egophony being commonly found at a particular situation, viz., at the lower angle of the scapula, and over a narrow space extending from this point in the direction of the ribs to the nipple (the patient being examined in a sitting posture), has led to the supposition that the peculiar modification of the vocal sound is produced at the level of the liquid; in other words, that the zone just mentioned indicates the height on the chest to which the eifusion rises. It is not, how- ever, as has been stated, always limited to the situation described ; and, as remarked by Fournet, it is more probable that the points at which the sign is heard, are those where the stratum of liquid has precisely the requisite thinness, the quantity above being too small, and below too large. This conclusion is sustained by evidence afforded by the percussion and respiratory sounds, found above and below the site of the aegophony. Dulness of the sound on percussion, and diminution of the respiratory murmur, have been observed to be progressively and gradually more marked in descending from a cer- tain distance above the limits of the segophony ; flatness and the absence of respiration existing at the lower part of the chest,^ As exceptions to the general rule, aegophony is occasionally well marked in cases in which the quantity of liquid is quite large, sufficient even to occasion considerable enlargement of the chest. In the rare instances in which ^gophony is heard over the greater portion of the chest on one side, the explanation offered by Laennec is, that, owing to adhesions of the pleural surfaces, at numerous disconnected points, the lung is prevented from being pushed upward before the accumu- lating liquid, which consequently is diffused over the whole pulmo- nary surface, except where the morbid attachments exist, the stratum being uniformly of the requisite thinness. In two instances he veri- fied the correctness of this explanation by the appearances found after death. The shifting of the seat of the jegophony, or its sup- pression, when the position of the patient is varied (a point first observed by M. Reynaud, a contemporary with Laennec), is explained by the change of relation, which takes place between the lung and the surrounding liquid. Assuming that the sign requires an inter- vening stratum of fluid of a certain depth, it is not difficult to conceive that, having been discovered at a particular part while the patient is 1 Earth and Koger, op. cit. p. 202, edition of 1854. 2 Fournet, op. cit. AUSCULTATION IN DISEASE. 253 in the sitting posture, its situation should be found to be movable as the body is inclined to one side or the other, or far forward, in con- sequence of the relative disposition of the liquid being so changed that the locality in which the necessary physical conditions are present, varies. It is also intelligible, that a change of position by which the lung displaces a thin stratum of liquid, and comes into contact with the walls of the chest, as when a patient, after having been examined in the sitting posture, lies on the abdomen, should cause suppression of segophony. These phenomena have been re- peatedly observed, but by no means uniformly in the cases in which eegophony occurs, which accords with the well-known fact, that it is only in a certain proportion of cases that the level of the effused fluid is affected by changes of the position of the patient. In the vast majority of the instances in which aegophony is ob- served, it is incident to simple pleuritis. It is very rarely found in empyema, the quantity of liquid being too large. It may occur in hydrothorax, and be present on both sides of the chest. It has been known, as an anomalous fact, to accompany hydro-pericardium. In pneumonitis the occurrence of well-marked segophony is exceedingly rare ; it is not, however, very uncommon for the thoracic voice to assume some approximation toward eegophony. The sign is, in fact, a variety of bronchophony ; tremulousness, or the bleating charac- ters, being characters superadded to those which belong to bron- chophony. It is not uncommon to have weak bronchophony without the segophonic characters, under the conditions which occasionally give rise to aegophony. The voice, however, under these circum- stances, is not near the ear, but more or less distant. The mechanism of gegophony is a mooted point which it would be unprofitable to discuss, and I shall give to this branch of the subject but a few words. Laennec attributed the tremulousness of the voice to the agitation of the liquid by the act of speaking. It may be conceived that the vocal sound transmitted through a stratum of fluid under these circumstances, would acquire a corresponding vibratory character. Whether this explanation be correct or not, none other more satisfactory has been ofi'ered. The other segophonic element, viz., the elevation of pitch, Laennec accounted for by supposing that the bronchial tubes, flattened by the compression of the liquid, are made to resemble the mouthpiece of certain musical instruments, like the bassoon or hautboy, and that the modification of tone was due to this condition. This theory is generally deemed unsatisfac- 254 PHYSICAL EXPLORATION OF THE CHEST. tory ; but of the various substitutes that have been proposed, no one has sufficiently commended itself to be generally adopted. As re- gards the pitch of the sound, it seems to me sufficient to attribute it to a limited extent of condensation of lung near the level of the liquid, the condensation being due to the pressure of the liquid. In so far, the sign is essentially bronchophony, except that the pres- ence of liquid renders the voice distant as compared with ordinary bronchophony. Here, however, as in other instances in which the physical principles involved in the mechanism of signs are unde- termined, the question is one of speculative rather than practical interest. In conclusion, from the facts contained in the foregoing account of segophony, its claims to be recognized as a veritable individual sign appear to me to be not less valid than those of pectoriloquy. Like the latter sign, it has distinctive traits, by which, when well- marked, it is distinguished without difficulty from other signs. Moreover, notwithstanding the opinion of Skoda to the contrary, it has a positive significance, indicating, certainly in the vast majority of the cases in which it is observed, a special pathological condition, viz., a certain amount of liquid effusion between the pleural surfaces. Nevertheless, as stated at the outset, in view of the infrequency of its occurrence in connection with the pathological condition which it represents when it does occur, its brief duration, and, in general, the sufficiency of other physical signs denoting pleuritic effusion, its clinical value is comparatively small, and it might, without much detriment to physical diagnosis, be dropped from the catalogue of signs. It is to be classed among the curiosities of physical explora- tion, rather than among the phenomena possessing much practical importance. In connection with the phenomena incident to the voice, may be mentioned a novel'method of exploration proposed by M. Hourmann, in which the auscultator observes the effect of his own voice on the chest of the patient. With the ear placed in apposition to the chest, but not pressed too firmly against it, more or less resonance and vibration are perceived, when words are pronounced with a loud voice, and in a manner to secure reverberation through the nasal passages. To this method M. Hourmann applies the title aiitophonia} Whatever clinical value attaches to autophonic phenomena, of course 1 From ni/rU, and <^a)v'ut. AUSCULTATION IN DISEASE. 255 depends on certain modifications representing certain morbid con- ditions. It is alleged that when the density of the lung is abnor- mally increased, the resonance and vibration communicated to the • thoracic walls are proportionally exaggerated, and hence a disparity between the two sides of the chest in this respect belongs among the signs of solidification from pneumonia, crude tubercle, &c. Barth and Roger state, as the results of a series of clinical observa- tions made with a view to determine the value of this method, that in about one-half of the instances in which solidification existed, either from the presence of tubercle or inflammatory exudation, the autophonic phenomena were more marked ; in the other half no ap- preciable difference existing between the healthy and diseased sides ; and that, in general, in the cases in which a disparity was apparent, it was slight in degree, being sometimes not appreciable without the closest comparison. In no instance did the sound present any spe- cial character which might indicate something more than the fact of increased density of the lung. The information to be derived from this method, therefore, corresponds to bronchophony ; and it may be occasionally useful when the voice of the patient is lost. Except in cases of aphonia, it seems hardly deserving of attention ; and under any circumstances, its value consists in the confirmation which it may afford of other auscultatory signs far more reliable. SuMMAR"^ OF Facts pertaining to Vocal Signs. — The normal thoracic resonance of the loud voice, in connection with certain morbid conditions, may be increased or diminished, and the reso- nance of both the loud and whispered voice may present abnormal phenomena as regards quality, pitch, etc., of sound. The various deviations from health constitute the following signs: exagger- ated vocal resonance, and bronchophony; exaggerated bronchial whisper, and whispering bronchophony; diminished and suppressed vocal resonance ; pectoriloquy, including amphoric voice, cavernous and amphoric whisper, and segophony. In exaggerated vocal reso- nance, the diffused, distant resounding of the voice, accompanied with more or less vibration or thrill, which constitutes the normal vocal resonance, is increased in intensity, without any notable alter- ation in other respects. Bronchophony is characterized by an ab- normal concentration and elevation of the pitch of the vocal sound, the voice seeming to be near the ear. The vocal resonance may be slightly, moderately, considerably, or greatly exaggerated. Bron- 256 PHYSICAL EXPLORATION OF THE CHEST. chophony, also, may be more or less marked. If slightly or mod- erately marked it is called weak, and if it have considerable or great intensity, it is called strong bronchophony. Strong bron- chophony may exceed in intensity the sound heard over the trachea or larynx; on the other hand, in weak bronchophony the reso- nance may be less intense than in health. The pitch of sound is not always the same as that of the tracheal or laryngeal voice* The vibration or thrill which generally accompanies exaggerated res- onance, is not necessarily increased in proportion to the abnormal strength of the bronchophonic voice, and it may be diminished. Exaggerated vocal resonance habitually exists on the right, con- trasted with the left side of the chest, and the thoracic voice at the summit of the right side of the chest, in front, may even be bron- chophonic without denoting disease. Exaggerated vocal resonance and bronchophony, represent different degrees of increased density of lung. They occur in connection with the physical conditions Avhich give rise to the broncho-vesicular and the bronchial respiration. They are generally marked in the second stage of pneumonitis, and it is in that disease especially that strong bronchophony is observed. Situated at the summit of the chest on one side within a circum- scribed area, making due allowance for a normal degree of disparity, they are valuable signs of a tuberculous deposit. Increased density of lung from compression, in cases of pleurisy with liquid effusion, may give rise to these signs, situated over a part of the chest cor- responding to the space occupied by the condensed pulmonary struc- ture; and this situation, save in some exceptional instances, will be at the superior part of the chest. Exaggerated vocal resonance may also, in connection with other signs, together with symptoms, denote carcinoma of the lung, melanotic deposit, extravasated blood or apoplexy, gangrene, serous infiltration, or extra-pulmonic morbid growths. It is rare that well-marked bronchophony exists in connection with these several affections. Dilatation of the bronchi, accompanied with surrounding solidification, furnishes conditions cal- culated to give rise to strongly marked bronchophony. Slight or moderate solidification of lung increases the intensity of the normal bronchial whisper, and may give rise to a sound with whispered words in situations in which no sound is appreciable in health. The sound is also somewhat tubular in quality and higher in pitch than the normal bronchial whisper. This sign of slight or moderate solidification of lung may be called the exaggerated bron- AUSCULTATION IN DISEASE. 257 chial whisper. It may be present when exaggerated resonance of the loud voice and the broncho-vesicular respiration are not avail- able. It is a valuable sign in the diagnosis of a small or moderate deposit of tubercle. Complete or considerable solidification of lung generally gives rise to notable intensity of the bronchial whisper, which is also tubular and high in pitch. This sign may be called whispering bronchophony. Diminution and suppression of the normal vocal resonance are incident to the rarefaction of the lung which obtains in emphysema; to obstruction of one of the large bronchi; to liquid effusion, and the presence of air within the pleural sac ; to cavities filled with liquid; and, exceptionally, to solidification of lung. Pectoriloquy is the transmission, more or less complete, of ar- ticulate words through the chest to the ear of the auscultator. This sign may be present, when various circumstances favorable to its production concur, in cases of pulmonary cavities; but it is by no means a sign distinctive of an excavation, as was held by Laennec. It is sometimes well marked in cases of solidification of lung in the second stage of pneumonitis, and from crude tubercle. When due to a tuberculous cavity, it is unaccompanied by the characters of broncho- phony, the space in which it is heard is circumscribed, situated, in the vast majority of cases, at the summit of the chest, and it may be asso- ciated with the cavernous respiration and rales. In connection with pulmonary cavities arising from abscess or circumscribed gangrene it is seldom present, the several circumstances necessary for its pro- duction rarely concurring. It is not always heard, even when tuber- culous cavities exist, the various conditions upon which it depends being either permanently wanting, or only transiently present. A cavernous voice sometimes has a musical tone resembling the sound produced by speaking into an empty vase. It is then called amphoric. This modification is noticed, for the sake of convenience as incidental to pectoriloquy, but it may or may not coexist with transmission of speech. It is a sign distinct from pectoriloquy, and is much more significant of a cavity than the latter. The transmis- sion of articulated words, or pectoriloquy, does not sustain any fixed relation to the amount of thoracic resonance, or to the strength of the oral voice. It may be strongly marked when the voice is feeble and even extinguished. Whispering pectoriloquy may accompany solidification of lung, as well as an excavation ; in the former case the voice is high and tubular, in the latter case, low and hollow or 17 258 PHYSICAL EXPLORATIOy OF THE CHEST. blowing. An amphoric vocal sound is more apt to occur in pneumo- hydrothorax, than in tuberculous excavations. It may be well marked in pouch-like dilatation of the bronchi, a lesion of very rare occurrence. Cavernous whisper is a non-tubular, hollow, or blowing sound, low in pitch, and of variable intensity, heard over pulmonary cavi- ties. It is a valuable sign for determining the existence of, and local- izing a tuberculous cavity. An amphoric whisper is frequent in cases of pneumothorax ; if heard within a circumscribed space, and pneumothorax be excluded, it is a sign of a tuberculous cavity. ^gophony is characterized by bleating or tremulo.usness, together with a high pitch of the thoracic voice. These characters are some- times due to peculiarities of the oral voice, and care is necessary to avoid attributing them to morbid conditions under these circum- stances. Morbid segophony may be strongly marked, or the thoracic voice may be slightly segophonic, and the abnormal modifications may have every shade of gradation between these extremes. It is most apt to be heard at or near the lower angle of the scapula, and if it extend from this point, it is generally found within a narrow zone following the direction of the ribs toward the nipple. It may, how- ever, be heard at any part of the chest, and is sometimes diffused over the whole side. It occurs when a small or moderate amount of liquid effusion is contained within the pleural sac. It is therefore incident to pleuritis, hydrothorax, and occasionally to empyema and pneumonitis. If it be sometimes observed in connection with solidi- fication, without liquid effusion, as held by some, these instances are rare exceptions to the general rule. In the vast proportion of the instances in which it is observed, it is incident to simple pleuritis ; but it is seldom discovered even in that affection, owing to the precise amount of liquid requisite for its production existing only in certain cases, and in these only for a brief period. When discoverable it is usually at an early period after the attack, or late in the progress of the disease. Occurring in connection with pneumonitis, it has been observed to disappear from the lower scapular region when the body is inclined far forward, and to be replaced by ordinary bron- chophony. Although very rarely well marked in cases of pneumo- nitis, it is not uncommon for the bronchophonic voice, in that affec- tion, to present slight tremulousness with elevation of pitch, in other words to manifest an approximation to ?egophony. In cases of pleuritis the sign has been observed to shift its seat in the prog- AUSCULTATION IN DISEASE. 259 ress of the disease, following the increase, on the one hand, and the diminution on the other hand, of the quantity of liquid effusion. PHENOMENA INCIDENT TO THE ACT OF COUGHING. Tussive phenomena possess comparatively small importance, inas- much as the information which they afford is, in general, obtained more satisfactorily, and with greater facility, by auscultation of the respiration and voice. !N^evertheless, the signs pertaining to cough are by no means undeserving of attention, and in some instances they are valuable auxiliaries in diagnosis. A voluntary act of coughing is often useful incidentally with reference to other signs. Sometimes, when from nervous agitation, or awkwardness, a patient breathes unnaturally and fails to comply with the directions to in- crease the intensity of the respiration, if requested to cough he in- voluntarily takes a deep inspiration preparatory to, and after the act, and the respiratory murmur may then be well developed, when before it was hardly appreciable. In this way a crepitant rale may perhaps be evolved, not otherwise perceptible. By an act of cough- ing, an obstruction seated in some of the bronchial tubes may be removed, and the respiratory murmur reproduced in parts of the chest in which it had been temporarily suspended. The cause of the absence of the murmur is thus determined. Instances occasion- ally occur in which it is diflBcult to decide from the characters per- taining to the sound whether a rale emanates from the bronchial tubes or pleura. In such a case, if it be found to disappear or undergo a material modification after coughing, it is bronchial, but if it remain unaffected it is likely to be pleural. The tussive sounds incident to health have been briefly described. Those heard over the chest undergo certain modifications in conse- quence of intra-thoracic disease, and certain adventitious sounds may also be produced by coughing. Both species of signs, i. e. modified natural sounds, and new sounds, are few in number com- pared with those derived from respiration and the voice ; moreover, each of the tussive signs will be found to have its analogue among those incident to respiration. All the phenomena incident to the act of coughing which are practically important, may be arranged into two classes, viz., 1. Bronchial Cough ; 2. Cavernous Cough. 260 PHYSICAL EXPLORATION OF THE CHEST. 1. Bronchial Cough. — The tussive sound is bronchial or tubular, when, in place of the feeble, short, diffused sound, unaccompanied by much, if any, impulse or shock, heard over the chest in health, the ear receives a concussion more or less forcible, together with a tubular sound, more or less intense, prolonged, concentrated, high in pitch, conveying the impression of nearness. These characters are similar to those which belong to the phenomena produced nor- mally within the trachea by the act of coughing. The analogue of the bronchial or tubular cough is the bronchial respiration, and the loud voice is usually more or less bronchophonic. The characters which have just been mentioned are in fact identical with those which belono- to the expiratory sound in the bronchial respiration and they are also the characters of whispering bronchophony. They may be strongly marked in some cases in which bronchial respiration is feeble, and hence the tussive sign may be valuable, not only as con- firming, but as a substitute for the latter. It represents precisely the same physical conditions as the bronchial respiration and bron- chophony. The bronchial cough, therefore, occurs especially in the second stage of pneumonitis; next in frequency and prominence, in connection with crude tubercle ; also in pleuritis, over the lung ren- dered dense by compression, in apoplectic extravasation, oedema, dilatation of the bronchial tubes, etc. The mechanism of its pro- duction involves the same physical principles as the bronchial expi- ratory sound. It originates within the trachea and bronchial tubes; the column of air therein contained being expelled with force by the violent and quick expiration, the vocal chords at the same time ap- proximated, and the blowing sound transmitted with greater intensity to the ear of the auscultator in consequence of the density of the intervening pulmonary structure and the suppression of the vesicular murmur. 2. Cavernous Cough. — The cavernous cough embraces three distinct varieties. The first occurs when a pulmonary cavity is empty, i. e. free from liquid contents. Under these circumstances the act of coughing gives rise to a shock, often much more marked than in bronchial cough. The head of the auscultator seems some- times to be raised by the force of the impulse. It is accompanied by a blowing sound more or less intense and prolonged, lower in pitch than the expiratory sound in bronchial respiration, or the tubular sound accompanying whispered words ; and conveying the AUSCULTATION IN DISEASE. 261 impression of its being produced within a hollow space. These characters, contrasted with those belonging to the bronchial cough, are distinctive; but the discrimination involves, in addition, the fact that they are found within circumscribed limits ; and, inasmuch as pulmonary excavations are due to tuberculous disease, in the vast majority of cases they are almost invariably situated at the summit of the chest, in the infra-clavicular region. These two points, viz., the limited area and the locality, will serve to distinguish a cavern- ous from a bronchial blowing, taken in connection with the differences in the characters of the two sounds. The pathological significance of this variety of cavernous cough is, of course, the same as that of cavernous respiration : the latter is its analogue. The one may be well marked, when the other is not distinctly appreciable. A cavern- ous blowing produced by the act of coughing may, therefore, some- times be available, when with ordinary respiration it is not readily discovered. If both are present, they serve mutually to confirm each other. The mechanism, it is obvious, is the same in either in- stance. The circumstances which are favorable to the presence of both are identical, viz., in addition to emptiness of the cavity, its size, communication with the bronchial tubes, the latter being unob- structed, superficial situation, etc. The second variety is amphoric cough. A cavernous cough be- comes amphoric when it has a musical tone resembling that which constitutes a variety of the respiratory and vocal sounds to which the same term is applied. It occurs under the circumstances which give rise to amphoric voice, viz., in connection with a pulmonary cavity of large size, with rigid walls, or with pneumo-hydrothorax involving perforation. The significance and the mechanism are in all respects the same. The third variety is an adventitious sound produced when the cavity is partially filled with liquid. The analogue of this kind of cavernous cough is the gurgling rale accompanying respiration. Under the conditions which are necessary for the production of gurgling, the liquid contained within the cavity is more violently agitated by the movements involved in coughing, and a splashing sound is frequently produced. This sound, well marked, is more readily than gurgling distinguished from the bronchial mucous rales, and if situated at the summit of the chest, within a circumscribed area, it is the most significant of the physical signs denoting a tu- berculous cavity of considerable size. It will be likely to alternate 262 PHYSICAL EXPLORATION OF THE CHEST. ■with the dry variety of cavernous cough, with cavernous respiration, possibly also with pectoriloquy, and to coexist with gurgling; but it may be present when none of the cavernous signs just mentioned are distinctly marked. METALLIC TINKLING. The sign called metallic tinkling has not been included among the auscultatory phenomena incident to respiration, the voice, or cough, because it does not pertain exclusively to either, but is common to all. It is an adventitious sound, resembling the rales in the fact of its production within the chest being always due to disease, but as will be seen presently, an analogous sound is sometimes transmitted from the stomach. As an isolated sign it is one of the very few that possess a significance almost pathognomonic ; and its distinc- tive characters are singularly marked and appreciable. The title metallic tinkling is eminently descriptive of the charac- teristic sound. Laennec compared it to the sound emitted by "a cup of metal, glass, or porcelain, when gently struck with a pin, or into Avhich a grain of sand was dropped ;" and, again, to the "vibra- tion of a metallic wire touched by the finger." Other illustrations employed by different writers, are the tinkling of a small bell ; shak- ing a pin in a decanter; dropping small shot into a brass basin; the ebullition of fluid in a glass retort or flask. An apt comparison by Dr. Bigelow is to the "note of short brass wire in certain children's toys." In all these analogies there is a common feature, viz., a high-pitched, abrupt, short, silvery tone. There is no difiiculty in practically de- termining the presence of the sign; and by a description alone an observer is prepared to recognize it at once, the first time it is pre- sented to his notice. The tinkling may consist of a single sound, or, more commonly, of two, three, or more sounds, distinct, and fol- lowing in quick but irregular succession. As already stated, the sign may accompany respiration, speaking, and coughing. It is oftener produced by the two latter than by the first, and more espe- cially attends the act of coughing. The act of deglutition may also occasion it. This fact was first noticed by Dr. Charles T. Hild- reth, of Boston,^ in 1841. It has since been confirmed by other ob- 1 Vide Descriptive Catalogue of the Anatomical Museum of the Boston Society for Medical Improvement, page 124. AUSCULTATION IN DISEASE. 263 servers. Beau reported a case in which it was produced by the con- cussion arising from the heart's action, and this I have observed. Succussion, or shaking the body of the patient, is also found in many cases to give rise to it, and it is sometimes observed to occur in conse- quence of a change of position, from the horizontal to the vertical. When it accompanies respiration, it is more apt to be produced by the inspiratory than the expiratory act, although it may be present with either, or both. It occurs at the close of inspiration, the tink- ling sounds frequently being continued into the expiration. Some- times when it is not heard with ordinary breathing, it becomes devel- oped by a forced inspiration. It rarely accompanies each successive act of respiration, but it is heard at irregular intervals. It is impor- tant to bear in mind the fact that it may be found in connection with the voice and cough when it does not attend the respiration; and that it may be produced by coughing, when it is not observed either with the voice or respiration. Its situation is commonly at the mid- dle third of the chest, anteriorly, posteriorly, or laterally. It is sometimes confined to a circumscribed space at the summit. In other instances it is diffused over the entire chest on one side. In the prog- ress of the same disease it may be found to shift its seat, being heard at first over the middle of the chest, and afterward at a higher point. Its duration in dijBTerent cases differs. It may be transient, or per- sist for a long time. In constancy it is also variable. Sometimes it appears, ceases for a time, and it is again reproduced ; or, it comes and goes at irregular intervals. The sound in some instances ap- pears to be near the ear, and in other instances more or less remote. Finally, in sharpness and quality of tone, as well as intensity, there are variations which are clinically unimportant. For the most part the differences just mentioned are explicable by reference to varjnng circumstances connected with the physical conditions upon which the sign is dependent. In determining the presence of the sign, there is scarcely a possi- bility of confounding it with any other of the auscultatory phe- nomena. The only liability to error arises from the fact that a me- tallic tinkling sound, as already intimated, is occasionally produced within the stomach, and transmitted, so as to be apparent on auscul- tating the inferior portion of the left chest. Mere gastric tinklings, however, are never so frequently repeated or persisting as are gen- erally those produced within the chest. They occur irrespective of either respiration, voice, or cough, and this alone sufiices for the dis- 264 PHYSICAL EXPLORATION OF THE CHEST. crimination. Moreover, the associated signs and symptoms Avill always show the absence of the intra-thoracic affections to which it is incident when produced within the chest. The physical conditions involved in the production of metallic tinkling are sufficiently established. It requires the existence of a cavity of considerable size, containing a certain quantity of liquid, the remainder of the space being filled with air or gas. Skoda con- tends that the presence of liquid is not essential — an opinion he is in a measure bound to entertain for the sake of consistency with his peculiar theoretical notions respecting the mechanism by which the sign is produced. Observation and experiment appear to show that as the rule, with, perhaps, some exceptions, a certain amount of liquid is requisite. Laennec supposed communication of the cavity with a bronchial tube to be not a necessary condition, as is incorrectly stated by some writers, but to exist in the cases in which the sign is present, with very rare exceptions.' Subsequent observations have shown that it is not indispensable, although much more favor- able to its production by respiration, speaking, and coughing ; and, in fact, as stated by Laennec, the instances in which the sign occurs, when such a communication does not exist, are extremely infrequent. The essential conditions, viz., the existence of a space of consider- able size containing air and liquid, are furnished in pneumo-hydro- thorax and pulmonary excavations. Metallic tinkling represents invariably one of these two affections, excluding cases of simple pneumothorax as a form of disease of such exceeding infrequency that it may practically be disregarded. It does not occur in other forms of intra-thoracic disease. It is a rare incidental sign of a pulmonary cavity. It occurs when the excavation is large, with rigid walls, and then only at particular times, when the relative pro- portions of liquid and air happen to be favorable. From the infre- quency of its occurrence, and the sufficiency of other signs for the diagnosis, it is clinically of very little value in connection with this lesion. When produced within a pulmonary excavation, the latter, certainly, in the vast majority of cases, if not without any exception, proceeds from tuberculous disease ; hence, the sound will be found confined within a circumscribed space at the summit of the chest. In a practical point of view, it may almost be said that the sign is pathognomonic of pneumo-hydrothorax. It is frequently present in 1 Vide op. cit., Am. ed. of Forbes 's Translation, edition of 1830, pages 526 and GO. AUSCULTATION IN DISEASE. 265 cases of that affection. This fsict, taken in connection Avith its ex- treme infrequency in phthisis, would almost justify the practitioner in predicating the diagnosis upon the presence of this isolated sign, especially if it be situated at the middle third, or diffused more or less over the chest. But dependence on this sign exclusively is never necessary, the concomitant signs, denoting pneumo-hydrotho- rax, being quite distinctive, as has appeared from the phenomena incident to percussion and auscultation, which have already been considered. Although the physical conditions giving rise to this sign are so well understood, and its pathological significance so precise and well defined, the mechanism of its production has been the subject of much discussion and diversity of opinion. We have here, however, another exemplification of the fact, that the clinical value of physi- cal signs is not dependent on our ability to adduce all the physical principles which their production involves. Different writers may differ widely as respects the latter, but there is very little room for discrepancy of opinion concerning the pathological or anatomical relations of metallic tinkling. To discuss the various hypotheses which have been offered in explanation of the sign, would require more space than the importance of the subject, in a practical point of view, merits, and I shall therefore restrict myself to a brief notice of those which appear to be sustained by observation and experiment. Laennec attributed its production, in certain instances, to drops of fluid falling from the upper part of the space, upon the surface of the liquid below. He offers this explanation in the cases in Avhich the sound is observed to follow change from the recumbent to a sitting posture, and implies that it is not intended to apply to all other instances. That the falling of drops of liquid upon a quantity of liquid within a cavity will give rise to a tinkling sound, he demonstrated by inject- ing, in small quantities at a time, a fluid into the chest of a patient with empyema after the operation of paracentesis. An imitation of the sound takes place, when drops of liquid are made to fall into a vessel one-third full of water. Another explanation, suggested by Dr. Spittal, of Edinburgh, in 1830, and demonstrated by experi- ments reported by Dr. Jacob Bigelow, of Boston,^ Dance, Fournet, and Barth and Roger, in France,^ is, that the air, finding its way 1 Vide American Journal of Mod. Sciences, 1839, and a recent volume by Dr. Bigelow, entitled, Nature in Disease, etc. 2 Vide Treatises by Barth and Eoger, French edition of 1854, and by Fournet. 266 PHYSICAL EXPLORATION OF THE CHEST. through a fistulous orifice opening below the level of the liquid, rises to the surface of the latter, forming bubbles, which break and give rise to a tinkling sound. The experiments by Dr. Bigelow were made on the bodies of subjects dead with pneumo-hydrothorax, and with a recent bladder or stomach partially filled with liquid. When a catheter was introduced through an opening into the chest, and carried below the surface of the liquid, air blown through the instrument produced an exquisite metallic tinkling at the explosion of each bubble, resembling the sound heard during life. This result obtained only when a few ounces of liquid were contained wdthin the chest. If the quantity was increased by injection to the amount of two or more quarts, a bubbling sound was alone produced. Tink- ling also was produced by repeating Laennec's experiment, viz., let- ting fall drops of water from above upon the liquid in the chest. A bladder, and afterward a stomach, each containing a few ounces of water, and then inflated until thoroughly distended, were used to produce an imitation of the characteristic sound by a similar method.' "Whenever the inflating tube was pushed below the surface of the liquid, and the inflation continued so as to produce bubbles, a sharp tinkling was heard upon the explosion of every bubble by the ear applied, as in auscultating, to the outside of the bladder. In this experiment, the sound becomes more exquisitely metallic in proportion as the tension of the bladder is increased by farther inflation." Fournet produced similar results by injecting, during life, in a patient on whom had been performed the operation of paracentesis, air through a female catheter carried below the level of the liquid. This experiment was repeated several times. ^ Barth and Roger, on repeating the experiments made by Dr. Bigelow with a bladder, found the same results.^ This explanation, it is obvious, will only apply to the instances in which a communication exists be- tween the cavity and the bronchial tubes, or externally by means of an opening through the thoracic walls. Simple agitation of the liquid is competent to give rise to the sound. This is proved by succussion of the body of patients with pneumo-hydrothorax, both during life and after death.* A sufiicient amount of agitation, it may be imagined, takes place with respiration, but more especially with the acts of speaking and coughing. Again, experiments ap- 1 The bladder or stomach employed in these experiments should be recent. 2 Op. cit., t. 1, page 378, et seq. » Op. cit., ed. of 1854, page 239.- * Vide Dr. Bigelow's experiments, op. cit. AUSCULTATION IN DISEASE. 267 pear to show that the bursting of bubbles of mucus at the opening of a fistulous orifice situated above the level of the liquid, may oc- casion a sound resembling, but not absolutely identical with, metal- lic tinkling.^ Without citing other explanations, less satisfactorily established, the mechanism of the sign probably involves the several modes just mentioned, alternating with each other, or more or less combined together.^ Either explanation, taken singly, is met by objections derived from instances in which the sign is observed to take place ; but collectively, they render its production intelligible under the different circumstances pertaining to the physical condi- tions upon which it depends. Adopting this view of the subject, a frequent, perhaps the most frequent, cause of the phenomenon, is the explosion of bubbles of air on the surface of the liquid. In the rare instances in which no communication exists between the pleural cavity and the bronchial tubes, it is probably due to the agitation of the liquid, portions being thrown upward and falling back upon the surface. Under these circumstances, the sign will not be likely to accompany respiration, but only the voice and coughing, possibly being confined to the latter act. In this mode it is produced by change of position, or movements of the body. It is not difficult to conceive that the flocculent false membranes at the superior part of the space, may retain a small quantity of the liquid for a short period, after rising from the horizontal to the upright posture, which falls in drops, as supposed by Laennec. If there be fistulous com- munication with the bronchial tubes, and the opening be above the level of the liquid, the sound is probably owing to the bursting of bubbles at the orifice opening into the cavity. Different modes of the production of metallic tinkling may be conjoined, i. e., may operate in combination. Thus the sounds due to explosive bubbles and agitation of the liquid may occur simultaneously. It is also easy to understand that they may succeed each other in alternation. For instance, the orifice may at one time be above, and at another time below the level of the liquid, owing to variations in the pro- 1 Vide experiments by Bigelow, Fournet, and Earth and Koger. 2 The reader who may desire a fuller account of the experimental researches which have been made in order to elucidate the mechanism of the production of metallic tinkling, will find them detailed at length by the several authors referred to. I have deemed it inconsistent with the practical objects of this work to yield the space which their introduction at length would require. Skoda attempts to account for the sign by his favorite theory of consonance, but its application in this instance is even less satisfactory than to the explanation of other auscultatory phenomena. 268 PHYSICAL EXPLORATION OF THE CHEST. portionate quantity of the latter. The orifice, also, of the bron- chial tubes leading thereto, may at times be obstructed, and at other times pervious; an aperture may at one period of the disease exist, and afterward become permanently closed. These varying circum- stances will serve to explain the variations in quality, intensity, sit- uation, duration, persistency, etc., which have been seen to enter into the description of metallic tinkling. Metallic tinkling is frequently associated with amphoric respira- tion, voice, and cough, and it may be considered as essentially simi- lar to the three signs last mentioned. The pathological and diag- nostic relations are the same. Metallic tinkling, however, with few exceptions, occurs in cavities containing at the same time air and liquid. It is, indeed, possible that in one of the modes by which it is supposed to be produced, viz., by bubbles exploding at the open- ing of a fistulous communication, the presence of liquid within the cavity is not indispensable; but a fistulous communication, either with a pulmonary excavation or the pleural cavity, more especially with the latter, very rarely exists without the presence of more or less liquid ; and, moreover, in the case just instanced, a mucous liquid is required for the formation of the bubbles which explode at the point of communication. Amphoric respiration, cough, and voice, on the other hand, it is supposed, may occur in connection with empty cavities without bronchial communication, provided a thin septum only intervene between the space and a large bronchia. And when, as is generally the case, a communication exists, and liquid is present in the cavity, the latter does not take part in the production of amphoric respiration, voice, and cough ; whereas, certainly in a large proportion of instances, the liquid plays an im- portant part in the production of metallic tinkling. Amphoric res- piration, voice, and cough, demand only a space of considerable size filled with air. Metallic tinkling, occasioned, as has been seen, gen- erally by bubbles rising to the surface of a liquid, or by drops of liquid falling, or by agitation of a mass of liquid, cannot take place, save in the exceptional mode mentioned, in a cavity containing noth- ing but air. These statements are shown to be correct by facts de- tailed in connection with the experiments by Bigelow and others, to which reference has just been made. In subjects dead with pneumo- hydrothorax, or patients on whom had been practised the opera- tion of paracentesis, and with a recent bladder or stomach partially filled with liquid, whenever air was blown through a tube, introduced AUSCULTATION IN DISEASE. 269 into the cavity and carried above the level of the liquid, a sound analogous to the amphoric respiration was heard on applying the ear to the chest, or to the distended membrane ; and never the me- tallic tinkling, excepting saliva was carried into the tube, producing bubbles at its extremity. Summary. — Metallic tinkling requires, as a rule, a cavity of con- siderable size containing air and a certain quantity of liquid. In the vast proportion of cases the cavity in which it occurs communi- cates with the bronchial tubes. It is occasionally produced within tuberculous excavations, but occurs in a large proportion of cases of pneumo-hydrothorax. It is almost pathognomonic of the latter af- fection, and is found frequently to coexist or alternate with ampho- ric respiration, voice, and cough. ABNORMAL TRANSMISSION OF THE SOUNDS OF THE HEART. In auscultating the chest in health, the sounds of the heart may be heard in all directions, at a distance more or less remote from the prgecordial region, the extent of their diffusion and their in- tensity differing considerably in different persons. Provided the intra-thoracic organs are free from disease, it may be assumed that the loudness of the heart-sounds is proportionate to the proximity to the heart; and they will be found to diminish gradually, as the ear is removed from the praecordia, until, at length, they cease to be appreciable. If, therefore, they are discovered to be more in- tense at a certain distance, than at any intermediate point, it shows that a morbid condition exists, in consequence of which they are abnormally transmitted. For example, if the sounds are heard with greater distinctness and loudness just below the left clavicle, than at any point between this situation and the praecordia, it follows that there is an abnormal transmission to the part designated. Again, if the sounds have greater intensity in the right than the left infra- clavicular region, the former being farther removed from their source, it is due to a morbid condition. Abnormal transmission of the sounds of the heart may thus become a sign of disease. It is chiefly with reference to the diagnosis of tuberculous disease, that the sign pos- sesses clinical value. In that connection it is worthy of attention. 270 PHYSICAL EXPLORATION OP THE CHEST. The deposit of tubercle renders the portion of lung affected a bet- ter conductor of the sounds emanating from the heart. Another reason why the heart-sounds are louder over a deposit, in certain cases, is the diminution or suppression of the vesicular respiratory murmur in the part affected. A tuberculous deposit at the apex of the left lung may occasion an abnormal transmission to below the left clavicle, rendering the sounds more intense there than at any point between this situation and the prsecordia, and even more in- tense than in the latter region. Again, a tuberculous deposit at the apex of the right lung, may cause the sounds to be heard with distinctness in the right infra-clavicular or scapular regions, when they are inappreciable in the corresponding regions on the left side; or they may be decidedly more intense at the summit of the right, than of the left side of the chest. The latter is not infrequently observed in cases of tuberculous disease. The sign, under these circumstances, furnishes strong presumptive evidence in itself, of the existence of phthisis ; and it is entitled to considerable weight in combination with the various other signs Avhich concur to establish the diagnosis of that affection. To constitute this a sign of tuber- culosis, however, a condition is to be observed upon which we have seen to depend the significance of various other signs, viz., it must be limited to a circumscribed area at the summit of the chest. In comparing the heart-sounds in the right and the left infra- clavicular region, normal points of disparity are to be borne in mind. The first sound of the heart is somewhat louder on the left than on the right side in health ; and the second sound of the heart is louder on the right than on the left side. This statement is based on a large number of examinations of healthy persons. In consolidation from pneumonitis, and in cases of liquid effusion within the pleural sac, the sounds of the heart are unduly audible. In connection with these affections, the abnormal transmission ex- tends over a much larger space than in the cases of tuberculosis in which the sign occurs. In the diagnosis of these affections its value is insignificant, other signs being abundant and positive. Observed within a more limited space, but not confined to the superior portion of the chest, this sign may coexist with others of much greater reliability, denoting solidification from extravasated blood, carcinoma, etc. An abnormal diminution, as well as increase of the transmitted AUSCULTATION IN DISEASE. 271 heart-sounds, may constitute a physical sign of disease. Emphysema lessens the conducting power of the lung, and as one of the results of this affection, the sounds may be found to have greater intensity at a certain distance from the pr^ecordia, than at another situation less remote. Dr. Walshe states that in a case of intense emphysema of the left lung in which the disease was limited, and especially marked at the posterior aspect of the chest, he found the heart-sounds con- siderably more distinct posteriorly on the right than on the left side, there being no evidence of induration of the right lung to intensify the sounds on that side. The disparity here was attributed to an abnormal diminution of the transmission of the sounds to the pos- terior surface of the left side of the chest, the right side remaining in a normal condition in this respect. Without knowledge of the fact that the transmission may thus be abnormally diminished, a normal intensity may be mistaken for a morbid sign. Abnormal feebleness of the sounds of the heart in the prgecordial region is an effect of emphysema affecting the left lung. The en- largement of the lung from the over-distension of the cells causes it to extend over the whole of the surface of the heart, instead of the latter organ being in contact with the walls of the chest within a certain space. Under these circumstances it is easy to perceive that the sounds of the heart must be transmitted to the ear applied over the pr?ecordia Avith less intensity than in a normal condition. Abnormal diminution of the sounds of the heart in the prsecordia, in connection with undue intensity of the percussion-resonance, and absence of the heart's impulse, denotes that a thick layer of lung intervenes between the organ and the thoracic parietes. The cardiac sounds may not only be transmitted with undue in- tensity to different portions of the chest, but they may emanate from other situations than the prsecordia, in consequence of dis- placement of the heart. This will be found to enter into the history of pleuritis with large liquid effusion, and of pneumo-hydrothorax. Finally, a bellows arterial sound is sometimes heard within a cir- cumscribed space at the summit of the chest on one side, not trans- mittted from the heart, but limited to the subclavian artery, proba- bly produced by pressure upon the artery of the apex of the lung consolidated by tuberculous deposit. Dr. Stokes was the first to call attention to the occasional occurrence of this, as a physical sign of phthisis. He thinks that sympathetic irritation of the artery is sufficient to occasion it without pressure, basing this opinion on its 272 PHYSICAL EXPLORATION OF THE CHEST. intermittency, and his having observed it to subside after copious haemoptysis, and leeching in the subclavian or axillary regions.^ Whatever may be the explanation, the occasional occurrence of an arterial murmur, in connection with a tuberculous deposit of the apex of the lung, the sound being wanting in the brachial artery of the same side, in the heart, aorta, and carotid, and in the opposite subclavian, is a fact of some importance. But a fact to be borne in mind is that a subclavian murmur exists in some healthy persons, especially in males.^ History. Although allusion to listening in order to discover abnormal sounds within the chest may be found in the works of various writers even as ancient as those of Hippocrates, yet to so little extent was this method of investigation previously employed, and so insignifi- cant had been its results, that the honor of the discovery justly be- longs to Rdn^ Thdophile Hyacinthe Laennec, a native of Lower Brittany, born in 1781. The discovery was made by Laennec, while acting as chief physician to the Hospital Necker, in Paris, in 1816. It was communicated to the French Academy of Sciences in a memoir read in 1818, and during the following year was published the great work entitled, "i>g V Auscultation 3Iediate, ou Traite du diagnostic des Maladies des Poumons et du Cceur, fonde principale- ment sur ce nouveau moyen d' exploration." In the introduction to this work, Laennec announces the discovery, and relates the circum- stance which led to it in the following words : " In 1816, I was con- sulted by a young Avoman laboring under general symptoms of dis- eased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fat- ness. The other method just mentioned being rendered inadmissi- ble by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, and fancied, at the same time, that it might be turned to some use on the present occasion. The fact I allude to is the augmented impression of sound when con- veyed through certain solid bodies — as when we hear the scratch of a pin at one end of a piece of wood, on applying one ear to the other. 1 Stokes on the Chest, American edition, 1844, page 385. 2 Vide Clinical Essays, by B. W. Richardson, M. L>. London, 1862. AUSCULTATION IN DISEASE. 273 Immediately, on this suggestion, I rolled a quire of paper into a kind of cylinder, and applied one end of it to the region of the heart and the other to my ear, and was not a little surprised and pleased to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of the ear. From this moment I imagined that the circumstance might furnish means for enabling us to ascertain the character, not only of the action of the heart, but of every species of sound produced by the motion of all the thoracic viscera, and, consequently, for the exploration of the res- piration, the voice, the rale, or rhonchus, and perhaps even the fluc- tuation of fluid efi'used in the pleura or pericardium. With this con- viction I forthwith commenced, at the Hospital Necker, a series of observations which have continued to the present time. The con- sequence is, that I have been enabled to discover a set of new signs of disease of the chest, for the most part certain, simple, and prom- inent, and calculated, perhaps, to render the diagnosis of the dis- eases of the lungs, heart, and pleura, as decided and circumstan- tial as the indications furnished to the surgeon by the introduction of the finger or sound, in the complaints wherein these are used."^ It is a curious fact, that the suggestion which led to the discovery was an error in physics. The sound, in the illustration cited in the foregoing paragraph, is not augmented, but merely conducted better than through the atmosphere ; and it is now well established that intra-thoracic sounds are heard with the ear applied directly to the chest, as well as, if not better, than through the intervening medium, or stethoscope, to which Laennec attached so much importance as to name the new method mediate auscultation. In the remarkable work, the title of which has been given, the various phenomena revealed by auscultation are named, described, classified, explained, and their relations to morbid conditions deter- mined with a degree of completeness and accuracy, constituting it an imperishable monument of the industry and genius of the author. To such an extent Avas the science of auscultation perfected in the hands of its founder, that a considerable portion remains to the pres- ent moment unchanged, notwithstanding the labors of a host of observers, who have striven to enlarge the boundaries of its applica- tion to the diagnosis of diseases. Rarely, if ever, has there been an 1 Forbes's translation. 18 274 PHYSICAL EXPLORATION OF THE CHEST. instance of a discovery of equal importance in which so little was left by the discoverer to be performed by others. Moreover, as an exception to the general rule, the gratification was accorded to La- ennec of witnessing the acknowledgment of the value of his dis- covery, and its adoption by the most intelligent of his contemporaries. Nevertheless, the labors of those who have devoted attention to the cultivation of this department of medical science, since the discovery by Laennec, have by no means been without useful results. Some errors have been corrected, auscultatory phenomena have been studied in new aspects, important facts have been added, and, in short, the pliysical diagnosis of thoracic affection has been rendered more easy and precise by contributions to our knowledge from vari- ous persons already mentioned in the foregoing pages in connection with the particular services with which their names are identified. Laennec died, in 1826, of tuberculous disease of the lungs, in the forty-fifth year of his age. CHAPTER IV. INSPECTION. Physical exploration, by means of inspection, consists in an ocu- lar examination of the chest, in order to discover deviations from symmetry, or any abnormal appearances, as regards size and form, and also alterations of the natural movements incident to respira- tion. Important physical signs are determined by this method. In the relative value of the phenomena which it furnishes, it ranks next to auscultation and percussion. In the practice of physical explora- tion, this method should generally be first employed, because its re- sults are to be taken into account in estimating the importance which belongs to some of the phenomena obtained by the methods which have been already considered. Whenever a careful inspection is necessary, it is most convenient and satisfactory to survey the chest divested of all clothing. This may be done with propriety if the patient be of the male sex; but a due regard to delicacy requires that the entire chest of the female shall not be uncovered. To secure the advantages of a complete examination without offence to modesty, different sections may be inspected separately. The lower portion of the chest anteriorly, including the mammge, may be covered, while the upper part is ex- posed ; and afterward the upper part, with the mamm?e, covered, while the lower portion is denuded. This will suffice for all the purposes of exploration, without insist- ing on an exhibition of the mammary region. The examination may be made while the patient is recumbent, sitting, or standing. When circumstances render it practicable and proper, the last-mentioned position or the second is preferable to the first. Sitting or standing, the patient should be placed opposite a good light, and requested not to incline the body in either direction ; the attitude should be perfectly easy, the muscles relaxed, the upper extremities hanging loosely by the side, while the practitioner first surveys the chest at a suitable distance directly in front, and afterw'ards on each side, 276 PHYSICAL EXPLORATION OF THE CHEST. obtaining a view in profile. The anterior and posterior surfaces of the chest are to be inspected, observing the same precautions. The examination of the posterior surface, especially, is most conveni- ently made when the patient stands. If the recumbent attitude be necessary, on account of the feebleness of the patient, or other causes, care is to be observed that the body rests on an even plane. Inattention to this point may affect materially the results of the ex- amination. In the size, configuration, etc., of the chest, considerable differ- ences are observed in different persons free from thoracic disease. It is impossible to fix upon a normal standard which shall serve as a criterion by Avhich to estimate either the existence or the degree of abnormal deviations. The physical signs furnished by inspection, as a rule, are determined by observing a want of correspondence between the two sides. Taking advantage of the fact that, for the most part, intra-thoracic diseases involving physical changes are either confined to one side, or affect one side more than the other, and assuming that in a normal condition the two sides are symmet- rical (which, with certain exceptions, observation shows to be correct), a marked disparity in the visible appearances is fairly presumed to be the effect of disease. Moreover, observation teaches that diseases tend to produce different effects upon the size, form, and movements of the chest, and that different affections, individually, are charac- terized by their own special alterations. Hence, the source of the significance of the latter as physical signs. Their value, as indices of certain physical conditions, rests on the constancy of their con- nection with these conditions. Most of the facts which would fall under the head of inspection in health have already been stated in the introduction to this work. It is important to take cognizance of certain variations from the rule of symmetry of the two sides, occurring very frequently not only in health, but without spinal curvature, or any other deformity. In some persons the size of the right side at the middle and lower por- tions is obviously somewhat greater than that of the left. Generally, however, to determine the disparity which exists in this region, men- suration is requisite. The direction of the ribs on the right side is a little less oblique than on the left side. M. Woillez^ found, of 197 subjects in good health, and without spinal curvature, that in 47 1 Op. cit. INSPECTION. 277 only was the symmetry in all respects absolutely perfect. A pro- jection of the left side in front, either at, or above, or below the nipple, existed in the proportion of 26 per cent. An anterior pro- jection on the right side existed only in two instances. Hence, if a projection be observed on the right side, the probabilities of its being pathological are much greater than if it be on the left side. On the other hand, a posterior projection on the right side is very frequently observed, existing in 29 per cent, of the subjects examined byM. Woillez, while it is very rarely noticed on the left side. Variations, due to slight spinal curvature, are exceedingly common. The ma- jority of persons, especially laborers and mechanics, are not alto- gether exempt from disturbance of symmetry due to this cause. The inclination is commonly to the right, causing depression of the shoulder, and approximation of the ribs on that side. Slight cur- vature of the spine is also very common with females. Want of harmony between the two sides, not sufficiently marked to be ob- served without careful examination, may occasion an appreciable dis- parity as respects percussion, and, hence, the importance of first comparing closely by inspection wherever it is important to institute a close comparison by means of that method of exploration. It is especially with reference to the diagnosis in certain cases of tuber- culous disease, that slight deviations from symmetry, dependent on spinal curvature, or other causes, irrespective of existing disease, are to be taken into account. Alterations of size and configuration, when well marked, will, of course, not require for their discovery a close inspection. In such instances, the questions to be determined are, whether they are due to deformity, congenital or acquired, or injury of the thoracic walls ; to intra-thoracic afi"ections of an ante- rior date, more or less remote, which have left permanent effects on the conformation of the chest, or to present disease. The nature of the alterations, and the attendant circumstances, generally render it easy to decide in which of these categories abnormal appearances properly belong. The morbid appearances determined by inspection, which relate to present or pre-existing intra-thoracic disease, may be divided into those pertaining, first, to alterations of size and form, and second, to the respiratory movements. 1. Morbid Appearances Pertaining to the Size and Form OF the Chest. — The more important of these may be classified 278 PHYSICAL EXPLORATION OF THE CHEST. under two heads, viz., enlargement and contraction; each admitting of subdivision into general and partial. The enlargement or con- traction is general when the dimensions of either the whole or one side of the chest is increased or diminished. Partial enlargement or contraction is when there is either a projection or depression of a limited portion of the chest on one or both sides. General enlargement of the chest occurs, 1st, in consequence of augmented volume of the pulmonary organs, or 2d, from the accu- mulation of liquid, or air, or both, within the pleural sac. The en- largement from either of these causes, produces changes in the re- lations of the component parts of the chest analogous to those incident to a deep inspiration. The sternum and clavicles are elevated; the upper ribs converge; the lower ribs are more widely separated; and the abdominal space below the xiphoid cartilage, and between the false and floating ribs, is widened. It is generally practicable to determine by the appearances pertaining to the en- largement, on which of the two anatomical conditions just mentioned it is dependent, that is, whether it be owing to the augmented volume of the lung, or to the presence of liquid or air between the pleural surfaces. The lungs are rendered abnormally voluminous by the retention of an undue quantity of air within the pulmonary cells, constituting emphysema. If the lungs are highly emphysematous, the chest remains expanded as it is by a deep inspiration. The enlargement, however, is most marked at the superior and middle portions of the chest ; the reverse of this, as will be seen presently, obtains when the enlargement is due to liquid in the cavity of the pleura. The reasons for the fact just stated are, first, emphysema affects most the upper lobes ; and, second, the action of the diaphragm incident to the labored respiration occasioned by the disease, offers an ob- stacle to the enlargement of the inferior portion of the chest. The latter, indeed, may appear to be contracted, from the greater rela- tive dilatation of the superior and middle portions. In this respect the enlargement from emphysema differs from that due to liquid in the pleural sac, the expansion in the latter being more regular. Moreover, the enlargement from emphysema is never so great as that not infrequently observed from pleural effusion. Emphysema affecting both lungs, the two sides of the chest are, of course, en- larged. And if both lungs are equally enlarged, it is diflicult to determine to what extent the dimensions are increased, not having INSPECTION. 279 the advantage of a comparison of the two sides with respect to this point. It is, however, very rarely the case that emphysema does not affect one lung to a greater extent than the other; and observa- tions show that the left lung is more prone to a greater relative amount of augmentation than the right. Dilatation of the chest from emphysema is oftener limited than general, so that the anatom- ical condition constituting this affection will presently be cited as a cause of partial enlargement. General, but usually unequal en- largement of the chest, occurs in some cases of bronchitis, probably owing to dilatation of the air-cells, in fact to a temporary emphysem- atous condition. This obtains especially in bronchitis affecting the smaller bronchial tubes (capillary bronchitis) ; and it has been observed, in a marked degree, in the bronchitis complicating typhoid fever. ^ Supplementarily, the dimensions of the chest on one side become increased, when, from any cause, the functions of the lung on the other side are interrupted. Thus, a manifest enlargement of the healthy side occurs in chronic pleuritis, owing to the respiratory movements, and consequent inflation of the lung on that side, being increased to compensate for the partial or complete suspension of hsematosis in the diseased side. Increased voluntary respiratory efforts systematically continued, effect a considerable augmentation of the volume of the lungs, as shown by the enlargement of the chest which follows the use of the tubes of late years in vogue for that purpose. Gymnastic, or other muscular exercise, involving an unusual activity of respiration, also produce the same result. In pneumonitis affecting an entire lung, the chest on the affected side may be visibly enlarged. Generally, however, in cases of this disease, the inflammation being limited to a single lobe, the enlarge- ment, if it be sufficient to be apparent, is confined to a portion of the chest. The augmented volume of the lung incident to this affection, is due not necessarily to pleural effusion, but to the deposit of solid matter within the air-cells, in consequence of which the volume of the lung is sensibly augmented. It is in cases in which a large quantity of liquid, or air, or both, are contained in the pleural sac, that general enlargement of one side of the chest occurs most frequently, and is most marked. Uni- versal and not infrequently great dilatation on one side, is an im- portant physical sign in chronic pleuritis with abundant effusion, 1 Traits de Diagnostic Medical, par le Dr. Kacle, 1864. 280 PHYSICAL EXPLORATION OF THE CHEST. and in pneuuio-hjdrothorax. The enlargement in these affections is always confined to one side. An accumulation of liquid, or air, in both pleural cavities, sufficient to dilate the two sides, w^ould be incompatible with life, since it would involve diminution of the volume of the lungs to an extent to render them nearly or quite useless. The enlargement is more regular than in cases of emphy- sema, but it is most manifest at the lower part of the chest, in this respect presenting a contrast with the enlargement from emphysema. The concomitant signs, however, especially in simple pleuritis, render the discrimination sufficiently easy. In emphysema, the percussion- resonance is never lost, but is generally abnormally clear, with a quality more or less approximating to the tympanitic. In pleuritis. with abundant liquid effusion, there is flatness on percussion. In pneumo-hydrothorax, the difference, as regards the signs furnished by percussion, is less striking. The chest is highly resonant and tympanitic above the level of the liquid, flatness existing below that point ; but with the aid of the auscultatory signs, in connection with the symptoms and history, the differential diagnosis does not involve much difficulty. The expansion of the thoracic walls, if it be con- siderable, by the direct pressure of liquid or air, occasions other changes than those incident to simple enlargement, which have been mentioned. The direction of the lower ribs undergoes a change. They are less oblique. The intercostal depressions are effaced, and the integument between the ribs may even become pro- tuberant. It has been asserted that the effect on the intercostal spaces is characteristic of enlargement from the pressure of liquid or gas, in distinction from that due to the augmented volume of the lung.' The intercostal depressions, however, may be effaced in cases of emphysema. The error of supposing otherwise has perhaps arisen from observations having been confined to the lower part of the chest, where the depressions are most conspicuous in health. Liquid effusion obliterates the depressions in this situation, the dis- tension being, as has been seen, greatest at the lower part of the chest ; but emphysema, affecting most the superior portion of the lung, the depressions at the lower part may continue, and, if the respiration be labored, may even be greater with the inspiratory act than in health, notwithstanding the general enlargement of the chest. It is, however, undoubtedly true, that, at the superior portion of 1 Dr. Stokes. INSPECTION. 281 the cliest, the intercostal depressions, in persons in whom they are normally visible in these situations, may be diminished or lost in consequence of the pressure of emphysematous lung. Partial enlargement is incident to most of the anatomical condi- tions already mentioned, viz., to emphysema, pleuritic effusion, pneumo-hydrothorax, and pneumonitis, and to other affections not adequate to give rise to dilatation of the whole of one or both sides of the chest. The enlargement from emphysema is often er partial than general. It occasions undue prominence over a portion of the chest corresponding to the seat of the affection, and proportionate in aiiiount to the extent of the affection, with diminution or oblitera- tion of the intercostal depressions. Aff"ecting the superior portion of the lung generally, if not always, on both sides, but greater on one side than on the other, a characteristic appearance is an abnor- mal bulging above and below the clavicle. These appearances, more marked on one side than on the other, disconnected from other signs, might lead the observer to attribute the relative depression of the supra and infra-clavicular regions on one side to disease of the sub- jacent lung. The evidence derived from percussion and ausculta- tion suffice to correct this error. The physical evidences of the mor- bid conditions inducing abnormal depression will be wanting, while the concomitant sign of emphysema, viz., vesiculo-tympanitic resonance and feeble respiration, are found on the side on Avhich the greater prominence exists. Over the mammary region the emphysematous lung causes greater relative fulness, especially near the sternum, with diminished obliquity of the ribs, the intercostal spaces being concealed by the pectoral muscle and the mammary gland ; and if the affection exist on both sides, the chest presents an unnatural rounded or globular appearance, which is highly characteristic. In pleuritis with effusion the lower portion of the thorax yields to the distension from the fluid gravitating to the bottom of the pleural sac, before the superior part of the chest becomes obviously en- larged from the accumulation of the liquid. Unless the quantity of effusion be large, the dilatation is partial, and situated inferiorly, in this respect contrasting with enlargement from emphysema in the majority of cases of the latter aff'ection. The contrast as respects the signs derived from percussion and auscultation, however, gener- ally serve to distinguish these affections from each other as broadly as possible. In pneumo-hydrothorax the quantity of liquid at the bottom of 282 PHYSICAL EXPLORATION OF THE CHEST. the chest may be sufficient to occasion manifest enlargement when no obvious disparity exists above. Pneumonitis affecting a single lobe sometimes gives rise to an ap- preciably increased fulness of the part of the chest situated over the solidified lung, but the enlargement is apparent in only a small pro- portion of instances. Various conditions additional to these may produce partial en- largement, the more important of which are as follows: (1.) Circumscribed pleuritis, a collection of liquid sufficient to oc- casion bulging, being confined within a limited area by adhesions of the surrounding pleural surfaces. Cases of this description are sometimes observed, but they are rare. I have met with an instance of a large collection of purulent fluid confined to a space five or six inches in width extending around the entire semicircumference of the lower part of the chest, firm adhesions preventing an ascent of the liquid above this space.' (2.) Enlargement of the spleen. Marked projection of the lower portion of the left side is sometimes due to this anatomical condition, which occurs especially in protracted or frequently renewed attacks of intermittent fever. (3.) Distension of the stomach with gas, if considerable, occasions temporarily an abnormal protrusion of the lower left ribs. (4.) Enlargement of the liver, from tumors, abscess, fatty deposit, etc. In this case, of course, the partial enlargement of the chest will be situated on the right side. (5.) Liquid effusion within the pericardium, and enlarge- ment of the heart. The pr?ecordial portion of the chest may be rendered abnormally prominent by these affections. It is a curious fact that a projection in this situation in health was found by M. Woillez to exist in a larger ratio of instances than by Bouillaud in cases of hypertrophy of the heart. It is probable that the deviation from symmetry in this situation, which is found in the proportion of about one-fourth of healthy persons, has been often incorrectly at- tributed to the hypertrophy of the heart in the instances in which it has been observed in connection with that affection. (6.) Aneur- ismal and other intra-thoracic tumors. (7.) According to Dr. Cham- bers, deposit of tubercle may occasion bulging at the summit of the chest above and below the clavicle. This, however, has not been noticed by others, and the correctness of the observation needs con- firmation. 1 Essay on Chronic Pleurisy, by author. INSPECTION. 283 Variations in size and form, the reverse of those just considered, may, also, as has been stated, be general or partial. When contrac- tion is general, i. e., affecting the whole of one side or both sides, the relations of the component parts of the chest are analogous to those incident to a forced expiration. The upper ribs are more widely separated, while the lower are approximated to each other, and the space below the xiphoid and between the lower costal carti- lages is diminished. General contraction of one side is presented in a striking degree after recovery from chronic pleuritis. The chest is diminished in all its diameters, and so appears in whatever direction it be examined. The lung, after remaining collapsed and compressed for weeks and months, does not readily expand, after the liquid is absorbed, to its former volume. Moreover, the false membranes formed upon its surface, and the union of the pleural surfaces, offer a mechanical obstacle to its complete expansion. The atmospheric pressure, therefore, forces the thoracic walls to accommodate themselves to the diminished bulk of the pulmonary organ. The reduced dimen- sions, compared with the other side (the latter becoming increased in size), are sufficiently obvious on inspection, but the altered relations of different parts, component and accessory, pertaining to the chest, are also conspicuous. The shoulder is depressed. The inferior angle of the scapula falls below the level of that on the unaffected side, and projects from the chest. The width of the lower interscapular space is notably diminished. The ribs are approximated. The nip- ple on the affected side is lowered. More or less spinal curvature takes place, the lateral inclination being toward the affected side. All these appearances give a characteristic aspect, by which the fact that pleuritis, with copious effusion and enlargement of the chest, has existed, is evident at a glance. Abnormal diminution of the volume of the lung from any cause, provided the pleural cavity does not contain liquid effusion or air, is of necessity accompanied by a contraction of the chest exactly pro- portioned to the extent to which the pulmonary organ is reduced in bulk. Collapse, from obstruction of a large bronchus, involves an amount of general contraction corresponding to the diminished vol- ume of the lung. Condensation from inflammatory exudation within the air-vesicles, remaining after the removal of this exudation, leads to some reduction of bulk, and hence contraction is sometimes ob- served to follow the resolution of simple pneumonitis, and is general 284 PHYSICAL EXPLORATION OF THE CHEST. if the inflammation and solidification affected the entire lung. The contraction under these circumstances is rarely marked, unless abundant liquid effusion has coexisted. Slight general contraction has also been observed to accompany atrophy of the pulmonary parenchyma in connection with dilated bronchial tubes. Extensive tuberculous disease induces a shrinking of the lungs, and corre- sponding diminution of the size of the chest ; and this effect follows long confinement to the bed with any disease.^ The morbid conditions which, oftener than any other, give rise to partial contraction of the chest, are incident to tuberculous disease. Abnormal depression above and below the clavicle, and more or less flattening at the summit, are occasionally observed in phthisis, and in some instances are among the striking physical evidences of that disease. These appearances may be presented early in the disease, showing that the apex of the lung becomes in some instances reduced in volume in consequence of the presence of crude tuberculous mat- ter ; but they are found more frequently and in a more marked de- gree after softening and excavation have taken place. In connection with the changes by which cavities are formed, their rationale is sufficiently plain, since there occurs an actual loss of pulmonary substance to a greater or less extent. It is needless to add, that to constitute a physical sign of disease, the contraction must be manifested on one side of the chest by a comparison with the other side. Other conditions inducing partial contraction, less frequent, and clinically less important, are the absorption of liquid effusion re- tained by pleuritic adhesions within a circumscribed space; removal of the exudation-matter deposited in pneumonitis when the latter is confined to a single lobe ; and limited collapse or atrophy. 2. Morbid Appearances pertaining to the Respiratory Movements. — The respiratory movements in health have been con- sidered in the introduction to this work, inclusive of certain modifi- cations incident to sex, age, etc., and also variations, irrespective of disease, presented in different individuals, all of which are impor- tant by way of preparing the observer to estimate correctly morbid appearances. Incidentally, in connection with the physiological facts relating to this subject, allusion has already been made to the 1 Vide Sibson's Medical Anatomj-, Fasciculus 1. I INSPECTION. 285 more prominent of those aberrations of the respiratory movements which constitute physical signs of disease. Abnormal frequency of the respirations may be ascertained by inspection. By observing the visible motions of the chest or abdo- men, the inspirations are enumerated, and the number in a given time determined. For this end, it is not necessary that the chest be exposed. Diminished frequency of the respirations implies a morbid condition seated in the nervous system, the respiratory function being affected secondarily, or symptomatically. Increased fre- quency is incident to various affections compromising the function of hgematosis, such as pleuritis, pneumonitis, phthisis, and in a notable degree to capillary bronchitis. The number may be in- creased from the healthy average, ranging between 14 and 20 per minute, to 40, 50, and even 60. Abnormal frequency of the respi- rations does not necessarily denote disease of the pulmonary organs. It is incident to disorders affecting the circulation, and to hysteria. In tracing it to its source, a point of some utility is the ratio which should exist between the respirations and the pulse. As a rule, four beats of the heart take place in health during the time occupied by each respiration. This ratio is usually preserved in diseases not involving the heart or lungs. A pulmonary affection may be pre- sumed to exist whenever an increase in the number of respirations is unattended by a corresponding increase in the frequency of the pulse. This may be stated as a maxim which will generally hold good ; but, of course, the existence of pulmonary disease is to be determined in all cases by evidence more direct and positive. The rhythm of the respiratory movements is affected differently in connection with different morbid conditions. The inspiratory movement is somewhat shortened, as a rule, whenever dyspnoea exists, the want of fresh supplies of air instinctively causing the act to be hurried. Shortened inspiration is especially marked in emphysema for another reason, viz., the chest is already dilated, and the extent of its capability of expansion proportionally les- sened ; hence it is more quickly performed. This occurs in cases in which pain is produced by a full or deep inspiration, as in pleuritis, intercostal neuralgia or pleurodynia. The patient instinctively represses the inspiratory movements, and thus, as far as possible, consistently with the introduction of sufficient air for hgematosis, shortens the duration of inspiration. An abrupt arrest of inspira- tion, with manifestations of acute pain, is a sign highly distinctive 286 PHYSICAL EXPLORATION OF THE CHEST. of the affections just named. The inspiration is also shortened by an obstruction in the larynx arresting the current of air before the act is completed. This occurs in oedema glottidis, in croup, and in spasm of the glottis. On the other hand, the expiration is pro- longed in emphysema, owing to the impaired contractility of the lung ; in bronchitis, attended with obstruction of the smaller bronchial tubes; and in spasm of the bronchial muscular fibres, con- stituting asthma. The prolongation is great when the three morbid conditions just mentioned are combined. Under these circum- stances, the difficulty in the performance of expiration is especially manifest at the close of the act. The air is expelled from the lungs with a slowness which increases until the act is completed. Ob- struction seated in the larynx, throat, nasal passages, or bronchi, is also attended by prolonged expiration. In all these instances the slowness with which the air is expelled is uniform through the expiratory act, in this respect differing from the instances in which the obstruction arises from want of contractility, or from obstruc- tion seated in the smaller bronchial tubes. Sibson's observations show this to be a point of distinction.^ To determine with considerable accuracy the relative duration of the inspiration and expiration, the following plan is usually adopted : beating time rapidly and regularly with the finger, and counting the number of beats during each act. An obstruction within the larynx, trachea, throat, or nasal pas- sages, preventing the free ingress of air into the pulmonary organs, occasions certain peculiar modifications of the thoracic movements with the act of inspiration. The vacuum produced by the action of the inspiratory muscles not being filled by an adequate admission of air, the pressure of the external atmosphere causes depression at certain points where the resistance is least. These points are above and below the clavicles, the lower part of the sternum, and antero- laterally over the lowermost of the ribs attached to the sternum. This effect, reversing the healthy movements of the chest with in- spiration, will be marked and extensive in proportion to the degree of obstruction. If the obstacle to the entrance of air be slight, the lower portion of the sternum only falls backward. The collapsing movement extends over the sides in proportion to the difficulty at- tending the ingress of air ; and, in extreme cases, the entire thoracic 1 On the Movements of Kespiration in Disease. INSPECTION. 287 walls are contracted, excepting the ribs to which the diaphragm is attached. Owing to the action of the diaphragm, the latter are still moved outwardly.^ An exception to the effect on the chest just stated, occurs when, from old age, the costal cartilages have become rigid and unyielding. Under these circumstances, the thoracic walls, resisting the pressure of the atmosphere, expand, and the abdomen retracts with inspiration. The effect of obstruction on the thoracic movements is especially marked in children, owing to the greater flexibility of the thoracic walls in early life. Continued obstruction in this way leads to permanent contraction and deformity of the chest. In treating of the respiratory movements in health, it has been seen that they may be divided into different types, viz., abdominal, and costal ; the latter being further divisible into the superior and the inferior costal type. The combination of these several types, and their relative predominance, respectively, in other words, dif- ferent modes of breathing, constitute, as already stated, important physical evidence of disease. In breathing voluntarily forced, or in laborious respiration from any morbid cause, all three types, viz., abdominal, inferior costal, and superior costal, are exemplified ; but especially the two latter become prominent, compared with the habitual tranquil breathing in the male, the latter involving chiefly, and sometimes almost exclusively, the abdominal type. In cases of peritonitis, in which the play of the diaphragm occasions acute pain, the respiratory movements are in a great measure restricted to the thoracic walls : the breathing is costal. The same effect is produced by mechanical obstruction to the descent of the diaphragm from hydro-peritoneum, pregnancy, tympanitis, or abdominal tu- mors. On the other hand, in cases of pleuritis, intercostal neu- ralgia, or pleurodynia, in which the thoracic movements occasion acute pain, these movements being instinctively restrained, the ab- dominal are proportionately increased, and the breathing is said to be abdominal or diaphragmatic. In a case of double pleuritis, which came under my observation, in which the chest on both sides was half filled with liquid effusion, the lungs firmly adherent above the level of the fluid, the type of breathing was almost exclusively superior costal. The respiratory movements at the summit of the chest were remarkable. It is a repetition to state that the superior 1 On the Movements of Eespiration in Disease. 288 PHYSICAL EXPLORATION OF THE CHEST. costal type of breathing, in health, is exemplified much more in the female than in the male. In paralysis affecting the costal muscles, the abdominal type of respiration becomes strongly marked. Disparity between the two sides of the chest, as respects the res- piratory movements, constitutes, in some instances, important diag- nostic evidence of disease. In the dilatation of the chest on one side from large liquid effusion, the movements on that side are notably diminished, and may be almost null, whilst, on the opposite side they are supplementarily increased. A similar disparity, but never to the same extent, exists in some cases of emphysema, in which the affection is more marked on one side. The same contrast exists in pneumo-hydrothorax. In simple pneumonitis, affecting either the upper or lower lobes, the respiratory movements, in a certain proportion of cases, are obviously restrained; and this is to be observed after acute pain has ceased, or in cases in which that symptom is not present. This was denied by Laennec ; but a care- ful comparison of the two sides, in a series of cases, must convince any one of the correctness of the statement.^ A local disparity at the summit of the chest is sometimes a highly significant sign of tuberculous disease. The superior costal movements, owing to pleu- ritic adhesions, or other causes, in some instances are notably less on the side in which a tuberculous deposit exists, than on the oppo- site side. This will be more manifest if the respiration be labored, so as to call into action the superior costal type of breathing. It may be obvious if the respiration be forced, when it is not apparent with tranquil breathing. It will be more marked in females than in males, owing to the superior costal type being more prominent in them than in males, irrespective of disease. An inspection of the chest, with reference to a careful comparison of the relative mobility of the two sides at the summit, is a point not to be omitted in an exploration for evidence for or against the existence of tuber- culous disease. The diagnostic value of this sign of course depends on the assumption of equality in the movements of the summit of the chest in health. As the rule, provided the two sides be sym- metrical in conformation, this may be assumed; but in making ex- aminations of persons presumed to be free from disease, I have, in a few instances, observed a slight disparity in that situation, as well 1 Laennec, it is to be remarked, paid very little attention to the physical signs derived from inspection. Indeed, he declared that the ocular examination of the chest with reference to the resjiiratory movements is of very little utility. INSPECTION. 289 as at the lower part of the chest. In view of these occasional ex- ceptions to the general rule, a disparity in rnobilitj, as an isolated sign, should be distrusted; but, associated with other signs, it is entitled to considerable weight. Finally, a marked disparity in the movements of the two sides obtains in cases of spinal hemiplegia. The scapul?e, in health, in forced respirations, are more or less raised with the act of inspiration; and diminished or arrested eleva- tion-movement of the scapula on one side is a morbid sign of some value. This sign is observed in cases of pleuritis with eflfusion, of pneumo-hydrothorax, in some cases of pneumonitis, and when one side is contracted as a sequel of pleuritis. It is also observed in some cases of tuberculosis, and it is chiefly with reference to the affection last named that the sign is of value ; it belongs in the col- lection of signs which are combined in making the diagnosis of this affection. SUMMAEY. The phenomena determined by inspection embrace morbid appear- ances pertaining (1), to the size and form of the chest; and (2), to the respiratory movements. The morbid appearances pertaining to size and form are resolvable, for the most part, into enlargement and contraction, both of which may be general, i. e. extending over the chest at least on one side ; or partial, i. e. limited to a portion of the chest on one or both sides. General enlargement involves either augmented volume of the lung on one or both sides, or the presence of liquid or air in one of the pleural cavities. To the former of these anatomical conditions is due the enlargement in cases of emphysema, which affects both sides of the chest. Enlargement of the chest from emphysema is most marked at the superior and middle portions of the chest anteriorly; and the surfaxje rarely presents a uniform, regular dilatation. A more fre- quent anatomical condition giving rise to general enlargement is the accumulation of liquid in the pleural sac in cases of chronic pleuritis. General enlargement from this cause is necessarily con- fined to one side. The dilatation from the pressure of liquid is more uniform, and the surface of the chest presents a more regular appearance. The intercostal depressions are effaced, in chronic pleuritis, where they are normally most conspicuous, viz., anteriorly and laterally at the lower part of the chest. In this situation they are rarely, if ever, effaced by the pressure of an emphysematous 19 290 PHYSICAL EXPLORATION OF THE CHEST. lung SO as not to be marked with inspiration ; but they may be di- minished or lost over the superior part of the chest in cases in which they are normally apparent in that situation. General enlargement of the chest may also proceed from pneumo-hydrothorax, and, in a slight degree, from simple pneumonitis aifecting an entire lung. Partial enlargement, oftener than general, is incident to emphysema, pleuritis, pneumo-hydrothorax, and pneumonitis. It is also incident to circumscribed collections of liquid ; enlargement of the spleen ; distension of the stomach ; augmented size of the liver ; pericarditis, with effusion and hypertrophy of the heart ; aneurismal and other intra-thoracic tumors. General contraction of the chest is especially marked after re- covery from chronic pleuritis. It results from collapse of a lobe following obstruction of the bronchus leading to it ; it accompa- nies, in a slight degree, the diminished volume succeeding pneumo- nitis affecting an entire lung; and it may also coexist with dilated bronchial tubes. Partial contraction above and below the clavicle is sometimes marked in cases of phthisis, being incident to the early stage in some instances, but it is more frequent and more marked in an advanced period of the disease. It follows the removal of pleural effusion, attends limited collapse, and the reduction in the volume of the lung succeeding pneumonitis. Increased frequency of the respirations is incident to affections compromising the function of hsematosis, and is therefore observed in pleuritis, pneumonitis, phthisis, and especially in capillary bron- chitis. Occurring oftener than in the ratio of one to four beats of the heart, pulmonary disease of some kind is generally indicated. The inspiration is shortened, as a general rule, in dyspnoea. It may be arrested, before the act is completed, by an obstruction of the wind- pipe, and is voluntarily arrested, in consequence of pain, in pleuritis and intercostal neuralgia. It is short in emphysema, owing to the permanent expansion of the chest. The expiration is prolonged in emphysema, owing to the diminished elasticity of the lung, and in cases of obstruction in the air-passages. If, owing to obstruction in any part of the air-passages, the air-cells are not filled propor- tionably to the enlargement of the chest, the act of inspiration causes depression of the thoracic walls at certain points, viz., above and below the clavicles, and laterally and anteriorly at the lower part of the chest. This is more marked in children than adults, and is one of the causes of deformity of the chest. The respiration INSPECTION. 291 is abnormally thoracic or costal, when the play of the diaphragm is voluntarily restrained in consequence of the pain which it occasions in peritonitis, and when its descent is prevented mechanically in tym- panites and ascites, by tumors, and in pregnancy. Abdominal or dia- phragmatic respiration is marked when the thoracic movements occa- sion suffering in pleuritis or intercostal neuralgia, and in paralysis of the costal muscles. In health, the type of respiration in the male is chiefly abdominal ; but whenever the breathing is labored, the infe- rior and costal types are also manifested. When the chest on one side is greatly dilated in chronic pleuritis, the side affected is nearly immovable, the movements on the unaffected side being supplement- arily increased. The same disparity, but in a less degree, may be exhibited in cases of emphysema in which the affection is more marked on one side. It is observed in pneumo-hydrothorax. A disparity in the respiratory movements of the summit of the chest is sometimes a valuable sign of tuberculous disease. In cases of spinal hemiplegia, the movements of the chest on the paralyzed side of the body are diminished, and those on the opposite side increased. Di- minution or arrest of the elevation-movement of the scapula on one side occurs in pleuritis, pneumo-hydrothorax, pneumonitis, when the chest is contracted after pleuritis, and in some cases of tuber- culosis. Its value as a morbid sign is chiefly in the diagnosis of tuberculous disease. History. Inspection was doubtless resorted to, in the investigation of dis- eases, from the earliest date in the history of medicine ; but the impulse given to the subject of the physical exploration of the chest by the discovery and researches of Laennec led practitioners to em- ploy, to a much greater extent than previously, and with vastly more advantage, this method of examination. The value of results ob- tained by inspection is very greatly enhanced by their association with the phenomena furnished by other methods, more especially by percussion and auscultation. CHAPTER V. MENSURATION. In the physical exploration of the chest, it is sometimes useful to ascertain the extent of abnormal alterations, as respects size, and of the respiratory movements, with greater accuracy than can be deter- mined by the eye. For this end, measurements are resorted to. These constitute a distinct method of examination, called mensura- tion. For ordinary clinical purposes, in other words, with reference to diagnosis, the practical value of this method is very limited. It is rarely important, because the information obtained by inspection is sufficiently exact, and, in some instances, even more satisfactory. The two objects for which mensuration is employed, viz., to deter- mine abnormal alterations in size, and in the extent of respiratory movements, are quite distinct and require separate notice. 1. Mensuration with reference to abnormal alterations IN size. — Measurements with reference to alterations in size may be made in different modes. The diametrical distance between oppo- site points may be determined by means of compasses, constructed for that purpose, called callipers. For example, the antero-posterior diameter of each side, in different situations, is ascertained by plant- ing the extremities of the two blades of the instrument in front and behind, successively, on corresponding points on the two sides, and noting the extent of the separation of the blades as indicated on a graduated scale connected with the instrument. A comparison of the relative size of the two sides at any situation, with due care, may in this way be instituted. If, however, certain precautions are not carefully observed, such as placing the extremities of the instrument on exactly corresponding points in the examination of the two sides, and being cautious not to make greater pressure on one side than on the other, the results will be likely to be fallacious ; and in view of this liability, partial enlargements or contractions on one side are generally more satisfactorily appreciated by comparison with the eye. MENSURATION. 293 A difference between the two sides in any of the diameters, sufficient to become an important physical sign, is apparent on careful ex- amination and comparison by inspection. It is chiefly in noting facts for analytical investigation, that an exactness of measurement by this or other modes, which can be expressed numerically, is de- sirable. For examinations with a view simply to diagnosis, it is not requisite ; and this being the case, the objections to the use of an instrument, cumbrous and somewhat formidable in appearance, have justly precluded its introduction into private practice. The variations in size obtained by this mode of measurement are those already noticed under the head of Inspection, viz., on the one hand, enlargement, general and partial, due to emphysema, pleuritic efi'u- sion, etc. ; and, on the other hand, contraction, incident to recovery from pleuritis, tuberculosis, etc. Another application of mensuration consists in measuring dis- tances on the surface of the chest, between certain prominent anatomical points. For example, the nipples, in a chest perfectly symmetrical, of an adult male, are situated on the fourth rib, or interspace, equidistant from the centre of the sternum. Enlarge- ment of one side in connection with morbid conditions which have been already mentioned, removes the nipple on the aiFected side to a greater distance from the mesial line, at the same time raising it above the level of the other. Contraction of the chest, on the other hand, diminishes the distance, and depresses it below its natural situation. The extent of these changes may be accurately measured. The distance from the posterior margin of the scapula to the spinal column is increased when the chest is dilated, and di- minished when the chest is contracted. In the first instance, the inferior angle of the scapula is observed to be elevated above the level of that on the unaffected side ; and, in the second instance to be lowered. These deviations from symmetry incident to disease, may be accurately ascertained by comparative measurements. The extent to which the ribs are separated or approximated by different morbid conditions may also be measured. In recording cases, it is well to express the amount of disparity between the two sides, as respects the points just mentioned, in figures ; but so far as con- cerns the bearing of the facts on diagnosis, such precision is super- fluous. The facts, as estimated by the eye, are sufficiently exact. Another mode of practising mensuration, consists in measuring the horizontal circumference of the chest, and comparing the two 294 PHYSICAL EXPLORATION OF THE CHEST. sides in this respect. This may be done -without difficulty, by means of a common tape or cord, with the aid of an assistant, if the patient be able to be raised to a sitting posture. The cord or tape is passed around the chest just below the scapula, one end being accurately fixed to the mesial line over the sternum in front. After being evenly adjusted with equal pressure on both sides, taking pains to see that the direction is as circular as possible, an assistant marks the point at which it crosses the spinous process of the vertebra with ink, or by inserting a pin. The point meeting the extremity fixed at the centre of the sternum is also marked. The data for determining the circumference of the whole chest, and that of each side are in this way obtained; and since, practically, the chief ob- ject is usually to compare the two sides, it suffices to double the cord or tape from the point at which it crossed the spine, and ascertain how much one portion exceeds the other in length. In place of a common cord or tape (which answers every purpose if other means are not at hand) a graduated measure, such as tailors use, may be employed. The semi-circumference at each side is sometimes mea- sured separately; but a difficulty in the way of accuracy arises from the liability of the chest not being equally expanded while the mea- surements of the two sides are taken in succession. This difficulty may in a great measure be obviated by requesting the patient to take a deep inspiration as each side is measured, and to hold the breath until the measurement is made. The best plan, however, is to use two graduated tapes joined together, the scale of inches and fraction of inches commencing on each tape at the line of junction. One great advantage of the latter plan is, it may be applied while the patient is recumbent. The point of junction being fixed over the spine, and the two tapes brought forward, the circum- ference of each side is shown by a 'glance at the centre of the sternum. Comparison of the semicircular measurements of the two sides enables the examiner to form an idea of the extent to which the dimensions of one side are either increased or diminished by disease; but the actual difi"erence of size, it is to be borne in mind, does not represent exactly the amount of a morbid increase or diminution, since, as a general rule, the two sides are normally unequal. In the majority of persons the right semi-circumference exceeds the left, the mean disparity being about half an inch. In a small proportion of individuals the two sides are equal, and in a few instances the left semi-circumference exceeds the right. The MENSURATION. 295 latter is found to occur oftener among left-handed persons. Owing to these natural differences, the fact of a disparity, as shown by mensuration, if it be but small or moderate, does not necessarily denote disease. To become a morbid sign it is to be taken in connection with other signs, unless the disparity exceed the range of normal variations ; and if this be the case, comparison of the two sides by inspection suffices to establish the existence of morbid enlargement or contraction. Mensuration under these circum- stances only assists in forming a closer estimate of the extent of the deviation from the normal dimensions, a point not without interest, but not essential to diagnosis. Moreover, measurement of the horizontal circumference of the chest affords evidence only of general, not of partial enlargement or contraction of one side. Partial projection or depression may exist without a corresponding increase or diminution of the semi-circumference of the side affected, and under these circumstances the latter must be determined by in- spection, or by the callipers. The advantage of circular measure- ment does not relate to the determination of the existence of a morbid disparity in size between the two sides, so much as to another object, viz., to ascertain the variations in the amount of morbid in- crease at different periods in the same case. This object has refer- ence mainly to a single disease, viz., chronic pleuritis, including empyema. Mensuration employed daily, or at intervals more or less brief, during the continuance of this disease, the result being noted, affords exact information respecting the progress in the accu- mulation or removal of the liquid effusion. The practitioner, in other words, is able to determine with precision whether the quantity of effusion be increasing or lessening, or stationary. Information on these points may also be derived from inspection, but not so promptly and less accurately. The positive or negative effects of different therapeutical measures are demonstrated in this way by the evidence afforded by mensuration, and in this point of view measurements repeated more or less frequently are of not a little utility in regulating the treatment. These remarks with reference to pleuritis, are measurably applicable to pneumo-hydrothorax, and to some extent to emphysema. The progress in the slow expansion of the chest after the contraction which immediately follows the removal of liquid effusion, may also be determined, from time to time, by measurements, with greater precision than by means of ocular examinations. 296 PHYSICAL EXPLORATION OF THE CHEST. The foregoing remarks have reference to a comparison of the two sides of the chest, by means of whicli, as has been stated, morbid alterations in size are usually determined. Abnormal deviations in this respect, as in other points, are not ascertained by reference to any fixed criterion or average, but the chest on one side is taken as the healthy standard peculiar to the individual. The variations in the size of the chest are so great within the limits of health, that mean dimensions obtained by a series of measurements are of little value in estimating the changes due to disease. The horizontal cir- cumference of the whole chest, i. e. of both sides, may range, ac- cording to Walshe, between twenty-seven and forty-four inches; the mean, in the adult male, being about thirty-three inches. With such an extensive range between the extremes of health, it is of little value to take into consideration the united dimensions of the two sides in determining the existence or the nature of disease ; the disparity between the sides is the point to be considered. The re- searches by M. Woillez, however, have led to some interesting re- sults as respects the changes in the general capacity of the thorax which are to be observed during the career of acute diseases. These results, expressed as concisely as possible, are as follows:' Examined by mensuration at different stages of the course of dif- ferent acute affections, accompanied by well-marked febrile move- ment, the size of the chest is found to present almost constantly a series of changes. The changes may be arranged in three periods, which follow in regular succession, viz., first, progressive enlarge- ment, next, a stationary period, and lastly, a gradual return to the normal dimensions. These three periods are of variable duration, corresponding to the varying course and character of different affec- tions. The alterations in capacity are accompanied by propor- tionate modifications of the elasticity of the thoracic walls. The elasticity diminishes as the enlargement increases, and again, gradu- ally returns to the normal degree as the chest resumes its natural size. The extent of enlargement varies from three-fifths of an inch to a little over three inches, the mean increase being about one and a half inches. In the exanthematous fevers, the enlargement is shorter in duration than in other acute affections ; and in variola especially, a return to the normal size takes place prior to the com- plete development of the eruption. Particular causes, affecting the 1 Traite de Diagnostic Medical, par Kacle. , MENSURATION. 297 regular course of any acute affection, may disturb the regularity of the succession of the several periods into which the alterations of thoracic capacity are divided. The enlargement of the chest, and the diminished elasticity, are attributed by M. Woillez, to pulmonary congestion accompanying the development and career of acute af- fections. These changes in the size of the chest, revealed by men- suration, he regards as evidence that pulmonary congestion is an important element of all acute diseases. Mensuration enables the practitioner to observe the extent and progress of this element. In degree, the enlargement sustains no constant relation to the fre- quency of the pulse ; and it is affected neither by bloodletting, nor gastro-intestinal evacuations, nor by any course of alimentation. The presence of gas in the stomach, in variable quantity, is a cause of variation in the size of the chest, not to be overlooked. Pro- gressive emaciation is another cause of diminished size by mensu- ration, which is to be distinguished from the effect of the reduced volume of the pulmonary organs. Occasionally, irregular oscilla- tions in the amount of pulmonary congestion appear to occur, giving rise to variations in the thoracic capacity. But, as a rule, increas- ing enlargement of the capacity of the chest denotes a progressive development of the disease, a stationary condition of enlargement indicates a persisting acuteness, and a decrease in the dimensions of the chest often precedes the symptoms and other signs which afford evidence of commencing resolution of the malady. These conclusions, purporting to have been deduced from a series of meas- urements in a variety of acute affections, are striking, and not unimportant. Of their correctness, I am unable to speak from personal observations. 2. Mensuration with reference to Abnormal Alterations IN THE extent OF RESPIRATORY MOVEMENTS. — Measurement of the extent of motion, at different portions of the chest, involved in the respiratory acts, is made by instruments which have been already described. By means of the " chest-measurer," invented by Dr. Sibson, movements in a diametrical direction may be determined with great accuracy. A great number of examinations, with the aid of this instrument, enabled Dr. Sibson to arrive at interesting and important results respecting the actual and relative extent of the motion of different parts of the chest in health, with the pecu- liarities incident to sex, age, etc. ; and, also, the effects of different 298 PHYSICAL EXPLORATION OF THE CHEST. forms of disease, in modifying the normal respiratory movements. The more important of the facts deduced by Dr. Sibson have been ah-eady referred to in the introduction to this work, and under the head of Inspection, in the preceding chapter. Dr. Sibson's in- genious instrument, however, only measures the forward movements of the chest. It does not show the actual amount of expansive mo- tion. For this end, the " stethometer" of Dr. Quain is preferable. Moreover, the last-mentioned instrument is less cumbrous,- and is applied with much greater facility. The value of both chiefly relates to scientific researches, in which it is convenient to express the results of observations with numerical exactness. For ordinary clinical objects, this is not necessary. It sujffices to determine the existence of certain abnormal modifications, without ascertaining, with arithmetical precision, the extent of the deviations from health. This information is furnished by inspection. Mensuration, with reference to the respiratory movements, is even less essential, and less resorted to, than with reference to deviations in size. Ocular examination, comparing carefully the two sides of the chest, enables the observer to distinguish, without difiiculty, an amount of abnormal alteration in the respiratory movements, sufficient to constitute a physical sign of disease. When it is desired to confirm the evidence which the eye discovers by resorting to measurement. Dr. Quain's stethometer is convenient. To measure partial movements, this or some analogous instrument is required. But to ascertain the amount of expansive movement of both sides, or of the two sides, separately, in order to institute a comparison between the two, it is sufficiently accurate for practical purposes to take the circular dimensions with the graduated tape, first during a full inspiration, and next after a forced expiration. According to Hutchinson, the average range of motion, as thus ascertained, in persons of middle stature and weight, is about three inches, seldom amounting to four inches. If the cir- cumference of the two sides, when fully dilated, and subsequently when contracted, be obtained, the simple rule of subtraction gives the range and expansibility at the part of the chest where the cir- cular measurement was made. The expansibility of each side being in the same way ascertained, a comparison of the two sides, as re- spects the amount, of course gives the extent to which the move- ments on one side are abnormally diminished, or on the other side increased, or, again, what is oftener the case, diminished on one side, and, at the same time, increased on the other side. The effect MENSURATION. 299 of disease on the respiratory movements is most strikingly exempli- fied in cases of chronic pleuritis with large effusion. As stated by Walshe, the difference between the fullest expiration and the fullest inspiration on the side affected, may not exceed one-sixteenth of an inch, while the other side, in consequence of its movements being supplementarily increased, may show a difference of two and a half inches, — an extent as great as the movements of both sides united, in health. The various forms of disease which occasion notable modifications of the respiratory movements, have already claimed consideration in connection with the subject of inspection. To consider them in connection with mensuration, would involve a repetition of the facts contained in Chapter IV, to w^iich the reader is referred. Mensuration may be extended to embrace the measurement of the capacity of the chest, as regards the quantity of air which it is capable of receiving with inspiration, and expelling by the act of expiration. An instrument, called the spirometer, invented by Dr. Hutchinson, is designed for this purpose. This instrument has been already noticed in connection with mensuration of the chest in health; and in that connection, its application to the study of disease was incidentally considered. In view of the extensive range of capacity within the limits of health, and also of the fact, that the quantity of air which can be voluntarily expelled from the lungs is subject to considerable variations from causes irrespective of the condition of the pulmonary organs — causes affecting muscular powder — the utility of the spirometer in the diagnosis of disease is very limited. The information which it is capable of affording is, for the most part, negative ; that is, if the vital capacity, adopting the expression used by Hutchinson, be great, it is presumptive evidence that intra- thoracic disease does not exist ; but found below the average, it is by no means proof of the existence of pulmonary disease. Even when the existence of disease is positively indicated by this mode of mensuration, it furnishes no indications of the nature or seat of the morbid condition. If the vital capacity of an individual in health have been ascertained, whether it be great or small, so long as it continues undiminished, it may be rationally inferred that the lungs remain free from disease. With reference to such a comparison, it is desirable that persons should test the power of expiration in health, and note the result. Repeated trials with the spirometer, also, during the course of disease, will afford some evidence as to 300 PHYSICAL EXPLORATION OF THE CHEST. the extent of its progress ; biit this evidence cannot be much relied upon, owing to the influence of circumstances other than pulmonary lesions. The spirometer employed by Dr. Hutchinson is so cumbrous an instrument as to be only available in hospital or office practice. Mr. Coxeter, surgical instrument maker, in London, has invented a sub- stitute, which is very convenient and portable. It consists of a bag, made of India-rubber cloth, of sufficient size to hold the utmost amount of air that a person with the largest vital capacity can expel from the lungs, with two apertures, to one of which is fitted a glass mouth-piece, while the other communicates with a cylindrical bag holding, when fully distended, fifty cubic inches of air. The latter is the meter, and by a scale marked on its exterior, any quantity less all the amount it will contain may be measured. The orifices of the large bag or reservoir are regulated by stopcocks ; and by an orifice at the extremity of the meter, also regulated by a stop- cock, its contents may be expelled. The patient breathing into the reservoir with as prolonged an expiration as possible, the air is re- tained by closing the stopcocks. It is then measured, by refilling the meter until all the contents of the reservoir are expelled. The whole apparatus can be folded compactly, and placed in a leathern case not too bulky to carry in the pocket. Summary. The objects of mensuration are to determine, first, alterations in the size of the chest, which may be partial or general ; and, second, alterations in the extent of respiratory movements. Partial en- largement or depression is measured by means of callipers ; general enlargement or contraction is determined by comparing the hori- zontal semi-circumference of the two sides, which is ascertained by the employment of a graduated inelastic tape, and by measuring distances between certain anatomical points, such as the distance of the nipple from the mesial line, and the space between the posterior margin of the scapula and the spinal column. In scientific re- searches involving observations recorded for analytical investigation, it is convenient and important to employ the instruments just men- tioned, expressing results in figures ; but, in general, alterations in size may be ascertained sufficiently for diagnosis, by inspection. Clinically, the advantage of mensuration with reference to compari- MENSURATION. 301 son of the dimensions of the two sides, relates to variations taking place at different periods in the same case, these variations some- times being important to be considered in connection with thera- peutical agencies ; and, thus restricted, pleuritis with effusion is the affection in which this method of exploration is particularly useful. According to the researches of M. Woillez, mensuration practised daily during the career of acute diseases, shows, first, a progressive enlargement of the whole thorax during the development of the dis- ease ; second, a stationary condition of enlargement while the acute symptoms continue ; and, third, a gradual return to the normal size while resolution of the disease is going on. This series of altera- tions is accounted for by M. Woillez on the hypothesis of pulmonary congestion existing as an important element of all acute affections. Aberrations of the respiratory movements are determined by the chest-measurer, and by the stethometer. The first measures the ex- tent of motion, at any part of the chest, in the direction of its diameter ; the latter measures the amount of expansive movement. These instruments, although extremely serviceable in certain scien- tific researches, are not needed in determining the existence or non- existence of abnormal movements, inasmuch as comparison of the two sides Avith the eye suffices for that purpose. To institute a com- parison between the two sides as respects the relative extent of gen- eral expansibility, the difference may be taken between the horizontal circumference after a deep inspiration, and that after a forced expi- ration : this mode of determining the extent of general motion does not secure complete accuracy, but it is sufficiently exact for ordinary practical purposes. The spirometer invented by Dr. Hutchinson is designed to deter- mine the "vital capacity " of the lungs, by ascertaining the quan- tity of air which can be expelled by a single prolonged expiration. The results of this method of mensuration are, however, in a great measure, dependent on circumstances affecting muscular power, ir- respective of the condition of the pulmonary organs; and the de- gree of the vital capacity of different individuals is found to differ widely in health. It is rarely, therefore, that positive information respecting the existence of pulmonary disease is to be obtained from this source, in cases in which symptoms and other signs fail to indi- cate the fact. In a negative point of view, however, the spirometer may sometimes be useful. If the degree of vital capacity be found to equal or exceed the average, it warrants the presumption that 302 PHYSICAL EXPLORATION OF THE CHEST. f disease does not exist ; or, if the amount of vital capacity proper to j an individual in health be known, and it be found that this amount \ is not diminished, it may be fairly presumed that the pulmonary organs are sound. i \ History. ^ The remarks made under this head, in connection with the subject j of Inspection, Chapter IV, are equally applicable to Mensuration. j CHAPTER VI. PALPATION. Examination by palpation consists in simply applying the palmar surface of the hand or the fingers to the exterior of the chest. This is one of the least important of the methods of physical exploration, but in some cases of disease it furnishes signs of considerable im- portance. In general, the evidence of disease which it affords is auxiliary to, or confirmatory of, information, more positive and com- plete, derived from other methods. The phenomena appreciable by the application of the hand to the chest are of different kinds. I shall proceed at once to notice those which are important to be borne in mind with reference to the diagnosis of intra-thoracic diseases. By means of the touch, the existence of tenderness on pressure, its degree, situation, and extent, are ascertained. Manual exami- nation assists in determining whether it be seated in the integument, or within the thorax. If it be owing to sensitiveness of the surface, it will be superficial ; mere contact of the fingers will excite pain, which is not proportionately increased if firm pressure be made. If intra-thoracic, the hand lightly applied will be supported, and the suffering will be according to the force employed. In short, the rules by which a neuropathic tenderness is distinguished from that due to inflammation are available here, as in other situations. The elasticity of the thoracic walls is ascertained by manual ex- amination. Information on this point, it is true, may be obtained, incidentally, in practising percussion ; but in order that the attention shall not be divided between two objects, it is useful to make pres- sure with express reference to the sense of resistance. The elasti- city of the walls of the chest is diminished in proportion as the pulmonary substance is rendered non-elastic by solidification ; and, also, in a notable degree, when a considerable quantity of liquid is contained within the pleural sac. In connection with other signs, this possesses considerable importance. 304 PHYSICAL EXPLORATION OF THE CHEST. Bj passing the hand over the thoracic surface, we are aided in judging of the nature and extent of changes in form and size inci- dent to disease. Inequalities, due to depressions or projections, are sometimes better appreciated by the touch than by inspection. By the touch, it is ascertained wliether enlargement arises from a mor- bid condition exterior to the walls of the chest, for example, oedema, or abscess, or whether it be intra-thoracic. If the latter, the sensa- tions communicated to the hand sometimes afford important infor- mation as to the character of the disease. A circumscribed enlarge- ment, produced by an aneurismal tumor, may be accompanied by a pulsation, Avhich, in connection with other signs, serves to establish the diagnosis. It is important, hoAvever, to remark, that a circum- scribed pulsating tumor may be caused by a collection of pus be- neath the skin, communicating with an accumulation within the chest by means of a perforation through the thoracic walls. In this case, the pulsation is due to the cardiac impulse propagated through the mass of liquid. Throbbing, diffused over a considerable extent of surface, has also been repeatedly observed in cases of empyema without perforation of the thoracic walls, the pus being retained en- tirely within the pleural cavity. These instances have given rise to a variety of the affection called "pulsating empyema."^ Under these circumstances, the heart's impulse, communicated to the puru- lent collection, is sufficient to cause an appreciable movement of the walls of the chest. The same phenomenon has been observed by Dr. Graves in a case of pneumonitis, and by Dr. Stokes, in con- nection with a large cerebriform tumor springing from the posterior mediastinum, and displacing the upper lobe of the left lung.^ In the latter instances, it is doubtful whether the pulsation was the transmitted cardiac impulse, or whether it was due to arterial throb- bing of the parts within the chest. The last is the explanation adopted by Dr. Stokes. These different morbid conditions under which an abnormal pulsation, circumscribed or diffused, is discovered by palpation, are to be discriminated by calling to our aid, in addi- tion to symptoms, the associated signs determined by the several methods of exploration. Fluctuation is occasionally distinctly felt in cases of chronic pleu- ritis, or empyema, in the distended intercostal spaces. I have met 1 Vide Walshe on Diseases of the Lungs, etc. 2 Stokes on the Chest, second American edition, 1844, page 280. PALPATION. 305 with instances in whicli it was well marked over a large excavation in patients extremely emaciated. The concussion produced by liquid within a superficial cavity thrown with force against the tho- racic walls by the act of coughing is sometimes very plainly per- ceptible to the touch, as well as to the eye. The divergence and convergence of the ribs, whether persisting or incident to the respiratory movements, are appreciated by palpation better than by inspection. Placing a finger in the intercostal spaces, they can be accurately compared with respect to their relative width on the two sides, and the manner in which they are afiected by respiration. In this way it may be ascertained that when one side of the chest is enlarged, either by increased volume of lung or by pleural efi'usion, the lower intercostal spaces are widened, and those between the upper ribs narrowed. The ribs, under these circum- stances, on the affected side, will be found to remain comparatively motionless during the movements of respiration, while, on the oppo- site side, those situated at the lower portion of the chest manifestly become more widely separated by the inspiratory act. Obliteration of the hollows between the ribs, from the pressure of a liquid, is more distinctly felt than seen. The smooth, even surface which characterizes the affected side in cases of chronic pleuritis, or em- pyema, with notable dilatation of this side, is appreciated by the touch better than by the eye. In the same manner, tactile exam- ination serves to distinguish the comparatively unequal enlargement due to emphysema. With the hand applied on the chest, the extent of motion at that part with inspiration is apparent. A comparison of the two sides at different points may in this way be made with respect to the relative amount of expansibility, the evidence obtained by ocular examination being thus confirmed or modified. In exploring the female chest, if sensitiveness on the score of delicacy preclude a satisfactory examination by inspection, palpation may be employed as an alternative. The respirations may be conveniently enumerated by means of palpation. In one respect this method has an advantage over in- spection, viz., the movements being felt, the eyes are left unoccupied except to note the time during which the respirations are counted. In the female, the hand may be applied, for this object, in the infra- clavicular region ; in the male, the upper part of the abdomen is to be preferred. 20 306 PHYSICAL EXPLORATION OF THE CHEST. The situation of the apex-impulse of the heart is sometimes an important point in the diagnosis of diseases affecting the pul- monary organs. In large pleuritic effusions, and in some cases of emphysema, the heart is removed from its normal situation. Under these circumstances the impulse may be felt, as well as seen, at a point more or less distant from that where it is to be sought for in health. A collection of liquid in the right pleural sac pushes the heart in a line gomewhat diagonal, upward and outward, to the left of its normal situation. If the liquid be contained in the left pleural cavity, and sufficiently copious, the organ is carried upward and lat- erally to the right, and may be found to pulsate between the fifth and seventh ribs to the right of the sternum. The absorption of large liquid effusion in either side also tends to displace the heart, through the influence of atmospherical pressure or suction. This effect, but to a less extent, has been observed in other affections at- tended with diminution of the bulk of the lung, viz., after absorption of inflammatory exudation, collapse, or atrophy, and in cases of tuberculosis involving considerable destruction of the pulmonary substance. Absence of the heart's impulse, owing to the organ being pushed backward from the thoracic walls by the increased volume of the overlapping lung, is one of the signs of emphysema ; and in some instances of this affection the heart is depressed, so that its impulse is transferred to the epigastrium. Finally, vibratory motions of the walls of the chest, accompany- ing the act of speaking, and, under certain circumstances, respira- tion, constitute physical signs possessing in some cases considerable importance. If the palmar surface of the hand be lightly applied over the healthy chest in certain situations, the vibrations of the vocal chords, propagated along the bronchial tubes, and communi- cated to the thoracic parietes, give rise to a thrilling sensation, called the vocal vibration or fremitus. This is strongly marked if the fingers are placed upon the larynx or trachea. It is more or less apparent in the infra-clavicular region ; in an inferior degree in the mammary and the infra-mammary region; ceasing below the line of hepatic dulness ; slight, if appreciable, behind over the scapulae ; generally felt, and sometimes Avell marked, in the inter^ and infra- scapular and axillary regions. The normal vocal fremitus, like the vocal resonance, the respiratory murmur, and the sound on percus- sion, is found to present great variations in degree in different indi- viduals entirely free from pulmonary disease. In some persons it is strongly marked; in others it is moderate, and in others slight; PALPATION. 307 and sometimes it is nowhere appreciable. Other things equal, it is stronger in proportion as the chest is thinly covered with fat and muscle. The character of the voice, also, materially affects its inten- sity. In general, the fremitus is notably stronger in persons whose voices are powerful and low in pitch. It is therefore ofteuer present, and is more apt to be intense, in adult males, than in females and chil- dren,whose voices are feebler and more acute. It is appreciated by the ear applied to the chest, even better than with the hand, and, in connection with the subject of vocal resonance, it has already been incidentally noticed. As already remarked in that connection, the vocal fremitus does not sustain any fixed relation to vocal reso- nance. The latter may be intense while the former is slight, and vice versa. This statement applies equally to health and disease. A loud shrill voice is most favorable for intensity of vocal resonance, whether normal or morbid ; on the contrary, as just stated, bass tones are most likely to give rise to a strong fremitus. The in- tensity of the fremitus, in health or disease, is affected by position. In the great majority of instances, it is more strongly marked if the patient be recumbent, than in the sitting posture. With respect to the normal vocal fremitus, it is important to bear in mind that uniformity of the two sides of the chest is the excep- tion rather than the rule. In the larger proportion of individuals it is more marked on the right than on the left side. This is true, not only of the summit of the chest, but at the lateral-posterior portion inferiorly. This natural disparity must be taken into ac- count in estimating the effects produced by disease. The vocal fremitus may be increased, diminished, or suppressed, by morbid conditions. In a positive and negative point of view, therefore, the voice, by means of palpation, furnishes physical evidence of disease. An increase of the vocal fremitus occurs in solidification of lung, especially from inflammatory -exudation and tuberculous deposit ; less frequently and in a less degree, in con- nection with oedema, extravasation of blood, or carcinoma. Bear- ing in mind the disparity between the two sides just stated, a relatively greater amount of fremitus on the right than on the left side, affords equivocal evidence of the existence of disease. If, however, a greater amount be found on the left side, it is highly significant of a morbid condition. Seated at the summit of the chest, in conjunction with symptoms denoting a chronic pulmonary affection, it points to a tuberculous deposit. In the second and the resolving stage of pneumonitis, fremitus is sometimes increased and sometimes 308 PHYSICAL EXPLORATION OF THE CHEST. diminished. When notably diminished, in most cases the diminu- tion is due to the presence of liquid. The normal vocal fremitus is diminished or suppressed, as the rule, whenever the lung is removed from the thoracic walls by the accumulation of liquid or gas within the pleural cavity. Generally, in cases of pleuritis with effusion, of hydrothorax, and of pneumo- hydrothorax, fremitus on the affected side is absent, or, if present, relatively feeble. This negative sign is of more value if it be found on the right side, the rule in this instance being the reverse of that applicable to increased fremitus. The reason for the rule is obvious. Were we to attempt to arrive at a diagnosis by exclusive reliance on the vocal fremitus, it would be necessary to enjoin caution not to regard the normal fremitus remaining on the left side, in cases in which it is diminished or suppressed by disease on the right side, as proceeding from a morbid condition of the left lung. The liability to this error will always be obviated by attention to associated signs. In some cases of pleuritis, the vocal fremitus is increased at the summit of the chest, over the lung condensed by compression, while it is feeble or null below the level of the liquid. As already remarked, the normal vocal fremitus on the right side ceases below the line of hepatic flatness. In cases of enlargement of the liver, in which it encroaches on the thoracic space, absence of fremitus constitutes one of the signs assisting in determining the fact that the flatness on percussion, extending a greater or less distance above the normal limits, is not due to consolidated lung. The sign is important in this connection, because when the lower lobe of the right lung is solidified, percussion may give flatness equally over the liver and the solidified lung. Certain motions of the chest, perceptible on manual examination, are occasionally incident to the respiratory movements. The bronchial rales, both dry and moist, i. e., the mucous, sonorous, and sibilant, and the gurgling incident to cavities, sometimes cause a vibratory thrill, appreciable on application of the hand. This is called the rhonchal fremitus. In some of the instances in which a pleural friction-sound is present, the rubbing of the roughened sur- faces is distinctly apparent on palpation. This never occurs save when a friction-sound is, at the same time, strongly marked on auscultation. It is observed at a late stage in pleurisy, after ab- sorption of liquid has brought the pleural surfaces into contact, the period of the disease when the friction-sound is oftenest observed, and is most apt to be loud and rough. PALPATION. 309 Summary. Palpation furnishes information respecting the degree, situation, and extent of soreness of the chest ; the degree of ehisticity of the thoracic walls ; the changes in form and size ; inequalities of the surface; the condition of the intercostal spaces, and the amount of convergence or divergence of the ribs in respiration. In some instances, by determining the existence of fluctuation, it establishes the presence of liquid in the pleura, or in a superficial pul- monary excavation. It may be employed in estimating the extent of motion with the respiratory acts, and in a comparison of the two sides of the chest, in difi'erent situations, in this respect. It affbrds a convenient mode of enumerating the respirations. It is useful in determining whether the heart remains in its normal position, or has been dislocated in connection with disease affecting the pulmonary organs. The vocal fremitus, felt when the hand is applied to the healthy chest, is increased, diminished, or suppressed, in connection with dif- ferent forms of disease. It is frequently increased in cases of solidi- fication, especially from inflammatory exudation, and from tubercle. An increased amount of fremitus, situated on the left side, accord- ing to the part of the chest at which it is observed, is a significant sign of either phthisis or pneumonitis. Diminished or suppressed fremitus is incident to diseases in which the lungs are removed from contact with the thoracic walls, viz., pleuritis with efi"usion, and pneumo-hydrothorax. It coexists with flatness on percussion over the space occupied by an enlarged liver. Diminished and suppressed fremitus are much more valuable as physical signs when they occur on the right side, in consequence of the normal fremitus being gen- erally more marked on that side. A fremitus sometimes accompanies the bronchial rales, and gur- gling; and a rubbing sensation is occasionally felt in conjunction with a loud and rough friction-sound, occurring in pleuritis, generally after the removal of the liquid efi"usion. History. The general remarks under this head, made with reference to In- spection, Chapter IV, are also applicable to palpation. The absence of the normal vocal fremitus, as a sign of pleuritic efiusion, was first pointed out by M. Reynaud. CHAPTEE VII. SUCCUSSION. Sudden agitation of the body, under certain circumstances of dis- ease, occasions a splashing noise which is quite pathognomonic. To produce it, the practitioner, applying his ear to the chest, grasps the shoulder of the patient, and moves abruptly, but not violently, the trunk backAvard and forward, or laterally. This method of exami- nation is called Suceussion. A splashing noise is the only physical sign developed by this method ; and, as just stated, it has a special signification, representing, in the vast majority of the cases in which it occurs, a particular form of disease, viz., pleuritis with perfora- tion, or the affection commonly called pneumo-hydrothorax. The term splashing is descriptive of the character of the noise. It may be imitated by shaking a bottle, partially filled with water, the remainder of the space being occupied with air. The conditions re- quisite for the production of the sign are a cavity of large dimen- sions, partially filled with liquid, and partially with air or gas. These conditions obtain in pneumo-hydrothorax. In that afi"ection, air, or gas, and liquid, are contained within the pleural cavity. It involves, in the great majority of cases, perforation of the lung, but this is not essential to the production of the sign. Air and gas within the pleural sac, without communication with the bronchial tubes, and without perforation of the thoracic walls, suflSce for its manifestation. The sign would be entirely pathognomonic, except that it is sometimes observed in cases of a very large tuberculous excavation. It is ob- vious that a cavity of great size may, at times, furnish the necessary physical conditions, viz., sufficiency of space containing liquid and air. With this exception (and the exceptional instances are ex- tremely infrequent), the sign belongs exclusively to pneumo-hydro- thorax. The intensity of the splashing noise, and the facility with which it is produced, vary considerably in different cases. It may not be SUCCUSSION. 311 apparent save when the ear is either in contact with, or in close proximity to, the chest; but in some instances, it is suflSciently loud to be heard at a distance. I have known it to be so intense as to be audible throughout a large lecture-room. It is produced, not alone by succussion practised for that purpose, but by any sudden, quick motions sufficient to occasion agitation of the liquid. Hence, it not infrequently arrests the attention of the patient. Dr. Stokes relates a case in which a patient, affected with pneumo-hydrothorax, was able to take horseback exercise, but whenever he rode in a gal- lop, or hard trot, he was annoyed by the splashing within the chest. An analogous case has fallen under my observation. The patient, a female, lived for several months after the occurrence of perforation in connection with tuberculosis, followed by pneumo-hydrothorax, and retained sufficient strength to walk about, and to ride in the open air. Sudden change of position, rising up, sitting down, etc., produced a splashing noise, very apparent to herself ; and in riding in a carriage, every jolt was attended with the same effect. The sign is not uniformly present in cases of pneumo-hydrothorax. Its absence in a certain proportion of instances depends on the too large proportion of liquid to the quantity of air or gas, or on the too great consistency of the liquid, or on both combined. The thinner the liquid, the more readily is the splashing produced. The quality of the noise, as well as its intensity, varies. It frequently has a high-pitched amphoric tone, and it may be commingled with well-marked metallic tinkling. A noise resembling somewhat thoracic splashing originates within the stomach when this organ contains a certain quantity of liquid, and is at the same time distended with gas. The associated symp- toms and signs will always obviate the liability to doubt arising from this resemblance. Aside from the evidence afforded by succussion, the diagnostic criteria of pneumo-hydrothorax are unequivocal, so that the former might, without much inconvenience, be dispensed with. The diagnosis of phthisis, also, at the stage of the disease when it would be possible for succussion to be available, is suffi- ciently clear without resorting to this method of examination. Summary. Generally in cases of pneumo-hydrothorax, and occasionally in cases of phthisis with a very large excavation, succussion causes a 312 PHYSICAL EXPLORATION OF THE CHEST. splashing noise, produced by the agitation of liquid in a space of considerable size, partially filled with air or gas. History. Hippocrates was aware of the fact that by shaking the bodies of patients a splashing noise was sometimes produced. This method was practised by him, and hence the sign is sometimes called the "Hippocratic succussion-sound." The fact is also mentioned by several of the ancient writers. Hippocrates attributed the noise to the presence of pus, without recognizing the necessity of the pres- ence of air or gas. He regarded it as a sign of empyema. Its pathognomonic significance has been established by modern investi- gations. TABULAR VIEW, ETC. 313 1 5 Second stage of acute pneumonitis. Chronic pneumoni- tis. Tuberculosis. Collapse. Carcino- ma. Extravasation of blood. Pleuritis with large effusion. Pleuritis with pneu- mothorax. Resolving stage of pneumonitis. Chro- nic pneumonitis. Tuberculosis. Car- cinoma. Pleuritis, with moderate or considerable effu- sion. Pneumo-hy- drothorax, involv- ing moderate con- densation of lung. Hydrothorax. >> a. 2 5 a, l| -Sa a o X> a. Vocal fremitus some- times increased and sometimes diminished. Abnormal sense of re- sistance. Vocal fremitus fre- quently increased. Ab- normal sense of resist- ance sometimes appre- ciable. a'^ ■o g a S o * to a a o ws ia Diminished respiratory movements in some cases. Increased size of chest on affected side, if the volume of the affected lung be increased. h to o S la SI o %^ GO •s a a* '^ -a .2 li • . 31 >> .a . •IS Bronchia] or tubular respiration. Broncho- phony with the loud and whispered voice. High pitch of bubbling and crepitant rales. Broncho-vesicular or vesiculo-tubular respira- tion. Bronchophony with the loud and whispered voice, if the solidification be suflBcient for a bron- cho-vesicular respira- tion approximating to the bronchial. Exagge- rated bronchial whisper and exaggerated reso- nance of the loud voice, if bronchophony be not present, l^itch of bub- bling and crepitant rales moderately raised. ■Sa a. 2 ■S 3 a fn Flatness, or notable dulness. Tympanitic resonance from air in the trachea and bron- chial tubes ; or trans- mitted from the sto- mach and colon. If the solidification ex- tend over the whole or the greater part of a lobe, vesiculo-tympan- itic resonance over the healthy lobe of the lung affected. u o 3 M ft s a t>> a jq o Complete or consid- erable solidification of lung. Partial, •*'. e., slight or moderate solidifica- tion of lung. 314 PHYSICAL EXPLORATION OF THE CHEST. o 5 3 5 Pleiiritis. Hydro- thorax. Pnoumo- hydrothorax. Pleuritis, primary or secondary to pneumonitis, tuber- culosis, etc. a ■J'i c -s p -" fcO in £ 5 "S .2 .= tr: := -3 c 5 " . ^ ^ _a -s 2 .£ - 1 c = M5)a5S-2 = 3s^-s 4^ g of-;: i "" c "= « E-^ g S "^ ^ -g . 1 = r=ii|'=:i Q ry, g &.._ K 2 c ej 3 2 IIP g a _ a * a. a = IB * ^ g;^ ^ S " ^ -f 5 g i ^ -J i 5 s s =1 g - = g -s .= - S 0-: i2 Q -t^ — g S ^ a .Q . •a = c s 5 3 £ £.2-= g c_^ ^ i-illlfiii ^ 2 Sk £ =i S » "-: 2 g- S S-a 7j2':;=s'=fc:>»c3 P^.i: S 5^ g::2 c*- g Is 11 ■ c s C — - 3 J c 3 .2 »' '--^ .5° c S B,? — "3 = -5 £ c - S^'C^ "3 ft "3 c -^ .2 M.| =5 rt S «S 3 W 2 ^^ o ■o V = ■-- , O M ® s t> =; o .a o SSt ^l^'S a ,o3 o o - -- .S m '^ ■" -a O .^ CQ fc- '^ "^ - A^ gl^s-l^as^ Mrs a » ® O g iS § 5 S .2 _2 03 ^- S ^ 3 ®'S 9 ^ ^ B J3 _. ■*-■ >-.£ -^ t»i ts =:' a bo • .: « -B P o ■^ E^: a J3 ^ C S t: « fl o - a o o ' S) ^ 5 B 'JS i M ° OS — S a m B o fi. o iyBBciciCicjBii.o B tM 0=:, 316 PHYSICAL EXPLORATION OF THE CHEST. a « 8 £> a a fl4 . 'So •is ii s a Bronchitis. Pul- monary oedema. Tu- berculosis. Bron- chorrhagia. Suppu- rative stage of pneu- monitis. Capillary bron- chitis. Pneumorrha- gia. Tuberculosis. Pulmonary oedema. Id a. 2 ^ i c g K 3 C02 a o S 3. p ho ■^ Is .a Z a S .11 -a g a '^ ■5 5 il ill III 3 " i ^ 9 3 ° 3 J- Oi '"• • M *• -^ ^ T . - f^ cs ^ a. 2 = a •2 3 1 'E 1 -S ci a " &: " E. !- g (U ci g t- -- to c a &5 » g ® *^ ja 3 § « ^ .2 — 3 = a — ■ 2, &. . "= ;f a ^ ^ II ■ 1 I 4i ja g; 9) ^- "" ^ ® 3 5 a|-3^*-iS C--" !- = - .s 3 3 g ''' - s 3 f^*" c » « § Sg.s'a'oS TABULAR VIEW, ETC. 317 •^ e8 p "S £^ Tuberculosis. Circumscribed gan- grene. Abscess of lung. Laryngitis. (Ede- ma o^ glottis. Lar- yngeal spasm. For eign bodies in la- rynx or trachea. Pressure of tumor. Accumulation of mucus or lymph. Pressure of a tu- mor, or presence of a foreign body. Plugging with mu- cus or lymph. For- eign body. Oblitera- tion of bronchial tubes. Succussion- sound in some rare cases. - Shock communica- ted to touch within a circumscribed space by act of coughing. Bulging within a cir- cumscribed space pro- duced by act of cough- ing. Circumscribed de- pression in some cases. Sinking in of soft parts above the clavicles in in- spiration. Contraction of lower part of chest in inspiration. Dry bronchial rales, sibilant or sonorous ac- cording to the size of the tubes in which they are produced. Frequently the sibilant and sonorous rales commingled. Bronchial respiration. (?) Bronchophony. (?) Cavernous respiration. Cavernous whisper. Am- phoric whisper. Pecto- riloquy. Metallic tink- ling. Gurgling. Respiratory murmur weakened or suppressed on both sides of the chest. Stridor. Respiratory murmur weakened or suppressed on one side of the chest. Murmur exaggerated on the opposite side. Respiratory murmur weakened or suppressed over a portion of the chest corresponding to the size of the obstructed bronchial tube. Sibilant or sonorous rales. Tympanitic reson- ance. Amphoric reson- ance. Cracked metal resonance. Temporary, irregu- lar constriction of bronchial tubes, by presence of adhesive mucus, swelling of the mucous membrane, and, especially, spasm of bronchial muscular fibres. Dilatation of bron- chial tubes, exclusive of the sacculated form. d 03 n o a "3 Incomplete obstruc- tion of larynx or tra- chea. Complete or incom- plete obstruction of primary bronchus on one side. Comyjlete or incom- plete obstruction of a bronchial subdivision of greater or less size. 318 PHYSICAL EXPLORATION OF THE CHEST. A a s a -^ a >> 11 sg = 02 in ■ 1 tw . tM ;S S <= 2 => S g: S " -J i g a «^ ^ ^ -13 _2 fl S O g ^ ft '" s § -a fl ^ a O cS 2 a .&! i cS C o ^ S -^ a ^.^ fl s -« .s ^ . M 0) -t; oj " a W jd fl *J fli H » is « OT S 3 - ^ a £ .2 5 t- T3 01 I. " © o a > cs o ^ oi o 5_ ■" -u al:ia-l •S,fl 2 *^£?- •^ S ^ fl ^ « -« .S E -^ •" ^ 5 § lii:iPI"^i:-f- isi:-|ii|t=l-N, a&.S£S g^g-al^ll^ ll in o fl o 'S So ^§ Eg .i g ^ 5 ^ £• o » ."t; •r' (i; " £ " ^^ OT ^ O a ■? o a . fl m H S -fl PART 11. DIAGNOSIS OF DISEASES AFFECTING THE KESPIRATORY ORGANS. PART II. DIAGNOSIS OF DISEASES AFFECTING THE HESPIEATOEY OEGANS. PRELIMIISrARY EEMAEKS. The diagnosis of diseases affecting the organs of respiration in- volves the practical application of the principles which it has heen the object, in the preceding pages, to elucidate. In the investiga- tion of diseases, however, at the bedside, the attention is by no means to be directed solely to signs. Invaluable as they are, their im- portance is greatly enhanced by association with symptoms and the knowledge of pathological laws. The results of physical explora- tion alone frequently leave room for doubt, and liability to error, when a due appreciation of vital phenomena and of facts embraced in the natural history of diseases insures accuracy and positiveness. An overweening confidence in the former is to be deprecated as well as exclusive reliance on the latter. And since the practical dis- crimination of intra-thoracic affections is always to be based on the combined evidence afforded by these three sources of information, in treating of the subject it is desirable that the attention shall not be limited to one source to the exclusion of the others. In taking up, therefore, in the succeeding pages, the diagnosis of individual dis- eases, I shall not disconnect physical signs from symptoms and pathological laws. After premising a few considerations, the signs belonging to each disease will be considered ; and under the head of Diagtiosis I shall adduce symptoms and pathological laws which are to be associated with the phenomena furnished by physical explora- tion in the discrimination of the disease. The diseases affectinor the respiratory organs, may be distributed according to their proximate anatomical relations into the following groups : 1. Those affecting the bronchial tubes ; 2. Those more immediately connected with the air-cells and pulmonary parenchyma ; 3. Those seated in the pleura. I shall take up the particular diseases embraced in these three groups, in the order just enumerated. Diseases affecting the trachea and larynx will form a fourth group. CHAPTER I. INFLAMMATION OF THE BKONCHIAL MUCOUS MEMBRANE— ORDINARY ACUTE BRONCHITIS— CAPILLARY BRONCHITIS— PSEUDO-MEMBRANOUS BRONCHITIS— CHRONIC BRONCHITIS- SECONDARY BRONCHITIS. Broxchitis, or inflammation of the mucous membrane lining the bronchial tubes, admits of being divided, nosologically, into two forms, the distinction being based on difference in seat. In one form, the inflammation is confined to the larger subdivisions of the bronchi ; in the other form, it is either restricted to the minute branches, or, more commonly, aifects them and the larger sub- divisions also. In the great majority of cases the disease is pre- sented in the first form, and, consequently, this may be distinguished as ordinary bronchitis. The second form is generally called cajnllary bronchitis. This name implies that the inflammation is seated in the capillary bronchial tubes, which is not the fact ; the smaller rami- fications are affected, but not the terminal twigs of the bronchial tree, or bronchioles, which are, properly speaking, the capillary tubes. This form ofi"ers striking peculiarities as regards symptoms, physical signs, and pathological laws. Another division, based on the duration and degree of the inflam- mation, is into acute and chronic bronchitis. The inflammation may be developed in the bronchial tubes as a primitive, idiopathic affection , and it may coexist with other dis- eases seated either in the pulmonary organs, or elsewhere. Im- portant points of difference pertain to this distinction. The aftection may be general, in other words, invading the bron- chial tubes to a greater or less extent on both sides ; and it may be partial or circumscribed, in the latter case occurring almost in- variably as a complication of some other antecedent pulmonary disease. Farther divisions were formerly made, based on the predomi- nance of certain symptoms, for example, the quantity and quality of the liquid products expelled from the bronchial tubes. By writers of the present day, these differences, although constituting important ACUTE BRONCHITIS. 323 modifications of the disease, are deemed insufficient grounds for multiplying nosological distinctions. The occurrence of a so-called plastic or fibrinous exudation on the mucous surface, however, is a peculiarity sufficiently striking and important to serve as the basis of a distinct variety. In treating of bronchitis with reference to its diagnosis, I shall consider under separate heads the following divisions : 1. Acute bronchitis. Under this head I include cases in which the disease, in addition to its acuteness, is idiopathic, and limited to the larger subdivisions ; in other words, ordinary and primary acute bronchitis. 2. Capillary bronchitis. 3. Pseudo-membranous or plastic bronchitis. 4. Chronic bronchitis. 5. Secondary bronchitis. Acute Bronchitis. The circumstances pertaining to the anatomical characters of acute bronchitis, which stand in immediate causative relation to the devel- opment of the characteristic physical signs are, unequal diminution of the calibre of the affected tubes, from swelling or thickening of the membrane, and, more especially, from the presence of tenacious mucus ; the presence or absence of liquid in the tubes ; the quantity when present ; the facility with which it is moved from place to place, and permeated by air; the size of the tubes, among those of large or medium dimensions, in which the disease and its products are chiefly situated ; obstruction, temporary or persisting, of some of the tubes, diminishing or cutting off the supply of air to the vesicles to a greater or less extent, and collapse of pulmonary lobules pro- portionate to the number and size of obstructed tubes. Physical Signs. — Percussion, in general, furnishes no positive signs in bronchitis, but negatively the information which it affords is of greater practical importance than any of the positive signs pertain- ing to the disease. Unaffected resonance on percussion is a funda- mental point in the diagnosis. As a rule, it holds good that the resonance continues vesicular and undiminished. The exceptions to this rule are infrequent. Moderate dulness, situated at the posterior and inferior part of the chest, is sometimes observed as a result of 324 DISEASES OF THE RESPIRATORY ORGANS. the accumulation within the bronchial tubes of the products of in- flammation, toward the close of the disease, in fatal cases charac- terized by an abundant secretion of these products. Collapse of portions of the lung from obstruction of certain of the tubes may also give rise to dulness. These exceptions do but little toward in- validating the rule. In the vast majority of the instances in which the resonance on percussion is diminished, the bronchial affection is a complication of some other pulmonary disease. The existence of bronchitis having been determined by symptoms, laws, and positive signs, the fact of the percussion-sound remaining unaffected serves to establish its idiopathic character. With an unimportant exception, auscultation furnishes all the positive physicg,l signs of bronchitis. These consist of the dry and moist bronchial rales. During the early part of the disease, so long as the matter of the expectoration is slight and adhesive, the rales are dry, generally sonorous, but sometimes approximating to the sibilant. The moist or mucous rales follow, when the liquid con- tained in the bronchial tubes becomes more abundant and less viscid. Both description of rales may be afterward commingled in varied proportions. The varieties of the dry and moist rales, with their distinctive fluctuations as respects intensity, persistency, etc., have been already fully described, and it is unnecessary to reproduce de- tails relative to these points. It will suffice to mention the follow- ing practical considerations : The dry rales alone do not constitute adequate proof of the existence of bronchitis, for contraction of the bronchial tubes from spasm, without inflammation of the mucous membrane, suffices for their production. Nor do bubbling rales, of themselves, invariably denote the disease, for they may proceed from either blood or pus, as well as serum and mucus, within the tubes, without involving bronchial inflammation. If, however, the two classes of sounds occur in succession, or if they are commingled, the diagnostic evidence of bronchitis is complete, but whether primary or secondary is to be determined by other signs. The occurrence of moist rales succeeding the dry is, in general, to be considered evidence of the progress of inflammation toward resolution. The combination of dry rales of different grades as respects pitch, in other words, the grave tones of the sonorous rale accompanying expiration, united with sounds approaching in acuteness the sibilant rale, the latter heard especially with inspiration, render it probable ACUTE BRONCHITIS, 325 that the bronchial inflammation extends over a considerable area, embracing the smaller bronchial subdivisions. This conclusion is also warranted by the combination of the coarse and fine varieties of the moist or bubbling rales. Another indication of the extent of the bronchial tree affected, is afforded by the diffusion of the rales over the chest. If the inflammation be confined to the larger tubes, the rales will be found to originate within a section corresponding to the middle third in front and behind ; if they emanate from the upper and lower thirds, the fact shows that the inflammation ex- tends beyond the larger tubes. Absence of the rales is by no means proof that bronchitis does not exist. Both the dry and moist bronchial rales are evanescent and variable. They may be absent at one examination and present at the next ; or they may disappear and reappear during the same examination. The different varieties may be presented in succes- sion, alternation, and in varied combinations. These diversities have been already described. But repeated explorations, in some cases of bronchitis, fail to discover any of the positive auscultatory signs. The physical conditions necessary for the production of the rales may not exist, or be present irregularly, and for brief periods, and thus they escape observation. The loudness of the rales and their constancy are not commensu- rate with the intensity or extent of the bronchial inflammation. The physical conditions requisite for the production of the dry and moist rales, may be present in a more marked degree in certain cases of mild bronchitis, than in other cases in which the disease is severe. A little reflection in connection with the mechanism of the produc- tion of these rales, will render the fact just stated intelligible. Finally, a highly important practical consideration is, the rales incident to idiopathic bronchitis are heard on both sides of the chest. The law of symmetry pertaining to this disease is often useful in the diagnosis, and hence, the value of the physical signs of the existence of the bronchial inflammation on the two sides. The vesicular murmur is frequently obscured, or even drowned by the bronchial rales. At the commencement of the disease, before the dry rales are developed, the murmur may be abnormally loud, the expiration being somewdiat prolonged, as in exaggerated respi- ration. The increased intensity may persist, if the characters of the vesicular respiration are not masked by the presence of the rales. Exaggeration of the respiratory murmur is observed es- 326 DISEASES OF THE RESPIRATORY ORGANS. pecially at the superior portion of the chest. In some cases of bronchitis the murmur is heard throughout the continuance of the disease, apparently not materially altered as respects its intensity. This is true of certain cases in which the inflammation is not severe, confined to the larger tubes, unaccompanied by much SAvelling of the membrane, and the secretion of mucus slight. The vesicular murmur is diminished oftener than exaggerated during the progress of bronchitis, and not infrequently it is suppressed partially or generally over the chest. Partial suppression may be caused by plug- ging of certain of the larger bronchial tubes with tenacious mucus, the passage of air being interrupted sufficiently to abolish sound. In this way bronchial rales, as well as the vesicular murmur, beyond the seat of the obstruction, may be arrested. Situated in the pri- mary or secondary divisions of the bronchi, the interruption to the passage of air may cause suppression over a considerable portion of the chest; indeed, the quantity and force of the current of air received by inspiration may be diminished by the adherence of the tenacious products of inflammation to the surface of the larger tubes of both lungs, so as to abolish universally respiratory sound, and yet the obstruction not be great enough to occasion dyspnoea. That partial suppression is frequently due to this cause, is shown by the vesicular murmur being suddenly developed after an act of coughing, in a portion of the chest where just preceding this act it had not been appreciable — a fact sometimes observed in auscultating patients aff"ected with this disease. This suggests a procedure which should be resorted to, in order to determine whether the diminution or sup- pression proceed from the presence of liquid products, viz., request- ing the patient to make a voluntary eff"ort of coughing, and auscul- tating immediately afterward. If the respiratory sound, with or without rales, reappear, or become more intense in a situation where, prior to the act of coughing, it was either absent or feeble, the result shows that the diminution or suppression proceeded from a movable cause of obstruction. The result may follow an act of coughing without expectoration, the collection of mucus being de- tached and thrown forward into tubes of larger size, to be subse- quently expectorated. The tumefaction and thickening of the mu- cous membrane may be sufficient to diminish, and even abolish, the vesicular murmur, in cases in which the inflammation extends to the smaller bronchial tubes. Marked diminution or suppression of re- ACUTE BRONCHITIS. 327 spiratory sound generally over the chest, under these circumstances, is evidence of the extent of the bronchial inflammation. As regards the other methods of exploration, inspection and pal- pation enable us to ascertain whether the respiratory movements are morbidly frequent, or abnormally modified. In the form of bron- chitis under present consideration, the frequency of the respirations is rarely more than moderately increased, and usually they are not labored nor attended by dyspnoea. The superior and inferior costal types of breathing are frequently somewhat more developed than in health. On applying the hand to the chest a vibration or fremitus may in some instances be felt, which is incident to the bronchial rales, and called the rhonchal fremitus. This is of little practical importance, inasmuch as it affords no information in addition to that obtained more satisfactorily by auscultation. Diagnosis. — The diagnosis of acute bronchitis, with the aid of physical exploration, is generally unattended with difficulty. Prior to the discovery of auscultation, it was confessedly impracticable, in many instances, to discriminate between inflammatory afiections seated in the mucous, serous, and parenchymatous structures. The application of physical signs, having rendered this discrimination easy and positive in the great majority of cases, has thereby con- tributed to the more successful study of the semeiological history of these different affections; so that, at the present time, the diag- nostic importance of symptoms and pathological laws is much better understood than previously. Yet, even now, cases not infrequently present themselves of which the diagnosis would be difficult and un- certain without the aid of physical exploration. Cases of pneumo- nitis and pleuritis are occasionally wanting in their most distinctive symptomatic phenomena ; and, on the other hand, cases of bron- chitis are sometimes equally deficient in its peculiar features. The differential diagnosis, under these circumstances, must rest mainly on the evidence obtained by physical exploration. Moreover, physical exploration enables the physician to discriminate with greater prompt- ness, ease, and confidence, as well as with much less liability to error, than if he relied exclusively on the symptoms. So far as the re- sults of exploration are concerned, the discrimination of idiopathic bronchitis from pneumonitis and pleurisy involves, first, undimin- ished resonance on percussion on both sides. In pneumonitis and pleuritis, as will be seen hereafter, dulness or flatness occurs on one 328 DISEASES OF THE RESPIRATORY ORGANS. side soon after the invasion. In bronchitis, the air-vesicles remain- ing filled with air, the percussion-sound retains its normal intensity, whereas, in pneumonitis the presence of solid matter within the vesi- cles, and in pleuritis the presence of liquid in the pleural cavity, di- minish or abolish the resonance. Second : the bronchial rales, often but not invariably present, to a greater or less extent, in bronchitis, exist on both sides of the chest. Bronchitis may complicate both pneumonitis and pleuritis, but the two latter affections being confined to one side in the vast majority of instances, the bronchial rales are manifested only on the aff'ected side. On the other hand, idio- pathic or primary bronchitis is a symmetrical disease, and the bron- chial rales, when present, are generally heard on both sides. It is in this way that the law of symmetry has an important bearing on the diagnosis. Third : in uncomplicated bronchitis certain distinc- tive signs present in cases of pneumonitis and pleuritis are absent. This point, like the first, is essentially negative, but its bearing on the diagnosis is quite positive. In pleuritis, auscultatory and other signs of liquid in the pleural sac, are readily appreciable. In pneu- monitis, the evidence, other than that furnished by percussion, of solidification of lung, together with the characteristic rale (the crepi- tant), are generally available. Hence, absence of the physical phe- nomena which characterize these two affections warrants their ex- clusion. Bronchitis in young children, and sometimes in adults, as will be seen hereafter, may lead to collapse of pulmonary lobules to a greater or less extent. Evidence of this, derived from physical exploration, is not always easily obtained. Symptoms are more to be relied upon than signs ; and the diagnostic symptoms are those which show the respiratory function to be compromised to a greater extent than is usual in cases of uncomplicated bronchitis, viz., frequency of the respirations, dilatation of the al?e nasi, lividity of the prolabia, etc. If, in connection with the local symptoms of ordinary bronchitis, the respirations be but little accelerated, the aire nasi not dilated, the blood properly oxygenated, and the physical signs of pneumonitis not discoverable, the affection may be considered to be simply bron- chial inflammation ; but if, in connection with the same local symp- toms, the respirations are hurried, the alae nasi dilating, the blood imperfectly oxygenated, the characteristic signs of pneumonitis being absent, collapse of lobules, especially in young children, is to be sus- pected. But this topic will be considered more fully in connection with ACUTE BRONCHITIS. 329 the diagnosis of broncliitis with collapse of lobules. In the remarks just made it is assumed that the bronchitis is of the ordinary form ; in other words, that the inflammation does not extend to the minute bronchial branches. General capillary bronchitis compromises the respiratory function to a greater extent than ordinary bronchitis with collapse of lobules ; and, hence, great frequency of the respi- rations, dilatation of the alfe, and lividity, may indicate the former, instead of the latter affection. The differential diagnosis of these affections, however, will present itself for consideration hereafter. The liability of confounding tuberculosis of the lungs Avith bronchitis, relates rather to the chronic than the acute form of the latter affection. In some cases of acute phthisis, the abrupt inva- sion and rapid progress of the disease, may lead the physician, at first, to suppose that he has to deal simply with acute bronchitis. With due investigation this error should be avoided. The fact of acute bronchitis being preceded, in a large proportion of instances, by inflammation of the air-passages above the trachea, has a bearing on this discrimination. In tuberculosis, the symptoms from the first are pulmonary. The coincidence of acute bronchitis and the development of tuberculous disease occurs in only a small proportion of cases. Hence, if an acute pulmonary affection have been ushered in by coryza, gradually advancing downward to the pulmonary organs, the presumption is in favor of its being simple bronchitis. Other points of difference are entitled to more weight than that just stated. Acute tuberculosis is frequently accompanied by hemorrhage. This does not occur in bronchitis, exclusive of the bloody streaks with which the sputa are occasionally marked. The pain in bronchitis is substernal, and is dull, obtuse, or burning in its character. Tuberculosis is sometimes accompanied by sharp, lancinating pains situated at the summit of the chest, frequently be- neath the scapula. The pulse in acute phthisis is accelerated out of proportion to the local pulmonary symptoms. The reverse is true of acute bronchitis. The respirations are much more frequent in acute phthisis than in ordinary bronchitis ; the loss of strength is notably greater, and the emaciation more rapid. But the physi- cal signs establish conclusively the differential diagnosis. In the majority of cases of tuberculosis, percussion reveals a disparity between the tw^o sides, and this may be associated with more or less of the auscultatory signs of solidification. The question, in cases of acute phthisis, whether the disease be simply bronchitis, 330 DISEASES OF THE RESPIRATORY ORGANS. can only arise dui-ing a short period after the invasion, for in the progress of the affection unmistakable evidence of its character is soon developed, in addition to that afforded by physical exploration. Acute ordinary bronchitis occurring in a person affected with em- physema, gives rise to embarrassment of the respiration and dysp- noea out of proportion to the extent and intensity of the bronchial inflammation. Without knowledge of the coexistence of emphysema, the symptoms would lead to the suspicion of an acute affection other than ordinary bronchitis, for example, pneumonitis or pleuritis. The history and physical signs enable the physician readily to de- termine the coexisting lesion which invests the attack of bronchitis with such unusual symptoms; but to point out the means of arriving at this conclusion, would be to anticipate the diagnosis of emphysema, to which a distinct chapter will be devoted. Bronchitis, unassociated with other pulmonary disease, occurs as a pathological element of certain general affections, more especially fevers. It forms an important element of rubeola ; and, present in a greater or less degree frequently in typhus and typhoid fevers, it may constitute a prominent feature of these affections. There is a liability, under these circumstances, to consider the dis- ease exclusively bronchitis. In rubeola, the bronchial symptoms preceding for several days the appearance of the eruption, this error does not imply want of care or skill on the part of the diag- nostician. The chief distinguishing points are the degree and per- sistency of the coryza, the irritation or inflammation extending along the lachrymal passages to the conjunctiva, and the dispropor- tion between the local evidences of bronchitis and the general symp- toms, such as febrile movement, pain in head and loins, loss of ap- petite, etc. These points, however, are not infrequently unavail- able ; and, in fact, in a certain proportion of cases, it is difficult, if not impossible, to predict that the affection will prove to be more than bronchitis. In continued fever the difficulty is less, and, indeed, with due attention and knowledge, it should rarely exist. Except in occasional instances, continued fever is not ushered in by marked symptoms of a bronchial affection ; these symptoms become developed after the fever is established. The disease has a prodromic period, in which usually other phenomena are more prominent than those pertaining to the pulmonary organs. Limit- ing attention to typhoid fever — the form of continued fever generally observed in this country, and the form in which the bronchial element CAPILLARY BRONCHITIS. 331 is often er marked — the duration of the stage of invasion and the characteristic symptoms frequently present in this stage suffice for the diagnosis. Afterward, in addition to the characters then present denoting the disease, viz., the abdominal symptoms, epistaxis, erup- tion, etc., the pulmonary affection, compared with the febrile move- ment, the prostration, anorexia, etc., is disproportionately mild. The rales observed are the sonorous and sibilant, more especially the latter ; and these continue, rarely merging into, or becoming combined with, the mucous rales. The facility with which the dis- crimination is made, in the vast majority of cases, renders it super- fluous to dwell longer on the details of the differential diagnosis. SUMMARY OF THE PHYSICAL SIGNS BELONGING TO ACUTE ORDINARY BRONCHITIS. Percussion-resonance undiminished on both sides of the chest. In the early stage, before liquid secretion takes place, the dry rales, especially the sonorous, present in a certain proportion of cases. After secretion, the moist rales frequently commingled with the dry. The rales heard on both sides. The respiratory murmur at the upper portion of the chest in front sometimes exaggerated in the early stage; subsequently liable to be diminished or suppressed over a part or the whole of the chest ; sometimes reproduced sud- denly after an act of coughing, in a part of the chest in which its suppression had shortly before been ascertained, and in mild cases preserving its normal intensity and characters. A rhonchal fremitus occasionally present. Capillary Bronchitis. Bronchitis is distinguished as capillary when the inflammation in- vades the minute bronchial branches. Inflammation of the larger tubes generally, but not uniformly, coexists. The capillary tubes or bronchioles, in other words, the terminal subdivisions, are not implicated. Capillary bronchitis was formerly described by medical writers under the names, peripneumonia notha, and suffocative catarrh. Its true character and seat have been but recently under- stood. It is with great propriety considered as a distinct form of bronchitis, differing from the ordinary form in important particulars 332 DISEASES OF THE RESPIRATORY ORGANS. pertaining to symptomg, laws, and signs, as well as to anatomical characters. The anatomical conditions, on which the physical signs arc imme- diately dependent, are, irregular contraction of the calibre of the minute tubes, the presence of liquid within the tubes, and obstruc- tion to the passage of air to and from the vesicles. The latter con- dition, i. e., the obstruction, is that to which the most distinctive and important symptoms stand in immediate relation. Physical Signs and Diagnosis. — In capillary, as in ordinary bronchitis, the air within the pulmonary vesicles remaining un- diminished, and, indeed, increased in quantity (excepting the reduc- tion due to the collapse of lobules, which takes place, to a greater or less extent, in a certain proportion of cases), the percussion-reso- nance is unimpaired, and may be exaggerated or vesiculo-tympanitic, especially at the superior and anterior portion of the chest. Un- diminished resonance on percussion, on the two sides, although nega- tive, is a fundamental point in the diagnosis. Dulness denotes either that the affection is complicated with pneumonitis, or that a certain amount of collapse has taken place. Auscultation furnishes, at the early part of the disease, and to a greater or less extent during its career, the dry bronchial rales. Both the sonorous and sibilant are incident to this variety of bron- chitis, but the latter is characteristic of extension to the minute tubes. The sibilant rale is sometimes in a marked degree acute or whistling in its character. The sonorous rales may be loud and musi- cal, as in cases of asthma, being appreciable by the patient himself and by others. Both varieties are generally diffused over the whole chest. The presence of the rales tends to drown the vesicular mur- mur, but the latter is rendered feeble, and may be abolished by the obstruction within the tubes, and the over-distension of the cells. The moist or mucous rales incident to ordinary bronchitis may be present, more or less, depending on the inflammation of the larger tubes, Avhich usually coexists, giving rise to the secretion of mucus in these tubes ; but a moist rale characteristic of an affection of the minute tubes is the suh-crepitant. This rale, in its sensible charac- ters, as well as in its source, holds an intermediate place between the mucous, on the one hand, and the crepitant, on the other hand. It is a bubbling rale, conveying to the ear the impression of the presence of liquid. The bubbles seem to be extremely small, and CAPILLARY BRONCHITIS. 333 somewhat unequal in size. The sound is finer than that of the finest mucous rales. It may accompany either inspiration or expiration, or hoth respiratory acts. Contrasted with the sub-crepitant, the crepitant rale is still finer ; it is dry, i. e., not conveying the idea of bubbles, and does not belong in the category of the bubbling rales ; the crepitations are equal, and it is limited to the inspiratory act. These several points of distinction enable the auscultator to discriminate between the two in the majority of instances, by the sensible characters alone. ^ The law of symmetry here, as in the ordinary form of bronchitis, has an important bearing on the diag- nosis. In conformity with this law, the sub-crepitant rale is found on both sides of the chest. This is a point distinguishing it from the crepitant rale which, in the vast majority of cases, is limited to one side. The sub-crepitant rale in capillary bronchitis is heard especially over the lower third of the chest posteriorly. Present in this situa- tion, diffused over a considerable space, on both sides, and the per- cussion-resonance unimpaired, this combination of signs in connec- tion with the symptoms of the disease, renders the diagnosis positive. The sub-crepitant rale, under these circumstances, becomes pathog- nomonic. Aside from its connection with capillary bronchitis, this rale occurs in oedema of the lungs, in hsemoptysis, in cases of phthisis, and in pneumonitis. But the associated signs and symp- toms in all cases render it sufficiently easy to distinguish between these several afi"ections and idiopathic capillary bronchitis. (Edema is a secondary affection, and gives rise to dulness on percussion. In haemoptysis, the bloody expectoration indicates the source of the sign, and hemorrhage (excepting the bloody streaks which the sputa occasionally present), does not belong among the events liable to occur in this, more than the ordinary form of bronchitis. In phthisis, the sub-crepitant rale is an occasional sign limited to a circumscribed space at the summit of the chest, and associated with more or less of the other signs, as well as with the symptoms, denoting tubercu- losis. In pneumonitis it occurs at a late stage of the disease, after the diagnosis has been determined, but the connection is easily es- tablished by the concomitant physical signs, viz., bronchial respira- 1 In a case of capillary bronchitis complicated with lobar pneumonitis in the adult, the sub-crepitant rale accompanied both respiratory acts, and the crepitant was distinctly appreciable at the end of inspiration. 334 DISEASES OF THE RESPIRATORY ORGANS. tion, bronchophony, dulness on percussion, etc., these signs being, in the majority of cases, limited to one side of the chest. If the practitioner were to be guided exclusively by the symptoms, he mijiht be at a loss in some instances to decide between the exist- ence of capillary bronchitis, and either acute pneumonitis, or pleuritis, occurring in the adult, albeit the distinguishing features in the for- mer, as contrasted with the two latter affections, are of a striking character. Acute pneumonitis and pleuritis are generally charac- terized by sharp, lancinating pains, which do not enter into the symptomatic history of capillary bronchitis. The latter, in the great majority of instances, supervenes on ordinary bronchitis. The former are preceded by an inflammatory affection of the bronchial mucous membrane in only a small proportion of cases. They are frequently ushered in by a chill, which is not observed to accompany the onset of capillary bronchitis. The suffering from orthopnoea, the cyanotic hue of the lips and surface, the great frequency of the pulse, the frequency of the respiratory acts, the rapid progress fre- quently to a fatal issue, distinguish severe cases of capillary bron- chitis, these symptoms not being present to the same extent, save in exceptional cases, of pneumonitis and pleuritis. But with the aid of physical exploration the discrimination is made with so little difficulty that it is not necessary to dwell on the subject. Both pneumonitis and pleuritis speedily present certain positive signs, so constantly present and so easily appreciated, that their absence war- rants the exclusion of these affections. These signs are incident to solidification of the lung in pneumonitis, and the presence of liquid effusion in pleuritis. In the vast majority of instances they are confined to one side in both affections. On the other hand, the sub- crepitant rale, and the dry rales belonging to capillary bronchitis, are diffused universally over the chest. An instance has fallen under my observation of phthisis in which the tuberculous deposit was so abundant and rapid as to induce great difficulty of respiration, accompanied with very rapid pulse, lividity of prolabia and face, and ending fatally by asphyxia within a fortnight. But in this case haemoptysis occurred, and the physi- cal signs denoted plainly tuberculous consolidation, most marked at the summit of the chest. In such an instance, an error of diagnosis could only befall one who depended entirely on symp- toms. Other diseases for which there is a liability of capillary bronchitis CAPILLARY BRONCHITIS. 335 being mistaken, and vice versa, are, first, certain affections of the larynx, inducing the phenomena of apnoea ; and, second, certain pulmonary affections in addition to those already mentioned, viz., asthma, ordinary bronchitis in connection with emphysema, ordinary bronchitis with collapse of pulmonary lobules, and the variety of bronchitis to be next noticed, called plastic or pseudo-membranous. The laryngeal affections referred to, are, oedema glottidis, spasm of the glottis, acute laryngitis in the adult, and in children diphthe- ritic laryngitis or true croup. In oedema glottidis, the seat of the obstruction is indicated by the sudden arrest of the inspiration, .the expiration remaining free : the reverse obtains in capillary bron- chitis. Ordinary bronchitis precedes and accompanies it only as a coincidence, not as a law. Auscultation, if there be no pulmonary complication, discovers only diminution or abolition of the vesicular murmur ; not the rales incident to capillary bronchitis. Moreover, with the finger carried to the top of the larynx, the existence of the oedema may be demonstratively settled by the touch. Spasm of the glottis, rare in the adult, but not uncommon in early life, is a paroxysmal affection, the respiration in the intervals being either free or but slightly embarrassed. It is characterized frequently by a sonorous, crowing inspiration, distinctive of its laryngeal origin. It is unaccompanied by the frequency of the pulse which belongs to capillary bronchitis. The difficulty of res- piration incident to the latter, although increased at times, is persist- ing. The positive signs of inflammation of the minute bronchial tubes are wanting. Laryngitis always presents distinctive characters referable to the voice, in addition to other points of difference. The voice is hoarse, husky, or extinguished, while its quality remains unaffected in capil- lary bronchitis. Moreover, in croup the sonorous, tubular breathing and cough are diagnostic. The respiratory acts are slow, labored, but not increased in frequency, whereas in capillary bronchitis they are extremely frequent. The absence of the auscultatory signs of capillary bronchitis in both these afi"ections, as in the foregoing in- stances, renders the diagnosis positive. A paroxysm of asthma is characterized by symptoms not unlike those presented in capillary bronchitis. The orthopnoea and ap- pearances denoting defective hasmatosis are similar in the two affec- tions. The situation of the obstruction is the same, viz., in the small bronchial branches ; and the physical signs, exclusive of the 836 DISEASES OF THE RESPIRATORY ORGANS. mucous and subcrepitant rales, are identical in character. The sonorous and sibilant rales are much more marked in asthma. In this affection the pathological element is spasm, and the affection is paroxysmal, although the paroxysms may have considerable dura- tion. The liability of the patient to attacks of asthma is known, since in the great majority of instances they occur in persons who are habituated to them. Generally, the previous history and physi- cal signs denote the existence of emphysema. The pulse furnishes a grand point of difference. In asthma, the pulse may remain un- affected in frequency, and r^ever is accelerated to the degree ob- served in capillary bronchitis. Acute bronchial inflammation, extending beyond the larger, but not to the minute branches, occurring in a person affected with em- physema, induces a train of symptoms resembling closely those of the capillary form of bronchitis. The suffering and labor with res- piration and the impaired oxygenation of the blood may be equally marked, but the prognosis is far less grave. The existence of em- physema is readily determined by present signs taken in connection with the previous history. The sonorous and sibilant rales will be likely to be present in connection with the mucous rales, but not the subcrepitant. The coexistence of the emphysema renders the symptoms pertaining to the respiration and hgematosis much less ominous than if this complication did not exist. The pulse, which, under these circumstances, is a better index of immediate danger than the symptoms just referred to, is less frequent than in capillary bronchitis. Mild capillary bronchitis occurring in an emphysematous subject, gives rise to dyspnoea out of proportion to the actual amount of ob- struction. Moreover, as such subjects are generally liable to asthma, spasm of the muscular fibres of the bronchial tubes is a more promi- nent element than in cases in which the capillary bronchitis is un- complicated, and hence the difficulty of breathing is in a more marked degree paroxysmal. Under these circumstances the pulse denotes less intensity of inflammation and danger than might be inferred from the pulmonary symptoms alone. These facts, however, have relation to the prognosis, and the importance of active therapeutical interference, rather than to the diagnosis. Finally, capillary bronchitis presents symptoms and signs be- longing alike to the form of bronchial inflammation called plastic or pseudo-membranous, which will presently be noticed under a dis- PSEUDO-MEMBRANOUS BRONCHITIS. 337 tinct head. Remarks on the diagnostic points distinguishing these affections from each other, will be more appropriate in connection with the latter. SUMMARY OF THE PHYSICAL SIGNS BELONGING TO ACUTE CAPILLARY BRONCHITIS. Percussion-resonance on both sides not diminished, but often ex- aggerated ; sonorous and sibilant rales diffused over the chest, the latter more prominent and abundant than in ordinary bronchitis; the sub-crepitant rale on both sides, and observed especially at thfe inferior posterior portion of the chest ; coarsie and fine mucous rales intermingled to a greater or less extent. Pseudo-Membranous or Plastic Bronchitis. This variety of bronchitis is characterized by the exudation of lymph on the mucous surface of the smaller bronchial tubes, form- ing what is termed false membrane, identical with the deposit which takes place within the larynx and trachea in croup. The false membrane, in cases of croup, sometimes extends downward into the bronchial subdivisions. These cases are not embraced under the. present head. The deposit in plastic or pseudo-membranous bron- chitis commences in the minute branches, and extends upwards to- wards the trachea. A fibrinous exudation in some of the tubes is occasionally observed as a contingent anatomical element of capil- lary bronchitis; but it is the basis of a distinct form of bronchial inflammation, when it constitutes the most distinctive and important feature of the disease. Pathologically, it denotes a peculiar modi- fication, without necessarily great intensity, of the inflammatory process. The expectoration of false membrane is preceded by cough more or less violent, generally accompanied by dyspnoea. These charac- teristic sputa are expectorated at intervals varying greatly in dif- ferent cases; days, weeks, months, and sometimes even years inter- vening. Aside from this peculiar feature, the symptoms may be those of an acute or subacute bronchial inflammation. Dyspnoea and the evidences of defective hgematosis may be absent, or present in a degree proportionate to the amount of obstruction and the num- ber of the bronchial ramifications affected. The danger and the rapid 22 338 DISEASES OF THE RESPIRATORY ORGANS. career of the disease depend on the circumstances just mentioned. The expectoration of false membrane may be followed by relief more or less complete. Collapse of pulmonary lobules may occur, adding to the gravity of the symptoms, and the danger. Cases in which the exudation takes place extensively throughout the lungs, present all the distressing and alarming symptoms incident to severe capillary bronchitis, and under these circumstances the disease may prove rapidly fatal. In other instances, a small number only of the bronchial ramifications being affected, the symptoms are compara- tively mild, and not indicative of danger. Under the latter cir- cumstances, the affection may continue indefinitely, or recur from time to time, or, after the expectoration of the membraniform pro- ducts, terminate in complete recovery. This form of bronchitis is exceedingly rare. It occurs in males oftener than in females. It is not limited to any period of life, but it is most frequent between the ages of twenty and fifty. Persons debilitated, or who have previously had some pulmonary affection, are more liable to the disease than those in robust health. Haemoptysis is an event not belonging to this more than to other forms of bron- chitis, irrespective of the bloody points or streaks which the sputa occasionally present. The affection may be acute or chronic. It may be partial, i. e., affecting a certain number of the bronchial tubes only; or general, extending over the greater portion of the tubes. It obeys the law of symmetry, like the other varieties of bronchitis, when it is idio- pathic. If the exudation take place extensively, or if it occur in connection with other pulmonary affections, a fatal result may be expected. Of the cases, however, in which false membrane, in more or less abundance is expectorated, a large proportion end in recovery.^ Physical Signs and Diagnosis. — The physical signs in plastic or pseudo-membranous bronchitis do not differ materially from those incident to the varieties of the disease previously considered. Ex- clusive of certain incidental morbid conditions, viz., collapse and great accumulation of liquid products within the air-tubes, percus- sion elicits a resonance undiminished on the two sides. The sonor- 1 For the results of an analysis of forty-eight cases, collected from various sources by Dr. Peacock, vide London Med. Times, Dec. 1854, and American Jour, of Med. Sciences, April, 1855. PSEUDO-MEMBRANOUS BRONCHITIS. 339 ous and sibilant rales will be likely to be beard, on auscultation, more or less diffused over both sides of the chest. The moist or bub- bling rales are developed in the progress of the disease, as in the other forms of bronchitis. Suppression of the rales and of all respi- ratory sound over portions of the chest is liable to occur either from obstruction of the tubes by the exudation, in -which case it may be temporary, and variable in situation and extent, or from collapse, in the latter case being more persisting both in seat and duration. The sub-crepitant rale may be discovered, but it is limited to certain portions of the chest. A diagnostic point pertains to the fact last stated. The presence of the sub-crepitant rale distinguishes this from ordinary bronchitis, and the limited extent of surface over which the rale is heard distinguishes the aifection from capillary bron- chitis ; in the latter variety, the sub-crepitant rale is diffused over the chest. Barth and Cazeaux, separately, have reported each a single case in which a peculiar valvular or flapping sound {jjetit bruit de soupape), was heard on auscultation, attributable to the vibration of partially detached portions of membranous exudation. It is doubtful whether the sound be sufficiently distinctive to represent the presence of this peculiar product within the tubes. Were it a diagnostic sign, the fact of its being only occasionally observed would render it practically of little value. The diagnosis of plastic or pseudo-membranous bronchitis, as dis- tinguished from other varieties of inflammation of the bronchial mucous membrane, must be based almost exclusively on the charac- teristic expectoration. Prior to false membrane being expelled, the symptoms and signs are not sufficiently distinctive for the practi- tioner to decide that this particular form of bronchitis exists. If membraniform patches are discovered in the matter of expectora- tion, their appearance may at once denote their source, and, conse- quently, the locality of the inflammation, as well as its peculiar character. Solid or cylindrical casts not only show their bronchial origin, but indicate the size, and, in some measure, the extent of the tubes involved. But if the false membrane expectorated consist simply of fragmentary pieces or shreds, the fact of the exudation, being bronchial is settled by the quality of the voice remaining un- affected, and the absence of other evidences of laryngeal disease. The circumstances just mentioned suffice for the difierential diag- nosis between croup and plastic or pseudo-membranous bronchitisi The period of life at which this affection is most apt to occur has 340 DISEASES OF THE RESPIRATORY ORGANS. some importance in a diagnostic point of view. In this respect it differs from capillary bronchitis, as well as from croup. The latter are eminently infantile diseases, whereas the affection under consid- eration is oftenest observed in persons between the ages of twenty and fifty. It should be added, that the occurrence of the characteristic ex- pectoration is not invariable. The disease may run on rapidly to a fatal termination before sufficient time has elapsed for the processes upon which the exfoliation of the exudation depends to be com- pleted. The discrimination of this form of bronchitis from affections, other than bronchitis, which compromise respiration and the function of haematosis, involves the same diagnostic points already noticed in treating of ordinary and capillary bronchitis. SUMMARY or THE PHYSICAL SIGNS BELONGING TO PLASTIC OR PSEUDO- MEMBRANOUS BRONCHITIS. In addition to the physical phenomena, positive and negative, incident to other varieties of bronchitis, a peculiar valvular or flap- ping sound {bruit de soupajje) has been observed. The sub-crepitant rale, if present, less diffused than in most cases of capillary bron- chitis. Chronic Bronchitis. Bronchitis, existing primarily as an acute affection, may be pro- longed and assume the chronic form, but occasionally the inflamma- tion is subacute from the commencement. Contrasted with the acute variety of the disease, chronic bronchitis offers some important points of difference, not only in its symptoms, effects, and patholo- gical relations, but as regards the affections from which, clinically, it is to be distinguished. It therefore merits separate consideration. Physical Signs. — So long as chronic bronchitis remains uncompli- cated with any other pulmonary affection, or with lesions affecting the size of the tubes or cells, which are apt to supervene, the chest, as a rule, yields the normal vesicular resonance on percussion. The only exception to this rule is, occasionally the occurrence of slight or moderate dulness from excessive accumulation of the liquid pro- ducts of inflammation within the bronchial tubes. Exclusive of CHRONIC BRONCHITIS. 341 this exception, a marked disparity between the two sides as respects resonance, assuming the chest to be well formed and symmetrical, denotes that the bronchitis is complicated either with some aflFection which increases the density of the lung, such as collapse, pneumo- nitis, tuberculosis, or, on the other hand, with rarefaction from em- physema. Complications exist in chronic, oftener than in acute bronchitis; and hence, equality of the percussion-resonance on the two sides is found in connection with the symptoms of the former, less commonly than in the latter affection. The bronchial rales, moist and dry, are heard in different cases with every diversity as respects character, intensity, combination, and relative predominance of the different varieties. The bubbling rales are abundant and diffused in proportion to the quantity of liquid within the tubes, its thinness admitting the passage of air, and the extent of its diffusion. They are loud and coarse when produced in the larger tubes ; finer and less intense in the smaller branches. These rales predominate in cases characterized by copious expectoration. The vibrating rales are especially prom- inent in cases in which the matter of expectoration is small in quantity and viscid, adhering tenaciously to the walls of the tubes, and not readily traversed by air. In cases characterized by the formation of small, solid, mucous pellets, a clicking valvular sound was described by Laennec as occasionally present, and attributed by him to their being moved within the tubes to and fro by the current of air. As the inflammation is generally limited to the larger tubes, the sonorous is oftener heard than the sibilant rale ; and, as in the majority of cases the expectoration is more or less copious, the mucous are more common in chronic bronchitis than the dry rales. Both the dry and moist rales may be commingled in various propor- tions, and the different varieties of each species may be heard si- multaneously at different points on the chest. The numerous diver- sities which these rales may present are not only illustrated in a series of cases, but sometimes at different periods in the progress of the same case. On the other hand, in a certain proportion of cases of chronic bronchitis, the bronchial rales, so far from being prominent, are nearly wanting. They may be only present occasionally, and repeated explorations may fail to discover any of them. These are cases in which the quantity of liquid products is small, and their removal by expectoration is speedily effected. Sometimes in cases of this description rales may be discovered if pains be taken to aus- 342 DISEASES OF THE RESPIRATORY ORGANS. cultate early in the morning, before the matter which has accumu- lated during sleep is removed ; whereas, afterward, during the day, the tubes being kept clear by repeated acts of coughing, the chest is free from adventitious sounds. The presence or absence of the rales, and in a great measure their diversities, thus depend on con- tingent circumstances which are irrespective of the severity of the disease. While the presence of the rales, in connection with the symptoms, is evidence of the existence of bronchitis, the converse does not hold true ; that is, bronchitis may exist without any of the rales being discoverable. The rales may be suspended temporarily in a portion of the chest by obstruction of one or more of the bron- chial subdivisions, and suddenly reproduced after an act of cough- ing by which the obstruction is removed. The vesicular murmur, when not obscured or drowned by the rales, is variable as respects intensity, but generally more or less dimin- ished, and in some instances scarcely, if at all, appreciable. Occa- sionally a respiratory sound is heard resembling an exaggerated vesicular murmur, but harsher, as well as louder, than the normal respiration. This modification is not peculiar to chronic bronchitis, but has already been noticed in connection with the acute form of the disease. As remarked by Walshe, it is probably not of ve- sicular but of bronchial origin. It is, in fact, an approximation to a rale. Laennec probably had reference to this modification, in stat- ing that in some cases of chronic bronchitis the vesicular murmur becomes puerile, — a statement not confirmed by subsequent obser- vations. And it is probably this modification which Dr. Bowditch terms a mucous respiration} A rational explanation is, the swell- ing of the mucous membrane, or the presence of a little mucus occa- sions an audible bronchial sound, but does not furnish the physical conditions for a fully developed dry or moist rale. The vocal resonance and fremitus in chronic bronchitis, as a rule, remain unaffected. The exceptions to this rule are certainly ex- tremely infrequent. Exclusive of the vibration perceptible to the touch, which sometimes accompanies loud rales, it may be doubted if exceptions ever occur, provided the bronchitis be uncomplicated. The relatively greater degree of resonance and fremitus on the right side in health, which in some persons is marked, may have given rise to apparent exceptions to this rule. 1 The Young Stethoscopist, page 38, second edition. CHRONIC BRONCHITIS. 343 Diagnosis. — The diagnosis of chronic bronchitis, so far as con- cerns the determination of the fact of its existence, is attended prac- tically with little difficulty. The points which call for attentive and skilful investigation relate to the presence or absence of complica- tions and resulting lesions. Is the bronchitis uncomplicated ? or is it associated with dilated bronchial tubes, emphysema, pneumonitis, chronic pleuritis, or tuberculosis ? These questions are not answered so easily as the simple inquiry whether chronic bronchitis be or be not present. In general terms, the coexistence of other morbid conditions than those pertaining to the mucous membrane is to be determined by the presence or absence of the signs and symptoms which belong to them respectively. The signs and symptoms dis- tinctive of other affections will, of course, be embraced in the con- sideration of these affections, individually, hereafter, and it would involve a needless repetition to introduce them in this connection. Of the several affections mentioned, the question of the coexistence of tuberculosis with the symptoms of chronic bronchitis is oftenest presented in practice ; and there are few problems in diagnosis more important than the discrimination of the latter uncombined, from its combination with the former. Is this simply a case of chronic bronchitis, or is there superadded a deposit of tubercle ? is a ques- tion not infrequently arising in medical practice, which is of mo- mentous import to the patient, and which, for many reasons, it is extremely desirable for the practitioner to be able to answer defini- tively. Prior to the introduction of physical exploration, this ques- tion often presented insuperable difficulty. Cases of chronic bron- chitis were considered cases of phthisis, and vice versa ; and it was impossible to avoid these errors. They are now necessarily incident to the practice of those who ignore physical diagnosis. In view of the importance of this discrimination, some of the points which it involves may be here mentioned, but the subject could not be fully considered without anticipating what will come under the head of the diagnosis of tuberculosis. The discrimination is to be based mainly on the presence or absence of more or less of the positive indications of tubercle ; but there are certain considerations per- taining to the symptoms, signs, and laws of chronic bronchitis, which have a bearing on the question, and in cases in which the positive evidence of tubercle is doubtful, they are entitled to con- siderable weight in the diagnosis. To these considerations attention will be at present limited. 344 DISEASES OF THE RESPIRATORY ORGANS. Chronic bronchitis occurring at the period of life when the tuber- culous deposit generally takes place, succeeds, in the majority of cases, the acute form of the disease ; tuberculosis is ushered in by acute bronchitis in but a small proportion of cases. Hence, in a doubtful case, if acute bronchitis have existed at the commencement, the chances are in favor of its not being phthisis. Pain is generally absent in chronic bronchitis, and, if present, is slight, dull, and sub- sternal ; acute stitch pains are very common in the course of phthisis, due to the circumscribed pleuritis which almost invariably accompanies tubercle, and they are referred to the summit of the chest on one side, or frequently to beneath the scapula. The respira- tions are habitually more or less accelerated in phthisis ; this obtains rarely in chronic bronchitis, and if acceleration occurs it is generally in paroxysms. The pulse is often notably accelerated in phthisis, and but rarely in chronic bronchitis. Febrile paroxysms, occurring gener- ally in the progress of tuberculosis, do not belong to the history of chronic bronchitis. Haemoptysis is an event of very frequent oc- currence in phthisis, and, excepting the occasional bloody streaks which the sputa present, it is never incident to mere bronchitis. The characteristic sputa of tuberculosis, viz., solid, nummular masses, striated, parti-colored, with ragged edges, are not observed in bron- chitis. The microscope reveals in the sputa of phthisical patients, frequently, fibres exfoliated from the pulmonary structure ; these do not enter into the composition of the sputa furnished by the bronchial mucous membrane. The loss of weight in phthisis is gen- erally considerable and progressive ; it is less marked in chronic bronchitis. The bronchial rales are incident to phthisis, as well as to chronic bronchitis ; but in the latter affection they are most apt to be heard, or are more abundant, at the inferior and posterior part of the chest on both sides ; whereas, in the former aftection they are heard at the superior part of the chest in front, and frequently either limited to, or more pronounced, on one side. The preceding points are quite distinctive; but, in addition, in tuberculosis there are present more or less of the positive signs of that disease, rendering the evidence complete. These will be enumerated hereafter in treating of the diagnosis of tuberculous disease. SECONDARY BRONCHITIS. 345 SUMMARY OF THE PHYSICAL SIGNS BELONGING TO CHRONIC BRONCHITIS. Clearness of the resonance on percussion. The dry and moist bronchial rales, variously intermingled, frequently but not invari- ably present, heard especially over the base of the lun^s on both sides. A harsh respiratory sound occasionally present. The vesicular murmur and rales sometimes temporarily suppressed, and reproduced suddenly by an act of coughing, as in cases of acute bronchitis. Secondary Bronchitis. Bronchitis, either acute or subacute, occurs as an intrinsic element in certain fevers, viz., typhus and typhoid, especially the latter, and rubeola. It may occur as a contingent element in other varieties of essential fevers. It becomes developed under circumstances which lead the pathologist to consider it one of the forms of the local expression of certain constitutional affections other than fever. It is regarded in this light when it coexists with gout, rheumatism, syphilis, scrofula, Bright's disease, etc. In all these instances the bronchitis is secondary to some general disease. It is liable, also, to be produced as a complication of different pulmonary diseases. Thus it is apt to accompaiiy tuberculosis and pneumonitis, in these diseases differing from the idiopathic form in being frequently limited to one side, and even more circumscribed ; in other words, being unilateral, not bilateral. In diseases of the heart it is often devel- oped as a secondary affection. Questions relating to the origin of the affection when thus secondarily produced, and other points of pathological interest, do not fall within the scope of this work. Considered in a diagnostic point of view, the varieties of secondary, as distinguished from idiopathic bronchitis, present peculiarities which are important. Some of these have been already incident- ally noticed. Others will be conveniently referred to in treating of the diseases which remain to be considered. It does not, there- fore, seem advisable to bestow upon the diagnosis of bronchitis oc- curring secondarily special consideration under a separate head. CHAPTER 11. DILATATION AND CONTRACTION OF THE BRONCHIAL TUBES —PERTUSSIS— ASTHMA. The affections named in the caption of this chapter are those which, in addition to bronchitis and pulmonary catarrh, have their seat or special manifestations in the bronchial tubes. The two first, viz., dilatation and contraction, are lesions affecting the calibre of the tubes. Pertussis or hooping-cough is an infantile disorder, the primary and prominent local symptoms of which pertain to the pul- monary air-passages. Asthma is characterized by phenomena de- pendent on spasm of the bronchial muscles. Dilatation of the Bronchial Tubes.^ Dilatation of the bronchial tubes was scarcely known to patholo- gists prior to the researches of Laennec. The inference naturally drawn from this fact relative to the rare occurrence of the lesion is not altogether correct. The inattention paid to the condition of the bronchial tubes in autopsical examinations led to the existence of dilatation beinsr often overlooked, and sometimes confounded with tuberculous excavations. The same remark will apply in a great measure to examinations since the time of Laennec; so that at the present moment it is not easy to determine very accurately the degree of its frequency. Grisolle estimates that in a very active hospital service an average of one or two cases will be likely to be met with annually. Generally, if not uniformly, associated with bronchitis, it probably, in most instances, involves the latter affec- tion in its production. The mode in which it is produced is an in- teresting point of pathological inquiry admitting of extended dis- cussion. But it would be a digression from the range of practical topics to which this work is limited, to indulge in more than a brief 1 Called Bronchiectasis. DILATATION OF THE BRONCHIAL TUBES. 347 passing allusion to it. Laennec attributed the dilatation chiefly to mechanical distension from the accumulation of mucus. This ex- planation is now deemed inadequate, and the accumulation is re- garded as rather the effect than the cause of the dilatation. A morbid condition of the walls of the tubes, impairing their elasticity, and rendering them less resisting to a dilating force, is, probably, as first pointed out by Dr. Stokes, a prerequisite, the result usually of prolonged inflammation. Hence, the lesion is one of the sequels of chronic bronchitis. With regard to the causes more immediately engaged, they are doubtless not in all cases the same. Extraordi- nary efforts of the respiratory organs, as in the violent paroxysms of coughing which occur in pertussis, may prove the efficient cause in some instances. Obstruction of a bronchus by the pressure of an enlarged bronchial gland, or other causes preventing the exit of air and mucus, may occasion sufficient distension behind the ob- struction to lead to permanent enlargement. But in the great majority of cases, there is reason to believe the dilatation depends on a prior morbid condition of the pulmonary parenchyma. Dr. Corrigan' has described an affection involving this lesion, consisting in a morbid production, around the tubes, of fibro-cellular texture, leading to atrophy and obliteration of the pulmonary cells, and, in some instances, even contraction of the entire lung. Under these circumstances, according to his views, two active forces are com- bined in producing bronchial dilatation. One is the pressure of the atmosphere from within the tubes in an outward direction, to fill the vacuum caused by the diminution of the bulk of the surrounding parenchyma. The other is the traction exerted on the bronchial walls in consequence of the adventitious fibro-cellular production becoming attached to the longitudinal fibres of the tubes, so that dilatation in this way results from the shrinking of the surrounding tissue. The morbid condition supposed to induce the lesion in the manner just mentioned, Dr. Corrigan calls cirrhosis of the lung, from its pathological analogy to the affection of the liver known by that name. The contraction of portions of lung incident to the tuberculous deposit, and still more to the cicatrization of cavities, may induce dilatation of the bronchial tubes, the walls expanding to compensate for the vacant space. More frequently, however, this result follows obliteration of more or less of the pulmonary 1 Dublin Medical Journal, May, 1838. 348 DISEASES OF THE RESPIRATORY ORGANS. cells from pneumonitis, and the compression to which they are sub- ject in cases of pleurisy. When the parietes of the chest do not readily collapse to fill the space left by the absorption of the intra- vesicular deposit in pneumonitis, or of the liquid effusion in pleuritis, the bronchial tubes, previously weakened by the process of inflam- mation, yield to the pressure of the inspired air. Under these circumstances what will be presently noticed as the uniform or cy- lindrical variety of dilatation occurs, affecting in some instances the tubes of an entire lobe or lung. Finally, according to Hope and Rokitansky, collapse of portions of lung from obstruction of the lesser bronchial twigs in some cases of bronchitis, when the col- lapsed portions are situated at considerable depth in the lung, and near a larger bronchial tube, may give rise to dilatation, on the principle which plays the most important part in the production of the lesion in connection with most of the affections to which it is consecutive, viz., expansion from the pressure of the inspired air to fill a vacuum.^ With reference to physical exploration, dilatation of the bronchial tubes is a lesion of interest and importance, from its giving rise to signs which are liable to lead to errors of diagnosis. Following Laennec, subsequent writers have described three va- rieties of dilatation. One variety consists in a spherical, sacculated, or pouch-like dilatation, occurring usually in the third or fourth subdivisions, forming, in effect, a cavity which may attain the size of a walnut, and according to Rokitansky, a hen's egg. A second variety, which is essentially similar, consists in a series of globular dilatations along the course of a tube, the calibre of the intermediate portions retaining the normal size. The tube presents an appear- ance compared by Elliotson to a string of beads. In the third va- riety, a cylindrical and nearly uniform enlargement of a tube, with more or less of its branches, takes place. The last species of dila- tation sometimes extends over a whole series of bronchial subdivi- sions, the enlargement gradually increasing toward their extremi- ties, ending abruptly in cul-de-sacs, the appearance when laid open being not unlike that of the finger of a glove. Occasionally the several forms of dilatation are combined in the same lung. 1 The reader desirous of a fuller exposition of the mechanism of the produc- tion of this lesion may consult with advantage the works on Pathological Anat- omy by Hasse, Am. ed., page 280, et seq. ; Jones and Sieveking, Am. ed., page 389; and Rokitansky, Syd. ed., vol. iv, page 5. DILATATION OF THE BRONCHIAL TUBES. 349 Bronchial dilatation, associated with obliteration of the cells, and contraction of the pulmonary parenchyma, is attended with a corresponding amount of diminution of the size of the chest, and with displacement of the movable viscera. In all such instances, probably, the diminished bulk of the lung and consequent collapse of the thoracic parietes precede the dilatation. The surrounding pulmonary parenchyma is more or less con- densed. This is necessarily, to some extent, a result of the pressure of the expanded portion of the tube ; but according to Corrigan, in a certain proportion of cases it is increased by the production of solid material which preceded the dilatation. The dilated tubes contain puriform liquid in greater or less quantity. Cases have been observed in which several globular dilatations existed near the apex of the lung, communicating by intervening bronchial tubes, so as to resemble closely a united group of excava- tions similar to those not infrequently met with in subjects dead with tuberculous disease. Under these circumstances the lesion, on a superficial examination, might readily be considered to have pro- ceeded from phthisis. In the other forms, bronchial dilatation was formerly, as already remarked/ confounded with phthisical cavities. On the other hand, in the opinion of a distinguished pathologist, many of the instances of the so-called cirrhosis of the lung, are, in fact, cases of tuberculous cavities.^ , The anatomical conditions sustaining proximate relations to the physical signs in cases of dilatation, are the degree and extent of the enlargement, and the particular form which it assumes ; the size of the bronchial tubes connected directly with the dilated portion, or portions ; the presence or absence of mucus, and its abundance when present ; the diminished bulk of the lung, and the consequent contraction of the thoracic walls. Physical Signs. — Dulness on percussion generally attends dilata- tion of the bronchial tubes. The dulness is mainly due to the con- densation and contraction of the parenchyma, which accompany the dilatation, and it is marked and diffused in proportion to the degree * The test of cavities formed by bronchial dilatation, in doubtful cases, is the presence of the characters of the mucous membrane in the tissue lining the cavities, as determined by microscopical examination. 2 Prof. J. Hughes Bennett. Treatise on the Pathology and Treatment of Pulmonary Tuberculosis. 350 DISEASES OF THE RESPIRATORY ORGANS. and extent of the abnormal density which the lung acquires. The dulness may be somewhat increased at times by an accumulation of mucus within the enlarged tubes. To the foregoing rule there are exceptions. Increased intensity of percussion-resonance is occasion- ally observed, notwithstanding the pulmonary parenchyma surround- ing the enlarged tubes is more or less condensed and contracted. This arises from the air within the tubes being sufficient to over- balance the abnormal density of the lung. The resonance under these circumstances becomes either purely tympanitic, or vesiculo- tym- panitic. The vesicular quality, in other words, is impaired or lost, and the pitch is always raised. The resonance may even assume an amphoric character. Increased intensity of resonance is of course only present when the bronchial tubes are free from morbid pro- ducts ; and as their condition in this respect varies at different times, percussion will elicit only at certain periods an increased resonance which will be found to alternate with dulness, the latter being present when the tubes are more or less filled with mucus. The physical conditions are favorable for the production of bron- chial respiration when the tubes are unobstructed, provided the dilatation be of the cylindrical variety. The enlarged calibre of the tubes and the pulmonary condensation combine to render the respiratory sound non-vesicular and tubular. The bronchial char- acters are strongly marked and the sound intense, cceteris paribus^ in proportion to the enlargement and increased density. The diffu- sion of the bronchial respiration will correspond with the space over which the dilatation extends. The presence of mucus within the dilated tubes in greater or less abundance gives rise to moist bronchial or bubbling rales, occurring at irregular periods, and variable in loudness, as in simple bronchitis. A degree of coarseness approaching to gurgling will be likely to characterize these mucous rales if the calibre of the tubes be con- siderably enlarged. The vocal resonance is generally exaggerated, and bronchophony may be strongly marked. Vocal fremitus is increased sometimes in a notable degree. An abnormal transmission of the heart-sounds may also be observed. The affection in some instances leads to changes apparent on inspection. The condensation and contraction of the pulmonary parenchyma may be sufficient to cause depression of the chest over the site of the lesion, rarely, however, so great as obtains in some DILATATION OF THE BRONCHIAL TUBES. 351 cases of advanced tuberculous disease. In the form of the disease described by Corrigan, the diminished bulk of the lung leads to an obvious contraction of one side of the chest. In the sacculated or cystic variety of dilatation, provided the en- largement be considerable, there may be present the physical signs of a cavity, viz., ordinary cavernous or amphoric respiration, gurg- ling, and in some cases pectoriloquy. Even metallic tinkling was observed in a case reported by Dr. Barlow, of London.^ Diagnosis. — The diagnosis of dilatation of the bronchial tubes is attended with great difficulty, owing to the physical signs being simi- lar to, and indeed identical with, those incident to other forms of dis- ease. The liability to error arising from the fact just stated renders it important to bear in mind the diagnostic points by which this lesion is to be discriminated from affections involving analogous physical conditions, but differing widely in pathological features. Bronchial respiration, increased vocal resonance, bronchophony, and exaggerated fremitus, are signs which accompany the consolida- tion of lung incident to pneumonitis, and tuberculosis. With acute pneumonitis, dilatation of the tubes can hardly be confounded, ex- cept the attention be directed exclusively to the physical signs. The one is an acute, and the other a chronic affection. As respects acute symptoms, a resemblance exists only when acute bronchitis supervenes on bronchial dilatation. Under these circumstances the pulmonary symptoms will be those belonging to bronchitis, the dis- tinctive features of pneumonitis, viz., lancinating pains and the rusty or bloody expectoration, being absent. The characteristic aus- cultatory sign of pneumonitis, viz., the crepitant rale, is absent. Were the mistake to occur of attributing the combined phenomena of bronchial dilatation and acute bronchitis to pneumonitis, the progress of the disease would in a short time lead to a correction of the error, for the physical signs which were incorrectly supposed to denote inflammatory solidification are found to remain, and perhaps become more marked after the local and general symptoms of acute inflammation have disappeared. In pneumonitis, on the contrary, these signs cease to be observed, or at least are notably lessened, shortly after the symptoms denote the resolving stage of the inflam- mation. From chronic pneumonitis the discrimination is less easy. But chronic pneumonitis is an affection so rare that, practically, the 1 Guy's Hospital Reports, 1847. 352 DISEASES OF THE RESPIRATORY ORGANS. fact of its occasional occurrence may almost be disregarded. When it occurs, it is generally preceded by tlie acute form of the disease. If, in a doubtful case, the prc-existence of acute pneumonitis be clearly determined, this constitutes an important diagnostic point. More- over, chronic pneumonitis is accompanied by general symptoms in- dicative of a graver malady than simply bronchial dilatation. The situation of the pulmonary affection, as indicated by the physical signs, is a point of importance. Pneumonitis, in the great majority -of cases, attacks the inferior lobe; bronchial dilatation, in most in- stances, is seated in the upper lobe. Tlie difficulty of diagnosis relates especially to the discrimination of bronchial dilatation from tuberculous disease. Each of the two forms of dilatation, viz., the sacculated and cylindrical, furnishes signs which belong equally to different stages of phthisis. Bronchial respiration, bronchophony, increased vocal fremitus, which attend cylindrical dilatation, denote, under certain circumstances, the pres- ence of crude tubercle. Cavernous or amphoric respiration and gurgling are the signs of an excavation in the vast majority of cases tuberculous in its origin. The discrimination is to be based, not on intrinsic differences in the physical phenomena, but on circumstances incidental thereto, and on the symptoms. Reasoning from negative facts, we may arrive at the conclusion that the phenomena are due to bronchial dilatation, because the absence of coexisting evidence of tuberculous disease renders it probable that the latter disease may be excluded. The differential diagnosis involves different points, whether the dilatation be cylindrical or sacculated, but the physical signs being different in these two varieties, they claim separate consideration. Dilatation of the cylindrical variety may present, as just stated, a group of physical signs which, in connection wdth cough and expectoration, appear to indicate a tuberculous deposit. What are the circumstances showing these signs and symptoms to be due, not to tuberculous disease, but to dilatation of the tubes ? The sit- uation of the physical signs, viz., the bronchial respiration and bron- chophony, is an important point. A deposit of tubercle takes place, in the vast majority of cases, first at or near the apex of the lung. The physical signs of tuberculous consolidation are therefore found at the summit of the chest, especially marked in the scapular and infra-clavicular regions. The phenomena due to bronchial dilata- tion, on the other hand, are oftener manifested over the middle por- DILATATION OF THE BRONCHIAL TUBES. 353 tion of the chest than at the summit. Taken in connection with other circumstances, this is a strong diagnostic point ; but it is to be borne in mind that the rule with respect to the situation of the tu- berculous deposit is not without exceptions, so that this point, by itself, is by no means sufficient for the diagnosis. More or less dulness on percussion, as has been seen, attends dila- tation, dependent on the degree and extent of the coexisting conden- sation. The bronchial respiration and bronchophony are due, in pa,rt, to the greater density of the pulmonary tissue, and in part to the enlarged calibre of the tubes. In tuberculous disease, these phenomena proceed exclusively from the consolidation, and, other things being equal, they are marked in proportion to the increased density of lung. Hence, in tuberculous disease, bronchial respira- tion and bronchophony are not observed in a notable degree without physical evidence of a considerable amount of consolidation being at the same time afforded by percussion. In dilatation, on the con- trary, the enlargement of the calibre of the bronchial tubes may be considerable, and the condensation comparatively moderate or slight. Under these circumstances, the bronchial respiration and broncho- phony may be strongly marked, while the percussion-resonance is but little impaired. A striking disproportion, then, between these auscultatory phenomena and the evidence furnished by percussion of pulmonary solidification, authorizes, to say the least, a presump- tion in favor of dilatation. The point to which most importance is to be attached is the ab- sence of the rational evidence of phthisis derived from the history and symptoms. In cases of dilatation, cough and expectoration gen- erally have existed for a long period. If the affection be tuberculous, certain events and results are to be expected, which, if the affection be dilatation, the case will not be likely to present. Among these events and results, the most prominent are progressive and marked emaciation, loss of muscular strength, pallor of the countenance, hsemoptysis, lancinating pains in the chest, diarrhoea, marked ac- celeration of the pulse, hectic paroxysms, night perspirations, and chronic laryngitis. If all these be absent, this fact favors the sup- position of dilatation being the pathological change giving rise to the physical phenomena which, associated with more or less of the symp- tomatic events just enumerated, would denote unequivocally the ex- istence of tuberculous disease. Occasionally, however, it happens in cases of phthisis, that nearly all these rational indications are want- 23 354 DISEASES OF THE RESPIRATORY ORGANS. ing. Hence, it is not safe to decide positively from their absence that tuberculosis may be excluded. From this consideration of the differential diagnosis it will be justly inferred that it is extremely difficult to determine that cer- tain physical signs are due to cylindrical dilatation of the bronchial tubes, and not to tuberculous solidification. In fact, the discrimi- nation can rarely be made with great positiveness. This would be a serious impediment in the way of determining the existence of phthisis, were cases of dilatation of frequent occurrence. Fortu- nately for diagnosis, although unfortunately for human life, the latter lesion is as rare as the former affection is common. And for this reason, were the practitioner to disregard the fact that cases of di- latation are occasionally met with, and not attempt to make the discrimination in practice, the chances of a false diagnosis are small. Dilatation of the sacculated or cystic variety, giving rise to caver- nous signs, viz., cavernous respiration, circumscribed mucous rales or gurgling, and in some instances pectoriloquy, have occasionally led those most experienced and skilled in physical exploration into the error of inferring the existence of a tuberculous excavation. The situation of the cavity is an important point, for reasons already stated. Tuberculous excavations are generally surrounded with considera- ble solidification from the presence of tubercle. Hence, the cavernous signs furnished by auscultation usually coexist with marked dulness on percussion. This is less uniformly true of cavities formed by dilatation of the bronchial tubes. The presence of cavernous signs, therefore, with but slight dulness surrounding the site of the cavity, favors the hypothesis of dilatation. The signs of cavities from dila- tation may be unattended by any appreciable dulness on percus- sion. This was true of a case of bronchial dilatation, simulating phthisis, reported by Louis. ^ In view of the law of phthisis by which the deposit almost uniformly takes place, first at, or near, the apex of the lung, if the percussion-resonance above the site of a cavity be found to be undiminished and vesicular, this, although by no means positive proof against the existence of tuberculosis, since the law just stated is not invariable, concurs with other circum- stances to render the supposition of dilatation probable. Another point pertaining to the physical signs is applicable to ^ Eecherches sur la Phthisie. DILATATION OF THE BRONCHIAL TUBES. 355 both varieties of dilatation, but to the present variety more particu- larly. The dilatation is generally, or at least frequently, limited to one lung. A tuberculous deposit takes place first in one lung, and in the great majority of cases, shortly afterward in the other lung. In cases of phthisis, therefore, advanced to the stage of ex- cavation, there may be expected to be present on both sides of the chest physical signs of tuberculous disease. Now, if, with the evi- dences of a cavity on one side, the other side yield no signs of dis- ease, this fact favors the exclusion of tuberculous disease. If a case have been under observation for a considerable period, the existence of tuberculosis is evinced by the physical signs of ex- cavation becoming developed where previously the signs had denoted solidification. This succession of physical phenomena does not be- long, certainly to the same extent, to the history of dilatation. And with some qualification and occasional exceptions, the general rule laid down by Stokes on this subject, probably holds good, viz. : "In phthisis, we have first dulness, and then cavity; while in dilated tubes, we have first cavity, and then dulness." The persistency of the cavernous signs without material altera- tion for weeks, months, and even years, is another point, pertaining to physical exploration, which has considerable diagnostic weight. A stationary condition, after the stage of excavation in phthisis is reached, belongs to the history of some cases, but only as an excep- tion to the rule. A notable decree of flattening of the chest at the summit is strong CO o evidence against dilatation, the depression, thus limited, in this aff"ec- tion never being strongly marked. The absence of the rational evidence of phthisis, derived from the history and symptoms, applies with greater force to the discrimina- tion when the question relates to the presence of sacculated dilata- tion or phthisis advanced to excavation, for a longer duration of the tuberculous disease, if it exist, is implied, and therefore the events and results characteristic of the latter affection are less likely to be wanting. A cavity without notable emaciation, loss of strength, pallor, haemoptysis, lancinating pains, recurring diarrhoea, frequency of pulse, hectic fever, night perspirations, or chronic laryngitis, but associated with more or less cough and expectoration of long dura- tion, may be attributed to dilatation with considerable confidence. In this statement it is of course understood that cavities from ab- scess, or circumscribed gangrene, are excluded. 356 DISEASES OF THE RESPIRATORY ORGANS. In connection with the subject of the differential diagnosis of di- latation and tuberculosis, the fact is not to be lost sight of that both may exist conjointly. As remarked by Walshe : " This compound state is, probably, beyond the reach of diagnosis." Dr. Bowditch^ gives an instance of a youth who consulted him five minutes after an attack of haemoptysis, stating that he had been quite well up to this occurrence, save that he was liable at times to a cough, and in early life had had severe pulmonary symptoms. Expecting to find few if any physical signs of disease, Dr. B. was surprised at discovering' bronchial and cavernous respiration, with bronchophony and pecto- riloquy, throughout the whole of the left lung. On this side there was a contraction as if from old pleurisy. Three months afterward death occurred from tubercles developed in the other lung, and the bronchial tubes, enormously dilated, were found to fill up the major part of the lung over which had been heard the physical signs just named. The protective influence of dilatation against tubercle was illustrated in this instance, the deposit taking place in the lung free from that lesion. A case which recently came under my observation will serve to illustrate certain of the diagnostic points involved in the differential diagnosis of dilatation and tuberculosis, and, at the same time, the difficulty of discriminating with positiveness. The patient, aged 45, a blacksmith, had suffered from cough and expectoration for fifteen years. He stated that he had had several hemorrhages from the lungs. He had, however, continued to labor at his trade till within a few weeks, and was then interrupted, not by an increase of his pulmonary symptoms, but by an affection of a testicle. He was not emaciated ; he did not present the aspect of a tuberculous patient, and he had recently gained in weight. Over the left side of the chest the percussion-resonance was moderately dull, with a some- what tympanitic quality. Over the upper and middle thirds, in front, of the left side, bronchial respiration was intense, the expira- tion notably prolonged, and high in pitch. Strong bronchophony coexisted, the voice seeming very near the ear. Whispered words were accompanied by a strong souffle, and transmitted to the ear with considerable distinctness (whispering pectoriloquy). The right side presented a well-evolved and perfectly normal vesicular respiration, with clear, vesicular percussion-resonance. 1 Young Stethoscopist, second edition, page 104. SUMMARY OF THE DIAGNOSTIC CHARACTERS. 357 Tlie history, symptoms, and signs in this case certainly point to dilatation. But the occurrence of haemoptysis renders it doubtful whether the case be not one of tuberculosis, presenting deviations from the usual course of that disease. I cite the case to show the uncertainty which must frequently attend the diagnosis. SUMMARY or THE MORE IMPORTANT OF THE DIFFERENTIAL DIAGNOS- TIC CHARACTERS, AS CONTRASTED WITH PNEUMONITIS AND PUL- MONARY TUBERCULOSIS. The physical signs accompanying cylindrical dilatation, viz., bronchial respiration, exaggerated vocal resonance, bronchophony, and increased vocal fremitus, found to be persistent, and, unless acute bronchitis exist, unattended by any of the signs and symp- toms of acute pneumonitis. If acute bronchitis coexist, certain of the signs and symptoms distinctive of acute pneumonitis absent, viz., lancinating pains, bloody or rusty expectoration, and the crepi- tant rale. The bronchial respiration and bronchophony not dimin- ished, and perhaps increased, after the symptoms of acute bronchitis have disappeared. The previous history not showing the existence of prior acute pneumonitis, which is generally true of cases of chronic pneumonitis. The bronchial respiration and bronchophony oftener found over the upper than over the lower lobe. Frequently a disproportion between the auscultatory phenomena and the evi- dence of solidification afforded by percussion. The general symp- toms denoting a less grave affection than chronic pneumonitis. Contrasted with phthisis, the auscultatory phenomena, viz., bron- chial respiration, bronchophony, cavernous respiration, gurgling, and pectoriloquy, rarely found at the summit of the chest. Fre- quently, the dulness on percussion, relatively to these auscultatory phenomena, proportionately less than in most cases of tuberculosis ; and in some instances no dulness existing, the percussion-resonance being undiminished at the summit. The physical signs, Avhen strongly marked and diffused over a considerable space, inclusive of the phenomena due to cavities, frequently limited to one side of the chest. The cavernous signs not preceded, but sometimes fol- lowed, by notable dulness on percussion. The physical phenomena persisting for a long period without any material alteration. Ab- sence of the rational evidence of phthisis derived from the symptoms 358 DISEASES OF THE RESPIRATORY ORGANS. and effects of the latter affection, such as great emaciation, feebleness, ansemia, hemoptysis, sharp pleuritic pains, tuberculous fever, hectic, night perspirations, and chronic affection of the larynx. Contraction of the Bronchial Tubes. Abnormal diminution of the calibre of the bronchial tubes may be produced in different modes, and it occurs in various pathological connections. It varies in extent, being sometimes limited to a small space, and in other instances extending to considerable dis- tance. Its situation may be near, or more or less remote from the primary bronchus. In degree it is variable. It may end in com- plete obliteration. Obliteration of the bronchial tubes, strictly considered, is a lesion distinct from contraction. For practical purposes, however, it suffices to notice both under the head of con- traction. As occurring in connection "with the different varieties of bronchitis, contraction and even obliteration of the tubes have been already referred to. Exclusive of these connections, existing as permanent lesions, they are rare, and to determine their existence during life by signs and symptoms, in the great majority of instances, is impossible. To the diagnostician they are interesting, chiefly in the light of disturbing elements, as it "were, in physical explora- tion, giving rise to phenomena "which may simulate other affec- tions or modify their characters, occasioning embarrassment and error. The attention of pathologists "was first called to the occasional oc- currence of permanent contraction and obliteration of the bronchial tubes by a French observer, M. Reynaud, in 1885.^ Reynaud "was led by his observations to the opinion that bronchial obliterations "were not very uncommon. Hasse, ho"wever, suggests that he may not have distinguished in all instances bet"ween the simple obstruc- tion produced by the presence of exudation of lymph in plastic bronchitis, and obliteration arising from adventitious tissue, or ad- hesion of the "walls of the tubes. As described by Reynaud and others, contraction and obliteration may be continuous, extending either over a single tube or a series, and sometimes all the tubes of a lobe, compared by Prof. Gross, to continuous stricture of the 1 Mem. de TAcademie Roy. de 'SIM. vol. iv, 1835. CONTRACTION OF THE BRONCHIAL TUBES. 359 urethra, or the tubes may be narrowed or closed at one or more points, as if a ligature had been applied. The obstruction incident to obliteration, or a considerable degree of contraction, induces other physical changes in the pulmonary organs. Dilatation of the tubes, forming either a pouch-like cavity just before the point of the obstruction, or an enlargement extend- ing more or less along the tube leading to that point, is apt to fol- low. Beyond the contracted or obliterated tubes, the pulmonary lobules dependent thereon for their supply of air become atrophied, shrivelled, or collapsed. And in consequence of these effects the surrounding lobules are likely to become abnormally enlarged, be- coming, in other words, emphysematous. This compound state defies diagnosis. It is obvious, the extent of the consecutive pulmonary changes, together with the symptoms and signs, will depend on the size of the bronchial tube, or tubes, contracted or obliterated, as well as on the amount of obstruction, provided complete occlusion does not exist. Continuous obliteration aifects usually the smaller divisions of the tubes. Contraction or obliteration, if limited to a small section, is observed principally in the second or third bronchial subdivisions.^ Obstruction more or less complete, however, has been met with at diflFerent situations between the primary bronchi and the minute ramifications. Seated in a primary branch, or, if the contraction or obliteration be continuous, extending over all the tubes of an entire lobe, the functions of the lobe will, of course, be interrupted or suspended, according as the supply of air is more or less dimin- ished or cut off. The atrophy and collapse of the lobe which ensue are proportionate to the obstruction. These results will be less ex- tensive, of course, in proportion as the obstruction is limited to the smaller tubes. The immediate local causes of diminished calibre of the tubes, and obliteration, are either situated within or exterior to the bron- chial tubes. Within the tubes, they consist of exudation upon the mucous surface ; a tuberculous deposit, occurring at the same time within the vesicles ; hypertrophy of the mucous membrane ; morbid excrescences springing therefrom; contraction from cicatrized ulcers; foreign substances received from without, and solid morbid products, 1 These two varieties are described and figured in Gross's Pathological An- atomy, to which the reader is referred. 2 Gross's Path. Anat., page 419. 360 DISEASES OF THE RESPIRATORY ORGANS. viz., calcareous formations, inelatiotic cysts, or acephalocysts gaining entrance into the tube from "within. In the list of causes seated in the interior of the tube are also to be included submucous deposits of serum, or lymph, carcinomatous matter, etc. The causes situated exteriorly act by producing pressure on the tube, or tubes. Among the numerous causes embraced in this class are enlarged bronchial glands, masses of tubercle, aneurismal or other tumors, and pleu- ritic effusions. Several cases were reported some years ago by Mr. T. W. King, of London,^ in which pressure of the left auricle, in connection with enlargement of the heart, was found to have occa- sioned considerable flattening of the left bronchus, reducing its calibre sufficiently to produce partial obstruction. From the fore- going enumeration, it is evident that, as already stated, the patho- logical relations of contraction and obliteration of the tubes are various. That these lesions give rise to important symptoms and signs is certain. Embarrassment of respiration, manifested by dyspnoea, may accompany cases in which the obstruction is seated in a bron- chial tube of large size, more especially when the obstruction is rapidly induced, and if it occur in connection with some other affec- tion which compromises the pulmonary functions. Nothing, how- ever, pertaining to the embarrassment of respiration would indicate specially these lesions. The signs, theoretically determined, are dulness on percussion in proportion to the number of pulmonary lobules shrivelled or collapsed, provided emphysematous dilatation of the surrounding cells be not sufficient to compensate for the con- densation ; in the latter case the resonance may be preserved, and it will be vesiculo-tympanitic in character. Both conditions, i. e., the collapse of certain lobules, and the over-distension of others, com- bine to render the respiratory murmur feeble or inaudible. The phenomena incident to bronchial dilatation may coexist, and super- sede those due directly to the contraction or obliteration of the tubes. In like manner the signs belonging to the latter may be lost among those to which the various associated morbid conditions give rise. If the situation and degree of the obstruction be such as to occasion collapse, more or less complete, of an entire lobe, depres- sion of the thoracic walls will follow. This, as well as the other 1 Guy's Hospital Reports, April, 1838. For summary, see Gross's Path. Anat., page 420. PERTUSSIS — AVHOOPING-COUGH. 361 signs, -will be likely to be presented over the superior and middle thirds in front, owing to the fact that the lesions have been oftener found in the upjjer than in the lower pulmonary lobes. Finally, to determine positively the existence of these lesions during life, as already stated, is not to be expected in the great ma- jority of instances. The coexistence of feebleness or absence of respiratory sound, with dulness and perhaps depression, under cir- cumstances when this combination of signs is not otherwise explic- able, points to obstruction of a large bronchial tube, and this opinion may sometimes be formed with considerable confidence. The grounds for this opinion are less in proportion as the contraction and oblitera- tion are limited. The same combination of signs, situated elsewhere than at the summit of the chest, warrants a suspicion of the exist- ence of these lesions. This suspicion may be entertained the more if the patient have suffered from chronic bronchitis.; and still more if lymph, in the form of bronchial moulds, has bqen expectorated. Situated at the summit of the chest, these signs would be considered to denote a tuberculous deposit; and, it is not improbable, as inti- mated by Stokes, that in a certain proportion of the instances in which a false diagnosis of phthisis is made, the physician is misled by the phenomena due to permanent obstruction of bronchial tubes. Fortunately for diagnosis, the lesions are extremely rare. Pertussis — Whooping-Cough. The seat of whooping-cough is indeterminate ; but its primary and prominent symptoms appear to depend on a morbid condition of the bronchial tubes. Nosologically, it may properly enough be classed among neurotic aifections, and, like other neuroses, it is devoid of any appreciable anatomical characters. The morbid appearances found after death do not belong intrinsically to the disease, but are due to its complications, independently of which it very rarely, if ever, proves fatal. The most frequent complications are bronchitis and pneumonitis. Others less common, are tuberculosis, croup, pleuritis, enteritis, and convulsions. Collapse of pulmonary lobules and emphysematous enlargement of the lobules which are not col- lapsed, have been observed after death. I have observed abdominal tympanites irrespective of any other apparent intestinal complica- 362 DISEASES OF THE RESPIRATORY ORGAXS. tion, a symptom mentioned by M. Blaclie as incident to this affection. Bronchial dilatation and pulmonary emphysema are occasional sequels of whooping-cough, the latter, according to Rilliet and Bar- thez, much less frequently than is generally supposed. External emphysema of the areolar tissue, from rupture of the lungs, has been known to be produced by the violence of the cough. Physical Signs and Diagnosis. — There are no physical signs characteristic of whooping-cough. During the development of the disease, the bronchial rales incident to bronchitis may be heard, and also, more or less, during the continuance of the disease. These, of course, only show coexisting inflammation of the mucous membrane. During the paroxysms, the series of expiratory efforts exhaust the quantity of air in the pulmonary cells, sufficiently to produce an appreciable diminution of the percussion-resonance ; and during the prolonged whooping inspiration, the expansion of the cells is un- accompanied by an audible vesicular murmur. The diagnosis of whooping-cough is to be based on the symptoms and laws of the disease. These are so striking and distinctive that it is recognized in the great majority of cases without difficulty after the characteristic traits become developed. During the early period the disproportionate violence of the cough in comparison with the other pulmonary symptoms, its abruptness and paroxysmal character, with more or less of the peculiarities which are after- ward so prominent, furnish grounds for a probable diagnosis ; but without the opportunity to observe for himself, relying upon the description given by others, the practitioner is often at a loss to form a positive opinion until the affection has passed to the spas- modic stage. At this period, in children, there is little room for hesitancy, save when the symptoms are so extremely mild that the special characteristics are not prominent. Cases of this kind are, however, extremely rare. In adults, the affection is less readily recognized from the fact that the whooping inspiration is less uni- formly present. Moreover, from the infrequency of cases of the disease in adults, it may escape detection because the possibility of its existence may not occur to the mind of the physician. Physical exploration may furnish useful information concerning complications which are liable to become developed in the course of the disease. The presence of the dry and bubbling rales during the ASTHMA. 363 intermissions between the paroxysms of coughing, shows the co- existence of bronchitis, and by their character, extent, and situa- tion, the practitioner is enabled to judge of the number and size of the tubes aifected, as in cases of primary bronchial inflammation. Negatively, the absence of physical signs, or the presence only of those belonging to bronchitis, is important in determining the non-existence of other and more serious complications, viz., pneu- monitis, tuberculosis, pleuritis, and emphysema. The existence of any one or more of the complications just named is to be deter- mined by means of the physical evidence of their presence, taken in connection with vital phenomena. But inasmuch as the diagnosis of these several affections will be considered fully hereafter, and the points involved in their discrimination, when they are superadded to whooping-cough, are essentially the same as when they are primary, it would involve a needless anticipation of future topics to treat of their symptoms and signs in this connection. Asthma. The term asthma, formerly applied to dyspnoea occurring as a symptom of different diseases of the organs of respiration and of the circulation, should be restricted to a paroxysmal affection, the primary local manifestations of which consist in spasmodic contrac- tion of the circular muscular fibres of the smaller bronchial tubes. Like the affection last considered (whooping-cough), it belongs, noso- logically, among the neuroses, and is consequently wanting in ap- preciable anatomical characters. Although not a very rare form of disease, it is very rarely met with in practice as a purely neurotic affection; in other words, in a large proportion of cases it is asso- ciated with morbid conditions other than spasm, to which it stands in the relation either of cause or effect. Its existence, however, independently of other affections, is sufficiently established. Physical Signs. — The physical signs during the paroxysms of asthma are not in a positive sense distinctive. Exploration of the chest is useful chiefly in a negative point of view, enabling the prac- titioner to exclude other affections accompanied by dyspnoea, and also to detect complications. Percussion elicits an exaggerated res- onance. From the very frequent coexistence of emphysema, the percussion-resonance, in the majority of cases, is more intense than 364 DISEASES OF THE RESPIRATORY ORGANS. in health, and vesiculo-tjmpanitic in character. It is stated by Walshe that if emphysema be not present, the volume of the lungs may be reduced by the expiratory efforts so as to diminish appre- ciably the clearness on percussion. As a rule, however, the volume of the lungs is increased by an abnormal accumulation of air within the cells; that is, a temporary emphysematous condition exists. Owing to the obstruction to the entrance of air into the cells, the lungs may not expand sufficiently to fill the vacuum caused by the enlargement of the chest by inspiration. Hence, the pressure of the atmosphere occasions obvious retraction of the epigastrium, of the thoracic walls of the lower part of the chest in front, and sometimes depression above and below the clavicles, with the inspiratory acts. The vesicular murmur is scarcely or not at all appreciable, and is replaced by sibilant and sonorous rales, commingled in varied and constantly varying proportions, the former generally predominant with inspiration. The dry rales also accompany the act of expira- tion, the sonorous oftener predominating during this act. The rales with inspiration frequently merge into those attending expira- tion, so that they appear to be continuous. They are diffused ex- tensively over the chest on both sides, and the sounds are generally loud and diversified, whistling, chirping, cooing, snoring, etc., in al- ternation, or heard simultaneously in different portions of the chest. The moist or bubbling rales are rarely present during the severity of the paroxysm, but they may be observed toward its close, at the time when expectoration is apt to occur. After the paroxysm, bron- chial rales generally continue to be heard for several days, and finally cease, provided the patient does not labor under a persisting chronic bronchitis. Diagnosis. — The diagnosis of asthma rests on the occurrence of paroxysms of labored respiration, presenting the physical phenom- ena just described, and the exclusion of other affections which may give rise to paroxysmal dyspnoea, resembling, more or less, that originating from spasm of the bronchial muscles. In a child, an attack of asthma may, at first, excite suspicion of croup. But a little examination suffices to show that the obstruc- tion is not seated at the larynx. The absence of the striking char- acters pertaining to the voice and cough, when the aperture of the glottis is diminished, whether it be from exudation or spasm, war- rants the exclusion of croup. From the infrequency of cases of ASTHMA. 365 asthma in childhood, the disease is not expected, and hence, when it does occur, other affections more common in early life are sus- pected until the diagnosis is settled. In the adult, laryngeal affec- tions accompanied by difficult respiration, viz., oedema glottidis, acute laryngitis, and occasionally spasm of the glottis, are referred to their true situation with still greater facility than in the child. In addition to the circumstances just named, which are equally ap- plicable, the patient's sensations indicate correctly the seat of the obstruction. Dyspnoea, occurring in paroxysms, is incident, in certain cases, to disease of the heart, giving rise to what has been known by the name cardiac asthma. The existence of heart disease may be pos- itively ascertained by means of physical signs. It is true that dila- tation of the heart occurs as a complication of asthma ; but under these circumstances asthma is known to have existed for a long time, and it is associated with emphysema. The dyspnoea occa- sioned by embarrassment of the pulmonary circulation differs in several obvious particulars from that caused by obstruction of the smaller bronchial tubes. It is accompanied by palpitation, by marked irregularity in the heart's action, by a sense of distress referred to the prrecordia, and a feeling of impending dissolution. The thoracic walls do not contract with inspiration, and the dry bronchial rales are either absent, or do not exist in that degree which characterizes an attack of asthma. Disease of heart, occasioning intense par- oxysmal dyspnoea, generally produces more or less habitual difficulty of breathing, or at least dyspnoea is frequently excited by slight causes, such as exercise, etc. Acute bronchitis occurring in a person affected with emphysema may give rise to great dyspnoea. Under these circumstances, bron- chial spasm is frequently a contingent element of the disease. The paro'xysmal increase of the dyspnoea generally depends on this ele- ment. But, in so far as the difficulty of respiration proceeds from the bronchitis in combination with the emphysema, irrespective of spasm, it is more persisting than in cases of pure asthma. It pursues a course corresponding to that of the bronchial inflammation, being developed less suddenly than when due to spasm alone, continuing during the continuance of the inflammatory condition of the mem- brane, and disappearing gradually in proportion as resolution of the bronchitis takes place. It is accompanied with more cough and ex- pectoration than belong usually to pure asthma, and the matter 366 DISEASES OF THE RESPIRATORY ORGANS, expectorated presents the characters of mucous inflammation. The moist bronchial rales are more likely to be present than in cases of pure asthma. The existence of emphysema is ascertained by means of its characteristic signs, which are hereafter to be considered. The dyspnoea which forms the most prominent symptom in capil- lary bronchitis, on a superficial examination, might, for a time, lead the practitioner into the error of supposing the case to be simply an attack of asthma. But a proper investigation should speedily correct this error. Capillary bronchitis generally succeeds, or is coincident with, inflammation affecting the larger bronchial tubes. The local symptoms of bronchitis are present, viz., cough, expec- toration of mucus more or less moilified, and substernal soreness. The respirations are much more frequent. Great acceleration of the pulse is a distinctive feature. The sub-crepitant rale is discovered on auscultation. The dyspnoea and associated symptoms are per- sistent, increasing until the inflammation reaches its acme, and slowly diminishing as the inflammatory condition subsides, present- ing, thus, in its course, a striking contrast to an asthmatic paroxysm. In capillary bronchitis, as in ordinary bronchial inflammation com- bined with emphysema, the dyspnoea may present exacerbations Avhich are due to spasm ; but the spasm is only an incidental ele- ment of the aff'ection, not, as in pure asthma, the primary, and, in relation to the bronchial obstruction, the chief pathological condi- tion. In conclusion, the diagnosis of asthma, in most cases, is very easily made. The fact of its existence is generally well known in the cases which the physician meets with in practice, repeated attacks having been already experienced. It is only when few or no paroxysms have previously occurred that there is room for mo- mentary doubt, and, in such cases, the distinctive symptomatic characters, taken in connection w^ith the absence of the physical evidence of other aff'ections giving rise to embarrassment of respi- ration, suffice for a prompt and positive discrimination. As already remarked, instances of simple, uncomplicated asthma are rare. In most cases of confirmed asthma, the practitioner may expect to discover emphysema, and, in a certain proportion of cases, disease of heart. The existence or non-existence of these aff'ections is to be determined by the presence or absence of their diagnostic symptoms and signs. SUMMARY OF PHYSICAL SIGNS BELONGING TO ASTHMA. 367 SUMMARY OF PHYSICAL SIGNS BELONGING TO ASTHMA. Exaggerated percussion-resonance. Retraction of the base of the chest in front and the epigastrium in the act of inspiration. Vesic- ular murmur enfeebled or abolished. Sibilant and sonorous rales, with both respiratory acts, loud and diversified, extensively diffused over chest. Moist rales, in some cases, at the close of the par- oxysm. CHAPTER III. PNEUMONITIS— IMPEKFECT EXPANSION (ATELECTASIS) AND COLLAPSE. Pneumonitis, or inflammation of the pulmonary parenchyma, one of the most interesting and important of the diseases affecting the respiratory organs, occurs, generally, as an acute, but occasion- ally as a chronic affection. In connection with this affection will be considered imperfect expansion of more or less of the pulmonary lobules after birth (atelectasis), and collapse of pulmonary lobules, the latter having been heretofore known as lobular pneumonitis. Acute Lobar Pneumonitis. The ordinary form of acute pneumonitis in the adult is called lobar, this name importing that the inflammation extends over an entire lobe of the lungs. This is true, at least in the great majority of cases, provided the pneumonitis be primary. Secondary or in- tercurrent pneumonitis may be more or less circumscribed. Pri- mary lobar pneumonitis is of frequent occurrence. The disease is often associated with periodical, continued, eruptive, puerperal, and rheumatic fevers, and with purulent infection of the blood. It is developed also as a complication of croup, whooping-cough, acute affections of the heart, etc. In these various pathological connec- tions, the vital phenomena, or symptoms, are presented with addi- tions and modifications Avhich serve to enhance the importance of the physical signs in the diagnosis of the disease. Authors make several varieties of pneumonitis, based mainly on semeiological distinctions. So far as relates to diagnosis, it will suflice merely to enumerate the varieties generally recognized. If the phenomena of the disease indicate purely an acute inflam- mation unattended by any unusunl features, it is frequently styled frank pneumonitis. A better title is simple acute pneumonitis. ACUTE LOBAR PNEUMONITIS. 369 Accompanied by a marked degree of prostration, and more es- pecially passive or low delirium, it is called typhoid pneumonitis. Primitive pneumonitis sometimes presents these characters, but ty- phoid fever and typhus, complicated with inflammation of the lungs, and pneumonitis presenting what are ordinarily known as typhoid symptoms, are sometimes confounded. Occurring as a complication of bronchitis, which is apt to be the case when the latter affection prevails epidemically, constituting influenza, the disease has been distinguished as catarrhal pneumon- itis. When it follows a wound, or some external injury, it is traumatic pneumonitis. The term bilious, applied in an indefinite sense to various affections, is frequently used in connection with this disease. In its applica- tion to cases complicated with icterus, the term has an obvious sig- nificance which is less apparent when it is extended to cases in which the only evidence of disordered function of the liver are sal- lowness of the complexion, a greenish or yellow coating of the tongue, dulness of the intellect, and a sense of uneasiness in the epigastrium. In districts known as miasmatic, the disease is called bilious pneumonitis, and it is often combined, in these localities, with the phenomena of the periodical fevers. Pneumonitis is called latent, as already stated, when it exists without the local vital manifestations which are usually present. So far as diagnostic symptoms are concerned, it is sometimes remark- ably latent ; but under these circumstances the existence of the dis- ease may always be ascertained by means of physical exploration. In a large proportion of cases, lobar pneumonitis is confined to one side of the chest. In a certain proportion of cases, however, the inflammation affects both sides. This constitutes a variety called double pneumonitis. When confined to one side, usually a single lobe only is affected, but not very infrequently the inflamma- tion extends over the whole of one lung. This might properly enough be considered a variety of the disease, but it has no distinc- tive name. Most of the foregoing varieties of pneumonitis, it will be observed, relate to the disease occurring as a primitive affection. It is devel- oped, as already stated, in the course of numerous diseases. Occur- ring thus secondarily, it is often wanting in diagnostic symptoms, or they are masked by the phenomena of the disease of which it is a 24 370 DISEASES OF THE RESPIRATORY ORGANS. complication, so that without the aid of physical signs it would fre- quently escape detection. Following Laennec, pathologists agree in describing the anatom- ical characters in acute pneumonitis as belonging to three different periods. The career of the disease is divided into stages corre- sponding to these periods, and each stage or period during life is characterized by phenomena, vital and physical, which are more or less distinctive. The first period constitutes the stage of inflam- matory engorgement; the second, the stage of solidification or hepatization; the third, the suppurative period, stage of purulent infiltration, or gray hepatization. For a detailed description of the anatomical characters belonging to the diiferent stages, the reader is referred to works which treat of the morbid anatomy of the affection. The essential anatomical characters which are particu- larly involved in the production of the physical signs belonging to the disease, are the following. First stage. Increased density from engorgement, and the presence of a viscid fluid within the bronchi- oles and vesicles, which are, as yet, not closed to the entrance of air ; coexisting pleuritis. Second stage. Solidification in conse- quence of closure of the greater part of the vesicles of the affected portion of lung by morbid exudation ; increased volume of the affected lung, and its incapacity for collapsing in expiration. Exudation of fibrine on the pleura, with, in some cases, more or less liquid efi'usion within the pleural sac. Third stage. Puriform fluid escaping from the cells into the bronchial tubes in greater or less abundance ; per- sisting solidification ; in some cases formation of collections of puri- form matter resulting in cavities. Physical Signs. — The several methods of exploration, with the single exception of succussion, may all furnish signs in cases of lobar pneumonitis. The signs pertaining to the disease are, there- fore, numerous ; but it will be seen that, as regards particular phenomena and . their combinations, uniformity in the different stages of the disease and in the same stage in different cases does not exist. This want of constancy, however, is rarely the source of difficulty in the way of diagnosis, although it renders an acquaint- ance with the variations which are liable to occur, in a practical point of view, important. The percussion-resonance, in the first stage, or stage of engorge- ment, may be diminished ; in other words, the sound over the affected ACUTE LOBAR PNEUMONITIS. 371 lobe, compared ■with that elicited in a corresponding situation on the unaflFected side, is more or less dull. This statement accords with the views of most practical writers, but an opposite opinion is held by Skoda. He maintains that the percussion-sound remains unaltered, be the engorgement never so great, prior to exudation. This was, in fact, the opinion of Laennec. Inasmuch as a fatal result very rarely occurs in the stage of engorgement, opportunities to demon- strate the incorrectness of this opinion are seldom offered. An in- stance has fallen under my observation, in which, owing to the dis- ease being developed in a patient affected with great enlargement of the heart, death took place before the local changes, as proved by the autopsy, had advanced to the second stage. In this case, the limits of the affected lobe (the lower lobe of the right lung) had been easily defined by dulness on percussion, together with the presence of the crepitant rale. In general, however, it is probably true that if the resonance be diminished in a marked degree, exudation has occurred, a result which may follow within a few hours from the first appearance of local symptoms of the disease. In proportion as the solidification becomes more and more complete, the normal resonance progressively diminishes. Other things being equal, the loss of vesicular resonance is a measure of the amount of solidifica- tion. The vesicular resonance may, in fact, be abolished ; but it is rarely the case that absolute flatness exists. If a certain proportion of the air-vesicles of the affected lobe do not still contain air, the bronchial tubes are not completely filled with morbid products. The quantity of air which the latter contain is sufiicient to prevent total extinction of sound. In this respect the loss of resonance in cases of solidification differs from that which attends large pleural effusion. In the latter the abolition of sound is complete ; in other words, absolute flatness exists. In proportion as the density of the pulmonary parenchyma is in- creased, first by engorgement, and next by solid exudation, the sense of resistance felt in percussing over the affected lobe is greater than in a corresponding situation on the healthy side of the chest. This sign exists in a marked degree in the second stage of pneumon- itis, and constitutes a means by which, to some extent, the amount of solidification may be estimated. The resolution of the inflammation is accompanied by a return of the vesicular resonance, and the normal elasticity. Percussion, thus, enables us to determine the progress made in the removal of the solid 372 DISEASES OF THE RESPIRATORY ORGANS. deposit, and the completeness of the final restoration of the affected portion of the pulmonary organs. The phenomena elicited by percussion which have just been stated relate mainly to vesicular resonance. The effects on the sonorousness of the chest, which may be produced by the anatomical changes in pneumonitis, are not fully embraced in the foregoing description. Over lung completely solidified by intra-vesicular de- posit, whatever sonorousness remains must, of course, be non-vesic- ular, and consequently tympanitic. Exclusive of the rare instances in which, under these circumstances, there exists absolute flatness, the vesicular is replaced by a tympanitic resonance, which may be more or less marked. The term tympanitic expressing an abnormal quality of sound, irrespective of its intensity, the resonance may be in a marked degree diminished, and, indeed, but feebly appreciable, while its non-vesicular character is sufficiently apparent. In the second stage of pneumonitis, then, if there be not total extinction of sound, a tympanitic resonance will be observed. In some instances the vesicular resonance is replaced by a pretty intense tympanitic sound. In intensity the resonance over the solid- ified lung may even exceed that on the unaffected side. Its non- vesicular character and highness of pitch are the more striking, as contrasted with the normal resonance, in proportion to its intensity. Well-marked cracked metal and amphoric resonance are occasion- ally observed over the upper anterior portion of the aff'ected side. The sense of resistance on percussion, in addition to other circum- stances, serves to distinguish the tympanitic resonance occurring over solidified lung, from that of pneumo-thorax, and from the vesic- ulo-tympanitic resonance of emphysema, the thoracic parieties re- taining their elasticity in the latter affections. In cases of pneu- monitis affecting the left lung, a tympanitic resonance may be due to distension of the stomach with gas. This source is often suffi- ciently evidenced by the gastric character of the sound, viz., nota- ble acuteness of pitch, and a metallic quality. In some instances in which the upper as well as lower lobe is solidified, the gastric note is manifested at the inferior portion of the chest, while over the supe- rior part the tympanitic resonance is lower in pitch and without any metallic tone ; and a tympanitic resonance, in cases of pneumonitis affecting the entire left lung, may be marked over the upper and middle portions, while flatness exists at the base. On the right side a tympanitic resonance may be transmitted from the distended colon ; ACUTE LOBAR PNEUMONITIS. 373 but it is observed over the superior and the middle third on this side, in cases in which below the upper boundary of the liver percussion elicits a flat sound. The tympanitic resonance due to solidification of lung is much oftener marked, in cases in which the upper lobes are affected, on the anterior surface of the chest, and especially over the middle third. Excepting in cases in which, on the left side, a gastric sound is transmitted, it is rare that on the posterior surface more than an obscure or feeble non-vesicular resonance is discoverable. In cases in which an entire lung is solidified, I have observed a tympanitic resonance in different parts, varying, not only in intensity, but in pitch. Thus, in a case in which the right lung was solidified, the percussion-sound at the summit was feeble, but distinctly tympa- nitic and high in pitch ; over the middle third the pitch was con- siderably lower, but the tympanitic quality more intense ; in the axillary region the tympanitic quality was also marked, and the pitch still lower than over the middle anterior third. In some instances the tympanitic resonance persists from day to day, during the course of the disease, gradually diminishing, re- gaining by degrees the vesicular quality of sound, becoming vesiculo- tympanitic, and finally assuming the normal character. But in other instances marked variations are observed at examinations re- peated on successive days ; on one day the sound may be dull, amounting almost to absolute flatness, and on the next day it may become highly tympanitic. I have observed this change to occur within the space of an hour. Without entering into a discussion of these fluctuations, I will simply remark that a tympanitic resonance elicited over lung completely solidified, if not due to gas in the stomach or intestines, must be due to the presence of air within the bronchial tubes. The varying condition of the tubes, as respects the accumulation of mucus or other morbid products, will perhaps ac- count for the existence of sonorousness at one time, and dulness amounting nearly to flatness at another time. The situation in which the tympanitic resonance is apt to be most marked, viz., over the larger tubes, favors the just given explanation. In cases of pneumonitis affecting the lower lobe, the percussion- resonance over the unaffected lobe on the same side is generally exaggerated or vesiculo-tympanitic ; that is, the sonorousness is greater than in corresponding situations on the opposite side, higher in pitch, and vesiculo-tympanitic in quality. These characters are more marked on the anterior surface of the chest, but they are ap- 374 DISEASES OF THE RESPIRATORY ORGANS. parent posteriorly in the upper scapular region. In like manner, when the upper lobe is solidified, the resonance over the lower lobe is exaggerated, or vesiculo-tympanitic. If, as not infrequently happens, the upper and lower lobe of the right lung be solidified, the middle lobe remaining intact, the resonance over the latter is. notably intense and vesiculo-tympanitic. On the side free from dis- ease the resonance is usually strongly marked, and highly vesicular. By means of percussion the limits of pneumonitis in the second stage may generally be defined without difficulty. The change from the vesicular or a vesiculo-tympanitic resonance to dulness, flatness, or a tympanitic resonance is generally abrupt, and the line of de- marcation between the healthy and solidified lung is thus easily traced on the chest. In view of the fact that lobar pneumonitis ex- tends over an entire lobe, and in the majority of cases is limited to a single lobe, the line bounding the limits of the affected portion of the lung will be found to pursue a direction coincident with that of the interlobar fissure. Thus, if the lower lobe be affected, the line intersecting the several points at which the change in the percussion- sound is observed, extends obliquely upward and outward, from be- tween the fifth and sixth ribs, in a direction toward the vertebral extremity of the spinous ridge of the scapula, — this being the situa- tion of the fissure separating the upper and lower lobes on the left side, and the middle and lower lobes on the right side. On the right side, in cases in which the inflammation extends to the middle lobe, the line pursues a direction upward and outward from the fourth car- tilage. This is a point not only of interest, but one which may be in some instances of importance in diagnosis. In the absence of the auscultatory phenomena distinctive of solidification of lung, which, although generally present, may be absent, the question will perhaps arise whether marked dulness or flatness on percussion be not due to liquid effusion ; in other words, the differential diagnosis between pneumonitis and pleuritis is to be made. Now, if, under these cir- cumstances, the line denoting the limits of the dulness or flatness be found to occupy the situation of the interlobar fissure, while the body of the patient is in a vertical position, the question may be considered almost or quite settled. During the resolution of pneumonitis, in proportion as the solid exudation disappears, the vesicular resonance, as already stated, re- turns. This is gradual, though frequently much progress is made within a short space of time. The dulness is sometimes observed to ACUTE LOBAR PNEUMONITIS. 375 lessen materially in twenty-four hours. It is, however, often long before complete equality in the resonance of the two sides is restored ; a marked disparity may exist for weeks after the patient has appa- rently recovered perfect health. Auscultation, in most cases of pneumonitis, furnishes important signs. As the inflammation does not invade simultaneously the whole of a lobe, but, commencing at one or more points, advances thence in all directions, a certain period may elapse before any positive auscultatory phenomena are discoverable. This will be the case especially if the points of departure of the inflammation be centrally situated. The healthy parenchyma surrounding the por- tion inflamed prevents the auscultatory signs of the latter from reaching the ear. Under these circumstances, according to Fournet, the diagnosis, taking into account the symptoms, may sometimes be based on an exaggerated respiratory murmur over a portion of the chest. He states that the vesicles surrounding an inflamed portion of a lobe take on a supplementary activity, and give rise to an ab- normally loud respiration. It is stated also by Stokes that the first effect of inflammation prior to the production of the crepitant rale, is an exaggerated murmur. On the other hand, Grisolle states that the effect of inflammation upon the adjoining lung-substance is often er to diminish its activity, giving rise to an abnormally weak respiration. Both these statements, although they appear to be contradictory, are correct ; in other words, the respiratory sound in the immediate vicinity of an inflamed portion may be either exag- gerated or weakened. The opportunity of observing one or the other of these effects is occasionally presented in cases in which the existence of central pneumonitis is indicated by characteristic symptoms prior to the development of distinctive signs, the latter shortly making their appearance and showing that the inflamma- tion has extended fi'om its central situation to the surface. The opportunity is also presented in cases in which the inflammation passes from one lobe to another, gradually invading the latter. I have noted, under these circumstances, in different case's, both ex- aggerated and weakened respiration ; and in the same case I have observed on two successive days, in the same situation, first exag- gerated, and next weakened respiration. In some instances, while the area of the inflamed lung is limited, especially if it be situated near the surface, a broncho-vesicular respiration precedes the ap- pearance of other signs. 376 DISEASES OF THE RE S PI K A TORY ORGANS. The earliest and most characteristic of the positive signs of pneu- monitis, is the crepitant rale. This sign is incident to physical con- ditions belonging to the primary local effects of inflammation, and is heard when the inflamed portion is sufiiciently large, and near enough to the surface for the sound to be transmitted. Contrary to the opinion of Skoda, it is present in a majority of the cases of pneumonitis. Out of forty-four cases taken in regular order with a view to an analysis of the recorded physical signs, in thirty-two a crepitant rale was observed, and in twelve its presence was not noted. But of these twelve cases, in eight a single examination only Avas made, and in all it was made at a period more or less re- mote from the commencement of the disease. It is probable that repeated examinations, made at an earlier period, would not have been negative as regards this sign in the greater proportion of the few instances in which it was not discovered. Of 149 examinations, in forty-five cases, made at different periods in the progress of the disease, the presence of the rale is noted in eighty-five, and its ab- sence in sixty-four. The frequency of the rale in acute primitive pneumonitis, affecting the adult, is shown by the extensive researches of Grisolle. This author, in his treatise on Pneumonitis, based on an analysis of 373 cases, states that he has only met with four in- stances in which this sign was not discovered at some period during the course of the disease. Different cases, however, present great differences as respects its abundance, loudness, proximity or remote- ness, diffusion and continuance. The period when it is usually most abundant and loudest is early in the disease, prior to the time when the physical evidences of solidification, more or less complete, are present; that is to say, during the first stage. During this stage, in some cases it exists in a marked degree, occupying the whole or the greater part of the inspiratory act, in other instances being comparatively feeble, and heard only at the end of inspiration. In some cases, even during this stage, it is not discovered in ordinary respirations, but is developed by forced breathing, and especially by the deep inspirations which precede and follow acts of coughing. In a small proportion of cases the methods just named fail to elicit it, and the diagnosis must be based on other signs. It may be detected in many cases, for a greater or less period, after the disease has advanced to the second stage. It is then, generally, confined to the end of the inspiratory act, and much more frequently requires for its production that the force of the act be voluntarily ACUTE LOBAK PNEUMONITIS. 377 increased. In both stages it may be heard at different situations over the affected lobe or lobes, or it may be confined to a few points. It is much more apt to be diffused in the first stage, this, in fact, being very rarely the case in the second stage. Sometimes it seems to arise in close proximity to the ear, and at other times it appa- rently originates at a distance. It may be appreciable during the whole career of the disease, even into convalescence, or it may cease at a period more or less removed from this epoch. Laennec described the crepitant rale as generally disappearing in the progress of the disease, and afterward returning during the pe- riod of resolution. This must be ranked among the instances (sin- gularly few in number), in which the observations of the founder of auscultation were biassed by speculative notions. Moreover, the dis- tinctive traits of the true crepitant rale were not fully known by Laennec, and, hence, it was confounded by him with the sub- crepi- tant. The observer who seeks by daily explorations during the career of pneumonitis to verify the crepitant rale redux, will often meet with disappointment. The crepitant rale, as just stated, may continue through the whole course of the disease. It may disap- pear and reappear at irregular intervals. I have known it to be- come more marked after the lapse of several days than at an early period in the disease. I have observed it to become developed as late as the 17th day, when it had not been previously discovered ; but the regular occurrence of a returning crepitant rale, as a har- binger of recovery, cannot with propriety be said to belong to the natural history of pneumonitis. As a rule, when the rale, after continuing for a greater or less number of days, disappears, it is not reproduced, except as the sign of a new focus of inflammation. The sub-crepitant rale — a bronchial, not a vesicular rale, convey- ing the idea of small but unequal bubbles, wanting the equality, the dryness, and the extreme fineness of the true crepitant, and not lim- ited to the inspiratory act — may occur at any period of the disease. Present on both sides of the chest early, and diffused especially over the posterior base, it denotes capillary bronchitis. The crepitant and the sub-crepitant rale may be combined and distinguished from each other, the crepitant appearing at the end of the inspiration, and the sub-crepitant in both acts. Exclusive of the very rare instances in which pneumonitis and capillary bronchitis are associated, the sub- crepitant rale is more likely than the crepitant to occur at a late period in the disease, during the progress of resolution. Developed 378 DISEASES OF THE RESPIRATORY ORGANS. under these circumstances it is, in fact, the returning crepitant rale of Laennec. The true crepitant rale, however, does occur in a cer- tain proportion of cases in the third stage, and it may be combined with the sub-crepitant in this stage. The bronchial rales, other than the sub-crepitant, both moist and dry, are liable to occur in cases of pneumonitis. These rales, if dif- fused over both sides, denote that the pneumonitis is a complication of bronchitis, which is rare ; if present only over the lobe or lobes affected with pneumonitis, they denote bronchitis limited to the af- fected lobe or lobes; and the existence of bronchitis, thus circum- scribed, in cases of pneumonitis, is the rule. Clinical observations show that these rales are far from being common in cases of pneu- monitis. In the majority of cases, examinations, repeated at differ- ent periods, do not show their existence, except occasionally, and transiently. It is rare for them to be prominent in cases in which the disease does not advance beyond the second stage. In the third stage, the moist or bubbling rales are much more likely to occur than in the two preceding stages. The infrequency of the occurrence of the bronchial rales, irre- spective of the sub-crepitant, in ordinary cases of pneumonitis, is shown by the following: of 148 examinations at different periods in forty-five cases, a sibilant rale is noted in seven, a sonorous in six, and a mucous in three instances. A friction-sound is sometimes discovered in auscultating over an inflamed lobe, but the proportion of instances in which this sign occurs in pneumonitis is small. In forty-five cases, out of 149 ex- aminations, it is noted in five examinations made in three cases. In addition to adventitious sounds, the vast majority of cases of pneumonitis are characterized by important modifications of the re- spiratory sounds. The modifications constituting the bronchial and the broncho-vesicular respiration are very rarely wanting in the course of the disease. The bronchial respiration fails in but a small proportion of instances. Of the forty-five cases which I have selected for analysis, commencing with the last case recorded, and rejecting none till this number was completed, in five either the examinations were begun too late in the disease, or the records are imperfect with respect to this point. Excluding these five cases, out of the remain- ing forty the bronchial respiration was more or less marked in thirty- seven. In two the modification did not exceed that constituting the broncho- vesicular respiration ; and in the other exceptional case the ACUTE LOBAR PNEUMONITIS. 379 patient died on the second day in the stage of engorgement, the disease being complicated with dihatation of the heart. In the large collection of cases analyzed by Grisolle (373), the bronchial respi- ration was observed to cease two days before death in one, and was not developed in another of two cases in which the inflammation extended over an entire lung ; and of the cases in w'hich the inflam- mation was limited to a single lobe, it was wanting in nine.^ The absence of the bronchial respiration in certain cases may be due to the diminution or arrest of the respiratory movements on the aff"ected side. This sign is more likely to be absent if the entire lung be solidified, than if the pneumonitis be limited to a single lobe; and in the former case, the movements of the afiiected side are more dimin- ished or more likely to be arrested. The presence of liquid eifusion may account for its absence in some cases. Obstruction of the bronchial tubes is probably another cause of its absence and feeble- ness. The bronchial respiration is a sign of complete or considerable solidification. In connection with percussion it aff'ords evidence of the disease having advanced to the second stage. It denotes the continuance of the solidified state of the lung, and indicates by its gradual disappearance the removal of the solid exudation. As re- gards its development, it occurs much earlier in some cases than in others. I have known it to take the place of the vesicular murmur in the space of eight hours. It may not appear till the second or third day after the date of the attack, or even still later. In a very large proportion of hospital cases it is found when patients first come under observation. If we hav^e an opportunity of watch- ing its development, we may observe that the transition from the vesicular murmur is not abrupt, but takes place gradually, the broncho-vesicular preceding a well-marked bronchial respiration ; that is to say, the inspiratory sound loses the vesicular quality by degrees, until at length it becomes entirely tubular. In some in- stances the presence of the crepitant rale prevents us from appre- ciating a well-marked alteration afi'ecting the inspiration, until the sound becomes distinctly bronchial, the rale then either ceasing, or being heard only at the end of the act. In the progress of the disease the bronchial respiration attains its maximum, as respects intensity and completeness, continues without much diminution or I Op cit. 380 DISEASES OF THE RESPIRATORY ORGANS. alteration for a certain period, and gradually becomes less intense and complete, at length merging into the broncho-vesicular respira- tion. The bronchial respiration in acute lobar pneumonitis is, in general, not a variable or fluctuating sign. As a rule, after it is developed, it may be discovered at each successive examination, until, in the progress of the disease, it declines and disappears. There are, how- ever, occasional exceptions to this rule. I have known it to be absent and shortly reappear, its temporary cessation being perhaps due to casual obstruction of the tubes. Such obstruction during the period of the disease when the bronchial respiration may be ex- pected to be present, rarely occurs in ordinary cases of pneumonitis. During the progress of the disease in 40 cases, the bronchial respira- tion existed in 107 out of 146 examinations made on different days. Of the remaining 39 cases, in 7 there was absence of respiratory sound, and in 32 the modification came under the denomination of broncho-vesicular. These enumerations show the persistency of this sign in cases of pneumonitis. The intensity of the bronchial respiration and other of its char- acters, vary in different cases. Generally cases of pneumonitis present, for a greater or less period, all the elements which this physical sign in its completeness embraces, viz., a tubular, shortened, high-pitched inspiration, followed, after an interval, by an expira- tion, prolonged, more intense, and higher in pitch than the sound of inspiration. Of 27 cases, in the records of which the bronchial respiration is described as respects the presence or absence of these several elements, in 24 they were all present for a period greater or less. In two cases a tubular inspiration existed without any sound of expiration, and in one case an expiratory sound existed alone. Enumerating the successive examinations made on different days in these 27 cases, and the result is as follows : Out of 86 examinations, in 65 all the elements of the bronchial respiration were present. Of the remaining 21 examinations a tubular inspiratory sound, without a sound of expiration, existed in 11, and an expiratory, without an inspiratory sound, in 10. In 6 of the latter 10 instances, how- ever, the inspiratory sound was drowned by the crepitant rale. It was stated by Jackson, and it is repeated by Grisolle, that in the development of the bronchial respiration the abnormal modifica- tion is first manifested by a prolonged expiration. The earliest change is, to say the least, generally more obvious in expiration ACUTE LOBAR PNEUMONITIS. 881 than in inspiration. The former frequently is not only prolonged, but becomes intense and high in pitch, while the latter is compara- tively feeble, and still retains more or less of the vesicular quality — in other words, is broncho-vesicular. It is never the case, that in connection Avith a prolonged, intense, high-pitched expiration, the inspiratory sound is not at the same time more or less altered, being less vesicular and higher in pitch than on the opposite side of the chest, and also shortened or unfinished. On the other hand, at a later period, when the bronchial is about to merge into the broncho-vesicular respiration, the change is frequently, if not gene- rally, first manifested in the inspiration, which becomes weaker and assumes more and more the vesicular quality, while the expira- tion remains prolonged, high-pitched, and relatively more intense. At a still later period the expiratory sound may disappear, leaving the inspiration, still less, vesicular and higher in pitch than the nor- mal murmur. The transition from a bronchial to a broncho-vesicular respira- tion, like that of the percussion-sound from marked to moderate or slight dulness, is gradual ; yet in the one, as in the other case, frequently a considerable alteration is often observed to take place within a short space of time. A striking diminution in inten- sity of the bronchial respiration, and the conversion of a purely tubular to a vesiculo-tubular inspiration, are sometimes observed by comparing the examinations of two successive days. A return to the normal vesicular murmur is rarely complete for some time after convalescence is established. Even when the patient is sufficiently restored to be out of doors, the respiration over the affected lobe, or lobes, may continue to be broncho-vesicular. When the characters of the bronchial and the broncho-vesicular respiration have disappeared, the respiratory sound over the affected lung is often abnormally feeble, being sometimes scarcely appreciable except the breathing be forced ; and for a time the vesicular quality of the inspiratory sound is notably marked, and the pitch is low. Fournet states that the bronchial respiration is apt to be succeeded in the affected por- tion of lung by an exaggerated vesicular murmur. Judging from the cases that I have observed, I should say that the rule is directly the reverse. With respect to this point, the following are the ob servations of Grisolle : Of 103 convalescents discharged from ho- pital, between the twentieth and fifty-fifth days of the disease, 37 382 DISEASES OF THE RESPIRATORY ORGANS, had no morbid signs ; in 36 the respiration was weak ; in 14 the respiration was slightly blowing ; and in 16 there existed sub-crepi- tant or other bronchial rales. In the majority of cases of pneumonitis, the disease being limited to the lower lobe of one lung, the abnormal modifications of the respiratory sounds, as well as other physical phenomena, are to be sought for especially on the posterior surface of the chest below the spinous ridge of the scapula. They are also manifested on the lateral surface below a diagonal line corresponding to the interlobar fissure. Anteriorly the bronchial respiration, and also the crepitant rale, may be discovered at the base of the chest, but it not infre- quently happens that over the small portion of the lower lobe which extends in front, auscultation fails to detect any morbid phenomena. Posteriorly and laterally, if the stethoscope be employed bypassing the instrument over successive portions of the chest, from above downward, the change from the vesicular murmur to the bronchial respiration is found to be abrupt, not gradual. If the line indica- ting the situation of the interlobar fissure have been already traced by the change in the percussion-sound, the transition from the vesicular murmur to the bronchial respiration will be found to take place on the same line. The limits of solidification may thus be defined by auscultation as well as by percussion, and it is in some cases easier to trace the boundaries by means of the former than by the latter method. On the back, the characters of the bronchial respiration are shown in striking contrast by auscultating alternately above and below the spinous ridge of the scapula. If the whole lung become afi'ected, the different lobes being attacked in succession, the bronchial respiration will present differ- ences as respects intensity, and other characters, in different situa- tions. On the right side in front, I have observed a striking dis- parity, in pitch and other points, over the upper, middle, and lower lobes, the pitch and intensity diminishing from above downward in these three situations. The same disparity I have also observed over different points within the boundaries of the same lobe. In ac- cordance with the fact that when an entire lung is affected, even if the upper lobe be invaded secondarily, resolution takes place first in this lobe, the bronchial respiration will be found to continue longer posteriorly below the spinous ridge of the scapula, than over the upper and the middle third in front. It will be found frequently, ACUTE LOBAR PNEUMONITIS. 383 if not generally, to continue longer in the lower scapular, than in the infra scapular region; but this is probably owing to the prox- imity, in the former region, to the larger bronchial tubes. The bronchial respiration, if intense, may be heard at some dis- tance beyond the situation of the solidified portion of lung. Thus, when the lower lobe of one lung is solidified, the sound may be heard beyond the spinal column on the opposite side ; or the sound may be heard above and below the affected lobe on the affected side. The expiratory sound, being more intense, is propagated further than the inspiratory sound. Sometimes over healthy lung, situated near a solidified portion of lung, a normal vesicular inspiratory sound is followed by a bronchial expiratory sound: the former emanating from the healthy lung, and the latter propagated from the solidified portion. Over the unaffected side, in cases of pneumonitis, the respiratory murmur is frequently intense, and the vesicular quality highly marked, in short, exaggerated. If the affection be limited to a lobe, according to Fournet, the respiratory sound over the unaffected lobe is even more exaggerated than on the opposite side on the chest. So far as my experience goes, the reverse of this is nearer the truth. The murmur over the upper lobe on the affected side is sometimes extremely feeble, almost null, so that conjoined with a vesiculo-tympanitic resonance or percussion, the physical evidences , of emphysema are present.'' I have, however, observed an exagge- rated respiration in the upper lobe when the lower was solidified, the intensity being notably greater than over the upper lobe in the unaffected side. Auscultation furnishes important vocal pheiiomena in pneumonitis. In the second stage, over the solidified lung, bronchophony occurs in a very large proportion of cases. Of 27 cases in the histories of which is noted either the presence or absence of this sign, it was observed in 25, and not discovered in two. By bronchophony, it will be borne in mind, I do not mean exaggerated vocal resonance, but a greater or less apparent approach of the voice to the ear of the auscultator, and the pitch notably raised. In many cases, this increased proximity of the voice is accompanied by an abnormal 1 In Part I, I have suggested that an emphysematous condition accounts for the vesiculo-tympanitic resonance which so frequently exists over the upper lobe when the lower is solidified. 384 DISEASES OF THE RESPIRATORY ORGANS. intensity of resonance, but not invariably. The voice sometimes seems very near the ear, and the pitch is notably raised, when the resonance is but little exaororerated. An increased vibration or thrill is sometimes felt by the ear applied either directly to the chest, or to the stethoscope ; but bronchophony not infrequently exists without increase of fremitus, and the latter may be less than in health. The bronchophony in different cases of pneumonitis is variable in degree. The vocal sound appears in some instances to emanate directly beneath the ear or stethoscope, and between this maximum and a slight bronchophonic alteration, every gradation may be observed in different cases, and in a series of successive ex- aminations in the same case. When the bronchophony is accom- panied by a notably intense resonance the vocal sound in some in- stances appears to strike the ear with force, giving rise to a sense of concussion or shock like that felt when auscultation of the voice is practised over the trachea. The pitch of the vocal sound in some instances is notably high, exceeding that of the tracheal voice. Other things being equal, the maximum of the degree of complete- ness to which bronchophony attains, in the progress of pneumonitis, denotes the greatest amount of solidification. It coexists, therefore, with the greatest loss of vesicular resonance on percussion, and with the maximum of intensity of the bronchial respiration. As the dis- ease pursues its course, this vocal sign reaches its maximum by degrees, and gradually becomes weaker as the solidification de- creases in the progress of resolution. In this retrograde course, when bronchophony and exaggerated resonance are associated, the former disappears first, the latter continuing to be more or less marked for a period varying considerably in different cases. With respect to the vocal, as well as the respiratory signs indicative of solidification, often a marked diminution is observed to occur Avithin a short space of time, and occasionally they disappear rather ab- ruptly. The duration of the vocal signs in different cases of pneumonitis is variable. Of 88 examinations, made on different days in 27 cases, bronchophony existed in 61 and was absent in 27. The examinations in which it was absent were mostly made during the latter part of the disease, the sign having probably existed, but disappeared. When, however, it is once developed, it is a persistent sign until it disap- pears as the consequence of the progress in resolution ; that is, it is ACUTE LOBAR PNEUMONITIS. 385 generally found at each successive examination. This statement is in opposition to the opinion of Skoda, who maintains that the bron- chophonic voice is constantly fluctuating, sometimes even appearing and disappearing in the course of a few moments. An analysis of a series of recorded examinations shows this opinion to be incorrect. Of the 88 examinations, in 27 cases, just referred to, in but two in- stances was the sign absent when its existence was noted at the ex- amination preceding, and at that succeeding the one on which it was found to be wanting. Bronchophony in the same case, at the same moment, is by no means equal, as regards intensity, at diiferent points over the af- fected lobe or lobes. Its greatest intensity is in cases in which the upper lobe is affected, over the portion of the summit of the chest, in front, situated nearest to the largest bronchial divisions. Poste- riorly, when the lower lobe is affected, it is generally more marked in the lower scapular than in the infra-scapular region. Well-marked bronchophony may exist over the larger bronchial tubes, while at a little distance from them the vocal resonance is simply exaggerated. It is not uncommon to find bronchophony over the scapula, and ex- aggerated resonance below the scapula. By means of an abrupt change in the vocal sound, limiting by the use of the stethoscope the space from which the sound is re- ceived, the interlobar fissure, in cases of pneumonitis affecting a single lobe, may be often traced on the chest as well as by the per- cussion and the respiratory sound, in the manner already described; and when this has been done by means of the latter, the ausculta- tion of the voice furnishes another method of verification. The transmission of the articulated voice, or speech, that is, pec- toriloquy, is a physical sign occasionally observed in cases of solidi- fication from pneumonitis. In 2 of 27 cases Avords (numerals) spoken aloud were transmitted. In 2 other cases whispering pectoriloquy was complete, and in several instances whispered words were imper- fectly transmitted. Contrary to the opinion of Walshe, who regards whispering pectoriloquy as eminently distinctive of a cavity, I have found it often er present in connection with solidification than the transmission of words spoken aloud. As stated in the first part of this work, pectoriloquy, both with the loud and whispered voice, when due to solidification of lung, presents features which distinguish it from cavernous pectoriloquy. 25 386 DISEASES OF THE RESPIRATORY ORGANS. The distinctive features are those which belong to bronchophony with the loud and the whispered voice.' In pneumonitis, pectoriloquy, if present, is incident to bronchophony. Whispering bronchophony and the exaggerated bronchial whisper are vocal signs Avhich claim the attention of the auscultator.^ In pneumonitis, and other affections involving solidification, e. g., tu- berculosis, they constitute valuable physical signs, their significance being the same as bronchophony, exaggerated vocal resonance, and the bronchial respiration. They are valuable, not only as confirma- tory of the fact of solidification, associated with the signs just named, but still more because they may be present in some instances in which those signs are wanting. In some cases of pneumonitis, it is stated, the voice in passing through the chest acquires the segophonic characters, viz., tremu- lousness, with acuteness of pitch. Some observers, indeed, have discovered strongly marked gegophony in pneumonitis ; and it is claimed that this vocal sign may occur in cases in which there is no pleuritic eflusion. The latter point it is difl^cult to establish, since if, in fatal cases, no liquid be found after death, it may have existed during life and been absorbed. Inspection of the chest discloses, in a certain proportion of cases of pneumonitis, abnormal appearances deserving attention. Coinci- dent with the attack, the movements of the affected side may be visibly restrained, attributable, at this stage, to the pleuritic pain which is generally present in the early part of the disease. At a later period, during the second stage, if a single lobe be affected, a disparity in expansion-movement at the inferior portion of the chest is sometimes obvious, and in other instances not apparent. If the entire lung become affected, a disparity is frequently marked. It is more marked if the breathing be labored, or voluntarily forced. Under these circumstances, the three types of breathing may be conspicuous on the unaffected side, while they are but feebly manifested on the side diseased. The deficient expansion of the affected side when pain has ceased to be a prominent symptom, in other words, in the second stage, is attributable to the augmented size of the lung, and the loss of its contractility. The side, in fact, is in a measure dilated permanently, and the incompressibility of the solidified lung prevents its contraction to the same extent as in 1 Fi(ic page 244. ^ ri(fe part 1, page 240. ACUTE LOBAR PNEUMONITIS. 387 health. The disparity, under these circumstances, is increased hy the healthy side taking on a supplementary activity. This statement is in opposition to the opinion of Grisolle, who, exclusive of instances in which the movements are restrained by excessive pain, does not admit a disparity between the two sides in this respect. The intercostal depressions are not lost, except in certain cases characterized by the presence of liquid effusion. After the stage of resolution, more or less contraction of the chest may be evident on inspection. It has been doubted by high authority^ whether this ever occurs except as the sequel of pleuritic effusion which coexisted with pneumonic solidification. On this point my own observations lead me to accord with the opinion of Stokes and Walshe, which refers the contraction succeeding pneumonitis in certain cases, to the diminished bulk of the affected portion of the lung in consequence of the removal of the solidifying deposit, and the contraction of the fibrinous exudation on the surface. With regard to mensuration, my recorded observations do not furnish sufiicient data to serve as the basis of any conclusions. Walshe states that in a minority of cases he has found positive, though slight, increase of size at the base of the chest on the af- fected side in the second stage of the disease. The occurrence of contraction of the affected side after recovery is indubitable. The only question relates to the pre-existence of liquid effusion in all such cases. Finally, palpation furnishes physical phenomena in different cases of pneumonitis somewhat contradictory. As a rule, the vocal frem- itus is increased, in the second stage of the disease, over the solidi- fied lung. But the exceptions to this rule are not very infrequent. In some of the exceptional instances no disparity as respects this sign is appreciable on comparing the two sides of the chest. In other instances the fremitus is greater on the unaffected side. If the left lung be the seat of the disease, the explanation may be that the fremitus over the solidified lung is not increased, as it is nor- mally more marked on the right than on the left side. But I have observed the fremitus to be greater on the left side, when the pneu- monitis was seated on the right lunor. This shows that an effect of solidification, under certain circumstances, is a diminution of the 1 Woillez, Grisolle. 388 DISEASES OF THE RESPIRATORY ORGANS. natural fremitus. The absence of fremitus, or its diminution, may- be accounted for in some cases by the presence of liquid eifusion. Diagnosis. — The space which has been devoted to the considera- tion of the physical signs belonging to pneumonitis may lead the reader not practically conversant with the subject to suppose that the diagnosis involves greater difficulties than actually exist. The truth is, with a knowledge of the semeiological phenomena of the disease, and an acquaintance with the diagnostic features of other affections presenting some characters in common, it is recognized with promptness and positiveness in the great majority of cases. If a person be seized with a chill, which is followed by high febrile movement and lancinating pain in the chest referred to the neigh- borhood of the nipple, accompanied by cough with an adhesive, rusty expectoration, and a well-marked crepitant rale be found on auscultating the posterior surface of the chest on one side, it is at once evident that he is attacked with pneumonitis seated in an in- ferior lobe. This group of diagnostic phenomena is presented in a pretty large share of the cases of simple acute pneumonitis at the time when they first come under the observation of the medical practitioner. Of these phenomena the characteristic expectoration and the crepitant rale may be said to be pathognomonic. A viscid expectoration, containing a variable quantity of blood in intimate combination, is a symptom belonging exclusively to inflammation of the pulmonary parenchyma. If this statement be not correct in the most rigorous sense, it may at all events be practically so re- garded.' So with regard to the crepitant rale, if We are sure of its presence, that is, if the characters which distinguish it from other rales are clearly made out, and it occur in the situation and in con- nection with the symptoms just mentioned, it affords positive proof of the existence of pneumonitis. It is only when more or less of the distinctive features of the disease are obscure or wanting, that there is room for delay and doubt, as regards the diagnosis. 1 According to the observations of Dr. Remak, of Berlin, if the sputa from a patient aiiected with pneumonitis, after having been macerated for some time in water, be placed on dark-colored glass, and carefully examined, minute fibrinous concretions may be discovered, which are probably casts moulded in the minute bronchial ramifications. Dr. Eemak succeeded in discovering fibrinous casts in 50 successive cases, between the third and seventh days of the disease. Other observers have not met with equal success. Vide Art. by Dr. Da Costa, Am. Jour, of Med. Sciences, Oct. 1855. ACUTE LOBAR PNEUMONITIS. 389 The group of phenomena characterizing the access of pneumonitis is sometimes incomplete during the development of the disease, while the inflammation is confined to a limited space, perhaps centrally situated, and gradually extending over the lobe. Under these cir- cumstances the rusty expectoration may be present, indicating the nature of the affection before any positive physical evidence is dis- coverable. In a case in which the symptoms denote some acute pulmonary disease, if the characteristic expectoration be observed, physical exploration, although at first negative, may be expected soon to furnish the signs of pneumonitis, and should therefore be often repeated. In such a case, should the respiratory murmur on one side be found abnormally feeble or exaggerated, or if the sound be somewhat changed, presenting the characters of the broncho- vesicular modification, these physical phenomena, although not in- trinsically significant of pneumonitis, taken in connection with the associated circumstances, render it probable that inflammation ex- ists, but as yet confined to a portion of the lobe. On repeating the examinations, a crepitant rale may be at length satisfactorily made out, and the fact of pneumonic inflammation is then established. The characteristic expectoration, however, is by no means uni- formly present in cases of pneumonitis, and if not altogether ab- sent, it is not always among the earliest symptoms of the disease. Under these circumstances, if the pathognomonic sign, viz., the crepitant rale, be discovered, the diagnosis is promptly made. But it will sometimes happen that both these characteristics are absent : a little delay is then requisite, until the symptoms and signs inci- dent to the second stage of the disease become developed. This delay is much oftener requisite in cases of pneumonitis affecting children. In children the expectoration is generally swallowed, and hence its diagnostic characters are unavailable. The crepitant rale is also frequently wanting. Adding to these circumstances the dif- ficulty frequently experienced in making a satisfactory exploration of the chest, owing to their timidity or restlessness, the means of determining positively the character of the disease are often insuffi- cient until the signs of solidification are apparent. Pneumonitis, as has been seen, in general runs rapidly into the second stage. In this stage new diagnostic features are added. The rusty expectoration and crepitant rale may continue, but generally they become less marked. The added symptoms and signs pertain chiefly to the solidified condition of the lung. The function of 390 DISEASES OF THE RESPIRATORY ORGANS. hsematosis being compromised in a greater degree, the respirations are accelerated, cceteris paribus, in proportion to the completeness of the solidification and the extent of the pulmonary organs involved. The alas nasi dilate, and there may be lividity of the prolabia and the face. The cheeks often present a circumscribed flush. The ac- celeration of the breathing is out of proportion to the frequency of the pulse. The physical evidences of solidification are easily ascer- tained. On percussion, the chest over the inflamed lobe is found to be notably dull, with a marked increase of the sense of resistance and diminished elasticity. In the majority of cases, as has been repeated more than once, a single lobe only is inflamed, and this is the lower lobe. It is important for the student to recollect the rela- tions of the inferior lobe to the anterior and to the posterior sur- face of the chest. So small a portion extends in front, that in many, if not most instances, physical examination anteriorly is com- paratively unimportant. The signs emanating from the affected lobe are to be sought after behind, below the spinous ridge of the scapula. The interlobar fissure crosses the lateral surface of the chest obliquely, and its situation is generally determinable by the abrupt change in the percussion-sound. The fact of a line indicat- ing the limits of dulness on the lateral surface of the chest, corre- sponding in direction with the interlobar fissure, and not varying with the position of the patient, is a diagnostic feature in itself al- most conclusive. Assuming the inferior lobe to be the seat of solid- ification, in the lower scapular and the infra-scapular region, and laterally below the line of the interlobar fissure, more or less of the characters embraced in the bronchial respiration are present in the vast majority of cases. Either bronchophony or exaggerated vocal resonance is present also, with few exceptions ; also the corre- sponding signs produced by whispered words. If the upper lobe be primarily the seat of the inflammation, the physical phenomena will, of course, be manifested within its limits, viz., in front above the fourth rib, behind in the upper scapular region, and laterally above the interlobar fissure. The occurrence of highly marked tympanitic percussion-resonance over solidified lung, especially anteriorly when the superior lobe is afi'ected, is a point not to be forgotten. It is superfluous to add that if the inflammation extend beyond the lobe primarily attacked, an event liable to occur at a period more or less remote from the date of the attack, the local phenomena will be re- produced over the lobe or lobes successively afi'ected. Of the signs which enter into the physical diagnosis of pneumonitis ACUTE LOBAR PNEUMONITIS. 391 advanced to the second stage, excepting the crepitant rale, none are peculiar to this disease. Dulness on percussion, the bronchial respi- ration, bronchophony, exaggerated vocal resonance, the whispering signs, and increased fremitus, may all be found in connection with other affections involving pulmonary solidification. The situation and limitation of the portions of the chest in which the signs are ob- served, together with the antecedent and concomitant symptoms, suffice for the discrimination of the solidification which arises from lobar pneumonitis. But the circumstances involved in the differential diagnosis will be noticed presently. The signs by which the progress of the disease from the first to the second stage is ascertained, have been already sufficiently con- sidered. It remains to devote a few remarks to the diagnostic characters which belong to the third or purulent stage. The trans- ition to this stage, in the rare instances in w-hich it occurs, is not, like that of the first to the second stage, signalized by the develop- ment of a new series of striking physical phenomena. The signs of solidification continue, and, in fact, there are no criteria by which the occurrence of the third stage may be in all instances positively ascertained. The existence of this stage is to be inferred after a protracted duration of the disease, when the evidences of resolution of the disease fail to occur, and the symptoms denote an unfavorable termination, not directly in consequence of the extent to which hgematosis is compromised, but as the result of asthenia and apnoea combined. A symptom which has a positive bearing on this ques- tion is an abundant puriform expectoration, sometimes taking place rapidly like the discharge from a ruptured abscess, and occasionally emitting a fetid odor. Physical evidence is afforded by abundant moist bronchial rales, at a late period, not having been preceded by general bronchitis coexisting with the pneumonitis, the dulness on percussion remaining undiminished, the bronchial respiration and voice becoming less marked, these circumstances being taken in connection with symptoms denoting a fatal tendency, viz., pros- tration, frequency and feebleness of the pulse, delirium, etc. The formation of abscesses, and their evacuation into the bronchial tubes, leaving cavities, are among the occasional events incidental to the progress of this disease.^ Do excavations thus formed give 1 Of 750 caries treated in the Hospital of Vienna, from 1847 to 1850, pulmonary abscess was observed in but a sino;le instance. 392 DISEASES OF THE RESPIRATORY ORGANS. rise to distinctive signs, viz., the cavernous respiration and voice, and tympanitic resonance on percussion, with, in some instances, the cracked-metal intonation? My own observations do not supply facts bearing on this question, except as regards the cavernous res- piration. This sign was well marked in a case of pulmonary ab- scess following pneumonitis, which came under my observation in the New Orleans Charity Hospital. On this point Skoda remarks as follows: "I have frequently examined patients suffering from pneumonia, in whose lungs newly formed abscesses were found after death; but I have never, in any single instance, recognized the presence of abscesses by the aid of auscultation or percussion. In every case, the abscess, though communicating with the bronchial tubes, was filled with pus or sanies."^ The progress of the resolution of pneumonitis is indicated by diminution of the dulness and the sense of resistance on percussion; decrease of the intensity of the bronchial respiration, which, be- coming first broncho-vesicular, gradually assumes the normal char- acters; cessation of bronchophony, and the return to the normal vocal resonance, the resonance, perhaps, being exaggerated, without the bronchophonic characters, for a certain period; disappearance of an undue vocal fremitus, — these changes in the physical phe- nomena associated, of course, and generally succeeding, rather than anticipating, a marked improvement in the cough, respiration, etc. Pneumonitis, so far as symptoms are concerned, is sometimes re- markably latent. Expectoration, cough, pain, may all be wanting, and the respiration may be but little or not at all increased in fre- quency. The disease fails to present its usual symptomatic phe- nomena Avhen it is consecutive, much oftener than when it is pri- mary ; as when it is developed in the course of fevers, purulent infection of the blood, etc. Under these circumstances the diag- nosis is to be based almost exclusively on the physical signs. But as regards the latter, the disease ma}' be to a greater or less extent latent; in other words physical phenomena which are usually present in a marked degree, may be obscure or absent. Thus, not only is the crepitant rale sometimes wanting, but also the bronchial respi- ration, bronchophony and exaggerated vocal resonance, and frem- itus. The solidification occurring in the latter stage of fevers and other afl'ections, and characterized by the absence of the usual 1 Op. cit., Am. edition, page 311. ACUTE LOBAR PNEUMONITIS. 393 granular deposit (hypostatic pneumonitis), is the form most apt to be deficient in the group of signs just named. Instances in which, together with these signs, all the distinctive symptoms are also want- ing, must be exceedingly rare; yet it is not impossible that such a case may be met with. The diagnosis would then rest mainly on the evidence of solidification extending over a lobe, which by means of percussion would still be available. Fortunately a clinical prob- lem so intricate, although within the limits of possibility, is far from probable. The different affections from which pneumonitis is practically to be discriminated are, acute ordinary bronchitis, capillary bronchitis, acute pleuritis, dilatation of bronchial tubes, acute phthisis, and pulmonary oedema. I will consider briefly the more important of the points involved in the differential diagnosis from these affections respectively. With a proper knowledge and application of physical exploration, pneumonitis need never be confounded with acute or- dinary bronchitis ; but guided exclusively by symptoms, the dis- crimination is not always easy, and in some cases it is impracticable. Moreover, the two affections may be conjoined, and under these cir- cumstances the question whether the bronchitis be complicated with pneumonitis, or not, is to be settled mainly by the physical signs. Simple bronchitis and simple pneumonitis present a striking con- trast in several prominent symptoms. The pain in pneumonitis is sharp, lancinating, and generally referred to the vicinity of the nip- ple. In bronchitis, if pain be present, it is dull, contusive, and situated beneath the sternum. The expectoration in bronchitis rarely contains blood, and, when present, it is in the form of bloody points or streaks. In pneumonitis, bloody expectoration is common, and the blood is intimately mixed with viscid mucus, giving rise to the characteristic rusty sputa. The febrile movement in cases of acute pneumonitis is generally intense, whereas in ordinary bron- chitis, however acute, it is only moderate. More or less accelera- tion of the breathing generally characterizes cases of pneumonitis, and occurs rarely in ordinary bronchitis. But the physical phenomena are more distinctive. The crepitant rale is wanting in bronchitis, nor in the ordinary form of that affec- tion is there any rale approximating to the crepitant sufficiently to occasion any liability to error. The sonorous, sibilant, and mucous rales may be present more or less combined, and these rales are rarely prominent in cases of pneumonitis, except it be associated with gen- 394 DISEASES OF THE RESPIRATORY ORGANS. eral bronchitis. When observed in cases of pneumonitis not asso- ciated with general bronchitis, they are limited to one side of the chest, save in the rare instances of double pneumonitis ; but in bron- chitis they are found on both sides. The chest, in cases of bron- chitis, everywhere preserves its normal sonorousness on percussion. In pneumonitis, on the other hand, soon after the access of the dis- ease, marked dulness, with increased sense of resistance, is found to exist over a space corresponding in extent and situation to one of the pulmonary lobes. The bronchial respiration, bronchophony with the loud and whispered voice, exaggerated vocal resonance, and increase of fremitus, belong to the history of pneumonitis, and are never produced as effects of bronchitis. Between pneumonitis and capillary bronchitis there are more points of similitude ; nevertheless, the points of dissimilitude are amply sufficient for the differential diagnosis. Capillary bronchitis is accompanied by greater embarrassment of respiration and suffer- ing from defective hsematosis, than obtain in pneumonitis. The acceleration of the pulse is greater. The rusty sputa are want- ing ; blood, if present, is in streaks. Reliance, however, must be placed chiefly on the physical signs. The percussion-resonance in capillary bronchitis generally remains undiminished, and may be abnormally increased. If dulness occur, it arises from collapsed lob- ules, and is not found to extend over a space corresponding to an entire lobe. Auscultation discloses the sub-crepitant rale, which may succeed, or coexist with the sibilant rale, and is present on both sides of the chest. The existence of this rale on the two sides is a fact eminently distinctive, but, aside from this fact, the intrinsic differences between the sub-crepitant and the true crepitant rales, which have been fully pointed out, suffice for their discrimi- nation from each other. Finally, in capillary, as in ordinary acute bronchitis, bronchial respiration, bronchophony with the loud and whispered voice, and increased vocal resonance, are wanting. The diagnostic features of acute pleuritis are to be considered hereafter. It suffices for the present object to state that the more important of these features arise from the accumulation of more or less liquid effusion within the pleural sac. The physical signs de- noting the presence of fluid in the chest, together with the absence of the crepitant rale, and of the signs denoting a marked degree of pulmonary solidification, establish the differential diagnosis. More- over, in pleuritis the febrile movement is less intense than in acute ACUTE LOBAR PNEUMONITIS. 395 pneumonitis; cough and expectoration are frequently slight, or alto- gether absent ; the rustj sputa are wanting, and the matter of the expectoration, unless bronchitis be associated, is unaltered mucus. It is not very uncommon for practitioners possessing an imperfect knowledge of the principles and practice of physical exploration to mistake pneumonitis for pleuritis, and vice versa. Due acquaintance with the circumstances involved in distinguishing pulmonary solidi- fication from liquid effusion, will obviate the liability to this error. The points of distinction between these two morbid conditions have been ah-eady considered, and will be recapitulated in connection with the subject of pleuritis. Dilatation of the bronchial tubes, in connection with an attack of acute bronchitis, may give rise to certain of the physical signs present in pneumonitis, viz., bronchial respiration and bronchophony or exaggerated vocal resonance, together with dulness on percussion. The symptoms incident to the acute bronchitis, associated with the physical phenomena pertaining to the bronchial dilatation, if the practitioner be not aware of the previous existence of this lesion, might lead to the suspicion of pneumonitis advanced to the stage of solidification. An investigation of the previous history and present phenomena, in such a case, will show that chronic cough and expecto- ration have existed for a greater or less period prior to the attack, and that the signs suggesting pneumonic solidification are not, as in lobar pneumonitis, either bounded by a line coincident with the in- terlobar fissure, or extending over the entire lung on one side. In the progress of the case, after the symptoms of the acute bronchial inflammation are relieved, percussion and auscultation show the phy- sical phenomena still persisting, owing to the permanency of the lesion. Dilatation of the bronchial tubes is of such rare occur- rence that it falls to the lot of but few physicians to be called to discriminate between it and other affections. Cases of rapid and extensive tuberculosis may present a group of symptoms and signs, which, without due attention, may for a time deceive the practitioner. Dulness on percussion, the bronchial respiration, bronchophony with the loud and whispered voice, ex- aggerated vocal resonance and whisper, and fremitus, with the sub- crepitant, and possibly a crepitant rale, may coexist with accelerated breathing, frequent pulse, cough and expectoration, lancinating pains, these symptoms having been so rapidly developed as not to 396 DISEASES OF THE llESPIRATORY ORGANS. suggest at once the idea of tuberculosis. Careful and continued investigation, however, will lead to the discovery of certain of the positive features of phthisis, and at the same time authorize the ex- clusion of pneumonitis by the absence of some of its distinctive traits. In the vast majority of cases of phthisis, the deposit occurs first near the apex of the lungs. The physical signs will, therefore, be found at the summit of the chest. Pneumonitis attacks the upper lobe primarily in but a small proportion of cases, and hence, the situation of the physical phenomena in itself should excite suspicion of tubercle. A tuberculous deposit rarely extends within a brief period over an entire lobe, so that the signs will be likely to be limited to a space more or less circumscribed below the clavicle, when, if the affection were simple pneumonitis, the entire lobe would be soon invaded, and its boundary line determined by means of per- cussion and auscultation to be in the situation of the interlobar fis- sure. Hemorrhage will be likely to occur in connection with tuber- culous disease, and not in pneumonitis, except in so far as it enters into the production of the rusty sputa. The lancinating pains in phthisis are generally referred to the summit of the chest, or they are seated beneath the scapula, not fixed in a point at or near the nipple, as in pneumonitis. The characters of the pulse in " tuberculous fever" differ from those which belong to the febrile movement symp- tomatic of an acute local inflammation. In the former the pulse is often very frequent, vibratory or thrilling, denoting irritability rather than increased force in the ventricular contraction. In the latter the pulse is less rapid, but stronger, indicating abnormal power in the action of the heart. Rapid loss of weight characterizes acute phthisis. Diarrhoea frequently occurs. The patient, notAvith- standing the greater frequency of the pulse, and with an equal, if not greater disturbance of the respiration than ordinarily attends pneumonitis, does not yield to the disease and take to the bed, as when attacked wdth pneumonic inflammation. Acute phthisis, when it is most rapidly developed, does not present the abrupt access which generally characterizes cases of pneumonitis. The differential diagnosis may be more difficult when the tubercu- lous deposit, in deviation from the usual course of the disease, takes place first at the base of the lung, and gradually extends upward. This unusual course of tuberculous disease, according to the obser- vations of Dr. H. I. Bowditch, occurs in a ratio of 1 to from 150 or ACUTE LOBAR PNEUMONITIS. 397 200 cases.' The greater liability to error of diagnosis in this variety of phthisis arises from the physical signs being manifested in the same situation as in most cases of pneumonitis, viz., on the posterior surface of the chest, especially below the scapula, and also from the presence of the crepitant rale, which was observed in seven of eight cases reported by Dr. Bowditch. The combination of physical signs, in fact, may be precisely that which characterizes pneumonitis. The incongruousness of the associated symptoms, on the supposition that pneumonitis exists, and the presence of certain of the traits signifi- cant of phthisis, point to the nature of the disease. With the physi- cal signs just mentioned, patients preserve strength suflScient to be up and out of doors. The disease, even if rapidly developed, is always more gradual than pneumonitis. Hemorrhage occurs in a certain proportion of cases. The ragged opaque sputa of phthisis are sometimes observed. Acute symptoms are by no means uni- formly present in this variety of tuberculous disease. The crepitant rale is persistent, continuing for weeks and even months. Although, therefore, the combination of physical signs and their situation are the same as in pneumonitis, the associated circumstances and the progress of the disease present points of disparity which speedily lead to the correction of an error in diagnosis liable to arise from inadvertency or a premature conclusion. (Edema of the lungs extending over one or more lobes may give rise, to some extent, to the physical signs incident to the stage of solidification from pneumonitis. Over oedematous lung there will be dulness on percussion, with, possibly, bronchial respiration, bron- chophony or exaggerated vocal resonance, and fremitus. These aus- cultatory phenomena, however, are rarely marked, and often absent. A well-marked crepitant rale is sometimes observed, but the sub- crepitant is much oftener present. (Edema occurring always as a secondary afi"ection, from hypostatic congestion in fevers, from a changed condition of the blood leading at the same time to serous infiltration in other parts, from the obstruction proceeding from disease of heart, etc., its existence may be presumed when the physical signs denoting solidification become developed in those pathological connections, without being preceded or accompanied by 1 Cases of Anomalous Development of Tubercles, etc., by Henry I. Bowditch. American Medical Monthly, JST. Y., 1855. From the number of instances which I have observed since the first edition of this work was published, 1 should say that the percentage is larger than is estimated by Bowditch. 398 DISEASES OF THE RESPIRATOBY ORGANS. the symptoms of acute pneumonitis. Moreover, the causes pro- ducing the oedema acting equally on both lungs, the local evidences of the solidification, are found on each side of the chest. An cedematous condition may occur as a sequel of pneumonitis in the portion of lung which has been the seat of the inflammation. SUMMARY OF THE PHYSICAL SIGNS BELOXGIXG TO ACUTE LOBAR PNEUMONITIS. The vesicular percussion-resonance diminished during the stage of engorgement, but in a more marked degree after solidification has taken place; sense of resistance notably increased; the limits of the dulness and loss of elasticity corresponding to the boundaries of the afi"ected lobe; the vesicular resonance sometimes replaced by a tympanitic sonorousness, more or less marked; the crepitant rale generally discovered by auscultation, accompanied or followed by the broncho-vesicular and the bronchial respiration ; bronchophony with the loud and whispered voice generally present ; increased vocal fremitus over the solidified lung existing in a certain propor- tion of cases; occasionally pectoriloquy; the crepitant and the sub- crcpitant rale during the resolution of the disease in some instances; the moist and dry bronchial rales occasionally heard, but rarely prominent unless the disease advance to the stage of purulent infil- tration, when the moist rales may be more or less abundant ; a friction-sound heard in a small proportion of instances ; on the unaffected side exaggerated respiration ; diminished respiratory movements on the affected side sometimes apparent on inspection, if the affection be limited to a single lobe, oftener observed, and in a more marked degree, if the inflammation extend over an entire lung; contraction of the side affected after resolution in some cases. Imperfect Expansion (Atelectasis) and Collapse of Pul- monary Lobules. The morbid conditions denoted by the terms atelectasis and col- lapse of pulmonary lobules, have heretofore been considered as arising from inflammation which, instead of extending over an entire lobe, is circumscribed, being confined to lobules, either isolated or in I J PULMONARY LOBULES. 399 clusters, situated at different points, more or less numerous and dis- seminated in the pulmonary organs on both sides of the chest. These conditions were first described, under the name lobular pneumonitis occurring in children under six years of age, in this country by Gerhard,^ and in France by Rufz,^ Rilliet and Barthez,^ Valleix,^ and others. As described by the writers just mentioned, the so-called lobular pneumonitis embraces cases in which, after death, the lungs are found to present solidified portions varying in size from a pea to a filbert, scattered irregularly, occasionally confined to one side, but much oftener distributed over both lungs, varying in number from 2 to 30 ; the intervening parenchyma preserving the characters of the normal spongy tissue. This pathological condition in a large majority of instances is associated with the anatomical characters of bronchitis, and hence the afi'ection was called hroncho-'pneumonia^ by a German author, Seifert. Researches more recent have shed new light on the morbid anatomy and the pathology of affections heretofore included under the appel- lation of lobular pneumonitis and broncho-pneumonia. In 1832, Prof. Jorg, of Leipsic, published an account of a morbid condition found in the bodies of newly born children, analogous to that re- garded as characteristic of lobular pneumonitis, which he attributed to imperfect expansion of the lungs by the first inspirations after birth ; in other words, more or less of the lobules remaining in the foetal state. To this morbid condition he applied the name atelec- tasis. This condition had been previously described by a French writer, M. Dug^s, in 1821, in a thesis which failed to attract atten- tion to the subject. The anatomical characters regarded as distinc- tive of a persisting foetal condition, are as follows : the solidified lobules giving rise to depressions on the surface of the lung ; the pleu- ral covering retaining its glistening polished aspect; the size of the lobules afi'ected, and of the lobe in which they are found, not aug- mented, but diminished ; the cut surfaces, when the solidified lobules are incised, not having a granular appearance, but smooth, like muscle, and the tissue not softened or friable as it is in the second stage of ordinary pneumonitis. The morbid appearances, in other words, are those which belong to the condition called carnification. An important point of evidence, according to Jorg, of the morbid 1 Am. Jour, of Med. Sciences, 1834. 3 Traits des Maladies des Enfans. 2 Journ. des Conn. M^dico-Chir., 1835. * Ibid., nouv. nes, 1833. 400 DISEASES OF THE RESPIRATORY ORGANS. condition called by him atelectasis, was, that by insufflation the con- densed lobules are capable of being brought to a normal condition.^ Still more recently, the researches of Legendre and Bailly, of Paris, demonstrated that, in a certain proportion of the cases of so- called lobular pneumonitis, in which the affection is developed at a period more or less remote from birth, the affected lobules are in a condition analogous to that of foetal life : that is to say, the charac- ters pertaining to the condensation are those of carnification as dis- tinguished from red hepatization, and the fact that the air-vesicles are not occluded by a solid deposit, as in cases of ordinary lobar pneumonitis, is shown by the solidification being removed by insuf- flation. The authors just named first suggested this simple test of the fact of condensation, occasioned by morbid causes acting after birth, being due to a return to the foetal state, although the same means had been previously resorted to by Jorg in cases of atelec- tasis.^ The distinctive appearances of the parts in the one case preserv- ing, and in the other case resuming a foetal state, had by no means escaped the notice of earlier writers on the subject of lobular pneu- monitis. They had, however, attributed the production of this mor- bid condition to inflammation, attributing the differences in the anatomical characters — absence of the granular deposit, want of friability, etc., — to modifications of the inflammatory processes pecu- liar to early life. The investigations of Jorg, and Legendre and Bailly, led to the conclusion that the cases of so-called lobular pneu- monitis, in which the lobules are in the foetal state, or carnified, do not involve the existence of inflammation of the air-cells or paren- chyma, and that they are not properly cases of pneumonitis. Fuchs, of Leipsic, and W. T. Gairdner, of Glasgow, have published facts tending to show that condensation of more or less of the pul- monary lobules often occurs as the effect of collapse of the air-cells, due to partial obstruction of the bronchial tubes from accumulation therein of inflammatory products ; and in proportion as the name lobular pneumonitis is applied to cases of solidification thus pro- duced, the lesion is, in fact, incident to bronchitis, and the affection is not rightly called either lobular pneumonitis, or broncho-pneumonia. 1 The cases given by Valleix and others of lobular pneumonitis in still or newly born children, supposed to have existed in intra-uterine life, were probably cases of atelectasis. * Archives Generales de M^decine, 1848. PULMONARY LOBULES. 401 As a complication of bronchial inflammation, lobular collapse has been already referred to in connection with the consideration of bronchitis. The researches of Gairdner render it probable that col- lapse of portions of the lung is by no means an event exclusively pertaining to early life, and that bronchial obstruction sustains an important pathological connection with an aifection to be next con- sidered (emphysema). It is, however, entirely foreign to the plan of this work to engage in inquiries or discussions relative to ques- tions which concern the aetiology of the diseases affecting the respi- ratory organs, or their pathological character and relations, except so far as such questions are necessarily involved in the subject of diagnosis. In the present instance, the very brief history which has been given of the scientific developments pertaining to lobular pneu- monitis, has seemed to be requisite for a proper understanding of the affections heretofore so called. Physical Signs and Diagnosis. — In cases of imperfect expansion, or atelectasis, dulness on percussion is a physical sign frequently available. The existence of condensed lobules in both lungs is an obstacle in the way of a comparison of the two sides ; but the con- densation being usually more extensive on one side than on the other, a disparity in the percussion-resonance may be obvious. A greater relative dulness will oftener be found on the right than on the left side, the right lung being more apt to suffer from defective expan- sion. A judgment, however, may be formed, to some extent, of an abnormal deficiency of resonance on both sides, irrespective of a comparison between them, the sound being manifestly more dull than if the cells were fully expanded. Feebleness, or absence of respiratory sound, will be likely to be the result obtained by auscul- tation. The force of the respiratory movements is probably inade- quate, in most instances, to develop the bronchial, or even a well- marked broncho-vesicular respiration, the existence of which, in view of the solidification, might be rationally anticipated. Over the non-solidified portions of lung, the vesicular murmur, instead of being supplementarily exaggerated, will be abnormally feeble, owing to the same cause, viz., the weakness of the inspiratory efforts. The latter is also consistent with the fact that, for some time after birth, in health, the vesicular murmur is feeble, although subsequently it acquires an intensity, afterward again lost, constituting what is known as the puerile respiration. Inspection shows the visible move- 26 402 DISEASES OF THE RESPIRATORY ORGANS. ments of respiration to be unnaturally feeble, the type of breathing being abdominal ; and it has been pointed out by Dr. George A. Rees, of London, that the lower ribs, instead of expanding with the descent of the diaphragm, contract during the act of inspiration. With these signs, taken in. connection with the symptoms which have been mentioned, the diagnosis of imperfect expansion or ate- lectasis may be made with much positiveness. In cases of lobular condensation from collapse, if it be sufficient in extent to give rise to considerable embarrassment of respiration, percussion may be expected generally to furnish evidence of solidi- fication. The dulness will, of course, be marked in proportion to the number of lobules collapsed, and their proximity to the thoracic walls. Next to these conditions, the greater amount of collapse on one side of the chest is the circumstance most important, rendering the dulness obvious by contrasting the percussion-sound on the two sides. If the condensed lobules are in small disseminated clusters, and not far from equal in both lungs, the advantage of a comparison of the two sides is lost, and the fact of dulness may not be deter- minable. The proportion of such instances in cases of collapse re- mains to be ascertained by numerical investigations, but it is rare to find a near approach to equality in the amount of condensation existing in both lungs. The crepitant rale of pneumonitis does not, of course, belong to this form of disease. Auscultation discovers more or less of the dry and mucous rales in certain cases, but not uniformly. Collapse is not always, although in the large proportion of cases, associated with bronchitis ; and, moreover, the bronchial rales are far from being constant in cases of bronchial inflammation. More or less of the characters of the bronchial or the broncho-vesicular respiration, to- gether with exaggerated vocal resonance, increase of fremitus, and, possibly, weak bronchophony, are present in a certain proportion of cases. The suddenness with which the physical evidence of solidification becomes developed, a part, for example, being found to be notably dull on percussion, when the day previous there was no apparent diminution of resonance, is a point possessing diagnostic importance. The symptoms and attendant circumstances, taken in connection with the physical signs, have an important bearing on the diagnosis. Among the symptoms the absence of febrile movement is highly significant. The abrupt occurrence of difficult breathing, togetlier I CHRONIC PNEUMONITIS. 403 with the evidences of defective hsematosis, is another point possess- ing a certain amount of significance. The state of the muscular power, at the time the vital and physical evidences of condensation hecome apparent, is to he considered. Occurring during great ex- haustion, when the force of the inspiratory effort might be expected to be greatly reduced, the probability of collapse is certainly much greater than under opposite circumstances. Chronic Pneumonitis. Following the example of writers generally, who have treated of diseases affecting the respiratory organs, I shall dispose of the sub- ject of chronic pneumonitis in a summary manner. Our knowledge of this form of disease is imperfect. Laennec questioned its exis- tence. Nearly all pathological observers are agreed, as respects the infrequency of its occurrence, and different opinions on this point may be in a great measure accounted for by difference of views as to the morbid conditions to which the name of chronic pneumonitis is properly applied. Some writers (Andral, Hasse), who regard it as not very uncommon, embrace under this title cer- tain cases of tuberculosis, characterized by solidification of the pul- monary parenchyma between the tuberculous deposit. Under these circumstances the morbid condition, admitting it to be chronic pneumonitis, is incidental to tuberculosis, and it is not, therefore, to be considered a separate form of disease. It is probable that cases of collapse have been sometimes set down as instances of chronic pneumonitis. For example, a case reported by Requin, and de- tailed by Grisolle,^ in which the lower lobe of the right lung was found after death firmly condensed, non-granular, without tubercles or miliary granulations, may be suspected to have been of that de- scription. The same remark will apply to cases of carnification supposed to result from chronic inflammation of the pulmonary par- enchyma. An instance of this kind is quoted by Grisolle, from Rilliet and Barthez. According to Rokitansky, the morbid condition characteristic of chronic pneumonitis consists in the presence of inflammatory exuda- tion within the areolar tissue uniting the pulmonary lobules, and the 1 Traite Pratique de la Pneumonie, p. 351. This case is referred to by Dr. Walshe, under the head of Chronic Pneumonia. 404 DISEASES OF THE RESPIRATORY ORGANS. smaller groups of air-cells, and he applies to this form of disease the title of interstitial pneumonia. This infiltration within the inter- stitial tissue, he states, in the progress of time becomes organized and coalesces with the latter, so as to form a dense cellulo-fibrous substance which compresses and obliterates the air-cells, leading to contraction of the thorax and dilatation of the bronchial tubes. This is essentially the form of disease described by Corrigan, and designated by him cirrhosis of the lung, to which reference has been made in connection with the diagnosis of dilatation of the bronchial tubes. As a sequel of acute inflammation, chronic pneumonitis is exceed- ingly rare. Grisolle in his treatise giving the results of the analysis of 373 cases of pneumonitis, states that he has met with but a single instance in which the acute terminated in a chronic form of the dis- ease. M. Barth found but a single instance in a collection of 125 cases of acute pneumonitis.^ It is true that frequently after acute inflammation the physical evidences of solidification continue for some time, not disappearing entirely for weeks or even months. It would, however, be incorrect to say that under these circumstances the disease was perpetuated in a chronic form. In cases of veritable chronic pneumonitis succeeding the acute disease, the acute symp- toms disappear, but more or less febrile movement continues, occur- ring in paroxysms, or with marked exacerbations ; cough and ex- pectoration persist, the latter not preserving the characters signifi- cant of the acute disease ; the respiration is accelerated, with dyspnoea ; the appetite does not return, or, if it return, speedily, fails; the patient loses strength and weight, and, at length, dies, after the lapse of two or three months. The physical signs of solidification persist during the progress of the chronic disease, viz., notable dulness on percussion, with bronchial respiration, increased vocal resonance and fremitus, etc. In the case reported by Requin, above mentioned, the auscultatory phenomena denoting solidification, viz., bronchial respiration and exaggerated vocal resonance, were wanting. This occasionally happens in acute pneumonitis. Whether it is more likely to occur in the chronic form of the disease, it is impossible to say in view of the limited number of cases of the latter which have been reported. It is evident from the foregoing brief account of chronic pneumo- 1 Valleix, op. cit. CHRONIC PNEUMONITIS. 405 nitis that, except so far as it is involved in a lesion already con- sidered, viz., dilatation of the bronchial tubes, it is an affection pos- sessing comparatively small interest and importance in a practical point of view. Although the physician is very rarely called upon to make the diagnosis, the fact of its occasional occurrence is not to be lost sight of. In cases in which, after acute pneumonitis, physical signs denoting solidification are found to remain, associated with symptoms which indicate a grave malady, viz., febrile exacerba- tions, loss of strength and weight, cough and expectoration, etc., the question may arise whether the patient be affected with chronic pneumonitis or tuberculosis. If the physical signs denote solidifi- cation of the upper lobe, and especially if they denote that the solidification is confined to a portion of the lobe, the chances against the existence of tubercle are exceedingly small. The chances are greatly increased if the local affection be seated in the lower lobe ; but this situation is not conclusive evidence against the existence of tubercle, for, as exceptions to the general law, the tuberculous de- posit in some instances takes place first in the lower lobe. The differential diagnosis rests mainly on the presence or absence of the events characteristic of the progress of tuberculous disease, viz., haemoptysis, pleuritic pains, nocturnal sweats, etc., together with the physical evidences of the local changes incident to phthisis, viz., softening of the tuberculous matter and the formation of cavities. CHAPTER IV. EMPHYSEMA. The term emphysema is used to designate two quite diflFerent pul- monary affections. In one of these affections the morbid condition consists in an abnormal increase in size of the air-cells, and conse- quent over-accumulation of air within them. This is by far the more frequent in occurrence of the two affections, and is generally under- stood when the word emphysema is applied, without any qualification, to a morbid condition of the lungs. The term is manifestly inappro- priate, since there is only a remote analogy of this pulmonary affec- tion to the extravasation of air into areolar structure, the latter being the morbid condition designated by emphysema when it is used without special reference to the pulmonary organs. Dilatation of the air-cells, and rarefaction of the lung, are terms more expressive of the morbid condition, and are to be preferred. Vesicular emphy- sema and tr^ie pulmonary emphysema, are expressions employed by Laennec and subsequent writers to distinguish the affection now re- ferred to. The other affection to which the name of emphysema is applied, consists in the extravasation of air into the areolar structure uniting together the pulmonary lobules, and connecting the pleura with the superficies of the lung. This morbid condition, more correctly than the first styled emphysematous, is distinguished as interlobular and sub-jyleural emphysema. These two forms of the disease claim separate consideration ; but the latter will require comparatively brief space. I. Vesicular Emphysema. Vesicular Emphysema ; Dilatation of the Air-cells; Rarefac- tion of Lung. — Laennec was the first to give a clear description of this affection ; and in view of the originality and value of his re- VESICULAR EMPHYSEMA. 407 searches, a distinguished morbid anatomist of the present day^ has said that " had Laennec done nothing else for medical science, his discovery of this diseased condition, and of the causes giving rise to it, would have sufficed to render his name immortal." The patho- logical relations of dilatation of the air-cells, and the mode in which the lesion is produced, are subjects of much interest and importance, concerning which conflicting opinions are maintained by different writers. Conformity to the plan of this work renders it necessary to forego any consideration of these subjects, limiting the attention to the physical signs and the diagnosis of the affection.^ The following laws of emphysema, considered as an individual affection, are important to be borne in mind with reference to diag- nosis. Both lungs are affected in the great majority of cases. The affection may be limited to the upper lobes, and it is more marked in the upper than the lower lobes, if it extend to both. The two upper lobes are very rarely, if ever, equally affected ; that is, the emphysema is greater on one side. According to my experience, the emphysema is greater on the left side in the great majority of cases. The almost constant association of emphysema with chronic bronchitis, and the frequent association of asthma, are to be recol- lected. Physical Signs. — Dilatation of the air-cells is accompanied by physical signs which, combined, are quite distinctive of the affection. Percussion elicits, with few exceptions, an exaggerated resonance. The resonance is deficient in vesicular quality and the pitch is raised. The sound, in other words, without becoming purely tympanitic, acquires more or less of the tympanitic character ; it is vesiculo- tympanitic. The emphysema, existing on both sides, is usually greater on one side than on the other, and hence a disparity between the two sides is apparent. The vesiculo-tympanitic character of the sound is obvious on both sides, but this character is more strongly marked on the side which, at the same time, presents other signs 1 Rokitansky. 2 The author cannot forbear referring the reader to the views respecting the pathological relations and the production of dilatation of the cells, which have been advanced by Dr. W. T. Gairdner of Edinburgh. These views are certainly highly interesting and ingenious, if they are not destined to effect a radical change in the opinions commonly held on these subjects. Vide Brit, and For. Med. Chir. Keview, April, 1853 ; or a treatise entitled " On the Pathological Anatomy of Bronchitis, and the Diseases of the Lung connected with Bronchial Obstruction." Edinburgh, 1850. (Note in first edition.) 408 DISEASES OF THE RESPIRATORY ORGANS. denoting a greater amount of dilatation of the air-cells. Occasional exceptions to the rule of exaggerated resonance are observed. The resonance on the side on which the emphysema is greatest may be dull as compared with the opposite side. When a notable disparity as regards intensity of resonance be- tween the two sides exists, dulness may be supposed to exist on the side yielding the lesser degree of resonance, without due care. This error may always be avoided by attention to the pitch of the sound on both sides. If the disparity in the degree of resonance between the two sides be due to dulness on one side, the pitch of sound is higher on the dull side; if, on the other hand, the disparity be due to exaggeration of resonance on one side, the pitch of sound is higher on this side, and the vesiculo-tympanitic quality also more marked. To the rule just stated there are no exceptions. The sense of resistance is increased over emphysematous lung in proportion to its increase of volume. In cases in which the chest is partially or generally enlarged, this sign, incidental to the act of percussion, is present in a marked degree. An abnormal intensity of resonance is found in the prsecordia. The heart may be removed from contact with the walls of the chest, and carried downward, so that between the sternum and nipple the chest becomes highly resonant. If the emphysema aflFect the lower lobes, the pulmonary resonance extends below its normal limits, to- ward the base of the chest. For example, on the right side, in front, the line of hepatic flatness may be depressed to the ninth or tenth ribs on a vertical line through the nipple; and, owing to the permanent expansion of the lung, this line is found to vary but little with the successive acts of inspiration and expiration, even when they are voluntarily increased. A similar extension of the space occupied by pulmonary resonance is apparent on the lateral and posterior surfaces of the chest at the base, and also at the summit, in some instances, above the clavicle, and at the upper part of the sternum, where, from its relation to the trachea, the normal reso- nance is tympanitic. The auscultatory phenomena due to the emphysema are to be dis- tinjruished from those attributable to bronchial inflammation which so frequently coexist. Exclusive of the signs to which the bron- chitis gives rise, the signs pertaining to the respiration are, in them- selves, highly characteristic of the affection, and in combination with the evidence derived from percussion, their diagnostic signifi- VESICULAR EMPHYSEMA. 409 cance is quite positive. Feebleness of the respiratory murmur is one of the distinctive features. In some instances a respiratory sound is inappreciable with the ordinary stethoscope or by imme- diate auscultation, and is scarcely heard with Cammann's instru- ment. Other things being equal, the feebleness is proportionate to the degree of the emphysematous condition. A disparity exists be- tween the two sides in this particular, and the greater feebleness of respiratory sound is on the side presenting the greater intensity and vesiculo-tympanitic quality of percussion-resonance ; the respiratory murmur may be almost or quite null on this side, and the intensity relatively greater on the other side, but yet more or less below the normal amount. Apparent exceptions to this rule may be found at times, if the bronchial tubes on the side least affected happen to be obstructed from an accumulation of mucus ; under these circum- stances, at some examinations, the respiratory murmur may be stronger on the side most emphysematous. An exaggerated respira- tion may exist over the portions of lung to which the emphysema does not extend. When the emphysema is confined to the upper lobe, the respiratory murmur below the scapula, behind, will be found to be in a marked degree more intense than at the summit in front, the reverse being the case in health. The respiratory sound is frequently altered in other respects than intensity. It is changed in rhythm. The inspiration is shortened. The inspiratory sound is deferred; that is, more or less of the in- spiratory act takes place before the sound is appreciable. Some- times a very brief sound only is heard at the close of the act. The expiratory sound, on the other hand, is often prolonged, sometimes exceeding considerably in duration the sound of inspiration. The expiratory sound is always more or less feeble, but its intensity may be greater than that of the sound of inspiration ; the latter may be almost inappreciable while the former is distinctly although faintly heard. The respiratory sound also undergoes a change in quality. It is said to become rough. The inspiratory sound has less of the vesic- ular quality than belongs to the normal murmur, and is raised in pitch. So far it presents the characters of that abnormal modifica- tion generally distinguished as roughness. It has not, however, the tubulosity of the broncho-vesicular respiration which represents a morbid condition the opposite of rarefaction, viz., increased density of the pulmonary structure. The prolonged expiration, if it be a 410 DISEASES OF THE RESPIRATORY ORGANS. pure respiratory sound without an admixture of a sibilant rale, is lower in pitch than the sound of inspiration, whereas in the bron- cho-vesicular respiration, the pitch of the prolonged expiratory sound is higher than that of the sound of inspiration. In emphysema the expiratory is generally continuous with the inspiratory sound. In condensation of lung a brief interval separates the two sounds. The shortened inspiration in emphysema is deferred; in condensa- tion it is unfinished. In the majority of instances, at the time the aifection comes under the observation of the physician, it is associated Avith bronchitis, and frequently with bronchial spasm constituting an attack of asthma. Under these circumstances, physical signs are present, due to the coexisting affections, but more or less modified by the emphj^sema. The moist bronchial rales are observed in a certain proportion of cases, consisting of the fine mucous or the sub-crepitant variety, if the inflammation extend to the smaller tubes. Much oftener the dry rales are present — the sonorous and sibilant. In asthmatic paroxysms these rales are loud and diffused, accompanied by wheez- ing which may be heard at a considerable distance from the patient. Exclusive of asthma, they denote bronchial inflammation superadded to the emphysema. The rales often take the place of the respiratory sound, ^. e., nothing else is heard. They are generally more marked in expiration than in inspiration ; and the sibilant is oftener heard than the sonorous, exclusive of the complication of asthma. Auscultation of the voice furnishes negative, or at least doubtful, results in cases of emphysema. Judging from my own observations, I would say that the vocal resonance does not, in general, undergo either marked increase or diminution in this affection. It is certain that, if it be materially modified, the modifications are occasional, not constant. I have observed the naturally greater vocal reso- nance of the right side to be preserved when the emphysema was limited to the left side (as determined by other signs), and, on the other hand, I have observed the same natural disparity Avhen the greater amount of emphysema was on the right side. Walshe states that intense bronchophony may exist over lung greatly rarefied. I cannot but suspect in such instances that it is due to a normal peculiarity, existing irrespective of the emphysema. Auscultation in the prascordial region, wuth reference to the pul- monary and cardiac sounds, affords a means, in addition to percus- sion and palpation, of determining whether the heart be abnormally VESICULAR EMPHYSEMA. 411 overlapped by lung, or displaced from its normal situation. The presence of a layer of lung between that organ and the thoracic walls may be shown by a feeble respiratory murmur, or by the bron- chial rales diffused over the whole of the prgecordia. The heart- sounds, under these circumstances, are faint and distant. They may be inappreciable in the pra^cordia, but, if the displacement be down- ward toward the epigastrium, they may be heard with distinctness in the latter situation. Inspection furnishes striking corroborative evidence of the exist- ence of emphysema. The frequency of the respirations is often abnor- mal. Habitually, if dyspnoea be absent, and the breathing slightly or moderately labored, the number of respirations per minute may be found to be below the normal average. This may be the case if obstruction of the bronchial tubes from bronchitis or spasm accom- panies the emphysema. Slowness of respiration, however, by no means characterizes all cases of the affection. If the emphysema be sufficient to give rise, of itself, to dyspnoea whenever the circu- lation is accelerated, or from other causes irrespective of bronchial obstruction, and especially if the emphysema involve atrophy as a predominant anatomical element, frequency of the respirations may be a prominent feature. In a case of atrophous emphysema, I have observed the number of respirations, on exercise, increased to 60 per minute. In cases of general or extensive dilatation of the cells, the rhythm of the respiratory acts is altered, the deviation corresponding to that of the respiratory sounds. The inspiratory movement is shortened. The lungs being permanently expanded, the extent of their farther expansion with the inspiratory act is proportionally lessened ; the act, therefore, is more quickly performed, and, moreover, if dyspnoea be present, the want of a fresh supply of atmospheric air causes the act to be hurried. The expiration, on the other hand, is pro- longed in consequence of the impaired contractility of the pulmonary organs, and because more expiratory force can be exerted. When, in addition to the impaired contractility, the bronchial tubes are ob- structed, which occurs if the emphysema be complicated with in- flammation, or spasm affecting the smaller bronchial tubes, the ex- piratory movement is still more prolonged, owing to the obstruction offered to the passage of air from the cells. Under these circum- stances, and, indeed, from the impaired contractility of the lung 412 DISEASES OF THE RESPIRATORY ORGANS. alone, the labor and slowness -with which expiration is performed increase from the beginnin^r to the close of the act. Certain characteristic signs pertain to the appearance of the chest while in rest and in motion. If the volume of the upper lobes be considerably augmented, the form of the chest is altered. The superior and middle thirds present an unnaturally rounded, globular, barrel-shaped appearance. This change in some cases amounts to a deformity which is pathognomonic of the aflfection. It is more apt to be marked in cases in which the emphysema has been of long standing, and has existed from early life. Partial enlargement between the clav- icle and a point at or a little below the nipple, the degree of enlarge- ment approaching to that of full inspiration, is not uncommon. This abnormal fulness will, of course, be greater on one side than on the other, owing to the fact that the two lungs are rarely equally affected; and as the left lung is oftener more augmented in volume than the right, it will be oftener observed on the left side. In comparing the two sides with reference to this point, it is to be borne in mind that normally a disparity exists in the anterior portion of the chest in many persons. According to the observations of M. Woillez, the left side presents a projection obviously greater than the right, above a point at or a little below the nipple, in about 26 per cent, of persons free from disease or deformity. It is not improbable that, owing to this natural disparity having been overlooked, a greater relative fulness of the summit of the left side may in some instances have been incorrectly attributed to a larger amount of emphysema on that side. A test of the prominence here or else- where being due to the pressure of rarefied lung, is afforded by the results of percussion and auscultation. In some cases of emphysema the expanded lung effaces the de- pression existing above the clavicle, causing a bulging in this situa- tion. This, when present, is highly characteristic, but it is rarely observed. The inferior portion of the chest may appear to be considerably contracted. This is in part apparent, rather than real, in conse- quence of the enlargement of the superior portion, but it is, also, in some cases, to a greater or less extent, real ; the dimensions of the chest at its lower part are actually lessened. On the other hand, the upper part of the abdomen may acquire an unnatural fulness and resistance to pressure, owing to the flattening of the diaphragm ■which presses downward and outward the organs lying below it. VESICULAR EMPHYSEMA. 413 A close examination of the expanded portion of the chest shows the same relations of its different parts which obtain in health at the end of a full inspiration, viz., the obliquity of the ribs is dimin- ished ; the ribs and costal cartilages are nearly on a line ; the shoulders are raised ; the intercostal spaces are narrowed at the summit, and widened over the middle of the chest. Patients who have suffered long from emphysema generally pre- sent spinal curvature more or less marked. The dorsal curve is in- creased ; the lower angles of the scapulae project, and, hence, a stooping gait is somewhat characteristic. These changes are some- times highly marked. The condition of the intercostal spaces in parts of the chest en- larged by the distension of emphysematous lung has been a mooted point. According to Dr. Stokes, the effect is never to efface the depression between the ribs. Observation, however, appears to have established, what would rationally be expected, that at the summit of the chest the intercostal muscles yield to the pressure of the lung more readily than the ribs, and hence, that the depressions in per- sons in whom they are visible in this situation in health become di- minished, if not effaced. That this is rarely observed at the lower part of the chest in front and laterally, where the depressions are most conspicuous, is true. One reason for this is, the emphy- sema is limited to, or is much greater at, the upper portion of the lungs. Another reason is, the traction of the diaphragm renders the depressions deeply marked during inspiration, notwithstanding the increase of the volume of the lung. Characteristics relating to the movements of the chest are not less striking than those incident to alterations in size and configuration. When the augmented volume of the lung is sufficient to keep the chest permanently dilated at a point not much below the limits of a full inspiration, of course the range of expansive movement in res- piration is correspondingly restrained. The thoracic walls at the superior and middle portions contract but little with expiration, and the enlargement with inspiration is slight. The dyspnoea, however, especially when increased by any superadded cause affecting hgema- tosis, such as exercise, the existence of bronchitis, or bronchial spasm, gives rise to extraordinary efforts to expand the chest. The effect of these efforts, so far as they are exerted on the thoracic walls, is to elevate the ribs ; and, as the costal cartilages are already straightened by the permanent expansion, the elevation of the ribs 414 DISEASES OF THE RESPIRATORY ORGANS. carries the sternum upward, so that the whole chest, including in some instances the clavicles, rises and falls with successive respira- tory acts, as if it w"ere a solid bony case. The diaphragm participates in these exaggerated efforts ; but if the emphysema extend to the lower lobes, the range of the diaphrag- matic movement is diminished, and the rising and falling of the ab- domen is less than in health. If the emphysema be accompanied by bronchial obstruction, the lower part of the sternum, the epigas- trium, and inferior portion of the chest, laterally, are depressed with inspiration, the natural movements being reversed. This arises from the depression of the diaphragm elongating the lung, producing a vacuum which is not filled with sufficient rapidity by the air re- ceived into the bronchial tubes, and consequently the weight of the atmosphere presses the walls of the chest inward. This is less marked in aged persons in whom ossification of the costal cartilages has taken place. The lateral anterior intercostal depressions at the lower part of the chest, are generally deeply marked with the act of inspiration in proportion to the exaggerated diaphragmatic efibrt; and at the summit of the chest, the spaces above and below the clavicles are not infrequently depressed with this act. The foregoing account of the aberrations of motion have refer- ence to appearances manifested on both sides of the chest. Cases in Avhich the emphysema is limited to one side are extremely rare if they ever exist; but, as has been seen, when both lungs are affected, it is seldom that there does not exist an inequality in the amount of the affection in the two sides. The effects on the respiratory move- ments, as well as on the size and form, will then be more marked on the side which is most affected, the disparity as regards the signs furnished by inspection corresponding to the differences developed by a comparison of the results of percussion and auscultation. Mensuration affords a means of verifying the abnormal changes in size and the aberrations of motion, which are determined suffi- ciently for diagnosis by inspection. To state the results furnished by this method would be, for the most part, to repeat what has just been presented. Palpation furnishes some signs of importance. The alterations in shape, the condition of the intercostal spaces, the mobility of portions of the chest, the direction of the ribs, and their movements relatively to each other, are points which are ascertained by the I VESICULAR EMPHYSEMA. 415 touch as well as, and in some respects better than, by the eye. The sense of resistance, of which a judgment is formed incidentally while practising percussion, may be made a separate object of examina- tion, and it then falls under the head of palpation. As respects the vibratory thrill communicated to the thoracic walls by the voice, and felt by the hand applied to the chest, in other words the vocal fremitus, it is found to vary in different cases, being in some in- stances increased, oftener diminished, and in other instances re- maining unaffected. There is no constancy of relation between this sign and the affection ; hence, in its bearing on the diagnosis, it is unimportant. Examination .with the hand is important in order to ascertain the situation of the heart. The absence of the cardiac impulse in the prsecordia shows this organ to be removed from contact with the thoracic walls. When it is depressed to the neighborhood of the epigastrium, its pulsations may be felt to the left of the ensiform cartilage. The impulse is not infrequently transferred to this situ- ation. Diagnosis. — The physical phenomena incident to vesicular em- physema, as already remarked, are highly distinctive of the affec- tion. With an adequate knowledge of these phenomena the diag- nosis is sufficiently easy and positive. Without the advantage which this knowledge affords, the symptoms might be supposed to denote some other disease of which dyspnoea is a prominent feature, for example, disease of the heart, aortic aneurism, chronic pleuritis, pneumo-hydrothorax, capillary bronchitis, pneumonitis, and pul- monary tuberculosis. It will suffice to mention the more important points involved in the differential diagnosis from the several affec- tions just named. From heart disease emphysema is distinguished by the absence of the physical signs of the former, except it has become developed as a complication. If the complication have occurred, the previous history, in general, affords evidence of disturbance of the respira- tion for a long period prior to palpitations, or other symptoms of cardiac disturbance. With or without the conjunction of the symp- toms and signs of disease of heart, the existence of emphysema is evidenced by the combined physical phenomena distinctive of the affection, which have been fully considered. Aneurism of the aorta may cause a partial enlargement of the 416 DISEASES OF THE RESPIRATORY ORGANS. chest from the pressure of the tumor. But over the enlargement the percussion-sound will be dull or flat, in place of the increased resonance due to rarefied lung. The positive signs of emphysema will be wanting, while, on the other hand, an aneurismal tumor has its positive signs, viz., pulsation, thrill, and a bellows' sound syn- chronous with the heart's action. From pleuritis with effusion, emphysema is distinguished by the enlargement of the chest (if it exist) being on both sides, and at the summit, instead of the base, and by the absence of dulness or flat- ness on percussion, extending over more or less of one side. So far as physical signs are concerned, the afi'ection to which em- physema bears the nearest resemblance is pneumo-hydrothorax. In pneumo-hydrothorax the presence of air in the pleural sac causes dilatation of the chest, abnormal sonorousness on percussion, and suppression of the vesicular murmur of respiration. But as regards the physical phenomena, circumstances distinguishing the two affec- tions are suiEciently marked. In pneumo-hydrothorax the percus- sion-resonance is purely tympanitic, whereas in emphysema the vesic- ular quality of sound is diminished, but not lost. The latter afi'ec- tion never acquires the extreme drum-like sonorousness which char- acterizes dilatation of the chest from air within the pleural sac. In pneumo-hydrothorax the sonorousness frequently extends to a cer- tain distance from the summit of the chest, and below the point to which it extends there exists flatness on percussion, owing to the presence of liquid; in emphysema, when the afi'ection is limited to the superior portion of the lung, percussion-resonance exists at the lower part of the chest. Pneumo-hydrothorax is always confined to one side of the chest ; this is very rarely, if ever, true of emphy- sema. Moreover, pneumo-hydrothorax has its characteristic physi- cal signs, which never occur in connection with emphysema, viz., amphoric respiration, metallic tinkling, splashing on succussion. In the vast majority of cases, pneumo-hydrothorax occurs from perfo- ration in the course of tuberculosis of the lungs, and the existence of the latter disease is shown by the pre-existing and coexisting signs and symptoms. Emphysema complicated with ordinary acute bronchitis presents certain of the diagnostic features of bronchial inflammation seated in the minute tubes. In capillary bronchitis the percussion-sound may be exaggerated, and become vesiculo-tympanitic. The dyspnoea in both cases may be extreme. The one afi'ection is attended with VESICULAR EMPHYSEMA. 417 great danger, the other, however distressing the symptoms, is rarely dangerous. The symptoms and signs, taken in connection with the previous history, suffice for the discrimination. CapilLary bronchitis is accompanied by great acceleration of the pulse ; in emphysema with ordinary bronchitis the pulse is moderately, if at all, increased in frequency. In capillary bronchitis the sub-crepitant rale is dif- fused over the chest on both sides, especially over the posterior sur- face ; in emphysema it is an occasional sign, and never so much diffused. Capillary bronchitis occurs especially in childhood ; em- physema, sufficient to give rise to great disturbance of the respira- tion in connection with ordinary bronchitis, is rarely observed in early life. In cases of emphysema, in which the symptoms are ren- dered severe by an intercurrent ordinary bronchitis, the previous history, in the vast majority of cases, shows clearly the existence, for a long period, of dilatation of the cells, and, in a large propor- tion of instances, the patient is subject to attacks of asthma. These circumstances have an important bearing on the differential diagnosis, from not only capillary bronchitis, but other affections with which emphysema may possibly be confounded. From pneumonitis and phthisis the differential diagnosis is settled at once by the physical signs. In each of these affections there are present the physical phenomena denoting solidification of lung, viz., dulness on percussion, bronchial or broncho-vesicular respiration, increased vocal resonance or bronchophony, exaggerated bronchial whisper or whispering bronchophony, and increase of fremitus. These points of distinction are abundantly sufficient, irrespective of those pertaining to symptoms and pathological laws which are also distinctive. In conclusion, the diagnosis of emphysema requires only an ac- quaintance with its symptoms, signs and pathological laws. With this knowledge it is recognized without difficulty in cases in which the dilatation of the cells is sufficient to give rise to the character- istic phenomena of the affection. SUMMARY OF THE PHYSICAL SIGNS BELONGINa TO VESICULAR EMPHYSEMA. Exaggerated resonance on percussion, with a few exceptions, and the resonance vesiculo-tympanitic. Sense of resistance increased. 27 418 DISEASES OF THE RESPIRATORY ORGANS. Feebleness, and in some instances suppression of the respiratory murmur. Inspiratory sound shortened (deferred) ; expiration pro- longed, but the pitch of expiration not higher than that of inspira- tion. The bronchial rales denoting bronchitis, or spasm, often present, especially the dry rales, and usually more marked with expiration. The inspiratory movements quickened and shortened, and those of expiration prolonged. The upper anterior portion of the chest, enlarged, more or less, within the limits of a full inspira- tion. The space above and below the clavicle occasionally bulging. Curvature of the dorsal portion of the spine forward, if the dis- ease have been of long standing. The whole chest, in cases in which the affection is sufficient in degree and extent to give rise to dyspnoea, elevated as one piece, in inspiration, Avith but slight ex- pansion. The movements of the diaphragm restrained. The beating of the heart not felt in the prsecordia, but in some instances at the epigastrium. Interlobular Emphysema. In this form of emphysema air is extravasated into the areolar structure uniting together the pulmonary lobules. The morbid con- dition is identical with emphj-sema seated beneath the external tegu- ment of the body. To the latter, indeed, it may give rise, the air following the roots of the lungs into the mediastinum, thence into the subcutaneous areolar tissue of the neck, and becoming more or less diffused. Interlobular emphysema is almost invariably trau- matic, arising from rupture of the air-vesicles in consequence of» violent respiratory efforts. It is a rare affection. The anatomical characters consist of enlargement of the interlobular septa, the in- creased size being greater toward the surface of the lung, causing them to assume a wedge-like shape, and detachment of the pleura by the pressure of air beneath this membrane, producing air-bladders, variable in size, and more or less numerous. These air-bladders sometimes attain to a considerable size. I have seen a globular tumor thus formed, as large as an English walnut, and they have been observed still larger. In a case reported by Bouillaud, there existed a sac so large that it resembled the stomach. They are movable by pressure, and if there be several they may be made to coalesce. Similar sacs are sometimes found beneath the surface, differing from those caused by coalescence of the air-vesicles in the INTERLOBULAR EMPUYSEMA. 419 fact that they are seated in the interlobular areolar structure. In some cases the surface of the lung is studded Avith numerous small elevations of the pleura, presenting an appearance compared by Rokitansky to that of froth. Close examination of sections of lung affected with interlobular emphysema shows the air-vesicles to be unaffected, except by the pressure of the enlarged septa, and the cavities formed in the areolar tissue. This form of emphysema occurs in children more frequently than in adults. It is oftener situated in the upper than in the lower lobes, and is most prone to occur along the anterior borders of the upper lobes. The symptoms are those incident to defective hsematosis, this being proportionate to the extent to which the air-vesicles are com- pressed by the abnormal size of the interstitial areolar tissue, and to the mechanical obstacle to the expansion of the lungs from the presence of sub-pleural extravasation of air. Cases have been re- ported in which sudden death was attributed to the rapid escape of air from the cells into the areolar tissue. Rupture of the pleural air-bladders may take place, giving rise to pneumothorax, and col- lapse of the lung. Owing to the great infrequency of the affection, the histories of well-attested cases have not as yet accumulated suf- ficiently to furnish data for determining its symptomatic characters ; or, at all events, an analysis of recorded cases is yet to be made. The remark just made with respect to symptoms, will apply equally to physical phenomena. Laennec attributed to this affection two signs, neither of which have been found by subsequent observation to possess the significance attached to them by the discoverer of aus- cultation. One of these is the indeterminate sign styled by Laennec the dry crepitant rale with large bubbles {rale crepitant sec a grosses billies) ; and the other a friction sound [bruit de frottement). The first of these two signs is so doubtful in its character, as well as in its relation to pathological conditions, that it is clinically unimpor- tant. The second may possibly be present in some cases of inter- lobular emphysema, but occurs in the vast proportion of instances in connection with inflammation of the pleura. The rarefaction of lung induced by the presence of air in the areolar structure must, of course, give rise (except the tension of the thoracic walls be very great) to exaggerated resonance on percussion ; and, also, to feebleness of the respiratory murmur in proportion as the air-vesicles are compressed and the expansion of the lung restrained. The 420 DISEASES OF THE RESPIRATORY ORGANS. I combination of the physical signs furnished by percussion and aus- cultation is, thus, the same as in the ordinary form of emphysema, viz., dilatation of the air-cells. The differential diagnosis from the latter, with our present knowledge of the subject, so far as the symp- toms and signs referable to the chest are concerned, would be im- practicable. Circumstances in some cases incidental to the affection, may enable the physician to make the discrimination clinically. If the physical signs and symptoms denoting rarefaction of lung be developed suddenly, or with more or less rapidity, evidently proceed- ing from an injury occurring in connection with some unusual effort of the respiratory organs, for example, after violent coughing, the straining of parturition, a strong mental emotion, etc., the proba- bility is that the emphysema is traumatic and interlobular. If sub- cutaneous emphysema of the neck follow under these circumstances, the diagnosis is rendered quite positive. External emphysema, how- ever, unless it occur in conjunction with the physical signs denoting rarefaction of lung, is not evidence of this morbid condition, for it may proceed from rupture of the trachea or bronchi exterior to the pulmonary organs. Happily, owing to the great infrequency of this variety of emphysema, the absence of traits sufficiently distinctive to warrant a positive diagnosis in all instances is rarely the occasion of embarrassment in medical practice. CHAPTER y. PULMONAKY TUBEKCULOSIS— BRONCHIAL PHTHISIS. The affection called pulmonary tuberculosis, phthisis pulmonalis, or pulmonary consumption, involves, as the point of departure for a series of destructive processes, the deposit in the lungs of the mor- bid product called tubercle. The nature of this product, the pre- cise situation in which it is first deposited, its varying characters, the metamorphoses which it undergoes, and the structural changes incident to the progress of the disease, are subjects which could not be touched upon without risk of being led into details inconsistent with the limits, as well as the plan of this work. Presuming the reader to have a general acquaintance, at least, with the morbid anatomy of the disease, I shall simply enumerate the abnormal con- ditions which stand in immediate relation to the phenomena furnished by physical exploration. The presence of tubercle causes, in pro- portion to its quantity, an increased density of the affected lung. Existing in the form of small isolated deposits, more or less numer- ous, the intervening pulmonary parenchyma being healthy, it con- stitutes a form of miliary and disseminated tubercles. The increased density due to the presence of tubercles, either discrete or distrib- uted in small clusters, may be but slight, but will, of course, cor- respond to their abundance and approximation to each other. Ob- struction to the entrance of air into the cells, from the pressure of the tubercles on the small bronchial tubes, may not only abridge the respiratory processes in the part or parts affected, but cause a re- duction in volume by collapse of more or less of the cells not filled with tuberculous matter, and thus the density is still farther in- creased by condensation. The physical conditions represented by certain signs under these circumstances generally fall short of those incident to a more abundant exudation, when the deposits no longer remain isolated, but, enlarging by constant accretion, they at length coalesce and form continuous solid masses, frequently attaining to a considerable size. The latter constitutes more emphatically tuber- 422 DISEASES OF THE RESPIRATORY ORGANS. culous solidification, and a corresponding difference pertains to the representative physical signs. So also if tlie tubercles be dissem- inated, and the intervening parenchyma become consolidated by in- flammatory exudation (which not infrequently occurs), the physical conditions are the same, a continuous solidification in this case equally existing. The occurrence of circumscribed inflammation of the pulmonary parenchyma surrounding tuberculous deposits, may give rise to the auscultatory sign pathognomonic of pneumonitis, viz., the crepitant rale, and, taken in connection with certain circumstances, as will be seen, this sign is evidence of tuberculous disease. The processes of softening, ulceration, and evacuation of the liquefied tuberculous matter, leaving pulmonary excavations, give rise to anatomical conditions quite diff"erent from those which per- tain to the presence of crude tubercle, and these new conditions are represented by peculiar signs. But whereas, the fresh deposition of tubercle is usually going on while cavities are forming, and after they have formed, tuberculous solidification generally surrounds the excavations, and crude tubercles, in greater or less abundance, are distributed throughout the pulmonary parenchyma. Hence, the physical signs of difierent stages of the progress of tuberculous dis- ease, viz., solidification and excavation, are likely to be conjoined. The size of excavations, their situation, their number, and the firm- ness of their walls, as well as the varying contingent conditions re- lating to their contents, are found to afi"ect the physical phenomena to which they give rise. The bronchial tubes in proximity to tuberculous deposits and ex- cavations are the source of physical signs. Circumscribed bron- chitis, as will be seen, is evidence of the existence of tuberculosis. The presence of liquid in the tubes, either produced by bronchitis or derived from cavities, and the perviousness of the bronchial tubes, constitute important physical conditions. The loss of expansibility of lung solidified by tubercle, and the reduction in its volume which frequently ensues from collapse and destruction of pulmonary tissue, furnish conditions which are repre- sented by physical signs. The attacks of circumscribed dry pleuritis which occur from time to time almost uniformly over tuberculous portions of lung, may also give rise to phenomena which become, inferentially, evidence of tuberculosis. PULMONARY TUBERCULOSIS. 423 AbnormfERiCAN Ciie.mist," see p. 11.) (For " The Obstetrical Journal," see p. 22 ) 2 Henry C. Lea's J*ubltcation8 — (Am. Journ. Med. Sciences). ptuceed in his endeavor to place upon the table of every reading practitioner in the United States a monthly, a quarterly, and a half-yearly periodical at the comparatively trifling cost of Six Doli-ahs per anviim. These periodicals are universally known for their high professional standing in their several spheres. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES,' | Edited by ISAAC HAYS, M.D., 18 published Quarterly, on the first of January, April, July, and October. Each number contains nearly three hundred large octavo pages, appropriately illustrated, ■wherever necessary, It has now been issued regularly for nearly fifty years, during almost the whole of which time it has been under the control of the present editor. Throughout this long period, it has maintained its position in the highest rank of medical periodicals both at home and abroad, and has received the cordial support of the entire profession in this country. 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Thus, during the year 1873, the "Journal" furnished to its subscribers Seventy-seven Original Communications, One Hundred and 'i"wenty-five Reviews and Bibliograph- ical Notices, and Two Hundred and Ninety-four articles in the Quarterly Summaries, making a total of about Five Hundred articles emanating from the best profes- sional minds in America and Europe. That the efforts thus made to maintain the high reputation of the " Journal" are successful, is shown by the position accorded to it in both America and Europe as a national exponent of medical progress : — Dr. Hays keeps his great Ameriran Quarterly, in which he is now assisted by Dr. Miuis Hays, at the b^^id of his country's medical periodicals. — Dublin Mtidical Press and Circular, March S, 1871. Of English periodicals the i'rncei, and of American the Am. Journal of the Medical Sciences, are to be regarded as necessities to the reading practitioner. — .V. r. Medical Gazette, Jan. 7, 1S71. The American Journal of the Medical Sciences yields to none in the amount of original and borrowed mutter it contains, and has established lor itself a reputation in every country where medicine is cul- tivated as a science. — Brit, and For. Med.-Chirurg. Beview, April, 1871. This, if not the best, is one of the best-conducted medical quaiterlies in the English language, and tlie present number is not by any means iuferior to its predece.ssor.s. — London Lancet, Aug 23, 187U. Almost the only one that circulates everywhere, all over the Utiion and in Europe. — London Medical Times, Sept. 5, 1868. medal of merit to And by the fact, that it was specifically included in the award of a the publisher at the Vienna Exhibition in 1873. The subscription price of the "American Journal of the Medical Sciences" has never been raised, during its long career. It is still Five Dollars per annum ; and when paid for in advance, the subscriber receives in addition the " 2vIedical News and Library," making in all about 1500 large octavo pages per annum, free of postage. II. THE MEDICAL NEWS AND LIBRARY IB a monthly periodical of Thirty-two large octavo pages, making 384 pages per annum. Its "News Department'' presents the current information of the day, with Clinical Lectures and Hospital Gleanings; while the " Library Department" is de- voted to publishing standard works on the various branches of medical science, paged separately, so that they can be removed and bound on completion. In this manner subscribers have received, without expense, such works as " Watson's Practice," ■•Todd and Bowman's Physiology," "West on Children," '-Maloaione's Surgery." 00. Henry C. Lea's Publications — {Physiology). lifARSHALL (JOHN), F. R. S., J.tL Pro/esior of Surgery in University College, London, &c. OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. With Additions by Francis Gurnet Smith, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, &c. With numerous illustrations. In one large and handsome octavo volume, of 1026 pages, extra cloth, $6 50 ; leather, raised bands, $7 60. In fact, in every respect, Mr. Marshall has present- ed us with a mont complete, reliable, and scientific work, and we feel that it is worthy our warmest commendation. — St. Louis Med. Reporter, Jan. 1869. tive, with which we are acquainted. To speak of this work in the terms ordinarily used on such occa- sions would not be agreeable to ourselves, and wonld fail to do justice to its author. To write such a book requires a varied and wide range of knowledge, con- siderable power of analysis, correct judgment, skill in arrangement, and conscientious spirit. — London Lancet, Feb. 22, 1868. There are few, ifany, more accomplished anatomigte and physiologists than the distinguished professor of surgery at University College ; and he has long en- joyed the highest reputation as a teacher of physiol- ogy, possessing remarkable powers of clear exposition We may now congratulate him on having com- [ and graphic illustration. We have rarely the plea- pleted the latest as well as the best summary of mod- i sure of being able to recommend a text-booli so unre- ern physiological science, both human and compara- ' servedlyasthis. — British 3Ied. Journal, Jan 25,1868. We doubt if there is in the English language any compend of physiology more useful to the student than this work. — St. Louis Med. and Surg. Journal, Jan. 1869. It quite fulfils, in our opinion, the author's design of making it truly educational in its character — which is, perhaps, the highest commendation that can be asked. — Am. Journ. Med. Sciences, Jan. 1869. c A HP ENTER {WILLIAM B.), M.D., F.R.S., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new American from the last and revised London edition. With nearly three hundred illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, &c. In one very large and beautiful octavo volume, of about 900 large pages, handsomely printed; extra cloth, $5 50 j leather, raised bands, $6 50. We doubt not it is destined to retain a strong hold on public favor, and remain the favorite text-book in our colleges. — Virginia Medical Joiirnal. With Dr. Smith, we confidently believe "that the present will more than sustain the enviable reputa- tion already attained by former editions, of being ene of the fullest and most complete treatises on the subject in the English language." We know of none from the pages of which a satisfactory knowledge of the physiology of the human organism can be as well obtained, none better adapted for the use of such as take up the study of physiology in its reference to the institutes and practice of medicine. — Am. Jour. Med. Sciences. The above is the title of what is emphatically tht great work on physiology ; and we are conscious that it would be a useless effort to attempt to add any- thing to the reputation of this invaluable work, and can only say to all with whom our opinion has any influence, that it is our authority. — Atlanta Med. Journal. DY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- can, from the Fourth and Revised London Edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations Pp.752. Extra cloth, $5 00. As a complete and condensed treatise on its extended and important subject, this work becomes a necessity to students of natural science, while the very low price at which it is offered places it within the reach of all. J^IRKES ( WILLIAM SENHOUSE), M.D. A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, M.D., F.R.C.S. A new American from the eighth and improved London edition With about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- ume. Cloth, $3 25; leather, $3 76. {Now Ready.) Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, presenting within a narrow compass all that is important for the student. The rapidity with which successive editions have followed each other in England has enabled the editor to keep it thoroughly on a level with the changes and new discoveries made in the science, and the eighth edition, of which the present is a reprint, has appeared so recently that it may be regarded as the latest accessible exposition of the subject. On the whole, there is very little in the book which either the student or practitioner will notfind of practical value and consistent with our present knowledge of this rapidly changing science ; and we hdve no hesitation in expretsiug our opinion that this eighth edition is one of the best handbooks on physiology which we have in our language. — N. Y. MM. liecord, April 15, 1873. This volume might well be used to replace many of the physiological text-books in use in this coun- try. It represents more accurately than the works of Balton or Flint, the present state of our knowl- eilge of most physiological questions, while it is much less bulky and far more readable than the lar- ger text-books of Carpenter or Marshall. The book is admirably adapted to be placed lu the hands of students. — Boston Med. and Surg. Journ., April 10, 1873. la its enlarged form it is, in our opinion, still the best book on physiology, most useful to the student. —Phila. Med. Times, Aug. 30, 1S73. This is undoubtedly the best work for students of physiology extaut. — Vincinnati 3f(d. News, Sept. '73 It more nearly represents the present condition of physiology thiiu any other text-book on the subject. — Detroit Rev. of Med. Pharm., Nov. 1873. Henry C. Lea's Publications — {Physiology). 9 r\ALTON {J. C), M. D., -*^ Professor of Physiology in the College of Physicians and Stirgeona, New York, &c. A TREATISE OiS; HUMAN PHYSIOLOGY. Designed for the use of students and PractitioHers of Medicine. Fifth edition, revised, with nearly three hun- dred illustrations on wood. In one very beautiful octavo volume, of over 700 pages, extra cloth, $5 25 ; leather, $6 25. {Just Issued.) Preface to the Fifth Edition. In preparing the present edition of this work, the general plan and arrangement of the previous editions have been retained, so far as they have been found useful and adapted to the purposes of a text-book for students of medicine. The incessant advance of all the natural and physical sciences, never more active than within the last five years, has furnished many valuable aids to the special investigations of the physiologist ; and the progress of physiological research, during the same period, has required a careful revision of the entire work, and the modification or re- arrangement of many of its parts. At this day, nothing is regarded as of any value in natural science which is not based upon direct and intelligible observation or experiment; and, accord- ingly, the discussion of doubtful or theoretical questions has been avoided, as a general rule, in the present volume, while new facts, from whatever source, if fully established, have been added and incorporated with the results of previous investigation. A number of new illustrations have been introduced, and a few of the older ones, which seemed to be no longer useful, have been omitted. In all the changes and additions thus made, it has been the aim of the writer to make th« book, in its present form, a faithful exponent of the actual conditions of physiological science. New York, October, 1871. In this, the standard text-book on Physiology, all that is needed to maintain the favor with which it is regarded by the profession, is the author's assurance that it has been thoroughly revised and brought up to a level with the advanced science of the day. To accomplish this has required some enlargement of the work, but no advance has been made in the price. The fifth edition of this truly valuable work on Humau Physiology comes to us with many valuable Improvements and additions. As a text-book of physiology the work of Prof. Daltoa has long been well known as one of the best which could be placed la the hands of student or practitioner. Prof. Dalton has, in the several editions of his work heretofore published, labored to keep step with the ad van cement ia science, and the last edition shows by its improve- ments on former ones that he is determined to main- taia the high standard of his work. We predict for the present edition increased favor, though this work hds long been the favorite standard. — Buffalo Med. and Surg. Journal, April, 1872. An extended notice of a work so generally and fa- vorably known as this is unnecessary. It is justly regarded as one of the most valuable text-books on the subject in the English language. — St. Louie Med. Archives, May, 1872. We know no treatise in physiology so clear, com- plete, well assimilated, and perfectly digested, as Dalton's. He never writes cloudily or dubiously, or ta mere quotation. He assimilates all his material, and from it constructs a homogeneone transparent argument, which is always honest and well informed, and hides neither truth, ignorance, nor doubt, »o far an either belongs to the subject in hand. — Brit. Med. Journal,, March 23, 1S72. Dr. Dalton's treatise is well known, and by many highly esteemed in this country. It is, indeed, a good elementary treatise on the subject it professes to teach, and may safely be put into the hands of Eng- lish students. It has one great merit — it is clear, and, on the whole, admirably illustrated. The part we have always esteemed most highly is that relating to Embryology. The diagrams given of the various stages of development give a clearer view of the sub- ject than do those in general use in this country ; and the text may be said to be, upon the whole, equally clear. — London Med. Times and Gazette, March 23 1872. Dalton's Physiology Is already, and deservedly, the favorite text-book of the majority of American medical students. Treating a most interesting de- partment of science in his own peculiarly lively and fascinating style. Dr. Dalton carries his reader along without effort, and at the same time impresses upon his mind the truths taught much more successfully than if they were buried beneath a multitude of words. — Kansas City 3Ied. Journal, April, 1872. Professor Dalton is regarded j ustly as the authority in this country on physiological subjects, and the fifth edition of his valuable work fully justifies the exalted opinion the medical world has of his labors. This last edition is greatly enlarged. — Virginia Clin- ical Record, April, 1872. riUNGLISON {ROBLEV), M.D., -*-^ Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and extensively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes of about 1500 pages, extra cloth. $7 00. EHMANN [C. O.). ' PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- tion by Georse E. Day, M. D., F. R. S., &c., edited by R. E. Rogees, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiiological Chemistry, and an Appendix of plates. Com- plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two hundred illustrations, extra cloth. $6 00. T>T TBE SAME AUTHOR. MANUAL OP CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- vania. With illustrations on wood. In one very handsome octavo volume of 336 pages, eztia cloth. $2 26. 10 Henry C. Lea's Ptibltcations — (Chemistry). A TTFIELD [JOHN), Ph. D., -n. Prafenxiir of Praeticnl dhemi.ifry to the Phnrmacputicol Society of Great Britain, &c. CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; including the Chemiptry of the U. S. Pharmaoopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. Fifth Edition, revised hy the author. In one handsome royal 12mo. volume; cloth, $2 75; leather, $3 25. {Just Ready.) We commend the work heartily as one of the best text-books extant for the medical student. — Detroit Jiev. of Med. and Pharm., Feb. 1S72. The best work of the kind in the English language. N, Y. Psychologienl Journal, Jan. 1872 The work is constructed with direct reference to the wants of medical and pharmaceutical students; and, although an English work, the points of differ- ence between the Britisli and United States Pharma- copoDias are indicated, making it as useful here as in England. Altogether, the book is one we can heart- ily recommend to practitioners as well as students. —N. Y. Med. Tournal, Dec. 1871. It differs from other text-hooks in the following particulars: first, in the exclusion of matter relating to compounds which, at present, are only of interest to the scientific chemist ; secondly, in conlainine the chemistry of every substance recognized ofBcially or In general, as a remedial agent. It will be found a most valuable hook for pupils, assistants, and others engaged in medicine and pharmacy, and we heartily commend it to our readers. — Canada Lancet, Oct. 1871. When the original English edition of this work was published, we had occasion to express onr high ap- preciation of its worth, and also to review, in con- siderable detail, the main features of the hook. As the arrangement of subjects, and the main part of the text of the present edition are similar to the for- mer publication, it will be needless for us to go over the ground a second time ; we may, however, call at- tention to a marked advantage possessed by the Ame- rican work— we allude to the introduction of the chemistry of the preparations of the United States Pharmacopoeia, as well aa that relating to the British authority. — Canadian Pharmaceiitical Journal, Nov. 1S71. Chemistry has borne the name of being a hard sub- ject to master by the student of medicine, and chiefly because so much of it consists of compounds only of interest to the scientific chemist ; in this work sucli portions are modified or altogether left out, and in the arrangement of the subject-matter of the work, practical utility is sought after, and we think fully attained. We commend it for its clearness and order to both teacher and pupil. — Oregon Med. and Surg. Reporter, Oct. 1871. -DLOXAM {G. L.), J-^ Profensor of CheiniMry in King's College, London. CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- don Edition. In one very handsome octavo volume, of 700 pages, with ahout 300 illustra- tions. Cloth, $4 60 ; leather, $5 50. (Just Ready.) It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- sive for those studying the science as a branch of general education, and one which a student may use with advantage in pursuing his chemical studies atone of the colleges or medical schools. The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders the work especially useful to those who are being educated for employment in manufacture. It would he difficult for a practical chemist and very short paragraphs. One is surprised at the brief teacher to find any material fault with this most ad- mirable treatise. The author has given us almost a cyclopedia within the limits of a con venient volume, and has done so without penning the useles>s para- graphs too commonly making up a great part of the bulkof many cumbrous works. The progressive sci- entist is not disappointed when he looks for the record of new and valuable processes and discoveries, while the cautious conservative does not find its pages mo- nopolized by uncertain theories and speculations. A peculiar point of excellence is the crystallized form of expression in which great truths are expressed in space allotted to an important topic, and yet, after reading it, he feels that little, if any more, should have been said. Altogether, it is seldom you see a text-book so nearly faultless.— Cincinnati Lancet, Nov. 1873. Prjfessor Bloxam has given ns a most excelleat and useful practical treitise. His 666 pages are crowded with facts and experiments, nearly all well chosen, and many quite new, even to scientific men. . . . It is astonishing how much information he often conveys in a few paragraphs. We might quote fifty instances of this. — Chemical News. DLINO [WILLIAM), Lectitrer on Chemistry at St. Bartholomew's Huspital, *e. A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use of Medical Students. With Illustrations. From the Fourth and Revised London Edition. In one neat royal 12mo. volume, extra cloth. $2. {Lately Issued.) pALLOWAY (ROBERT), F.C.S., ^-^ Prof, of Axiplied Chemistry in the Royal College of Science for Ireland, &c. A MANUAL OF QUALITATIVE ANALY^SIS. From the Fifth Lon- don Edition. In one neat royal 12mo. volume, with illustrations ; extra cloth, $2 50. (JiiX Issued.) The success which has carried this work through repeated editions in England, and its adoption as a text-book in several of the leading institutions in this country, show that the author has suc- ceeded in the endeavor to produce a sound practical manual and book of reference for the che- mical student. Prof. Galloway's books are de.servedly in high esteem, and this American reprint of the fifth edition (1869) of his Manual of Qualitative Analysis, will be acceptable to many American students to whom the English edition is not accessible. — A7n. Jour, of Sci- enoe and Arts, Sept. 1872, We regard this volume as a valuable addition to the chemical text-books, and as particularly calcu- lated to instruct the student in analytical researches of the inorganic compounds, the important vegetable acids, and of compounds and various fecretions and excretions of animal origin. — Am. Journ. of Pharm., Sept. 1872. Henry C. Lea's Publications — (Chemistry, Pharmacy, <&c.). 11 fyHANDLER {CHARLES F.), and nUANDLER {WILLIAM H.), \y Prof, of nhemixtry in the N. Y. Coll. of ^ Prof of Ohe.mistry in the Lehigh Pharmacy. University. THE AMERICAN CHEMIST: A Monthly Journal of Theoretical, Analytical, and Technical Chemistry. Each nunaber averaging forty large double ool- umned pages of reading matter. Price $5 per annum in advance. Single numbers, 50 cts. O;^ Specimen numbers to parties proposing to subscribe will be sent to any address on receipt of 25 cents. *^* Subscriptions can begin with any number. The rapid growth of the Science of Chemistry and its infinite applications to other sciences and arts render a journal specially devoted to the subject a necessity to those whose pursuits require familiarity with the details of the science. It has been the aim of the conductors of " The American Chemist" to supply this want in its broadest sense, and the reputation which the periodical has already attained is a sufficient evidence of the zeal and ability with which they have discharged their task. Assisted by an able body of collaborators, their aim is to present, within a moderate compas.qo^. — Pacific Medical and Surgical Journal, appeared since the issuing of the British Pharmaco- 1 December, 1866. fjLLIS [BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions derived from the writings and practice of mnny of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poison.^. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- tion, carefully revised and much improved by Albert H. Smith, M. D. In one volume 8ve. of 376 pages, extra cloth, $3 00. {Lately Published.) This work has remained for some time out of print, owing to the anxious care with which the Editor has sought to render the present edition worthy a continuance of the very remarkable favor which has carried the volume to the unusual honor of a Twelfth Edition. He has sedu- lously endeavored to introduce in it all new preparations and combinations deserving of confidence, besides adding two new classes, Antemetics and Disinfectants, with brief references to the inhalation «f atomized fluids, the nasal douche of Thudichum, suggestions upon the method of hypodermic injection, the administration of anaesthetics, Ac. -^ Professor of Materia Medica and Pha.rmacp in the University of Pennsyloania, &e. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. With three Lectures on the Modus Operandi of Medicines. Fourth and revised edition, extra cloth, $3 00. DUNGLISON'S NEW REMEDIES, WITH FORMULA FOR THEIR PREPARATION AND ADMINISTRA- TION. Seventh edition, with extensive additions. One vol. Svo., pp. 770 ; extra cloth. $1 00. KOYLE'S MATERIA MEDICA AND THERAPEU- TICS. Edited by Joseph Casso.v, M. D. With ninety-eight illustrations. 1 vol. 8vo., pp. 700, ex- tra cloth. $3 00. CHRISTISON'S DISPENSATORY. With copious ad- ditions, and 213 large wood-engravings. By B. Eglesfbld Griffith, M.D. One vol. 8vo., pp. looo ; extra cloth. $4 00. CARPENTER'S PRIZE ESSAY ON THE USE OF Alcoholic Liqpors ix Health and Disea.se. New edition, with a Preface by D. F. Condik, M D., and explanations of scientific words. In one neat ]2mo volume, pp. 178, extra cloth. 60 cents. Db JONGH on the three kinds OF COD-LIVEB Oil, with their Chemical and Therapeutie Pro- perties 1 vol. 12mo., cloth. 7o cents. 14 Henry C. Lea's Publications— fPa/TioZo.g'yi '^c.). PENWICK [SAMUEL], M.D., Ansintnnt Physicifin to the. London Hosjnlnl. THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. Fn.m tlie Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. In one very handsome volume, royal ]2mo., cloth, $2 25. {Now Ready.) The very great success which this work has obtained in England, shows that it bus supplied .in admitted want among elementary books for the guidance of students and junior prMctitioners. Taking up in order each portion of the body or class of disease, the author has endeavored to present in simple language the value of symptoms, so as to lead the student to a correct appreci- ation of the pathological changes indicated by them. The latest investigations have been care- fully introduced into the present edition, so that it may fairly be considered as on a level with the most advanced condition of medical science. The arrangement adopted maj' be seen from the subjoined C03MX5E3SrSEID SXJ]S/I]yt,^Fl'5^' OF COnSTTBaSTTS. Chapter I. Introductory. II. Diseases of the Heart and Pericardium. III. Disenses of the Lungs. IV. liiseases of the Throat and Larynx. V. Diseases of the Kidneys. VI. Diseases of the Liver. VII. Diseases of the Stomach. VIII. Diseases of the Peritoneum and Intestines. IX. Abdominal Tumors. X. Diseases of the Brain. XI. Fevers. XII. Rheumatism and Gout. XIII. Diseases of the Skin. G BEEN {T. HENRY), M.D., Lecturer on Pathology and Morbid Anatomy at Charing-Croxs Hospital Medical School. PATHOLOGY AND MORBID ANATOMY. With numerous Hlus- trations on Wood. In one very handsome octavo volume of over 250 pages, extra cloth, $2 50. (Lately Published. ) We have been very much pleased by our perusal of this little volume. It is the only one of the kind with which we are acquainted, and practitioners as well as students will find it a very useful guide; for the information is up to the day, well and compactly ar- ranged, without being at all scanty. — London Lan- cet, Oct. 7, 1871. It embodies in a comparatively small space a clear statement of the present state of our knowledge of pa- thology and morbid anatomy The author shows that he has been not only a student of the teachings of his confr&res in this branch of science, but a practical and conscientious laborer in the post-mortem cham- ber. The work will prove a useful one to the great mass of students and practitioners whose time for de- votion to this class of studies is limited. — v47». o^owrn. of HyplMography, April, 1872. tical Relations. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. HOLLAND'S MEDICAL NOTES AND iJEFLEC- TiONS. 1 vol. 8vo., pp. 500, extra cloth. S3 50. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER Death in MEDro.4L Cases. Published under the authority of the London Society for Medical Obser- vation. From the second London edition. I vol. royal 12mo., extra cloth. $1 00. LATCOCK'S LECTURES ON THE PRINCIPLES AND METHOD.S OF MEDICAL OBSERVATION A.V'D RE- SEARCH. For the use of advanced students and junior practitioners. In one very nep.t royal 12juo. volume, extra cloth. $1 00. OLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidt, M. D. In one volume, very large imperial quarto, with 320 coppor-plate figures, plain and colored, extra cloth. $4 00. SIMON'S GENERAL PATHOLOGY, as conducive t< the Establishment of Rational Principles for th* Prevention and Cure of Disease. In one octavo volume of 212 pages, extra cloth. $1 25. SOLLY ON THE HUMAN BRAIN ; its Structure, Phy- siology, and Diseases. From the Second and much enlarged London edition. In one octavo volume of ."iOO pages, with 120 wood-cuts; extra cloth. $2 50. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeu- flROSS [SAMUEL D.), M. D., ^-^ Professor of Surgery in the Jefferson Medical College of Philadelphia. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings ; extra cloth. $4 00. TONES [C. HANDFIELD), F.R.S., and SIEVEKING [ED. H.), M.D., *J Assvdant Physicians and Lecturers in St. Mary's Hospital A MANUAL OF PATHOLOGICAL ANATOMY. First American edition, revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautifully printed octavo volume of nearly 760 pages, extra cloth, $3 60. (^TUBGES [OCTA VIUS), M.D. Cantab. O Fellow of the Royal College of Phy.':icians, ct-e .{•c. AN INTRODUCTION TO THE STUDY OF CLINICAL MED- ICINE. Being a Guide to the Investigation of Disease, for the Use of Students. In one handsome 12mo. volume, extra cloth, fiiil 25. {Now Ready.) Table of Contents. I. The Sort of Help needed by the Student at the Bedside. II. Some General Rules with Reference to the Examination of Patients. III. The Family and Personal History of the Patient. IV. Examination of the Functions. V. Examination of the Phenomena connected with the Brain and Cord VI. The Physical Examination of the Chest, its Inspection .and Palpation. VII. Percussion Applied to the Heart and Lungs. VIIC. Auscultation of the Chest. IX. Examination of the Abdomen and of the Secretions. X. The Diagnosis. XI. The Treatment. Henry C Lea's Publications — {Practice of Medicine). 15 JfTLINT [AUSTIN], 31. D., ■*■ Professor of the. Principles and Practice of Medicine in Bellevtie Med. College, N. T. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourtli edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 pages; handsome extra cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Just Issued.) By common consent of the English and American medical press, this work has been assigned to the highest position as a complete and compendious text-book on the most advanced condition of medical science. At the very moderate price at which it is offered it will be found one of the cheapest volumes now before the profession. Admirable and unequalled. — Western Journal of Medicine, Nov. 1869. Dr. Flint's work, though claiming no higher title than that of a text-book, is really more. He is a man of large clinical experience, and his book is full of such masterly descriptions of disease as can only be drawn by a man intimately acquainted with their various forms. It is not so long since we had the pleasure of reviewing his first edition, and we recog- nize a great improvement, especially in the general part of the work. It is a work which we can coidially recommend to our readers as fully abreast of the sci- ence of the day. — Edinburgh Med. Journal, Oct. '69. One of the best works of the kind for the practi- tioner, and the most convenient of all for the student. — Am. Journ. Med. Sciences, Jan. 1S69. This work, which stands pre-eminently as the ad- vance standard of medical science up to the present time in the practice of medicine, has for its author one who is well and widely known as one of the leading practitioners of this continent. In fact, it is seldom that any work is ever issued from the press more deserving of universal recommendation. — Do- minion Med Journal, May, 1869. The third edition of this most excellent book scarce- ly needs any commendation from ns. The volume, as it stands now, is really a marvel : first of all, it is Bxcellently printed and bound — and we encounter that luxury of America, the ready-cut pages, which the Yankees are 'cute enough to insist upon — nor are these by any means triHes ; but the contents of the book are astonishing. Not only is it wonderful that any one man can have grasped in his mind the whole scope of medicine with that vigor which Dr. Flint shows, but the condensed yet clear way in which this is done is a perfect literary triumph. Dr. Flint Is pre-eminently one of the strong men, whose right to do this kind of thing is well admitted ; and we say ao more than the truth when we affirm that he is very nearly the only living man that could do it with such results as the volume before us. — The London Practitioner, March, 1869. This is in some respects the best text-book of medi- cine in our language, and it is highly appreciated on the other side of the Atlantic, inasmuch as the first edition was exhausted in a few months. The second adition was little more than a reprint, but the present has, as the author says, been thoroughly revised. Much valuable matter has been added, and by mak- ing the type smaller, the bulk of the volume is not much increased. The weak point in many American works is pathology, but Dr. Flint has taken peculiar pains on this point, greatly to the value of the book. — London Med. Times and Gazette, Feb. 6, 1869. BAELOWS MANUAL OF THE PRACTICE OF MEDICINE. With Additions .by D. F. Condib, M- D. 1 vol. Svo., pp. 600, cloth. $2 50. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE Diseases. In one neat octavo volume, of 320 pages, I extra cloth. $2 50. F A Vr [F. W.), M. D., F. R. S., Senior Asst. Physician to and Lecturer on Phy.iiology, at Guy's Hospital, &c. A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- ders and their Treatment. From the second London edition. In one handsome volume, small octavo, extra cloth, $2 00. (Lately Ptiblisked.) The work before us is one which deserves a wide •Ireulation. We know of no better guide to the study of digestion and its disorders. — St. Louis Med. and Sv-rg. Journal, July 10, 1S69. A thoroughly good book, being a careful systematic treatise, and sufficiently exhaustive for all practical purposes. — Leavenworth Med. Herald, July, 1869. A very valuable work on the subject of which U treats. Small, yet it is full of valuable information. — Cincinnati Med. Repertory, June, 1869. TDF THE SAME AUTHOR. (In Press.) ON FOOD, PHYSIOLOGICALLY, DIETETICALLY, AND THE- RAPEUTICALLY CONSIDERED. In one handsome octavo volume. flH AMBERS {T. K.), M.D., v-^ Oon.nilting Physician to St. Mary''s Hospital, London, &c. THE INDIGESTIONS; or, Diseases of the Digestive Organs Fnnctionallj Treated. Third and revised Edition. In one handsome octavo volume of 383 pages, extra cloth. $3 00. (Lately Fiihllshed.) So very large a proportion of the patients applying i merit, we know of no more de.sirable acquisition to to every general practitioner suffer from s») me form a physician's library than the book before us. He of indigestion, that whatever aids him in their man- who should commit its contents to his memory would agement directly "puts money in his purse,'" and in- find its price an investment of capital that returned directly does more than anything else to advance his him a most usurious rate of interest. — N. Y. Medical reputation with the public. From this purely mate- Gazette, Jan. 2s, 1871. rial point of view, setting aside its higher claims to T)Y THE SAME AUTHOR. (Lately Published) RESTORATIYE MEDICINE. An Harveian Annual Oration, deliv- ered at the Royal College of Phy.iicians, London, on June 24, 1871. With Two Sequels^ In one very handsome volume, small 12mo., extra cloth, $1 00. Henry C. Lea's Publications — {Practice of Medicine). LTARTSHORNE {HENRY), M.D., 1.JL Prnfesftor 'if Hygiene in the. UniverKity of Penn.ijjlvinia. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- proved. In one handsome royal ]2mo. volutne. {Preparing.) This little epitome of medical knowledge has al- j mulas are appended, intended as examples merely, ready been noticed by us. It is a vade mecum of not as guides for unthinking practitioners. A corn- value, including in a short space most of what is es- I plete index facilitates the use of this little volume, in sential in the science and practice of medicine. The ' which all important remedies lately introduced, such third edition is well up to the present day in the i as chloral hydrate and carbolic acid, have received modern methods of treatment, audiu the use'of newly i their fall shareof attention. — Am. Journ. of P harm., discovered drugs. — Boston Med. and Surg. Journal, i Nov. 1871. Oct. 19, 1871. Certainly very few volumes contain so much pre- cise information within so small a compass. — N. Y. Med. Journal, Nov. 1871. The diseases are conveniently classified; symptoms. It is an epitome of the whole science and practice of medicine, and will be found most valuable to the practitioner for easy reference, and especially to the student in attendance upon lectures, whose time is too much occupied with many studies, to consult the causation, diagnosis, jtrognos'is, and treatment are , larger works. Such a work must always be in great carefully considered, the whole being marked by 1 demand. — Oincinaati Med. Repertory, Nov. 1871. briefness, but clearness of expression. Over 2.')0 for- ! TKTA TSON [THOMAS), M. D., ^c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illus- trations, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- sylvania. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. (Just Issued.) At length, after many months of expectation, we have [he satisfaction of finding ourselves this week in posjession of a revised and enlarged edition of Sir Thomas Watson's celebrated Lectures. It is a sub- ject for congratulation and for thankfulness that Sir Thomas Watson, during a period of comparative lei- sure, after a long, laborious, and most honorable pro- fessional career, while retaining full possession of his high mental faculties, should have employed the op- portunity to submit his Lectures to a more thorough revision than was possible during the earlier and busier period of his life. Carefully passing in review some of the most intricate and important pathological and practical questions, the results of his clear insight and his calm judgment are now recorded for the bene- fit of mankind, in language which, for precision, vigor, and classical elegance, has rarely been equalled, and never surpassed The revision has evidently been most carefully done, and the results appear in almost every page. — Brit. Med. Journ., Oct. 14, 1871. The lectures are so well known and so justly appreciated, that it is scarcely neces.sary to do more than call attention to the special advantages of the last over previous editions. In the revi- sion, the author has displayed all the charms and advantages of great culture and a ripe experience combined with the soundest judgment and sin- cerity of purpose. The author's rare combination of great scientific attainments combined with won- derful forensic eloquence has exerted extraordinary influence over the last two generations of physicians. His clinical descriptions of most diseases have never been equalled ; and on this score at least his work will live long in the future. The work will be sought by all who appreciate a great book. — Amer. Journal of Syphilography, July, 1872. We are exceedingly gratified at the reception of this new edition of. Watson, pre-eminently the prince of English authors, on "Practice." We, who read the first edition as it came to us tardily and in frag- ments through the "Medical News and Library," shall never forget the great pleasure and profit we derived from its graphic delineations of disease, its vigorous style and splendid English. Maturity of years, exten.sive observation, profound research, and yet continuous enthusiasm, have combined to give us in this latest edition a model of professional excellence in teaching with rare beauty in the mode of communication. But this classic needs no enlo- giam of OMXs.-rGhicago Med. Journ., July, 1872. fiUNOLISON, FORBES, TWEED IE, AND CONOLLY. ^^THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, RINTON { WILLI A31), M.D., F.R.S. "^LECTURES ON THE DISEASES OF THE STOMACH; with an Introduction on its Anatomy and Physiology. From the second and enlarged London edi- tion. With illustrations on wood In one handsome octavo volume of about 300 pages, extra cloth. $3 26. Henry C. Lea's Publications — (Diseases of Lungs and Heart). It WLINT [AUSTIN), M.D., ■*■ Priifesfmr of the Principles and Practice of Medicine in BeUevue Hospital Med. College, N. Y. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OP DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, extra cloth, $4. (Just Issued.) The author has sedulously improved the opportunity afforded him of revising this work. Portions of it have been rewritten, and the whole brought up to a level with the most advanced condition of science. It must therefore continue to maintain its position as the standard treatise on the subject. Dr. Flint chose a difflcult subject for his researches, | able for purposes of illustration, in connection with and has shown remarkable powers of observation and reflection, as well as great industry, in his treat- ment of it. His book must be considered the fullest and clearest practical treatise on those subjects, and should be in the hands of all practitioners and stu- dents. It is a credit to American medical literature. — Amer. Journ. of the Med. Sciences, July, 1860. We question the fact of any recent American author la our profession being more extensively known, or more deservedly esteemed in this country than Dr. i this work, for it fills a wide gap on the list of text- Flint. We willingly acknowledge his success, more ] books for our schools, and is, for the practitioner, the particularly In the volume on diseases of the heart, most valuable practical work of its kind.— iV. 0. Med. In making an extended personal clinical study avail- | News. ca.'jes which have been reported by other trustworthy observers. — Brit, and For. Med.-Chirurg. Review. In regard to the merits of the work, we have no hesitation in pronouncing it full, accurate, and judi- cious. Considering the present state of science, such a work was much needed. It should be in the hands of every practitioner. — Chicago Med. Journ. With more than pleasure do we hail the advent of DT THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, extra cloth, $4 50. Dr. Flint's treatise is one of the most trustworthy guides which he can consult. The style is clear and distinct, and is also concise, being free from that tend- ency to over-retinement and unnecessary minuteness which characterizes many works on the same sub- ject.— i>w6Zm Medical Press, Feb. 6, 1867. The chapter on Phthisis is replete with interest ; and his remarks on the diagnosis, especially in the early stages, are remarkable for their acumen and great practical value. Dr. Flint's style is clear and elegant, and the tone of freshness and originality which pervades his whole work lend an additional force to its thoroughly practical character, which cannot fail to obtain for it a place as a standard work on diseases of the respiratory system. — London Lancet, Jan. 19, 1867. This is an admirable book. Excellent in detail and execution, nothing better could be desired by the practitioner. Dr. Flint enriches his subject with much solid and not a little original observation.— Ranking^s Abstract, Jan. 1867. pULLER {HENRY WILLIAM), M. D., •*- Physician to St. George^ s Hospital, London. ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. Dr. Fuller's work on diseases of the chest was so accordingly we have what might be with perfect jus- favorably received, that to many who did not know tice styled an entirely new work from his pen, the the extent of his engagements, it was a matter of won- ' portion of the work treating of the heart and great der that it should be allowed to remain three years ; vessels being excluded. Nevertheless, this volume is out of print. Determined, however, to improve it, i of almost equal size with the first. — London Medical Dr. Fuller would not consent to a mere reprint, and ! Times and Gazette, July 20, 1867. JJ/'ILLIAMS (C. /. B.), M.D., Senior Consulting Physician to the Hospital for Consumption, Brompton, and imLLIAMS [CHARLES T.), U.D., Physician to the Hospital for Consumption. PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- ment. With an Analysis of One Thousand cases to exemplify its duration. In one neat octavo volume of about 350 page*, extra cloth. {Just Issued.) $2 60. He can still speak from a more enormous experi- ence, and a closer study of the morbid processes in- volved in tuberculosis, than most living men. He owed it to himself, and to the importance of the sub- ject, to embody his views in a separate work, and we are glad that he has accomplished this duty. After all, the grand teaching which Dr Williams has for the profession is to be found in his therapeutical chapters, and in the history of individual cases ex- tended, by dint of care, over ten, twenty, thirty, and even forty years. — London Lancet, Oct. 21, 1871. His results are more favorable than those of any previous author; but probably there is no malady, the treatment of which has been so much improved within the last twenty years as pulmonary consump- tion. To ourselves, Dr. Williams's chapters on Treat- ment are amongst the most valuable and attractive in the book, and would alone render it a standard work of reference. In conclusion, we would record our opinion that Dr. Williams's great reputation is fully maintained by this book. It is undoubtedly one of the most valuable works in the language upon any special disease. — Lond. Med. Times and Gaz., Nov. 4, ISffl. LA ROCHE ON PNEUMONIA. 1 vol. 8vo., extra cloth, of 500 pages. Price $.S 00. BUCKLER ON FIBRO-BRONCHITIS AND RHEU- MATIC PNEUMONIA. 1 vol. 8vo. $1 2.5. FISKE FUND PRIZE ESSAYS ON CONSUMPTION. 1 vol 8vo,, extra cloth. $1 00. SMITH ON CONSUMPTION ; ITS EARLY AND RE- MEDIABLE STAGES. 1 vol. 8vo., pp. 254. $2 25. WALSHE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Third American edition. la 1 vol. Svo.. 420 pp., cloih. $3 00. 18 Henry C. Lea's Publications — {PractAce of Medicine'). ROBERTS [WTLLTAM], M. D.. ■^•' Lecturer nn Medicine in the Mnnnhegter School of Medicine, Ste. A PRACTICAL TREATISE OX URINARY AXD REXAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravinfts. Sep- ond American, from the Second Revised and Enlarged London Edition Tn one large and handsome octavo volume of 61() pages, with a colored plate ; extra cloth, $4 50. (JuH Issued.) The author has .subjected this work to a very thorough revision, and has sought to embody in it the results of the latest experience and investigation?. Although every effort has been majle to keep it within the limits of its former size, it has been enlarged b.y a hundred pages, many new wood-cuts have been introduced, and also a colored plate representing the appearance of the different varieties of urine, while the price has been retained at the former very moderate rate. In every respect it is therefore presented as worthy to maintain the position which it has acquired as a leading authority on a large, important, and perplexing class of affections. A few notices of the first edition are appended. The plan, it will thus be seen, is very complete, au I the manner in which it has been carried out is ' in the highest degree satisfactory. The cliai'iicters of the different deposits are very well descrihed, and the microscopic appearances they present are illus- trated by numerous well executed engi'iivings It only remains to us to strongly recommend to our readers Dr. Roberts's work, as coniainiug an admira- ble rfnurni of the present state of knowledge of uri- i nary diseases, and as a safe and reliable guide to the clinical observer. — Edin. Med. Jour. I The most complete and practical treatise upon renal diseases we have examined It is peculiarly adapted to the wants of the majority of American practition- ers from its clearness and simple announcement of the facts in relation to diagno.sis and treatment of urinary disorders, and contains in condensed form the investi- gations of Bence Jones, Bird, Beale, Hassall, Front, and a host of other well-known writers upon thin sub- ject. The characters of urine, phy-iological and pa- thological, asindicated to the naked eye as well as by microscopical and chemical investigations, are con- cisely represented both by description and by well executed engravings. — Cincinnati Jnurn. of Med. I T>ASHAM ( W. R.), 31. D., .*-' Senior Phy.^ician to the Westminster Ho.rpital, &e. REXAL DISEASES : a Clinical Guide to their Diagnosis and Treatment With illustrations. In one neat royal 12mo. volume of .304 pages. $2 00. The chapters on diagnosis and treatment are very t ment render the book pleasingand convenient. — A.m good, and the student aud young practitioner will find them full of valuable practical hints. The third part, on the urine, is excellent, aud we cordially recommend its perusal. The author has arranged his matter in a somewhat novel, and, we think, use- ful form. Here everything can be easily found, and, what is more important, easily read, for all the dry Journ. Med. Sciences, July, 1S70. A book that we believe will be found a valuable assistant to the practitionerand guide to the student. — Baltirnure Med. Journal, July, 1870. The treatise of Dr. Basham differs from the rest in its special adaptation to clinical study, and its con- details of larger books here acquire a new interest ' densed and almost aphorismal style, which makes it from the author's arrangement. This part of the ! easily read and easily understood. Besides, the 3 get book is full of good work.— Chirurgienl Review, July, 1S70 The easy descriptions and compact modes of state- Brtt. and For' "Medico- author expresses some new views, which are we!! worthy of consideration. The volume is a valuable addition to this department of knowledge. — Pacijic Med. and Surg. Journal, July, 1870. OX FTJXCTIOXAL XERYOUS In one ha»dsome octavo volume of 348 pages, MORLAND ON RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. 1 vol. Svo., extra cloth. 7.5 cents. TONES [C. HANDFIELD), M. D., ^ Phy.iician to St. Mary's Hospital, &c. CLIXICAL OBSERYATIOXS DISORDERS. Second American Edition, extra cloth, $.3 25. Taken as a whole, the work before ns furnishes a i We must cordially recommend it to the profession short but reliable account of the pathology and treat- ! of this country as supplying, in a great measure, a ment of a class of very common but certainly highly deficiency which exists in the medical literature of obscure disorders. The advanced student will find it the English language. — Ke.w York Med. Journ., April, a rich mine of valuable facts, while the medical prac- | 1867. titioner will derive from it many a suggestive hint to aid him in the diagnosis of "nervous cases," and in ' The volume is a most admirable one — full of hints determining the true indications for their ameliora- and practical suggestions. — Canada Med. Journal, tion or cure. — Arner. Journ. Med. Sci., Jan. 1S67. April, 1867. s LADE [D. D.), M.D. DIPHTHERIA; its Xature and Treatment, with an account of the His- tory of its Prevalence in various Countries. Second and revised* edition. In one neat royal 12mo. volume, extra cloth. $1 25. TTUDSON [A.), M. D., M. R. 1. A., ■*■-*• Physician to the Meath Hospital. LECTURES ON THE STUDY OF FEYER. Cloth, $2 50. TYONS [ROBERT D.), K.C.C. In one vol. 8vo., extra A TREATISE OX FEYER; or, Selections from a Course of Lectures on Fever. Being part of a Course of Theory and Practice of Medicine. In one neat octavo Tolume, of 362 pages, extra cloth. $2 26. Henry C. Lea's Publications — ( Venereal Diseases, etc.). 19 D UMSTEA D { FR EEMA N J.). M.D.. -*-' Prafpftnor nf Vnnnrenl Dixeafies at the Col. of Phys and Surg., New To7-k. &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Third edition, revised and enlarged, with illustrations. In one large and handsome octavo volume of over 700 pages, extra cloth, $5 00 ; leather, $6 00. (Just Issued.) In preparing this standard work again for the press, the author has suhjected it to a very thorough revision. Many portions have been rewritten, and much new matter added, in order to bring it completely on a level with the most advanced condition of syphilography, but by careful compression of the text of previous editions, the work has been increased by only sixty-four pao-es. The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a complete and trustworthy guide for the practitioner. It is the most complete book with which we are ac- quainted in the language. The latest views of the best authorities are put forward, and the information is well arranged — a great point for the student, and still more for the practitioner. The subjects of vis- ceral syphilis, syphilitic affections of the eyes, and the treatment of syphilis by repeated inoculations, are very fully discussed. — London Lancet, Jan. 7, 1S71. Dr. Bumstead's work is already so universally known as the best treatise in the English language on much special commendation as if its predecessors had not been published. As a thoroughly practical boi)k on a class of diseases which form a large share of nearly every physician's practice, the volume before us is by far the best of which we have knowledge. — N. Y. Medical Gazette, Jan. 28, 1871. It is rare in the history of medicine to find any one book which contains all that a practitioner needs to know; while the possessor of "Bumstead on Vene- real" has no occasion to look outside of its covers for venereal diseases, that it may seem almost superfln- ; anything practical connected with the diagnosis, hi.-*- ous to say more of it than that a new edition has been | tory, or treatment of these affections, — A'. X Mediitnl Issued. But the author's industry has rendered this j Journal, March, 1871. new edition virtually a new work, and so merits as ' nUMSTEAD [FREEMAN J.), -*-' Professor of Venereal DLseaxe.i in the Colleg (lULLERIER (A.), and ^ Surgeon to the Hdpital du Midi. -«-»■ Professor of Venerea I Diseaxe.s in the College of Phy.'sicians and Surgeonx, N. Y. AN ATLAS OF VENEREAL DISEASES. Translated and Edited by Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-column's, with 26 plates, containing about 150 figures, beautifully solored, many of them the size of life; strongly bound in extra cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $3 per part. (Lately Published.) Anticip.ating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. We wish for once that our province was not restrict- | which for its kind is more nece.smrv for them to have. ed to methods of treatment, that we might say some- thing of the exquisite colored plates in this volume. — London Practitioner, May, lStj9. As a whole, it teaches all that can be taught by means of plates and print. — London Lancet, March 13, 1869. Superior to anything of the kind ever before issued on this continent. — Canada. Metl. Journal, March, '69. The practitioner who desires to understand this branch of medicine thoroughly should obtain this, the most complete and best work ever published. — Diyminion Med. Journal, May, 1869. This is a work of master hands on both sides. M. Cnllerier is scarcely second to, we think we may truly say is a peer of the illustrious and venerable Kicord, while in this country we do not hesitate to say that Dr. Bumstead, as an authority, is without a rival Assuring our readers that these illustrations tell the whole history of venereal disease, from its inception %o its end, we do not know a single medical work. —Calif )rnia Med. Gazette, March, 1869. The most splendidly illustrated work in the lan- guage, and in our opinion far more useful than the French original. — Am.Journ. Med. Science.';, Jan. '69. The fifth and concluding number of this magnificent work has reached us, and we have no hesitation in saying that its illustrations surpass those of previous numbers. — Boston Med. and Surg. Journal, Jan. 14, 1 S69. Other writers besides M. Cullerier have given us a good account of the diseases of which he treats, but no one has furnished us with such a complete series of illustrations of the venereal diseases. There i«, however, an additional interest and value possessed by the volume before us ; for it is an American reprint and translation of M. Cullerier.'s work, with inci- dental remark.'' by one of the most eminent American syphilographeis, Mr. Bumstead. — Brit, and For. Medico-Ohir . Review, July, 1869. JpLL [BERKELET], Surgeon to the Lock Hospital, London. ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. one handsome octavo volume ; extra cloth, $3 25. (Lately Published.) In Bringing, as it does, the entire literature of the dis- ease down to the present day, and giving with great ability the results of modern research, it is in every respect a most desirable work, aud one which should find a place in the library of every surgeon. — Cali- fornia Med. Gazette, June, 1S69. Considering the scope of the book and the careful attention to the manifold aspects and details of its subject, it is wonderfully concise. All these qualitie to whom we would most earnestly recommend its study ; while it is no less useful to the practitioner. — St. Louis Med. and Surg. Journal, May, 1S69. The most convenient and ready book of reference we have met with.— JV. Y. Med. Record, May 1,1869. Most admirably arranged for both student and prac- titioner, no other work on the subject equals it ; it is more simple, more easily studied. — Buffalo Med. and render it an especially valuable book to the beginner, I Surg. Journal, March, 1869 YEISSL (//.), 31. D. A COMPLETE TREATISE ON VENEREAL DISEASES. lated from the Second Enlarged German Edition, by Fkedekic R. Stukgis, M.D octavo volume, with illustrations. (Prepari)ig.) Trans- In one 20 Henry C. Lea's Publications — (Diseases of the Skin). TT'ILSON {ERASAIUS), F.R.S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. A SERIES OF PLATES ILl^USTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most cf them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. Such a work as the one before ns is a most capital and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his book on di-seases of the skin has long been re- s;arded as one or the best text-books extant on tlie subject. The present edition is carefully prepared, and brought up in its revision to the present time. In this edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases. — Cineinnati Lancet. No one treating skin diseases should be without a copy of this standard work. — Canada Lanctt, iugust, 1863. We can safely recommend it to the profession as the best work on the subject now in existence id the English language. — Medical Times and Gazette. Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases ; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin. — British and Foreign Medical Review. VT THE SAME AUTHOR. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- EASES OP THE SKIN. In One very handsome Toyal 12mo. volume. $3 50. {Lately Issued.) l^ELIGAN [J. MOORE), M.D., M.R.I.A. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M. D. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. Fully equal to all the requirements of students and 'heir value justly estimated ; in a word, the work is young practitioners. — DtMin Med. Press. fully up to the times, and is thoroughly stocked with Of the remainder of the work we have nothing be- n^o*' valuable information.— iV^ew York Med. Record, yond unqualified commendation to offer. It is so far ^^''^- ^^< ^®*'^- the most complete one of its size that has appeared. The most convenient manual of diseases of the and for the student there can be none which can com- skin that can be procured by the student. — Chicago pare with it in practical value. All the late disco- Med. Journal, Dec. 1866. veries in Dermatology have been duly noticed, and ^Y THE SAME AUTHOR. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of disease. Extra cloth, $5 50. The diagnosis of eruptive disease, however, under all circumstances, is very difiicult. ^Nevertheless, Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the "Practical Treatise," and we are Inclined to consider it a very superior work, com- bining accurate verbal description with sound views of the pathology and treatment of eruptive diseases. — Glasgow Med. Journal. A compend which will very much aid the practi- tioner in this difficult branch of diagnosis Taken with the beautiful plates of the Atlas, which are re- markable for their accuracy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man. — Buffalo Med. Journal. TIILLIER [THOMAS), M.D., •'■ Physician to the Skin Department of University College Hospital, Ac. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. Extra cloth, $2 25. We can conscientiously recommend it to the stu- dent; the style is clear and pleasant to read, the matter is good, and the descriptions of disease, with the modes of treatment recommended, are frequently illustrated with well-recorded cases. — London Med. Times and Gazette, April 1, 1865. It is a concise, plain, practical treatise on the vari- ous diseases of the skin ; just such a work, indeed, as was much needed, both by medical students and practitioners. — Chicago Medical Examiner, May, 1865. ANDERSON {3fcCALL), M.D., •^-^ Phy.iioian to the Dispensary for Skin Disea.i«s, Glasgow, d-e. ON THE TREATMENT OF DISEASES OF THE SKIN. With an Analysis of Eleven Thousand Consecutive Cases. In one vol. 8vo. $1. {Just Ready.) The very practical character of this work and the extensive experience of the author, cannot fail to render it acceptable to the subscribers of the "American Journal of the Medical SciBSCES." When completed in the "News and LiBRAiiT," it will be issued separately in a neat octavo volume. Henry C. Lea's Publications — (Diseases of Children). 31 SfMITH (J. LE WIS), M. D., *^ Professor of Morbid Anatomy in the Bellevue Ho-ipital Med. College, N. Y. , A COMPLETE PRACTICAL TREATISE ON THE DISEASES OP CHILDKEN. Second Edition, revised and greatly enlarged. In one handsome octavo volume of 742 pages, extra cloth, $5; leather, $6. (Just Issiied.) From the Preface to the Second Edition. In presenting to the profession the second edition of his work, the author gratefully acknow- ledges the favorable reception accorded to the first. He has endeavored to merit a continuance of this approbation by rendering the volume much more complete than before. Nearly twenty additional diseases have been treated of, among which may be named Diseases Incidental to Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, and the various forms of Paralysis. Many new formulse, which experience has shown to be useful, have been introduced, portions of the text of a less practical nature have been con- densed, and other portions, especially those relating to pathological histology, have been rewritten to correspond with recent discoveries. Every effort has been made, ho\»ever, to avoid an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of the page, the number of pages has been enlarged by more than one hundred. 227 West 49th Street, New York, April, 1872. The work will be found to contain nearly one-third more matter than the previous edition, and it is confidently presented as in every respect worthy to be received as the standard American text-book on the subject. Eminently practical as well as judicious in its teachings. — Cincinnati Lancet and Obs., July, 1S72. A standard work that leaves little to be desired. — Indiana Journal of Medicine, July, 1872. We know of no book on this subject that we can more cordially recommend to the medical student andthepractitioner. — Cincinnati Clinic, June 29, '72. We regard it as superior to any other single work on the diseases of infancy and childhood. — Detroit Rev. of Med. and Pharrnncy, Aug. 1872. We confess to increased enthusiasm in recommend- ing this second edition. — St. Louis Med. and Surg. Journal, Aug. 1872. pONDIE [D. FRANCIS), M. D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, extra cloth, $5 25 j leather, $6 25. {Lately Issued.) The present edition, which is the sixth, is fully up to the times in the discussion of all those points in the pathology and treatment of infantile diseases which have been brought forward by the German and French teachers. As a whole, however, the work is the best American one that we have, and in its special adapta- tion to American practitioners it certainly has no equal. — New York Med. Record, March 2, 1868. TTTESr ( CHARLES, M. D., ' ^ Physician to the Hospital for Sick Children, Ac. LECTURES ON THE DISEASES OP INFANCY AND CHILD- HOOD. Fifth American from the sixth revised and enlarged English edition. In one large and handsome octavo volume. {Nearly Ready.) Of all the English writers on the diseases of chil- I living authorities in the difficult department of medi- dren, there is no one so entirely satisfactory to us as | cal science in which he is most widely known. — Dr. West. For years we have held his opinion as I Boston Med. and Surg. Journal, April 26, 1866. jadicial, and have regarded him as one of the highest | DT THE SAME AUTHOR. (Lately Issued.) ON SOME DISORDERS OF THE NERYOTJS SYSTEM IN CHILD- HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., extra cloth, $1 00. S 'MITH {E USTA CE), 31. D., Physician to the Northwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, extra cloth, $2 50. {Lately Issued.) scribed as a practical handbook of the common dis- eases of children, so numerous are the affections con- sidered either collaterally or directly. We are acquainted with no safer guide to the treatment of children's diseases, and few works give the insight into the physiological and other peculiarities of chil- dren that Dr. Smith's book does. — Brit. Med. Journ., April 8, 1871. This is in every way an admirable book. The modest title which the author has chosen forit scarce- ly conveys an adequate idea of the many subjects upon which it treats. Wasting is so constant an at- tendant upon the maladies of childhood, that a trea- tise upon the wasting diseases of children must neces sarily embrace the consideration of many aflFections of which it is a symptom ; and this is excellently well done by Dr. Smith. The book might fairly be de- QVERSANT (P.), M. D., Honorary Surgeon to the Hospital for Sick Children, Paris. SURGICAL DISEASES OF INFANTS AND CHILDREN. Trans- lated by R. J. Dunglison, M. D. In one neat octavo volume, extra cloth, $2 50. {Now Ready. ) DEWEES ON THE PHY.SICAL AND MEDICAL TEEATilEIvT OF CHILDREN. Eleventh edition. 1 Tol. 8vo. of ulS pages. $2 80. 22 Henry C. Lea's Publications — (Diseases of Women). rjlHE OBSTETRICAL JOURNAL. THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Including Midwifery, and the Diseases of Women and Infants. With an American Supplement, edited by William F. Jenks, M.D. A monthly of about 80 octavo pages, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 60 cents each. Commencing with April, ]87.3, the Obstetrical Journal will consist of Original Papers by Brit- ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Ac. Collecting together the vast amount of material daily accumulating in this important and ra- pidly improving department of medical science, the value of the information which it will pre- sent to the subscriber may be estimated from the character of the gentlemen who have already promised their support, including such names as those of Drs. Atthill, Robert Barnes, Henrt Bennet, Thomas Chambers, Fleetwood Churchill, Matthews Duncan, Grailt Hewitt, Braxton Hicks, Alfred Meadows, W. Leishman, Alex. Simpson, Tyler Smith, Edward J. Tilt, Spencer Wells, &c. &c. ; in short, the representative men of British Obstetrics and Gynae- cology. In order to render the Obstetrical Journal fully adequate to the wants of the American profession, each number will contain a Supplement devoted to the advances made in Obstetric? and Gynaecology on this side of the Atlantic. This portion of the Journal will be under the editorial charge of Dr. William F. Jenks, to whom editorial communications, exchanges, books for review, Ac, may be addressed, to the care of the publisher. *iic* Gentlemen desiring complete sets will do well to forward their orders without delay. /jTHOMAS {T.GAILLARD),M.D., ■*- PrnfesKor of Ohstdrics, &e., in the ColUge of Physicians and Surgeons, N. Y., Ac. A PRACTICAL TREATISE OX THE DISEASES OF WOMEN. Third edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 784 pages, with 246 illustrations. Cloth, %b 00; leather, $6 00. {Lately Issued.) The author has taken advantage of the opportunity afforded by the call for another edition of this work to render it worthy a continuance of the very remarkable favor with which it has been received. Every portion has been subjected to a conscientious revision, several new chapters have been added, and no labor spared to make it a complete treatise on the most advanced con- dition of its important subject. The present edition therefore contains about one-third more matter than the previous one, notwithstanding which the price has been maintained at the former very moderate rate, rendering this one of the cheapest volumes accessible to the profession. As compared with the first edition, five new chap- We are free to say that we regard Dr. Thomas the ters on dysmenorihcea, peri-uterine fluid tumors, best American authority on diseases of women. Seve- composite tumors of the ovary, solid tumors of the ral others have written, and written well, but none ovary, and chlorosis, have been added. Twenty- have so clearly and carefullyarranged their text and seven additional woodcuts have been introduced, instruction as Dr. Thomas. — Gincinnati Lancet and many subjects have been subdivided, and all have Observer, May, 1S72. received important interstitial increase. In fact, the we deem it scarcely necessary to recommend this booK has been practically rewritten, and greatly in- ^^^^^ i^ physicians as it is now widely known, and creasert m value. Briefly, we may say that we know mg^, ^f (hem alreadv possess it, or will certainly do ot no book which so completely and concisely repre- g„ xo students we unhesitatingly recommend it as sents the pieseiit state of gynaecology ; none so full the be.st text-book on diseases of females extant.-5t. ot well-digested and reliable teaching; none which ^ojus Med. Reporter, June, 1869. bespeaks an author more apt in research and abun- ^, ,, , ,t , .,_ ,. ^ ,, dant in resources.— ,iV. Y Med Record May 1 1872 Of all the array of books that have. appeared of late ■ar„<,i,„ ij 1 I. J ■ , . ',*'.' years, on the diseases of the uterus and its appendages, ^i7Z , u'^X u^ °'"' "^"'^ ""*'® profession ^^ i^^ow of none that is so clear, comprehensive, and did we not tell those who are unacquainted with the practical as this of Dr. Thomas', or one that we should book how much It IS valued by gynacologists, and ^^,^ emphatically recommend to the young pr.Kti- how It IS in many respects one of the best text-books ^^^ ^s his snida.— California Med. Gazette, June, on the subject we possess in our language. We have ^ggg no hesitation in recommending Dr. Thomas's work as ^." , , . , , » ., ^. . , i. , one of the most complete of its kind ever published. . If "<>' *e l?est work extant on the subject of which. It should be in the possession of every practitioner '^ '^eats, it is certainly second to none other. So for reference and for study.- London Lancet, April fl»<"'t / t.>m« ^^s elapsed since the medical press 27 1S72 teemed with commendatory notices of the first edition, ' ■ ' that it would be superfluous to eive an extended re- Our author IS not one of those whose views never view ofwhat is now flrmlvestabHshed as f/ie American change." On the contrary, they have been modifiea text-book of Gynacology.— i^. Y. Med. Gazette, July in many particulars to accord with the progress made jy jg^g in this department oi medical science: hence it has the L, . . , . , ,.,. , , t. ^ freshness of an entirely new work. No general prac- This is a new and revised edition of a work which titioner can afford to be without it.-St. Louis Med. ^^ recently noticed at some length, and earnestly and Surg Journal, May, 1S72. ' commended to the favorable attention ot our readers. '^ ' ■" _ The tact that, in the short space of one year, this Its able author need not fear comparison between gecond edition makes its appearance, shows that the it and any similar work in the English language ; general judgment of the profession has largely con- nay more, as a textbook for students and as a guide firmed the opinion we gave at that timB.—Oincinnati for practitioners, we believe it is unequalled. In the Lancet Aug. 1869. libraries of reading physicians we meet with it ^ ofienerthanany other treatiseou diseases of women. ' It is so short a time since we gave a full review of Weconcludeourbriefreviewby repeating the hearty ' the first edition of this book, that we deem it only commendation of this volume gi'^en when we com- necessary now to call attention to the second appear- menced : if either student or practitioner can get but ance of the work Its succors has been remarkable, one book on diseases of women, that book should be and we can only congratulate the author on lbs "Thomas." — Amer. Jour. Med. Sciences, .\pril, brilliant reception his book has received. — S.Y.Med. 1872. I Tournal, April, IS69. Henry C. Lea's Publications — (DiseasP!^ of WonK^v). 23 E ODGE (HUGH L.), M.J)., Erneritiis Professor of Obstetrics , &c., in the Univtrsity of Pi-nnsylvrinia. ON DISEASES PECULIAR TO WOMEN; including Displficements of the Uterus. With original illustrations. Second edition, revised and enlarged. In one beautifully printed octavo volume of 5.S1 pages, extra cloth. $4 50. {Lately Issued.) From. Prop. W. H. Btford, of the Rush Medical College, Chicago. The book bears the impress of a master hand, and must, as its predecessor, prove acceptable to the pro- fession. In dispasps of women Dr. Hodge has estab- lished a school of treatment that has become world- wide in fame. Professor Hodge's work Is trnly an original one from beginniog to end, consequently no one can pe- ruse its pages without learning something new. The book, which is by no means a large one, is divided into two grand sections, so to speak : first, that treating of the nervous sympathies of the uterus, and, secondly, that which speaks of the mechanical treatment of dis- placements of that organ. He is disposed, as a non- believer in the frequency of inflammations of the uterus, to take strong ground against many of the highest authorities in this branch of medicine, and the arguments which he offers in support of his posi- tion are, to say the least, wel I put. Numerous wood- cuts adorn this portion of the work, and add incalcu- lably to the proper appreciation of the variously shaped instruments referred to by our author. As a contribution to the study of women's diseases, it is of great value, and is abundantly able to stand on its own merits. — JV. Y. Medical Record, Sept. 1.5, 1868. In this point of view, the treatise of Professor Hodge will be indispensable to every student in its department. The large, fair type and general perfec- tion of workmanship will render it doubly welcome. — Pacific Med. and Surg. Journal, Oct. 1868. V^EST (CHARLES), M.D. LECTURES ON THE DISEASES OF WOMEN. Third American, from the Third London edition. In one neat octavo volume of about 560 pages, extra cloth, $3 75 ; leather, $4 75. As a writer. Dr. West stands, in our opinion, se- , seeking truth, and one that will convince the student cond only to Watson, the " Macaulay of Medicine ;'' '• that he has committed hiin.''elf to a candid, safe, and he possesses that happy faculty of clothing instruc. ! valuable guide. — ^V. A. Med. -Ghinirg Review. tion in easy garments; combining pleasure with _, , , ^ .^ , . a i i -i ,, ^.l ^ ... profit, he leads his pupils, in spite of the ancient pro- I . ^e have to say of it, briefly and decidedly, that it verb, along a royal road to learning. His work is one "the test work on the subject in any language, and which will not satisfy the extreme on either side, but that, 't stamps Dr. West as the facile prineeps of it is one that will please the great majority who are t ^"''«^ obstetric authors.-£din6«r£?7i Med. Journal. "DARNES [ROBERT), M. D., F.R. G.P., J-9 Oh.9fetrir Physician to St. Thoma.s's Hospital, Ac. A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- CAL DISEASES OF WOMEN. In one handsome oetn.vo volume of about 800 pages, with 169 illustrations. Cloth, $5 00; leather, $6 00. (Just R^ady.^ The very complete scope of this volume and the manner in which it has been filled out, may be seen by the subjoined Summary of Contents. Introduction. Chapter I. Ovnries ; Corpus Luteum. II. Fallopian Tubes. III. Shape of Uterine Cavity. IV. Structure of Uterus. V. The Vngina. VI. Examinations and Diagnosis. VII. Significance of Leucorrhoea. VIII. Discharges of Air. IX. Watery Discharges. X. Puru- lent Discharges. XI. Hemorrhagic Discharges. XII Significance of Pain. XIII. Significance of Dyspareunia. XIV. Significance of Sterility. XV. Instrumental Diagnosis and Treatment. XVI. Diagnosis by the Touch, the Sound, the Speculum. XVII. Menstruation and its Disor. ders. XVIII. Amenorrhcea. XIX. Amenorrhcea (continued). XX. Dysmenorrhoea. XXI. Ovarian Dysmenorrhoea, &c. XXII. Inflammatory Dysmenorrhoea. XXIII Irregularities of Change of Life. XXIV. Relations between Menstruation and Diseases. XXV. Disorders of Old Age. XXVI. Ovary, Absence and Hernia of. XXVII. Ovary, Hemorrhage, Ac, of. XXVIII. Ovary, Tubercle, Cancer, &c., of. XXIX. Ovarian Cystic Tumors. XXX. Dermoid Cysts of Ovary. XXXI. Ovarian Tumors, Prognosis of. XXXII. Diagnosis of Ovarian Tumors. XXXIII. Ovarian Cysts, Treatment of. XXXIV. Fallopian Tubes. Diseases of. XXXV. Broad Liga- ments, Di.^eases of. XXXVI. Extra-uterine Gestation. XXXVII. Special Patholney of Ute- rus. XXXVIII. General Uterine Pathology. XXXIX. Alterations of Blood Supply. XL. Metritis, Endometritis, &c. XLI. Pelvic Cellulitis and Peritoniti,*, &o. XLII. Hfematocele, Ac. XLIII. Displacements of Uterus. XLIV. Displacements (continued). XIjV. Retroversion and Retroflexion. XLVI. Inversion. XLVII. Uterine Tumors. XLVIII. Polypus Uteri. XLIX. Polypus Uteri (continued). L. Cancer. LI. Diseases of Vagina. LII. Diseases of the Vulva, CHURCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PECULIAR TO WOMEN. 1 vol. Svo., pp. 4.50, extra cloth. $2 50. DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's last improvements and correc- tions. In one octavo volume of 536 pages, with plates, extra cloth. $^ 00. WEST'S ENQUIRY INTO THE P.\TH0LOGICAL IMPORTANCE OF ULCERATION OF THE OS CTERL 1 vol. 8vo., extra cloth. $1 25. MEIGS ON WOMAN: HER DISE.^SES AND THEIR REMEDIES A Series of Lectures to his Clas.s. Fourth and Improved Edition. 1 vol. Svo., over 700 pages, extra cloth, -iin 00 ; leather, $6 00. MEIGS ON THE NATURE, SIGNS, AND TREAT- iMENT OF CHILDBED FEVER. 1 vol. Svo., pp. 365, extra cloth. *2 00. ASHWELL'S PRACTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Third American, from the Third and revised Loudon edition. 1 vol. 8vo,, pp. 52i>, extra cloth. $3 dO. 24 Henry C. Lea's Publications — {Midwifery). ffODGE {HUGH L.), M.D., •^-*- Emeritus Professor of Midwifery, Ac, in the Universitjf of Pennsylvania, &c. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. The work of Dr. Hudge is something more than a We have examined Professor Hodge's work with simple presentation of his particular views in the de- great sati,>,faction ; every topic is elaborated mo?t partment of Obstetrics ; it is something more than an fully. The views of the author are comprehensive, ordinary treatise on midwifery ; it i.s, in fact, a cycle- and concisely stated. The rules of practice are jndi- paedia of midwifery. He has aimed to embody in a cious, and will enable the practitioner to meet every single volume the whole science and art of Obstetrics. ' emergency of obstetric complication with confidence. An elaborate text is combined with accurate and va- — Chicago Med. Journal, Aug. 1864. ried pictorial illustrations, so that no fact or principle is left unstated or unexplained.— .4m. Med. Times, \ More time than we have had at our disposal since Sept. 3, 1S64. '• we received the great work of Dr. Hodge is necessary We should like to analvze the remainder of tbis'*^" ^'^ ^' justice. It is undoubtedly by far the most ■>^).lnf f ^ i; if * 1 i^l ,?.'®™^.'''"®', ^ jloriginal, complete, and carefully composed treatise excellent Work, but already has this review extended „„?!,««,!„„; Ji.,0 ol J ,^-„«»;„„ t A\. » » ■ —i,. v i. K«„„«j , .!„,•. A TIT I 1 J iv i on the principles and practice of Obstetrics which has ^T.« Jm. r'f '?^'T ,7^ <=^'',r\'r'^S'^^?>," ever been issued from the American press.-Paci/fc notice without referring to the excellent finish of he ^^^ ^^ g Journal, July, 1S64. work. In typography it is not to be excelled; the " > /> paper is superior to what is usually afforded by our| We have read Dr. Hodge's book with great ple^i- Amencan cousins, qnite equal to the best of English i g^re, and have much satisfaction in expressing our books. The engravings and lithographs are most commendation of it as a whole. It is certainly highly beautifully executed. Th« work recommends itself instructive, and in the main, we believe, correct The for Its originality, and is in every way a most valu-! great attention which the author has devoted to the able addition to those on the subject of obstetrics.— mechanism of parturition, taken alone with the con- Canada Med. Journal, Oct. 1864. i elusions at which he has arrived, point, we think, It is very large, profusely and elegantly illustrated, conclusively to the fact that, in Britain at least, the and is titted to take its place near the works of great; doctrines of Naegele have been too blindly received. obstetricians. Of the American works on the subject j — Glasgow Med. Journal, Oct. 1864. It is decidedly the best. — Edinb. Med. Jour., Dec. "64. 1 *** Specimens of the plates and letter-press will be forwarded to any address, free by mail, en receipt of six cents in postage stamps. JUNNER (THOMAS H), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates andillustrationa on wood. In one handsome octavo volume of about 50(^pages, extra cloth, $4 25. The very thorough revision the work has undergone | pregnancy, but always ready to treat all the nume- has added greatly to its practical value, and increased j rous ailments that are, unfortunately for the civilized materially its efficiencv as a guide to the student and \ women of to-day, so commonly associated with the " - - - function.— iV'. r. ifed. Record, March 16 1868. We recommend obstetrical students, young and old, to have this volume in their collections. It con- tains not only a fair statement of the signs, symptoms, and diseases of pregnancy, but comprises in addition much interesting relative matter that is not to be found in anj other work that we can name. — Edin- burgh Med Journal, Jan. 1868. to the young practitioner. — Am. Jo%i.rn. Med. Sci., April, 1S68. With the immense variety of subjects treated of and the ground which they are made to cover, the im- possibility of giving an extended review of this truly remarkable work must be apparent. We have not a single fault to find with it, and most heartily com- mend it to the careful study of every physician who would not only always be sure of his diagnosis •f s WAYNE {JOSEPH GBIFFITHS), M. D., Physician-Accoucheur to the British General Hospital, &c. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised London Edition with Additions by E. R. Hutchiks, M. D. With Illustrations. In one neat 12mo. volume. Extra cloth, $1 25. (Now Ready.) *»* See p. 3 of this Catalogue for the terms on which this work is offered as a premium to subscribers to the " American Journal of the Medical Sciences." It is really a capital little compendium of the sub- i answers the purpose. It is not only valuable for ject, and we recommend young practitioners to buy it j young beginners, but no one who is not a proficient and carry it with them when called to attend cases of in the art of obstetrics should be without it, because labor. They can while away the otherwise tedious it condensea all that is necessary to know for ordi- hours of waiting, and thoroughly fix in their memo- ' nary midwifery practice. We commend the book ries the most important practical suggestions it con- 1 most favorably. — St. Louis Med. and Surg. Journal, tains. The American editor has materially added by I Sept. 10, 1870. his notes and the concluding chapters to the com- 1 pleteness and general value of the book. — Chicago Med. Journal, Feb. 1870. The manual before us containsin exceedingly small compass — small enough to carry in the pockei — about all there is of obstetrics, condensed into a nutshell of Aphorisms. The illustrations are well selected, and serve as excellent reminders of the conduct of labor — regular and difficult. — Cincinnati Lancet, April, '70. Thif is a most admirable lit tie work, and completely A studied perusal of this little book has satisfied us of its eminently practical value. The object of the work, the author says, in his preface, is to give the student a few brief and practical directions respect- ing the management of ordioary cases of labor ; and also to point out to him in extraordinary cases when and how he may act upon his own responsibility, and when he ought to send for assistance. — A'. T. Medical Journal, May, 1870. w 'INCKEL {F.), Professor and Director of the. Gynacologicul Clinic in the University nf Rostock. A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by James Read Chadwick, M D. In one octavo volume. (Preparing.) Henry C. Lea's Publioations — {Midwifery). EISHMAN ( WILLIAM), M.D., Regius Professor of Midwifery in the. Unive.r.nfy of QTaagoin, &c. A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF PREGNANCY AND THE PUERPERAL STATE. In one large and very handsome oc- tavo volume of over 700 pages, with one hundred and eighty-two illustrations. Cloth, $5 00 ; leather, $6 00. (Jmt Ready.) It was written to supply a desideratum, and we will be much surprised if it does not fulfil the purpose of its author. Taking it as a whole, we know of no work on obstetrics by an English authorin which the This is one of a most complete and exhaustive cha- racter. We have gone carefully through it,;and there is no subject in Obstetrics which has not been con- sidered well and fully. The result is a work, not only admirable as a text-book, but valuable as a work , student and the practitioner will find the information of reference to the practitioner in the various emer gencies of obstetric practice. Take it all in all, we have no hesitation in saying thatit is in our judgment the best English work on the subject. — London Lan- cet, Aus. 23, 1873. The work of Leishman gives an excellent view of modern midwifery, and evinces its author'sextensive acquaintance with British and foreign literature ; and not only acquaintance with it, but wholesome diges- tion and sound judgment of it. He has, withal, a manly, free style, and can state a difficult and compli- cated matter with remarkable clearness and brevity. — hdin. Med. Journ., Sept. 1S73. so clear and so completely abreast of the present state of our knowledge on the subject. — QUisgow Med. Journ., Aug. 1873. Dr. Leishman's System of Midwifery, which has only just been published, will go far to supply the want which has so long beeu felt, of a really good modern English text-book. Although large, as is in- evitable in a work on so extensive a subject, it is so well and clearly written, that it is never wearisome to read. Dr. Leishman's work may be confidently recommended as an admirable lext-book, aud is sure to be Itirgely used. — Load. Mad. Record, Sept. 1S73. E AMSBOTHAM [FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- CINE AND SURGERY, in reference to the Process of Parturition. A nevr and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. To the physician's library it is indispensable, while to the student, as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior. — Ohio Med. and Surg. Journal. When we call to mind the toil we underwent in acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which this work will afford Mm. — Am. Jour, of the Med. Sciences. We will only add that the student will learn from It all he need to know, and the practitioner will find It, as a book of reference, surpassed by none other. — Stetho.scope. The character and merits of Dr. Ramsbotham's work are so well known and thoroughly established, that comment is unnecessary and praise superfluous. The illustrations, which are numerous and accurate, are executed in the highest style of art. We cannot too highly recommend the work to our readers. — St. Louis Med. and Surg. Journal. /IHURCHILL [FLEETWOOD), M.D., M.R.I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additions by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- dren,'' &c. With one hundred and ninety-four illustrations. In one very handsome octavo volume of nearly 700 large pages. Extra cloth, $4 00; leather, $5 00. These additions render the work still more com- | has been added which could be well dispensed with. plete and acceptable than ever ; and with the excel- lent style in which the publishers have presented this edition of Churchill, we can commend it to the profession with great cordiality and pleasur*. — Oin- cinnnti Lancet. Few works on this branch of medical science are equal to it, certainly none excel it, whether in regard to theory or practice, and in one respect it is superior to all others, viz., in its statistical information, and therefore, on these grounds a most valuable work for the physician, student, or lecturer, all of whom will find in it the information which they are seeking. — Brtt. Am. Journal. The present treatise is very much enlarged and amplified beyond the previous editions but nothing An examination of the table of contents shows how thoroughly the author has gone over the ground, and the care he has taken in the text to present the sub- jects in all their bearings, will render this new edition even more necessary to the obstetric student than were either of the former editions at the date of their appearance. No treatise on obstetrics with which we are acquainted can compare favorably with this, in respect to the amount of material which has been gathered from every source. — Boston Med. and Surg. Journal. There is no better text-book for students, or work of reference and study for the practising physician than this. It should adorn and enrich every medical library. — Chicago Mad. Journal. JirONTGOMERY [W. F.), M.D., ■^^ Professor of Midwifery in the King's and Queen's College of Phy.sicians in Ireland. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREG- NANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume of nearly 600 pages, extra cloth. $3 75. BIGBT'S SYSTEM OF MIDWIFBET. With Notes improvements and corrections. In one octavo Tol- and Additional Illustrations. Second American ume, extra eloth, of 600 pages. $3 60.| edition. One volume octavo, extra cloth, 422 pages MEIGS' OBSTETRICS: THE SCIENCE AND THE •2 5r>. AKT. Fifth edition. With l.SO illustrations. 1vol. DEWEES'S COMPREHENSIVE SYSTEM OF MID- 8vo. Extra cloth, $3 r>0 ; leather, ^6 50. WIFERY. Twelfth edition, with the author's last S€ Henry C. Lea's Publications — (Surgery). 6yK0SS {SAMUEL D.), M.D., ' Fro/essor of Surgery in the Jt^fferson Medical College of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pages, strongly bound in lesither, with raised bands, $15. {Just Ready.) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every respect fully up to the day. To effect this a large part of the work has been rewritten, and the whole enlarged by nearly one fourth, notwilh.*tanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount ol matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, audits very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. It must long remain the most comprehensive work on this imijurtant part of medicine. — Bonton Medical and Surgical Journal, March 23, 18tio. We have compared It with most of our standard works, such as those of Erichsen, Miller, Fergusson, Syme, and others, and we must, iu justice to our author, award it the pre-eminence. As a work, com- plete iu almost every detail, no matter how minute or trifling, and embracing every subject known in the principles and practice of surgery, we believe it stands without a rival. Dr. Gross, in his preface, re- marks "my aim has been to embrace the whole do- main of surgery, and to allot to every subject its legitimate claim to notice;" and, we assure our readers, he has kept his word. It is a work which we can most confidently recommend to our brethren, for its utility is becoming the more evident the longer 1 1 is upon the shelves of our library. — Canada Med. Journal, September, 1865. The first two editions of Professor Gross' System of Surgery are so well known to the profession, and so highly prized, that it would be idle for us to speak in praise of this work. — Chicago Medical Journal, September, l&Bo. We gladly indorse the favorable recommendation of the work, both as regards matter and style, which we made when noticing its first appearance. — British and Foreign Medico- Chirurgical Review, Oct. 1865. The most complete work that has yet issued from the press on the science and practice of surgery. — London Lancet. This system of surgery is, we predict, destined to take a commanding position in our surgical litera- ture, and be the crowning glory of the author's well earned fame. As an authority on general surgical subjects, this work is long to occupy a pre-eminent place, not only at home, but abroad. We have no hesitation in pronouncing it without a rival in our language, and equal to the best systems of surgery in any language. — A'. Y. Med. Journal. Not only by far the best text-book on the subject, as a whole, within the reach of American students, but one which will be much more than ever likely to be resorted to and regarded as a high authority abroad. — Am. Journal Med. Sciences, Jan. 1S65. The work contains everything, minor and major, operative and diagnostic, including mensuration and examination, venereal diseases, and uterine manipu- lations and operations. It is a complete Thesaurus of modern surgery, where the •student and practi- tioner shall not seek in vain for what they desire. — San Francisco Med. Press, Jan. 1865. Open it where we may, we find sound practical in- formation conveyed in plain language. This book is no mere provincial or even national system of sur- gery, but a work which, while very largely indebted to the past, has a strong claim on the gratitude of the future of surgical science. — Edinburgh Med. Journal, Jan. 1865. A glance at the work is sufficient to show that the author and publisher have spared no labor in making it the most complete "System of Surgery" ever pub- lished in any country. — St. Louis Med. and Surg. Journal, April, 1865. A system ot surgery which we think unrivalled in our language, and which will indelibly associate his name with surgical .■science. And what, in our opin- ion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it is at the same lime one of the most valuable trea- tises which can be put into the hands of the student seeking to know the principles and practice of this branch of the profession which he designs subse- quently to follow. — The Brit. Am.Joum., Montreal. DY THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In 1 vol. 8vo. cloth, with illustrations, pp. 468. $2 76. SKEY'S OPERATIVE SURGEEY. In 1 vol. 8vo. cloth, of over 650 pages ; with about 100 wood-cats. $3 2f> COOPER'S LECTURES ON THE PRINCIPLES AND Pkacticeof SnROERY. Inl vol. 8 vo. cloth, 750 p. $)i. GIBSON'S INSTITUTES AND PRACTICE OF 8UR- uERY. Eighth edition, improved and altered. With thirty-four plates. Iu two handsome octavo vol- umes, aboutlOOO pp., leather, raised bauds. $6 80. M ILLER [JAMES), Late Professor of Surgery in the University of Edinburgh, &c, PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth. %'6 lb. Y THE SAME AUTHOR. B THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. Iu one large octavo volume of nearly 700 pages, extre cloth. $3 76. ^ARGENT {F. W.), M.D. ^ OH RA^DAGIJNG AND OTHER OPERATIONS OF MINOR SUIIQERY. New edition, with an additional chapter on Military Surgery. One handsoiiie royal l2mo. volume, of nearly 400 pages, with 184 wood-cute. Extra cloth, $1 76. Henry C. Lea's Publications — (Surgery). 2T ASHHURST {JOHN, Jr.), M.D., Surgeon to the EpUcnpal Hospital, Philadelphia. THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, extra cloth, $6 50; leather, raised bands, $7 50. {Just Issued.) The object of the author has been to present, within as condensed a compass as possible, a complete treatise on Surgery in all its branches, suitable both as a text-book for the student and a work of reference for the practitioner. So much has of late years been done for the advance- ment of Surgical Art and Science, that there seemed to be a want of a work which should present the latest aspects of every subject, and which, by its American character, should render accessible to the profession at large the experience of the practitioners of both hemispheres. This has been the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- torily. The plan and general outline of the work will be seen by the annexed CONDENSED SUMMARY OF CONTENTS. Chapter I. Inflammation. II. Treatment of Inflammation. III. Operations in general: Anaesthetics. IV. Minor Surgery. V. Amputations. VI. Special Amputations. VII. Eflects of Injuries in General : Wounds. VIII. Gunshot Wounds. IX. Injuries of Bloodvessels. X. Injuries of Nerves, Muscles and Tendons, Lymphatics, Bursas, Bones, and Joints. XI. Fractures. XII. Special Fractures. XIII. Dislocations. XIV. Effects of Heat and Cold. XV. Injuries of the Head. XVI. Injuries of the Back. XVII. Injuries of the Face and Neck. XVIII. Injuries of the Chest. XIX. Injuries of the Abdomen and Pelvis. XX. Diseases resulting from Inflammation. XXI. Erysipelas. XXII. Pyaemia XXIII. Diathetic Diseases : Struma (in- cluding Tubercle and Scrofula); Rickets. XXIV. Venereal Diseases; Gonorrhoea and Chancroid. XXV. Venereal Diseases continued : Syphilis. XXVI. Tumors. XXVII. Surgical Diseases of Skin, Areolar Tissue, Lymphatics, Muscles, Tendons, and Bursae. XXVIII. Surgical Disease of Nervous System (including Tetanus). XXIX. Surgical Diseases of Vascular System (includ- ing Aneurism). XXX. Diseases of Bone. XXXI. Diseases of Joints. XXXII. Excisions. XXXIII. Orthopaedic Surgery. XXXIV. Diseases of Head and Spine. XXXV. Diseases of the Eye. XXXVI. Diseases of the Ear. XXXVII. Diseases of the Face and Neck. XXXVIII. Diseases of the Mouth, Jaws, and Throat. XXXIX. Diseases of the Breast. XL. Hernia. XLI. Special Hernias. XLII. Diseases of Intestinal Canal. XLIII. Diseases of Abdominal Organs, and various operations on the Abdomen. XLIV. Urinary Calculus XLV. Diseases of Bladder and Prostate. XLVI. Diseases of Urethra. XLVII. Diseases of Generative Organs. Index. Its author has evidently tested the writings and expeiiences of the past and present in the crucible of a careful, analytic, and honorable mind, and faith- fiilly endeavored to bring his work up to the level of the highest standard of practical surgery He is frank and definite, and gives us opinions, and gene- rally sound ones, instead of a mere resume of the opinions of others. He is conservative, but not hide- bound by authority. His style is clear, elegant, and scholarly. The work is anadmirable taxt book, and a u.seful book of reference It is a credit to American prjfessional literature, and one of the first ripe fruits of the soil fertilized by the blood of our late unhappy •WA.T.—N. T. Med. Record, Feb. 1, 1872. Indeed, the work as a whole must be regarded as an excellent and concise exponent of modern sur- gery, and as such it will be found a valuable text- book for the student, and a useful book of reference for the general practitioner. — N. Y. Med. Journal, Feb. 1872. It gives us greatpleasure tocall the attention of the profession to this excellent work. Our knowledge of its talented and accomplished author led us to expect from him a very valuable treatise upon subjects to which he has repeatedly given evidence of having pro- fitably devoted much time and labor, and we are in no way disappointed.— P/ii.'rt. Mtd. Times, Fe\>. 1, 1872. piRRIE ( WILLIAM), F. R. S. E., -^ Prof essor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, &c. In one very handsome octavo volume of 780 pages, with 316 illustrations, extra cloth. $3 75. TJAMILTON [FRANK K), M.D., Professor of Fractures and Dislocations, &c., in Bellevue Hosp. Med. College, New York. A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS. Fourth edition, thoroughly revised. In one large and handsome octavo volume of nearly 800 pages, with several hundred illustrations. Extra cloth, $5 75 ; leather, $6 75. (Just Issued. ) rable treatise, which we have always considered the most complete and reliable work on the subject. As a whole, the work is without an equal in the litera- ture of the profession. — Boston Med. and Surg. Journ., Oct. 12, 1871. It is unnecessary at this time to commend the book, except to such as are beginners in the study of this particular branch of surgery. Every practical sur- geon in this country and itbroad knows of it as a most trustworthy guide, and one which they, in common with us, would unqualifiedly recommend as the high- est authority in any language. — A'. Y. Med. Record, Oct. 16, 1871. It is not, of course, our intention to review in ex- tenso, Hamilton on "Fractures and Dislocations." Eleven years ago such review might not have been out of place ; to-day the work is an authority, so well, so generally, and so favorably known, that it only remains for the reviewer to say that a new edition is just out, and it is better than either of its predeces- sors. — Cincinnati Clinic, Oct. 14, 1871. Undoubtedly the best work on Fractures and Dis- locations in the English language. — Cincinnati Med. R-'/jertorrj, Oct. 1871. We have once more before us Dr. Hamilton's admi- jU OR LAND (W. W.), M.D. DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations In one large and handsome octavo volume of .about 600 pages, extra cloth. $3 56. 28 Henry C. Lea's Publications — (Surgery). PRICHSEN {JOHN E.), •*^ Prn/fssor of Surgery in University College, London, etc. THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- gical Injuries, Diseases, and Operations. Revised by the author from the Sixth and enlarged English Edition. Illustrated by over seven hundred engravings on wood. In two large and beautiful octavo volumes of over 1700 pages, extra cloth, $9 00 ; leather, $11 00. {Jzist Ready.) Author^ s Prfface to the New American Edition. " Thefavorable reception with which the ' Science and Art of Surgery' has been honored by the Surgical Profession in the United States of America has been not only a source of deep gratifica- tion and of just pride to me, but has laid the foundation of many professional friendships that are amongst the agreeable and valued recollections of my life. "I have endeavored to make the present edition ofthis work more deserving than its predecessors of the favor that has been accorded to them. In consequence of delays that have unavoidably occurred in the publication of the Sixth British Edition, time has been afforded to me to add to this one several piragraphs which I trust will be found to increase the practical value of the work." London, Oct. 1S72. On no former edition of this work has the author bestowed more pains to render it a complete and satisfactory exposition of British Surgery in its modern aspects. Every portion has been sedu- lously revised, and a large number of new illustrations have been introduced. In addition to the material thus added to the English edition, the author has furnished for the American edition such material as has accumulated since the passage of the sheets through the press in London, so that the work as now presented to the American profession, contains his latest views and experience. The increase in the size of the work has seemed to render necessary its division into two vol- umes. Great care has been exercised in its typographical execution, and it is confidently pre- sented as in every respect worthy to maintain the high reputation which has rendered it a stand- ard authority on this department of medical science. These are only a few of the points in which the , states in his preface, they are not confined to any one present edition of Mr. Erichsen's work surpasses its • portion, hut are distributed generally through the predecessors. Throughout there is evidence of a I subjects of which the work treats. Certainly one of laborious care and solicitude in seizing the passing I the most valuable sections of the book seems to us to knowledge of the day, which reflects the greatest ' be that which treats of the diseases of the arteries credit on the author, and much enhances the value I and the operative proceedings which they necessitate, of his work. We can only admire the industry which j In few text-books is so much carefully arranged in- has enabled Mr. Erichsen thus to succeed, amid the formation collected.— iojicioji Med. Times and Gen., distractionsof active practice, in producing emphatic- I Oct. 26, 1872. allyTBEhookof reference and study for British prac- j tijq entire work, complete, as the great English titioners of surgery.— Z/(>«(to?i Lancet, Oct. 26, 1S72. | treatise on Surgery of our own time, is, we can assure Considerable changes have been made in this edi- ] our readers, equally well adapted for the most junior tion, and nearly a hundred new illustrations have j student, and, as a book of reference, for the advanced been added. It is difficult in a small compass to point j practitioner. — Dublin Quarterly Journal. out the alterations and additions ; for, as the author I I D RUITT {ROBERT), 31.R.G.S., ^c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition Illus- trated with four hundred and thirty -two wood engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00 j leather, $5 OP. practice of surgery are treated, and so clearly and perspicuously, as to elucidate every important topic. We tiave examined the book most thoroughly, and can say that this success is well merited. His book, moreover, possesses the inestimable advantages of having the subjects perfectly well arranged and clas- sified, and of being written in a style at once clear ind succinct. — Am. Journal of Med. Sciences. All that the surgical student or practitioner could desire. — Dublin Quarterly Journal. It is a most admirable book. We do not know when we have examined one with more pleasure. — Boston Med. and Surg. Journal. In Mr. Druitt's book, though containing only some seven hundred pages, both the principles and the A SET ON {T. J.). ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, from the fourth and enlarged London edition. With handsome illustrations. In one very beautifully printed octavo volume of about 300 pages. $3 25. JJIGELO W (HENRY J.), M. D., •*-' Professor of Surgery in the Mas-^ochusetts Med. College. ON THE MECHANISM OF DISLOCATION AND FRACTURE OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. With numerous original illustrations. In one very handsome octavo volume. Cloth. $2 60. {Lately Isstced.) TAWSON [GEORGE), F. R. G. S., Engl, ■*-" A.isistant Surgeon to the Royal L '. London Ophthalmic Hospital. Monrfields, RYANT [THOMAS), F.R.C.S., •*-' Surgeon to Guy's Hospital. THE PRACTICE OF SURGERY. With over Five Hundred En- gravings on Wood. In one large and very handsome octavo volume of nearly 1000 pages, extra cloth, $6 25; leather, raised bands, $7 25. i^Jicst Ready.) Again, the author gives us his own practice, his own beliefs, and illustrates by his own cases, or those treated in Guy's Hospital. This feature adds joint emphasi.s, and a solidity to his statements that inspire confidence. One feels himself almost by the side of the surgeon, seeing his work and hearing his living words. The views, etc., of other surgeons are con- sidered calmly and fairly, but Mr. Bryant's are adopted. Tlius the work is not a compilation of other writings ; it is not an encyclopasdia, but the plain statements, on practical points, of a mau who has lived and breathed and had his being in the richest surgical experience. The whole profession owe a debt of gratitude to Mr. Bryant, for his work in their behalf. We are confident that the American profession will give substantial testimonial of their feelings towards both author and publisher, by speedily exhausting this edition. We cordially and heartily commend it to our friends, and think that no livesurgeon can afford to be without it — Detroit Review o/Me'i. and Pharmacy, August, 1873. As a manual of the practice of surgery for the use of the student, we do not hesitate to pronounce Mr. Bryant's book a tirst-rate work. Mr. Bryant has a good deal of the dogmatic energy which goes with the clear, pronounced opinions of a man whose re- flections and experience have moulded a character not wanting in firmness and decision. At the same time he teaches with the enthusiasm of one who has faith in his teaching ; he speaks as one having au- and fairly, yet it is no mere compilation. The book combines much of the merit of the manual with the merit of the monograph. One may recognize in almost every chapter of the ninety-four of which the work is made up the acuteness of a surgeon who has seen much, and observed closely, and who gives forth the results of actual experience. In conclusion we repeat what we stated at first, that Mr. Bryant's book is one which we can conscientiously recommend both to practitioners and students as an admirable work. — Dublin Jonrn. of Med. Science, August, 1873. Mr. Bryant has long been known to the reading portion of the profession as an able, clear, and graphic writer upon surgical subjects. The volume before us is one eminently upon the practice of surgery and not one which treats at length on surgical pathology, though the views that are entertained upon this sub- ject are sufficiently interspersed through the work for all practical purposes. As a text-book we cheer- fully recommend it, feeling convinced that, from the subject-matter, and the concise and true way Mr. Bryant deals with his subject, it will prove a for- midable rival among the numerous surgical text- books which are offered to the student. — N. Y. Med. Record, June, 1873. This is, as the preface states, an entirely new book, and contains in a moderately condensed form all the surgical information necessary to a general practi- tioner. It is written in a sp'rit consistent with the present improved standard of medical and surgical thority. and herein Ties the'charm and excellence of I science. — American Journal of Obstetrics, August, his work. He states the opinions of others freely I 1873. [T/'ELLS {J. SOELBERG), ' ' Professor of Ophthalmology in King's College Hospital, &e. A TREATISE ON DISEASES OF THE EYE. Second Americar, from the Third and Revised London Edition, with additions; illustrated with numerous engravings on wood, and six colored plates. Together with selections from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume of nearly 800 pages ; cloth, $5 00 ; leather, $6 00. (Just Ready.) The continued demand for this work, both in England and this country, is sufficient evidence that the author has succeeded in his efl'ort to supply within a reasonable compass :t full practical digest of ophthalmology in its most modern aspects, while the call for repeated editions has en- abled him in his revisions to maintain its position abreast of the most recent investigations and improvements. In again reprinting it, every effort has been made to adapt it thoroughly to the wants of the American practitioner. Such additions as seemed desirable have been introduced by the editor, Dr. I. Minis Hays, and the number of illustrations has been largely increased. The importance of test-types as an aid to diagnosis is so universally acknowledged at the present day that it seemed essential to the completeness of the work that they should be added, and as the author recommends the use of those both of Jaeger and of Snellen for different purposes, selec- tions have been made from each, so that the practitioner may have at command all the assist- ance necessary. Although enlarged by one hundred pages, it has been retained at the former very moderate price, rendering it one of the cheapest volumes before the profession. A few notices of the previous edition are subjoined. In this respect the work before us is of much more i found difficult to th« student, he has dwelt at length service to the general practitioner than those heavy i and entered into full explanation. After a careful compilations which, in giving every person's views, 1 perusal of its contents, we can unhesitatingly com- too often neglect to specify those which are most in I mend it to all who desire to consult a really good accordance with the author's opinions, or in general work on ophhtalmic science. — Leavenworth Mde. Her- acceptauce. We have no hesitation in recommending 1 aid, Jan. 1870. this treatise, as, on the whole, of all English works i without doubt, one of the best works upon the sub on the subject, the one best adapted to the wants of j jg^t which has ever been published ; it is complete on the general pTa.clil\onei.- Edinburgh Med. Journal, [he subject of which it treats, and is a necessary work March, 1S70. A treatise of rare merit. It is practical, compre- hensive, and yet concise. Upon those subjects usually for every physician who attempts to treat diseases of the eye. — Dominion Med. Journal, Sept. 1869. In TA URENCE [JOHN Z.), F. R. C. S., Editor of the Ophthalmic Review, &e. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of PractitiOTiers. Second Edition, revised and enlarged. With numerous illustrations. one very handsome octavo volume, extra cloth, $3 00. (Lately Issued.) For those, however, who must assume the care of diseases and injuries of the eye, and who are too much pressed for time to study the classic works on the subject, or those recently published by Stellwag, Wells, Bader, and others, Mr. Laurence will prove a safe and trustworthy guide. He has described in this edition those novelties which have secured the confi- dence of the profession since the appearance of his last. The volume has been considerably enlarged and improved by the revision and additions of its author, expressly for the American edition. — Am. Journ. Med. Sciences, Jan. 1870. 30 Henry C. Lea's Publications — (Surgery, &c.). T HO MP SON {SIR HENR F), Surgeon and Professor of Olinical Surgery to University College Hospital. LECTURES ON DISEASES OF THE URINARY ORGANS. With illustrations on wood. In one neat octavo volume, extra cloth. $2 25. These lectures stand the severe test. They are iu- I fical hints so useful for the student, and even more structive without being tedious, and simple without valuable to the young practitioner.— £(iin?>Mr£r^ ilfed. being diffuse; and they include many of those prac- | Journal, April, 1S69. B Y THE SAME AUTHOR. ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETH15A AND URINARY FISTULiE. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, extra cloth, %'d 50. (Lately Published.) This classical work has so long been recognized as a standard authority on its perplexing sub- jects that it should be rendered accessible to the American profession. Having enjoyed the advantage of a revision at the hands of the author within a few months, it will be found to present his latest views and to be on a level with the most recent advances of surgical science With a work accepted as the authority upon the I ably known by the profes.sioa as this before us, must subjects of which it treats, an extended notice would | create a demand for it from those v?hi> would keep be a work of supererogation. The simple announce- i themselves well up in this department of surgery.— taent of another edition of a work so well and favor- | St. Louis Med. Archives, Feb. 1870. B Y THE SAME AUTHOR. {Just Ready.) THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY AND TREATMENT. Fourth Edition, Revised. In one very handsome octavo volume of i<55 pages, with thirteen piates, phiin and colored, and illustrations on wood. Cloth, $3 75. This work is recognized in Engliind as the lending authority on its subject, and in presenting it to the American profest^ion, it is hoped that it will be found a trustworthy and satisfactory guide in the treatment of an obscure and important class of afi'ectiuns. rUALES {PHILIP S.), M.D., Surgeon U.S.N. MECHANICAL THERlPEUTICS: a Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations: em*iracing Minor Surgery, Band- aging, Orthopraxy, and the Treatment of Fractures and Oislocations. With six hundred and forty-two illustrations on wood. In one large and handsome octavo volume of about 700 pages : extra cloth, $5 75 ; leather, $6 75. rPAYLOR {ALFRED S.), M.D., ■* Lecturer on Med. Jurisp. and Chemistry in Quy^s Hospital. MEDICAL JURISPRUDENCE. Seventh American Edition. Edited by John J. Reese, M.D., Prof of Med. Jurisp. in the Univ. of Penn. In one large octavo volume. Cloth, $5 00; leather, $G 00. {Noiv Ready.) In preparing for the press this seventh American edition of the " Manual of Medical Jurispru- dence" the editor has, through the courtesy of Dr. Taylor, enjoyed the very great advantage of consulting the sheets of the new edition of the author's larger work, " The Principles and Prac- tice of Medical Jurisprudence," which is now ready for publication in London. Tiiis has enabled him to introduce the author's latest views upon the topics discussed, which are believed to bring the work fully up to the present time. The notes of the former editor. Dr. Hartshorne, as also the numerous valuable references to American practice and decisions by his successor, Mr. Penrose, have been retained, with but few slight exceptions; they will be found inclosed in brackets, distinguished by the letters (U.) and (P.). The additions made by the present editor, from the material at his command, amount to about one hundred pages; and his own notes are dei^ignated by the letter (R.). Several subjects, not treated of in the former edition, have been noticed in the present one, and the work, it is hoped, will be found to merit a continuance of the confidence which it has so long enjoyed as a standard authority. .. - ,„„„...„„ -IJAr/ZOiJ. (Now Ready.) THE PRINCIPLES AND PRACTICE OF MEDICAL JtJRISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two very large octavo volumes, cloth, $10 00; leather, $12 00. This great work is now recognized in England as the fullest and most authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Ameri- can profession, the publisher trusts that i« will assume the same position in this country. Henry C. Lea's Publications — {Psychological Medicine^ &c.). 31 rpUKE [DANIEL HACK), M.D , J- Joint author of "The Mamial of Pnychnlngical Medicine," &g. ILLUSTPxATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the Imagination. In one handsome octavo volume of 416 pages, extra cloth, $3 25. (Now Ready.) The object of the author in this work has been to show not only the effect of the mind in caus- ing and intensifying disease, but also its curative influence, and the use which may be made of the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- ject have long been familiar to the profession, but no attempt has hitherto been made to collect and systematize them so as to render them available to the practitioner, by establishing the seve- ral phenomena upon a scientific basis. In the endeavor thus to convert to the use of legitimate medicine the means which have been employed so successfully in many systetns of quackery, the author has produced a work of the highest freshness and interest as well as of permanent value. DLANDFORD [G. FIELDING), M. D., F. R. C P., J-* Lecturer on Psychological Mtdicine at the School of St. George's Hospital, &c. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages: extra cloth, $3 25. (Just Issued.) This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of more value to the practitioner in this country, Dr. Ray has added an appendix which afi'ords in- formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment be called upon to take action in relation to patients. It satisfies a want which must have been sorely actually seen in practice and the appropriate treat- felt by the busy general practitioners of this country It takes the form of a manual of clinical description of the various forms of insanity, with a description of the mode of examining persons suspected of in- sanity. We call particular attention to this feature of the book, as giving it a unique value to the gene- ral practitioner. If we pass from theoretical conside- rations to descriptions of the varieties of insanity as ment for them, we find in Dr. Blaudford's work a considerable advance over previous writings on the subject. His pictures of the various forms of mental disease are so clear and good that no reader can fail to be struck with their superiority to those given in ordinary manuals in the English language or (so far as our own reading extends) in any other. — London Practitioner, i'eb, 1871. w INSLOW {FORBES), M.D., D.C.L., ^c. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo volume of nearly 600 pages, extra cloth. $4 25. EA {HENRY C). 'superstition AND FORCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; extra cloth, $2 75. (Lately Published.) We know of no single work which contains, in so small a compass, so much illustrative of the strangest operations of the human mind. Foot-notes give the authority for each statement, showing vast research and wonderful industry. We advise our confvtres to read this book and ponder its teachings. — Chicago Med. Journal, Aug. 1870. As a work of curious inquiry on certain outlying points of obsolete law, "Superstition and Force" is one of the most remarkable books we have met with. — London Athenaiiin,, Nov. 3, 1866. He has thrown a great deal of light upon what mast be regarded as one of the most instructive as well as interesting phages of human society and progress. . . The fulness and breadth with which he has carried out his comparative survey of this repulsive field of history [Torture], are such as to preclude our doing justice to the work within our present limits. But here, as throughout the volume, there will be found a wealth of illustration and a critical grasp of the philosophical import of facts which will reader Mr. Lea's labors of sterling value to the historical stu- dent. — London Saturday Review, Oct. 8, 1870. As a book of ready reference on the subject, it is of the highest value. — Westminster Review, Oct. 1867. B y THE SAME AUTHOR. ( Late' y Published.) STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 12mo. volume of 516 pp. extra cloth. $2 75. The story was never told more calmly or with greater learning or wiser thought. We doubt, indeed, if any other study of this field can be compared with this for clearness, accuracy, and power. — Chicago Examiner, Dec. 1870. Mr. Lea's latest work, "Studies in Chnrcl^ History," fully sustains the promise of the first. It deals with three subjects — the Temporal Power, Benefit of Clergy, and Excommuuieatiou, the record of which has a peculiar importance lor the Knglish student, and Is a chapter on Ancient Law likely to be regarded as final. We cau hardly pass from our mention of such works as these — with which that on "tiaeerdotal Celibacy" should be iucluded — without noting the literary phenomenon that the head of one of the first American houses is also the writer of some of its most original books. — London Aihenmum, Jan. 7, 1871. Mr. Lea has done great honor to himself and this country by the admirable works he has written on ecclesiologicalaud cognate subjects. We have already had occasion to commend his "Superstition and i'orce" and his "History of Sacerdotal Celibacy. ' The present volume is fully as admirable in its me- thod of dealing with topics and in the thoroughness — aquality so frequently lacking in American authors — with which they are investigated. — N. Y. Journal of Psychol. Medicine, July, 1870. 32 Henry C. Lea's Publioatione. INDEX TO CATALOGtJE. Ambrican Journal of the Medical Sciences American Chemist (The) .... Abstract, Half-Yearly, of the Med. Sciences Anatomical Atlas, by Smith and Horner Anderson on Diseases of the Skin Abhton on the Kectum and Anus . Attfieid's Chemistry .... Ashwell on Diseases of Females . Ashhurst's Surgery .... Barnes on Diseases of Women Bellamy's Surgical Anatomy Bryant's Practical Surgery . Bloxam's Chemistry * . . . Blaudford on Insanity .... Basham on Renal Diseases Brinton on the Stomach Bigelow on the Hip .... Barlow's Practice of Medicine Buwman's (John E.) Practical Chemisitry Bowman's (John E.) Medical Chemistry Buckler on Bronchitis .... Itumstead on Venereal .... Itumstead and Cullerier's Atlas of Venereal Carpenter's Human Physiology . Carpenter's Comparative Physiolngy . Carpenter on the Use and Abuse of Alcohol Carson's Synopsis of Materia Medica . Chambers on the Indigestions Chambers's Restorative Medicine Cliribtison and Griffith's Dispensatory Churchill's System of Midwifery . Churchill on Puerperal Fever Condie on Disease.s of Children Cooper's (B. B) Lectures on Surgery . Cullerier's Atlas of Venereal Diseases Cyclopedia of Practical Medicine . Dalton's Human Physiology . De Jongh on Cod-Liver Oil ... Dswees's System of Midwifery Dewees on Diseases of Females Dewees on Diseases of Children . Druitt's Modern Surgery Dungllson's Medical Dictionary . Dunglison's Human Physiology . Dunglison on New Remedies Ellis's Medical Formulary, by Smith . Erichsen's System of Surgery Fenwick's Diagnosis .... Flint on Respiratory Organs . Flint on tlie Heart Flint's Practice of Medicine . Pownes's Elementary Chemistry . Fox on Diseases of the Stomach . Fuller on the Lungs, &c. Green's Pathology and Morbid Anatomy Sibson's Surgery G luge's Pathological Histology, by Leidy Oalloway's Qualitative Analysis . ■ . Gray's Anatomy ..... Griffith's (R. E.) Universal Formulary Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gross's Pathological Anatomy Guersant on Surgical Diseases of Children Hamilton on Dislocations and Fractures Hartshorne's Essentials of Medicine . Hartshorne's Conspectus of tlie Medical Sciences Hartshorne's Anatomy and Physiology Heath's Practical Anatomy . Hoblyn's Medical Dictionary Hodge on Women Hodge's Obstetrics Hodges' Practical Dissections Holland's Medical Notes and Reflections Horner's Anatomy and Histology Hudson on Fevers .... Hill on Venereal Diseases Hillier's Handbook of Skin Diseases Jones and Sieveking's Pathological Anatomy Jones (C. Handfield) on Nervous Disorders Kirkes' Physiology Knapp's Chemical Technology PAGE 1 11 3 FAOB Lea's Superstition and Force . . . .31 Lea's .Studies in Church History .... 31 Leishnian's Midwifery 25 La Ruche on Yellow Fever 14 La Roche on Pneumonia, &c. . . . .17 Laurence and Moon's Ophthalmic Surgery ." . 29 Lawson on the Eye 28 Laycock on Medical Observation . . . .14 Lehmann's Physiological Chemistry, 2 vols. . 6 Lehmann's Chemical Physiology .... & Ludlow's Manual of Examinations ... 5 Lyons on Fever 18 Maclise's Surgical Anatomy ..... 7 Marshall's Physiology 8 Medical News and Library 2 Meigs's Obstetrics, the Science and the Art . . 25 Meigs's Lectures on Diseases of Women . . 2.3 Meigs on Puerperal Fever 23 Miller's Practice of Surgery 26 Miller's Principles of Surgery . . . .26 Montgomery on Pregnancy 25 Morland on Urinary Organs 27 Morland on Uraemia 18 Neill and Smith's Compendium of Med. Science . 5 Neligan's Atlas of Diseases of the Skin . . 20 Neligau on Diseases of the Skin . . . .20 Obstetrical Journal 22 Odling's Practical Chemistry . . . .10 Pavy on Digestion 15 Pavy on Food ]5 Prize Essays on Consumption .... 17 Parrish's Practical Pharmacy . . . .12 Pirrie's System of Surgery 27 Pereira's Mat. Medica and Therapeutics, abridged 13 Quain and Sharpey's Anatomy, by Leidy . . 6 Ranking's Abstract 3 Roberts on Urinary Diseases 18 Ramsbotham on Parturition 2fl Righy's Midwifery 25 Royle's Materia Medica and Therapeutics . , 13 Swayne's Obstetric Aphorisms . . . .24 Sargent's Minor Surgery 26 Sharpey and Quain's Anatomy, by Leidy . . 6 Simon's General Pathology 14 Skey's Operative Surgery 26 Slade on Diphtheria 18 Smith (J. L.) on Children 21 Smith (H. H.) and Horner's Anatomical Atlas . 6 Smith (Edward) on Consumption . . . .17 Smith on Wasting Diseases of Children . . 21 Solly on Anatomy and Diseases of the Brain . 14 StiU6's Therapeutics 12 Sturges on Clinical Medicine .... 14 Tanner's Manual of Clinical Medicine ... 6 Tanner on Pregnancy 24 Taylor's Medical Jurisprudence . . 30 Taylor's Principles and Practice of Med Jurisp. 30 Take on the Influence of the Jliud . . 31 Thomas on Diseases of Females . . . .22 Thompson on Urinary Organs .... 30 Thompson on Stricture 30 Thompson on the Prostate . . . . .30 Todd on Acute Diseases Ifl Wales on Surgical Operations ... .30 Walshe on the Heart 17 Watson's Practice of Physic 16 Wells on the Eye 29 West on Diseases of Females . . . . 23 West on Diseases of Children .... 21 West on Nervous Disorders of Children . . 21 West on Ulceration of Os Uteri .... 23 What to Observe in Medical Cases . . .14 Williams on Consumption 17 Wilson s Human Anatomy 7 Wilson on Diseases of the Skin . . . . 20 Wilson's Plates on Diseases of the Skin . . 20 Wilson's Handbook of Cutaneous Medicine . 20 WilsoD on Spermatorrhoea . . . , 19 Winslow on Brain and Mind . . . .31 Wohler's Organic Chemistry . ... 11 Wiuckel on Childbed '24 Zeissl on Venereal 19 For "The American Chemist" Five Dollars a year, see p. 11. For "The Obstetrical Journal" Five Dollars a year, see p. 22. UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. I