■"% PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. BY AUSTIN FLINT, M.D., PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF LOUISVILLE; HONORARY MEMBER OF THE MEDICAL SOCIETY OF VIP.GINIA. AND OF THE KENTUCKY STATE MEDICAL SOCIETY. PHILADELPHIA: BLANCHAED AND LEA. 1856. W56, Entered, according to Act of Congress, in the year 1856, BY BLANCHAED AND LEA, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. C. SHERMAN k SON, PRINTERS, 19 St. James Street. TO PROFESSORS C iARLES B. COVENTRY, CHARLES A. LEE, JAMES P. WHITE, FRANK H. HAMILTON, GEORGE HADLEY, BENJAMIN R. PALMER, JOHN C DALTON, JR., AND EDWARD M. MOORE, WITH WHOM CHE AUTHOR WAS FORMERLY ASSOCIATED IN THE ftiufomitg at §wffal0, AND TO HIS MEDICAL FRIENDS IN THE CITY OF BUFFALO, THIS VOLUME Is 3 RESPECTFULLY DEDICATED. PREFACE. The great importance of physical exploration in cases of thoracic disease is now generally admitted. While its scope of application, the significance of certain of its phenomena, and more especially the mode of their production, furnish occasions for discussion and differences of opinion, few intelligent phy- sicians, at the present day, refuse to acknowledge that the dis- covery of Laennec forms a memorable epoch in the history of medicine; nor will the claims of this branch of our art on the attention of the medical practitioner be denied by any who are qualified to place a proper estimate upon its value. But although these positions are indisputable, the number who give much attention to the principles and practice of physical exploration is quite small, its advantages being practically rejected by a large proportion of the medical profession. May not this be in a measure due to the paucity of works treating of the subject specially, and with a degree of fulness commen- surate with its importance ? This inquiry, mainly, has led to the preparation of this volume. The founder of auscultation succeeded in bringing the diagnosis of diseases affecting the pulmonary organs to an astonishing degree of precision. Yet the labors of those who have followed in the footsteps of their illustrious master, have done much for the improvement and extension of physical exploration; so that the great work of Laennec, remaining as it ever will a splendid monument of his genius and industry, is no longer adequate to a complete expo- sition of our existing knowledge. The few special treatises which have more recently appeared, are mostly designed as manuals for the medical student. The most comprehensive VI PREFACE. work published in our language within late years is the admi- rable treatise by Prof. Walshe. In this work, which includes diseases of the heart and aorta, embracing also the morbid anatomy and treatment, as well as the diagnosis, the conside- ration of physical signs is necessarily condensed. My aim has been to supply what appears to me a desideratum, viz., a work limited to diseases affecting the respiratory organs, treating in extenso, and almost exclusively, of the principles and practice of physical exploration as applied to the diagnosis of these affec- tions. So much, briefly, for the motives and objects which have prompted the undertaking. In preparing the volume now submitted to the profession, my plan has been to treat of the physical signs as regards their individual and differential characters, their significance and diagnostic relations, separately and combined, without impos- ing on myself restraint on the score of brevity. "Whilst I have desired not to be either tediously minute or diffuse, I have intentionally amplified, somewhat after the usual mode of oral teaching, under the belief that this course would best subserve the interests of the reader, and that the importance of the subject renders no apology necessary for the size of the book. I have striven to make the work as practical as possible; and, therefore, the various topics are considered with almost exclusive reference to their direct clinical bearings. Very little attention is devoted to theoretical questions. To the mechan- ism of physical phenomena 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 d priori 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. The recapitulation in different pathological connections of the distinctive characters of the different signs, which, as the reader will notice, is a feature of the work, has not arisen from inadvertency; for, whereas, perfect familiarity with these cha- racters is indispensable to skill or success in the practice of exploration, they are to be fixed in the memory by means of repetition, on the principle which underlies the oral system of PREFACE. Vll acquiring a foreign tongue. The motto, " repetition sans cesse," adopted by an author of French exercises constructed after this system,1 is well suited for the student or practitioner who is ambitious to excel in physical exploration. Whoever undertakes to write a didactic treatise, in effect, assumes that he is competent to the task. It is not, therefore, unbecoming for me to state that during several years devoted to clinical pursuits, the physical exploration of the chest has occupied a considerable share of my attention. Of most of the practical points embraced in this work, I am able to speak from experience. With respect to certain signs, the views which I have been led to form from personal observation are original. I may particularize here, the characters of pitch dis- tinguishing the respiratory sound commonly called rude or rough, and which give to a prolonged expiration its signifi- cance as a sign of increased density of lung from tuberculous or other solid deposit; also, the relative pitch of the inspira- tory and expiratory sounds in the cavernous, as contrasted with the bronchial, respiration. Other points, not dwelt upon by writers on this subject, which I may mention in this place, are the importance of determining the line of the interlobar fis- sure, as a means of distinguishing between the percussion-dul- ness of lobar pneumonitis and liquid effusion, and the clinical value of the souffle or bellows' sound, accompanying the act of whispering, as a sign of solidification. In the perusal of the work, the reader will perceive that occasionally the results of my own observation do not altogether accord with the opinions of others. Under these circumstances, I do not hesitate to follow a rule which, as it seems to me, in matters purely of observation, should not lead to the imputation either of egotism or presumption, viz., not to be more ready to distrust one's own accuracy than that of others. Were an opposite course to be required, there would be small encouragement for original research. While engaged in writing the work, I have been forcibly impressed with the need of farther analytical investigation of carefully recorded data. Questions have so frequently arisen which are to be settled only by an appeal to the results of observation, that I have sometimes been tempted to lay aside the pen, and have resumed it only under the con- 1 Manesca. Vlll PREFACE. viction that such questions must, for a long period, continue to arise ; and that to wait for the means of meeting promptly every inquiry, is equivalent to an indefinite postponement. This field of research, like every other in the extensive domain of medical science, offers scope for unlimited improvement; and it is to be expected that continued efforts in its cultivation will develope additional resources, rendering it more and more valuable. Endeavoring, as far as practicable, to exhibit the actual state of our present knowledge of the physical diagnosis of diseases of the respiratory organs, I have availed myself of the latest and most approved works on the subject. My acknowledg- ments are especially due to the Practical Treatise on the Diseases of the Lungs, Heart, and Aorta, by Professor Walshe, and to the Traite" Pratique d'Auscultation, etc., by MM. Barth and Roger.1 I have also consulted with advantage, the works of Stokes, Fournet, Gerhard, C. J. B. Williams, Hughes, Bow- ditch, Swett, Alfred Stilld, Holmes, J. Hughes Bennett, and Skoda. In addition, numerous papers on particular topics have been examined, as well as books treating incidentally of matters pertaining to physical exploration, which are referred to in the body of the work. One of the authors just named has enunciated views, which, from their novelty and boldness, have attracted considerable attention. I refer to Professor Skoda, of Vienna. The theory of consonance, by which this author attempts to explain some of the most important of the physical signs, and upon which he bases certain practical conclusions, appears to me very far from being satisfactorily established. In his classification and desig- nation of physical signs, I am unable to perceive that aught is gained in clearness or simplicity. Some of his assertions per- taining to matters of simple observation, involve a denial of the positive results of the experience not of one, but of nearly all observers—for example, that the crepitant rale, as described by Laennec, is rarely heard in pneumonitis, and that the per- cussion-resonance is not affected by the presence of isolated tubercles in a very considerable quantity, unless accompanied by an altered condition of the interstitial tissue. Moreover the pervading tone of the work tends to create in the mind of the ■The editions of both these works for 1854, are referred to. PREFACE. IX student a scepticism with respect to the value of physical exploration, which is at variance with the confidence of other observers not less experienced than himself. In venturing upon these critical remarks, I am alone actuated by a desire that the importance of the subject should not be undervalued. Frequent occasions for reference to the valuable contributions of Pro- fessor Skoda will appear in the following pages. In order that physical exploration shall be available in the hands of practitioners who have neither time nor inclination to devote to it special attention, to the prejudice of attainments in other branches of medical knowledge, as much simplicity in its principles and practice as comports with a due regard to its usefulness, is to be desired. Keedless distinctions and over refinements are to be deprecated. Mutations in classification and nomenclature are as much as possible to be avoided. With these views, I have refrained from suggesting additions or changes, which, should they even be considered improvements, might occasion complexity and confusion; and I have passed over some points which, from their dubious or unimportant character, seemed likely to prove a source of embarrassment, rather than an advantage to the student. The only innova- tions I have ventured to propose are the substitution of a new name for rude or rough respiration, viz., broncho-vesicular, and the use of the terms vesiculotympanitic resonance, applied to a percussion-sound combining the tympanitic and vesicular quali- ties, and broncho-cavernous respiration, denoting a mixture of the cavernous and bronchial modifications of the respiratory sound. In conclusion, I embrace this opportunity to express acknow- ledgments to my friend, Professor Alfred Stille, for kindly con- senting to read the proofs of the work as it has passed through the press. While I have no right to hold him responsible for any of its defects, I am truly grateful to him for many valuable suggestions. University of Louisville, Ky. February, 1856. I CONTENTS. INTRODUCTION. SECTION I. Preliminary Points pertaining to the Anatomy and Physiology of the Respiratory Apparatus, . . . . .17 1. Thoracic Parietes, ...... 17 2. Pulmonary Organs, . . . . . .34 3. Trachea, Bronchi, and Larynx, .... 46 a. Trachea, ....... 46 b. Bronchi, ....... 47 c. Larynx, ....... 49 SECTION II. Topographical Divisions of the Chest, .... 54 1. Anterior Regions, . . . . . . .56 2. Posterior Regions, . . . . . . 60 3. Lateral Regions, . . . . . . .61 PART I. Physical Exploration of the Chest, ... 65 CHAPTER I. Definitions—Different Methods of Exploration—General Remarks, 65 CHAPTER II. Percussion, ........ 75 I. Percussion in Health, ...... 78 a. Post-Clavicular Region, . . . . .80 b. Clavicular Region, ..... 81 c. Infra-Clavicular Region, . . . . .81 d. Scapular Region, ...... 83 * xu CONTENTS. e. Inter-Scapular Region, f. Mammary Region, g. Infra-Mammary Region, . h. Sternal Region, i. Infra-Scapular Region, k. Lateral Regions, II. Percussion in Disease, . a. Exaggerated Vesicular Resonance, b. Diminished Resonance or Duluess, c. Absence of Resonance or Flatness, d. Tympanitic Resonance, III. Summary, .... IV. History, .... CHAPTER III. Auscultation, ..... I. Auscultation in Health, a. Phenomena incident to Respiration, . 1. Tracheal Respiration, 2. Bronchial Respiration, 3. Vesicular Respiration, b. Phenomena incident to the Voice, 1. Tracheal Voice, 2. Bronchial Voice, . 3. Normal Vesicular Vocal Resonance, c. Brief Summary of Facts, d. Phenomena incident to the act of Coughing, II. Auscultation in Disease, a. Phenomena incident to Respiration, 1. Modified Respiratory Sounds, a. Increased Intensity of the Vesicular Murmur— Exaggerated Respiration, . b. Diminished Intensity of the Vesicular Murmur— Feeble or Weak Respiration, c. Suppressed Respiration, d. Bronchial Respiration, e. Broncho-Vesicular or Rude Respiration, f. Cavernous Respiration, g. Tabular View of the Distinctive Characters per- taining to the Different Abnormal Modifications in Quality, Pitch, etc., of Respiratory Sounds h. Shortened Inspiration, i. Prolonged Expiration, . k. Interrupted Respiration, 2. Adventitious Respiratory Sounds or Rales a. Table showing the Number, Names, and Anatomi- cal Situations of the Pulmonary Rales b. Sibilant Rale, 84 84 87 89 91 92 98 . 100 102 . 108 111 . 122 124 . 126 136 . 137 137 . 140 146 . 163 164 . 167 168 . 173 174 . 175 175 . 176 177 180 185 187 197 202 209 210 211 214 216 219 220 CONTENTS. xm c. Sonorous Rale, .... d. Mucous Rales, . e. Sub-crepitant Rale, .... f. Crepitant Rale, . g. Cavernous Rale or Gurgling, . h. Indeterminate Rales, . i. Table Exhibiting the Distinctive Characters and Diagnostic Indications of the Different Rales, j. Attrition or Pleural Friction Sounds, Phenomena Incident to the Voice, 1. Exaggerated Vocal Resonance and Bronchophony, 2. Diminished and Suppressed Vocal Resonance, 3. Cavernous and Amphoric Voice, Pectoriloquy, 4. iEgophony, ..... 5. Summary of Facts pertaining to Vocal Signs, Phenomena incident to the Act of Coughing, 1. Bronchial Cough, 2. Cavernous Cough, .... Metallic Tinkling, .... Abnormal Transmission of the Sounds of the Heart, History, . . . . 221 223 226 229 235 237 240 242 249 251 261 263 267 275 279 279 280 282 289 292 CHAPTER IV. Inspection, ........ 1. Morbid Appearances pertaining to Size and Form of the Chest, 2. Morbid Appearances pertaining to the Respiratory Movements, 3. Summary, ....... 4. History, ........ CHAPTER V. Mensuration, ........ 1. Mensuration with reference to Abnormal Alterations in Size, . 2. Mensuration with reference to the Abnormal Alterations in the Extent of Respiratory Movements, .... 3. Summary, ....... 4. History, ........ Palpation, . Summary, History, Succussion, Summary, History, CHAPTER VI. CHAPTER VII. 295 297 304 308 311 312 312 317 320 322 323 329 329 330 332 332 XIV CONTENTS. CHAPTER VIII. Recapitulatory Enumeration of the Physical Signs furnished by the Several Methods of Exploration, . CHAPTER IX. Correlation of Physical Signs, ...... 1. Signs Correlative to those furnished by Percussion, 2. Signs Correlative to those furnished by Auscultation, 333 336 338 342 PART II. Diagnosis of Diseases Affecting the Respiratory Organs, 351 to Acute Ordinary CHAPTER I. Bronchitis, Pulmonary or Bronchial Catarrh, 1. Acute Bronchitis, a. Physical Signs, b. Diagnosis, c. Summary of Physical Signs belonging Bronchitis, .... 2. Capillary Bronchitis, a. Physical Signs and Diagnosis, b. Summary of Physical Signs, . 3. Pseudo-Membranous or Plastic Bronchitis, a. Physical Signs and Diagnosis, b. Summary of Physical Signs, 4. Chronic Bronchitis, . a. Physical Signs, b. Diagnosis, c. Summary of Physical Signs, 5. Secondary Bronchitis, 6. Bronchial or Pulmonary Catarrh, CHAPTER II. Dilatation and Contraction of the Bronchial Tubes—Pertussis__ Asthma, ...... 1. Dilatation of the Bronchial Tubes, .... a. Physical Signs, .... b. Diagnosis, ...... c. Summary of the more important of the Diagnostic Cha- racters, ..... 2. Contraction of the Bronchial Tubes, . 352 353 353 357 362 362 362 369 369 371 372 373 373 375 377 377 378 380 380 383 385 391 391 CONTENTS. XV 3. Pertussis—Hooping Cough, ..... 395 Physical Signs and Diagnosis, . . • 395 4. Asthma,........397 a. Physical Signs, ...... 397 b. Diagnosis, ....... 398 c. Summary of Physical Signs, . . . . 400 CHAPTER III. Pneumonitis—Imperfect Expansion (Atelectasis) and Collapse, . 401 1. Acute Lobar Pneumonitis, . . . • • 401 a. Physical Signs, ... . . 404 b. Diagnosis, . . . . • • • 421 c. Summary of Physical Signs, ..... 431 2. Lobular Pneumonitis, ...... 432 a. Physical Signs and Diagnosis, .... 435 3. Chronic Pneumonitis, ...... 440 CHAPTER IV. Emphysema, ....•••• 443 1. Vesicular Emphysema, ..... 443 a. Physical Signs, ...... 444 b. Diagnosis, ...... 4o2 c. Summary of Physical Signs, . . . • .455 2. Interlobular Emphysema, ..... 455 CHAPTER V. Pulmonary Tuberculosis—Bronchial Phthisis, . • .458 a. Physical Signs, ...... 461 b. Diagnosis, ...-•••• 488 c. Summary of Physical Signs, ..... 502 Acute Phthisis, ...•••• 503 Retrospective Diagnosis of Tuberculosis, ... 506 Tuberculosis of the Bronchial Glands—Bronchial Phthisis, . 509 CHAPTER VI. Pulmonary CEdema—Gangrene of the Lungs—Pulmonary Apoplexy —Cancer of the Lungs—Cancer in the Mediastinum 1. Pulmonary GSdema, a. Physical Signs, b. Diagnosis, . c. Summary of Physical Signs, . 2. Gangrene of the Lungs, a. Physical Signs, b. Diagnosis, c. Summary of Physical Signs, . 3. Pulmonary Apoplexy, . 512 512 513 514 515 515 516 518 520 521 Xvi COME X T S. a. Physical Signs, . 522 b. Diagnosis, .... 522 c. Summary of Physical Signs, . . 524 4. Cancer of the Lungs, .... 524 a. Physical Signs, . 525 b. Diagnosis, .... 526 e. Summary of Physical Signs, . . 531 5. Cancer in the Mediastinum, 531 a. Physical Signs, . . 532 b. Diagnosis, .... 534 CHAPTER VII. Acute Pleuritis — Chronic Pleuritis Pneumothorax — Pneumo-Hydrot phragmatic hernia, 1. Acute Pleuritis, a. Physical Signs. b. Diagnosis, c. Summary of Physical Signs, 2. Chronic Pleuritis, a. Physical Signs, b. Diagnosis, c. Retrospective Diagnosis, d. Summary of Physical Signs, 3. Empyema, . 4. Hydrothorax, 5. Pneumothorax, 6. Pneumo-Hydrothorax. . a. Physical Signs, b. Diagnosis, c. Summary of Physical Signs, 7. Pleuralgia, 8. Diaphragmatic Hernia, a. Physical Signs, b. Diagnosis, CHAPTER VIII Diseases Affecting the Trachea and Laryn the Air-Passages, 1. Auscultation of the Trachea and Larynx 2. Examination of the Chest, 3. Foreign Bodies in the Air-Passages, a. Summary of Physical Signs, . - Empyema—Hydrothorax— iiorax -- pleuralgia -- dla- 538 538 540 559 562 564 565 568 572 577 578 586 587 587 590 595 596 597 602 604 . 606 x—Foreign Bodies in APPENDIX. Ok the Pitch of the Whispering Souffle over Pulmonary Exca- vations, .... 609 610 614 618 625 62; PHYSICAL EXPLORATION, INTRODUCTION. SECTION I. PRELIMINARY POINTS PERTAINING TO THE ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY APPARATUS. 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 bronchi and their subdivi- sions, the trachea, and larynx. The throat, mouth, and nasal passages, although involved in respiration, are rather adjuncts of the respira- tory apparatus than constituents of it, their construction having more direct reference to other functions. I. The Thoracic Parietes. The portion of the skeleton called the thorax is composed of the dorsal vertebrse, the ribs, and the bones of the sternum, forming by their union, together with their intervening cartilages, a truncated 2 i 18 ANATOMY AND PHYSIOLOGY. cone, designed to protect the organs which it contains, and to be sub- servient to certain movements concerned in respiration. The bony arches, the ribs, exclusive of the two last on each side (reckoning, 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 distinguished as the 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. 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 more acute with each inferior rib. The length of the costal cartilages also in- creases 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 their cartilaginous prolongations, are provisions for the respiratory movements, so far as these move- ments relate to the anterior and lateral portions of the chest. With the act of inspiration, more especially when its force is voluntarily 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 acute angle formed by the union of the ribs and cartilages. After the cessation of the motive power which effects these changes, in other THE THORACIC PARIETES. 19 words, with the act of expiration, the elasticity of the cartilages suf- fices to restore that relation to the ribs which is naturally assumed. These movements are abnormally increased and diminished in conse- quence 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-hydrothorax, and in some instances of abnormally distended lung, constituting a form of 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 constitute a portion of the active agents employed in carrying on the respiratory move- ments. These intervening muscular layers are depressed below the level of the ribs, causing furrows, which are called the intercostal de- pressions. In persons with small or moderate adipose deposit, these depressions are plainly indicated on the surface, being observable especially in front and laterally, at the lower part of the chest. They are everywhere visible, except in the portions covered by the scapula, in cases of great emaciation. A change as respects this anatomical point occurs in certain diseases, viz., when there is an accumulation of a large quantity of liquid ; and sometimes when the chest is dilated by over-distended lung in emphysema. Under these 20 ANATOMY AND PHYSIOLOGY. circumstances, especially with the former condition, the intercostal depressions are abolished, and the intervening integument may even project beyond the level of the ribs when a very large quantity of liquid is contained in the pleural sac. The scapula and clavicle, 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 vertebrse, 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 lungs 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 structure entering into the com- position of the diaphragm diminishes its vaulted form, depressing it to a plane, thereby enlarging 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 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 nearly symmetrical, so that any con- siderable deviations in this point of view, denote either present disease, or deformity. An exception relates to the semicircular THE THORACIC PARIETES. 21 measurement at the middle and inferior portion of the chest. The right side usually, but by no means 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 M. 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 measure- ment, 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 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 the fourth intercostal space, should be on the same transverse line, and equi- distant 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 its application, it is to be borne in mind that certain past affections are liable to leave devia- tions more or less permanent. The most common cause of deformity is spinal curvature, which may be sufficient to disturb the symmetry 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, without 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 pleurisy. The chest 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 on the contrary 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; contraction at the lower part of the chest in females, occasioned by tight lacing; distortions from fractures or other injuries, etc. These oo ANATOMY AND PHYSIOLOGY. deviations from symmetry are sufficiently obvious, and will not there- fore escape notice. Practically, they are of great importance in determining the physical signs of present disease. The greater portion of these signs, as will be seen hereafter, being based on the assump- tion that, irrespective of present disease, the two sides of the chest are in unison, it becomes obviously an essential preliminary to deter- mine, in individual cases, to what extent the law of symmetry is applicable. The researches by M. Woillez1 show that chests presenting in all particulars complete regularity of conformation are found in only the proportion of about twenty of every hundred per- sons. Deviations from symmetry, either disconnected from disease (physiological), or resulting from previous morbid conditions (patho- logical), therefore, exist to a greater or less extent, in a large proportion of individuals. This fact would impair very materially the value of physical exploration 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 re- spirations is considerably increased, rising for example in bronchitis affecting the smaller tubes, to 30, 40, 50, 60, or even a still greater number, per minute. On the other hand, an abnormal diminution in frequency accompanies certain morbid conditions of the nervous system affecting indirectly the respiration. Thus, the respirations are morbidly infrequent, or slow, in apoplexy, and 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 1 " Recherches pratiques sur Inspection et la mensuration de la poitrine, considers comme moyens diagnostiques complementaires de la percussion et de Tauscultation " Paris, 1837. Archives Generates de Medecine, 3eme Serie, tome i p. 73. THE THORACIC PARIETES. 23 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 .he elasticity of the dilated parts, but contraction beyond the dimensions which it naturally assumes, is effected by expiratory muscles. The move- ments incident to the two acts, respectively, in ordinary or tranquil respiration; the modifications exhibited when the breathing is exag- gerated or forced; the normal differences 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 appre- ciate 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 respiration, which, however much of interest they may possess for one desirous of investigating the subject fully, are not of special importance in view of pathological relations. 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 perceptible rising and falling of the abdomen. But in'certain diseases these movements are to a greater or less extent restrained, an$ they may even be com- pletely arrested. They are notably diminished in acute peritonitis, being unconsciously repressed in consequence of the pain which they occasion; and they are mechanically prevented by a great quantity of liquid within the peritoneal sac, by enormous distension of the stomach or intestines with gas, and by abdominal tumors, inclusive of pregnancy. Under these circumstances the thoracic muscles take on a supplementary activity, which are rendered sufficiently obvious by the increased movements of the thoracic walls. The breathing is then said to be thoracic or costal. On the other hand, the movements of the ribs are voluntarily repressed in consequence of the pain incident thereto in acute pleurisy, or in pleurodynia, and they are mechanically limited by rigidity and ossification of the costal cartilages. The diaphragm, in this case, takes on an increased 24 ANATOMY AND PHYSIOLOGY. action. The breathing is then distinguished as diaphragmatic or abdominal, the latter term denoting the fact that this supplementary activity is manifested by a corresponding increase in the visible rising and falling of the abdominal walls. The deviations from normal respiration known as thoracic or costal, and diaphragmatic 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; and in some instances, of the affection called emphysema when limited to one lung. Paralysis of the muscles of a lateral half of the body (hemi- plegia) may also be attended by diminished thoracic movements of the affected side. Analysis of the movements of the thoracic walls developes 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, which, as has been seen, pursue an oblique direction, forming an angular connection with the costal cartilages. In proportion as the ribs are thus raised, the angles just referred to become less acute, and the ribs approach to a horizontal direction, the ribs and cartilages together approxi- mating to a continuous line. At the same time the sternum is raised upward and projected forward. The ribs, also, are rotated back- ward 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 greater acuteness of the angle formed by the union of the former with the latter, 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 ordinary breathing, the ribs at the summit of the male chest appear to have little or no part in the thoracic movements. Accurate measurement shows that they 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, and frequently appearing to be chiefly 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 THE THORACIC PARIETES. 25 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 MM. Beau and Maissiat,1 which I am satisfied from my own ob- servations 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 respi- ratory acts, consist in the rising and falling of the abdomen. This is called the abdominal type of respiration. 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, pre- sented 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 characterized 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 Mr. John Hutchinson,2 the correct- ness of which may be easily verified by an examination of the nude chest in a living male subject. The respiratory movements, exa- mined when the respiration is tranquil, and, afterward, when volun- tarily increased, present, in the first instance, an abdominal motion more 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 some- times superadded. Mr. Hutchinson was led to think that, with this change, the diaphragmatic movements almost ceased. This, how- ' Recherches sur le mecanisme des mouvements respiratoires. Archives Generates de Medecine, Decembre, 1842. 2 Medico-chirurgical Transactions, vol. xxix, 1846. 26 ANATOMY AND PHYSIOLOGY. ever, is not the fact, as shown conclusively by Dr. F. Sibson. The expansion of the inferior ribs, which is measurably due to the dia- phragm, prevents the rising and falling of the abdominal walls from being apparent. Nevertheless, it takes place, as may be satisfac- torily proved by percussing the lower part of the chest before and after a deep inspiration. The evidence of ,the depression of the diaphragm thus afforded, will appear in a subsequent section. The intercostal spaces at the lower part of the chest are somewhat 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 inspiration, in consequence of each rib being raised slightly more than the one above it. The intercostal depressions which are apparent at the inferior por- tion of the chest laterally and anteriorly, especially 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 MM. 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 belonging 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 Dr. Walshe, "seems to the eye to breathe with the abdomen and the lower ribs, from about the tenth to the sixth; the adult female, with the upper third of the chest alone." In other words, the breathing peculiar to females is the superior costal type, while in males it is associated with the abdominal, 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 convulsively 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 differences in the two sexes—differences which it is of importance should be borne in mind with reference to the study of THE THORACIC PARIETES. 27 diseases of the respiratory apparatus. One of these reasons is, that nature has in this way provided for the due performance of respira- tion during the period of gestation, when the diaphragmatic move- ments 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. Another reason, more entitled to be called an explana- tion, is, that the movements of the diaphragm and lower part of the chest become permanently impaired in females by modes of dressing, involving 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 ques- tion whether the differences be natural or acquired ; and this question is to be decided by examining girls and adult females whose waists have not been encased in any restraining or contracting apparatus. With respect to this point the conclusions at which different observers have arrived, are not altogether uniform. Dr. Walshe states that he has examined a considerable number of fenfale children, aged be- tween four and ten years, who had never worn stays, or any substi- tute therefor, who presented, nevertheless, the predominant action at the summit of the chest, observable in adult females, the pecu- liarity, 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. MM. 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. Mr. John Hutchinson, in his valuable paper already referred to, says he " ex- amined 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." Mr. Francis Sibsonl attributes the peculiarity to modi- fications 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 10." Still, he 1 On the movements of respiration in disease, and on the use of a chest-measurer. Med. Chir. Trans of Royal Med. and Chir. Society of London, vol. xxxi, 1848. 28 ANATOMY AND PHYSIOLOGY. remarks, " 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 who, within the past few years, have made the respiratory movements the subject of extensive personal 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 wholly derived from that source. A collection of an extended series of observations relative to this point is, however, still a desideratum. The respiratory movements are modified by age. This is owing mainly 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 diaphragmatic movements are increased, and the costal proportionably diminished. Between the two extremes of life, the character of the respiration will be likely to approximate to that belonging to the one or the other, according to the proximity of the- individual to boyhood or old age. In aged persons, whose costal cartilages 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 over-distended lung in certain 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 up- ward in the act of inspiration "as if in one piece." Infants present this modification : the abdominal movements are less, and the thoracic 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 Dr. Sibson, which 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 THE THORACIC PARIETES. 29 tenths, to indicate the diameter of the chest; 3, a horizontal rod, moving by a slide on the upright rod, which can be lengthened by 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 revo- lution of the index indicates 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, Dr. Sibson has given the results of a large number of observations on the movements of respiration 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 inches 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 ribs 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 41 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 Dr. Sibson, and other contrivances to deter- mine the amount of motion with the same exactness, have the disadvantage of being more or less complicated and cumbersome. A simple graduated tape will suffice to determine, with tolerable 30 ANATOMY AND TIIYSIOLOGY. accurac}T, 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 approxima- tions 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 it is capable of moving over a graduated dial. The cord being extended 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.1 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 abnormal protrusion or bulging of a portion of the chest. The respiratory movements, as has been seen, are abnormally increased in pregnancy, and in various affections which compromise the function of hsematosis. When this increase is but moderate it is stated by MM. Beau and Maissiat-that the movements in one in- dividual 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 inferior costal, as well as abdominal, the movements of the lower ribs will be conspicuous; and if, as in females, it be superior costal the exaggeration will be found to affect chiefly the superior portion of the chest. In cases, however, in which the sense of the want of 1 Coxeter's Catalogue of Surgical Instruments and Apparatus. THE THORACIC PARIETES. 31 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 pos- sible enlargement of the chest, various muscles are employed which are capable indirectly of aiding in respiration. An erect or sitting posture, being most favorable for the action of these muscles, is also selected. These changes will claim attention in connection with the symptomatology of the diseases in which they are exemplified. The rhythmical succession of the two 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 interest, 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. Mr. Hutchinson,1 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. From the facts which have been stated relative to ordinary breathing, it follows, that the expiratory movement commences at the instant the inspiratory ceases. The latter is merged into the former, with scarcely any appreciable interval betAveen the two. So far as 1 Op. cit. 32 ANATOMY AND PHYSIOLOGY. the expiratory movement is readily appreciable, it appears to be con- siderably shorter than the inspiratory, and an interval of some dura- tion 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 recurrence of the act of inspiration, unless restrained by a voluntary effort. This is illustrated sometimes in cases of catarrh or mild bronchitis, in which a laryngeal rdle accompanies the entire act of expiration, the lungs not being affected so as to cease to represent the amount of collapse which takes place in health. As indicated by the continu- ance of this rdle, the expiratory movement is prolonged, almost, or even quite, to the subsequent act of inspiration. 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. Dr. Walshe estimates the interval between the end of one expiration and the beginning of the next inspiration, at one-tenth of the period occupied 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 Dr. 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 be- comes relatively lengthened. Neither the inspiratory nor the expiratory act is performed with a uniform degree of rapidity. The inspiration is at first slow becomes 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 in character which dis- tinguish the expiratory from the inspiratory sound, as determined by auscultation 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 THE THORACIC PARIETES. 33 cases of obstruction seated in the larynx, or other parts of the air- 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 involun- tary acts of respiration. The writer has called attention to the importance of this change in the rhythm of respiration in cases of continued fever, which will be found to precede often, in that disease, the occurrence of sudden coma.1 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 particular. The limits of variation in 994 cases in which the circumference was ascer- tained by Mr. Hutchinson, were from 30 to 40J inches. Dr. Walshe fixes the average size at about 33 inches ; but the normal de- viations 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 re- searches of Mr. Hutchinson show that the breathing capacity of the lungs dependent on the movements of the chest, bears no constant proportion to its size. Formerly it was supposed that contracted dimensions of the chest gave rise to 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 disease, is derived from this source. In determining variations in the size of the chest, either by measurement, or by the eye, with reference 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 individual is a matter of minor importance. 1 Clinical Reports on Continued Fever, etc., 1852. 3 34 ANATOMY AND PHYSIOLOGY. II. Pulmonary Organs. The lungs are the light spongy bodies contained within the chest, in which are effected the blood-changes constituting the function of haematosis. These organs are double, consisting of the right and left lung, each occupying a lateral half of the cavity 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 mem- branes 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 encloses the remnant of the thymus gland; approximating, and becoming united, they again separate, forming the middle mediastinum, which contains the pericardial membrane enclosing the heart; and by a third separation is formed the poste- rior mediastinum, through which pass the descending aorta, thoracic duct, etc. The portion of this membrane investing the lungs is called the pulmonic or visceral pleura; and that lining the walls of the chest, the costal or parietal pleura. A third portion, forming a cover- ing for the floor of the thoracic cavity—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 pleurisy, and hydro-thorax, 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, and than that covering the dia- phragm. The areolar tissue uniting the membrane to the parts PULMONARY ORGANS. 35 which it invests, called the subserous areolar tissue, is more abun- dant and looser in the former situation, and, consequently, the serous membrane is more easily detached from the walls of the chest than from the surface of the lungs. This, probably, explains a fact pertaining to inflammation of the pleura, viz., that the inflammatory action is more intense, and the products of inflammation are found to be 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 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. But there is another reason for the latter disparity. 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 irregularly triangular 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, about two inches; and horizontally, from the centre of the sternum, it extends about two and a half inches to the left. Overlapped by the lung, the heart extends still farther into the thoracic space, viz., ver- tically, from the third to the sixth costal cartilages; and, trans- versely, 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, notwithstanding, measured in a perpendicular direction, it is longer than the right lung. The right lung exceeds the left in weight as well as in volume. 36 anatomy and physiology. When free from disease, or the effects of disease, the lung is de- void of any direct connection with the surrounding parts, excepting the point at which it is connected with the bronchia, the blood- vessels, lymphatics, and nerves which enter it to communicate, severally, with corresponding structures forming portions of the pulmonary organs. United by areolar tissue, including lymphatic glands, and enclosed 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, or adherent, to a greater or less extent (as is very frequently the fact), in conse- quence of morbid attachments. In its situation, the root of the lung is about equidistant between the base and apex. The upper extremity of the lung, or apex, extends above the cavity of the chest, forming a blunted point, rising an inch and a half higher than the first rib. The latter fact is involved in the determination of tuberculous disease, or phthisis, in its incipient stage; that affec- tion generally attacking, primarily, the superior extremity of the lung on one side. 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 right 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 refer- ence to the diseases, which are to be subsequently considered, to note the situation of the fissures dividing the lungs into lobes, as indicated by corresponding imaginary lines on the exterior 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 pulmonary organs. 37 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 upper lobes passes from the fourth cartilage in a direction upward and outward, for a distance varying considerably in different individuals. It fol- lows 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, in the adult, is limited to the lower lobe. Inattention to this point may lead the medical practitioner to overlook that disease, limiting his examination to the anterior portion of the chest in cases in which the evidences of its existence are sufficiently apparent posteriorly. The interlobar fissure, according to Rokitansky, becomes changed in its direction by the affection called emphysema seated in the upper lobe, tending under these circumstances to a vertical line. 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 develope numerous points which are to be taken into account in studying their diseases. In addition to bloodvessels, nerves, and lymphatics, which are common to most of the important organs of the body, the lungs are composed of the divisions and subdivisions of the bronchice or the bronchial tube3, and the air-cells or vesicles. These, combined, give to the lungs their distinctive traits of structure. The bronchi, after penetrating the lung, divide and subdivide in all directions, the divi- sions 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, 38 anatomy and physiology. 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 pre- sent a great number of polygonal figures, indicated by dark lines. These lines, most marked in the adult, are the boundaries of the lobules, and the dark color is owing to pigmentary matter deposited in the interlobular areolar tissue. These lobulated divisions are very irregular both in form and size. As regards the latter, they vary from a quarter of an inch, to an inch in diameter (Kblliker). Dif- ferent lobules, although in juxtaposition, have not, as already stated, any direct communication with each other. This is demonstrated by the following experiment. If a blowpipe be introduced beneath the pleural covering 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 young subject, and espe- cially from the foetus, the different lobules may be separated from each other. They are then found to be quite distinct, being con- nected only by the minute bronchial tubes, called the lobular bronchial tubes, together with bloodvessels, nerves, and lymphatics. The different lobules of a lobe, thus separated, but attached to the branches of the bronchice, 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. Considered individually, each lobule is composed of the minute terminal branches of the lobular bronchial tube, which are sometimes called the PULMONARY organs. 39 bronchioles, in other words the capillary bronchial tubes, the air-cells, the vessels, and nerves,—these several anatomical constituents being supported and united by areolar tissue. This subdivision of the lobes into lobules is exemplified in a form of pneumonitis (inflammation of the lungs) peculiar to children, called lobular, in distinction from lobar pneumonitis. In this variety, lobules in different parts of both lungs are attacked separately, the disease being in this way disseminated more or less. Collapse of lobules, in greater or less numbers, may also occur as a consequence of obstruction of their lobular bronchial tubes, of a nature permitting the egress of air from the cells with expiration, and preventing its ingress with inspiration. Owing to feebleness, or other causes, it has been ascertained that 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 unfrequently, there is reason to suppose, 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,1 " 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 pheno- mena of disease. The areolar tissue forming the interlobular septa is the seat of the very rare form of emphysema of the lungs called interlobular emphysema, 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 surface of the lung, elevating the membrane in the form of a bleb. This is another form of emphysema. The form of that affection, however, which exists in the vast majority of cases, consists in Anatomy. 40 anatomy and physiology. enlargement of the air-cells, or vesicles, either by coalescence or dilatation. 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 and severally, end in double divisions, and with this rapid mul- tiplication in number there is a corresponding diminution in size, down to the minute lobular bronchial tubes, which, after penetrating the lobules, subdivide into the terminal branches,—the bronchioles, or bronchial capillaries.1 In referring to different sets of the bronchial tubes as the seats of disease, 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 un- striped, 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, manifestly, to propel, and thus assist in the removal, by ex- pectoration, of the secretions furnished by the mucous follicles in health and disease, as well as various morbid products formed within 1 Called by Mr. Rainey.the "intercellular passages." (Trans. Royal Med. and Chir Society, 1845.) PULMONARY ORGANS. 41 or poured into the tubes. This membrane is the seat of inflamma- tion in ordinary bronchitis, and of irritation in pulmonary catarrh. The smaller bronchial tubes present marked changes. The fibrous membrane, forming their basis, becomes thinner and thinner as the tubes diminish in size ; the cartilaginous plates are less and less numerous; the mucous membrane is more and more attenuated, and, at length, when the calibre of the tubes is reduced to about a twen- tieth 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, ramifying within the lobules, the ultimate bronchia termi- nating in the air-cells, as respects size, are truly capillary, having a diameter varying from one-fifteenth to one-thirtieth of an inch. These capillary tubes present still more important changes in struc- ture. The membrane constituting their walls is exceedingly thin, and its inner surface does not present epithelium, cylindrical and ciliated, but it is that variety called indifferently squamous, tes- sellated, or pavement epithelium. The pulmonary capillaries, in fact, lose the characters which belong to the bronchial tubes, and assume the structure of the air-cells, with which they are imme- diately connected. The anatomical changes which thus characterize different 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 differences 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 bronchia, 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 42 anatomy and physiology. 2&0 to Vu °f an incn< After birth they are never free from air, and their size will depend on their degree of distension, this being, of course, considerably greater after an act of inspiration than after expiration. They are attached to the extremities, and also along the sides of the terminal branches of the bronchioles, or capillary bronchial tubes, with which they communicate by free openings. Microscopical observers have differed as to the existence of direct lateral communications between the cells. According to the best authorities, they do not communicate with each other, except indi- rectly, through the bronchioles, or capillary bronchial tubes. Their connection, however, with the latter is such that, although not direct, the communication 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. It is stated that the air-cells are larger toward the surface of the lung, and also toward the edges, than in the inte- rior. Their size increases with age, and they are smaller in females than in males. Their walls possess much strength, shown by their not being easily ruptured by artificial inflation. The air-cells are surrounded by yellow elastic fibres, which 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 walls of the cells. Here, also, commence the various radicles and branches which pursuing a retrograde course, like that of the arteries, collect the oxygenated blood and convey it to the left auricle. The blood within the capillary meshes surrounding the cells is brought into suf- ficient proximity to the air contained in the latter, for that inter- change of principles to take place, by endosmosis and exosmosis which is concerned in hsematosis. 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 pneumonitis. Abnormal distension of the cells and capillary tubes, with or without PULMONARY organs. 43 atrophy and consequent destruction of more or less of the walls, giving rise to coalescence, constitutes the lesion in emphysema of the lungs, in the form in which it usually occurs. It will be seen hereafter 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 expansion of the lungs is attended by a certain amount of movement of the two pleural surfaces (the pulmonic and costal) remaining in contact, upon each other. This takes place especially at the inferior portion of the chest. As a provision against any injurious effects of the friction incident to this movement, which must involve a considerable degree of force, the free surfaces of the pleura are remarkably smooth, polished, and kept moist by the pre- sence 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 rendered rough or irregular by morbid products. The gliding movements are, under these circum- stances, 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 must be 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 pleurae are universally adherent in consequence of general 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. Hutch- inson has given an account of a case in which 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 is constantly fluctuating within certain limits. It is difficult to determine these limits with exactitude, but in its pathological bearings this is not 44 ANATOMY and physiology. a 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 [vide supra). Owing to the control which the will can exert over the breathing movements, much will depend on the influence of volition. Mr. John 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 experiments it is evident do not enable us to de- termine the quantity of air received and expelled in habitual respira- tion, 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 different individuals, remains after the most forcible act of expiration. Nevertheless the results obtained by Mr. Hutchinson are interesting. The vital capacity, in the sense in which this expression is used by Mr. H., is a constant quantity in each indi- vidual ; 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 occupations supposed to be in good health, Mr. H. 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 additional cubic inches of air at 60° are given out by a forced expiration." The reason for this relation to height Mr. H. confesses his inability to give. The fact, of course, involves the existence of some circum- stances pertaining to the conformation or movements of the chest which enables individuals in proportion to their height to increase' and diminish, with the alternate respiratory acts, the amplitude of the chest. In other words, the vital capacity is another name for pulmonary organs. 45 the breathing capacity, dependent on the extent to which the chest may be expanded with the act of inspiration, and contracted with the act of expiration. Dr. Hodgkin attributes it to the " increased length of the dorsal portion of the spinal column." Dr. Sibson offers as an additional reason the greater length and obliquity of the ribs in proportion to the stature, a fact which gives to a narrow-chested tall man a greater range of motion, and consequent breathing capa- city, 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 indivi- duals. Mr. 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 sus- pected. 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 disease. This must be the case if even slight fatigue of the respi- ratory 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 Dr. Wm. 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 healthy1 limits is very great, and also the fact, that even when presumptive evidence of thoracic disease is afforded, it gives no information respecting the nature or seat of the affection, will probably 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 5 ft. 10$ inches, it amounted to 202\ cubic, inches. 46 anatomy and physiology. III. Trachea, Bronchi, and Larynx. The trachea, bronchi, and larynx, are separate portions of the canal, or tube leading from the pharynx to the lungs, trasversed by the air in its passage to and from the latter organs. The larynx in addition contains the organs which chiefly compose the vocal ap- paratus. The three divisions require separate consideration. Trachea.—This portion of the tube extends from opposite the fifth cervical to the third dorsal vertebrse. It pursues a vertical direction, from the larynx to the point last mentioned, where it ends by dividing to form the two bronchi. According to Cruveilhier, 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 car- tilages 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 interspaces between the rings. By the contraction of these muscular fibres the walls of the trachea may be rendered tense, and its calibre diminished; 3d, areolar tissue, forming here, as elsewhere the medium of the union of the different 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 lym- phatic vessels and numerous lymphatic glands. The latter are liable to become enlarged by \lisease, 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 obstruc- tion 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 con- stant 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 catarrhal and inflammatory affections, which frequently proceed from the larynx downward to the bronchial tubes; and in that peculiar form of inflammation characterizing the infantile disease called croup, the exudation of lymph often extends below the larynx, sometimes descending to more or less of the bronchial subdivisions. Bronchi.—The portion of the air-passages situated below the trachea, and exterior to the lungs, consists of the bronchi. Certain anatomical points pertaining to the size and disposition of these tubes, possess considerable importance in their supposed relations to dif- ferences between the two sides of the chest, in the respiratory sounds heard in health and disease, to which reference will be made here- after. The lower part of the trachea is contained within the chest, passing behind the upper bone of the sternum, until it reaches the fourth dorsal vertebra, when it bifurcates, forming the right and the 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 diame- ter 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 some- what longer than the upper. In size or calibre the two bronchi united exceed the trachea, as the aggregate of the bronchial ramifi- cations within the lungs is greater, in this respect, than that of the bronchi; " so that the velocity of the expired air increases as it ap- proaches the exterior."1 The bronchi, like the trachea, are surrounded by numerous lymphatic glands, called the bronchial glands, and this is the case also with the bronchial ramifications within the lungs themselves. Enlargement of these glands occurs in bronchitis, in typhoid fever, scrofula and tuberculosis, pressing on 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 even producing obstruction, partial or complete, to the transmis- sion of air to the bronchial subdivisions and air-cells. The bronchi exterior to the lungs are rarely, if ever, the seat of disease not affecting, at the same time, the air-passages, either above or below. Foreign bodies introduced through the larynx, however, 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 suffocation, or from the effects of protracted irritation. The statistical researches of Prof. Gross, of the University of Louisville, 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 Mr. Goodall, of Dublin, to the presence of a spur, or ridge, which Prof. G. calls the bronchial septum, projecting upward within the trachea at the point of its bifurcation. This septum is situated not 1 Cruveilhier. LARYNX. 49 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.1 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 apparatus for the production of the voice. To describe the several parts enter- ing into its composition, and their respective offices, would involve details needless so far as concerns the general object of this introduc- tion. For these the reader is referred to treatises on anatomy and physiology. Certain anatomical and physiological points only will be noticed which are of special importance in their bearings on the study of 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 several 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 with- out and within its cavity. In this respect it differs from the other portions of the air-tube, which may be compressed or dilated by a moderate amount of mechanical force. This anatomical 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 deposit of certain morbid pro- ducts in this situation. It is owing to the circumstances just stated that some diseases of the larynx involve serious embarrassment of respiration, and frequently end fatally by inducing asphyxia. In- stances of this kind are exudative or true croup, acute laryngitis with submucous infiltration, and oedema glottidis. 1 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 AND PHYSIOLOGY. 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 triangu- lar 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, constituting the affection known as oedema glottidis. The areolar tissue uniting the mucous membrane to the subjacent structure, 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 inspira- tion, producing obstruction to respiration manifested in the inspira- tory 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 there- fore be determined by the touch, rendering the diagnosis of oedema glottidis2, positive. This accessibility also renders relief practicable, in a large proportion of cases, by resorting to incisions, or scarifica- tions with an appropriate surgical instrument, after the method prac- tised with signal success in a number of cases by Dr. Gurdon Buck,3 of New York; a method of treatment entitled to be ranked among the most valuable of the modern improvements of medical practice. It is an interesting fact that the loose attachment of the mucous membrane at the superior aperture of the larynx which exists in adults, does not obtain in children. In them, the membrane is closely connected with the parts beneath. Hence, oedema glottidis is not a disease affecting children, but occurs only after adult age. 1 This space is designated, by Prof. Palmer, of the University of Louisville the oval fossa of the larynx. 2 Incorrectly called oedema glottidis, inasmuch as the oedema is situated above not at the glottis. 3 See Transactions of the American Medical Association, Vols. I. and IY. LARYNX. 51 2. Glottis.—The portion of the larynx called the glottis, is that bounded by the chordce vocates, or vocal chords. The anatomical conformation at 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, sometimes become lodged. By the vocal chords the larynx is greatly narrowed at the glottis. Yiewed in the dead subject, the chords diverge from the point of their junction an- teriorly, 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 situation 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- stantly varying in consequence of movements connected with the use of the voice, and also with the acts of respiration. In speaking and 52 ANATOMY AND PHYSIOLOGY. singing the diversities in the tones of the voice are mainly due to different degrees of approximation and tension of the chords, pro- duced by the action of muscles attached to the arytenoid cartilages. The movements involved in vocalization, according to the recent re- searches of M. Claude Bernard,1 are governed by influences trans- mitted exclusively through the spinal accessory nerve. Paralysis of the arytenoid muscles, so far as they are concerned in phonation, is the result of destroying this nerve, the respiratory movements re- maining unaffected. Thus, if the nerve be destroyed in a rabbit, the breathing continues undisturbed, but the animal is unable to utter a cry when hurt.2 This physiological discovery is interesting, 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 thus become important diagnostic symptoms. Thus in simple inflammation, or even laryn- geal catarrh, as well as in croup, the voice is hoarse and may be temporarily lost; ulceration 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 that with ordinary respiration an alter- nate separation and approximation of the vocal chords take place, accompanying the two acts, inspiration and expiration, appears to have been but very recently ascertained. The interesting and im- portant function referred to, giving rise to what are called the "respiratory movements of the glottis," is fully established by expe- riments made on living animals by Prof. John C. Dalton Jr. of New York, the results of which he has reported for the American Journal of Medical Sciences, July, 1854. A dog being completely etherized, the common carotid artery on one side tied, and a dissec- 1 Recherches expfirimentales sur les fonctions du nerf spinal, ou accessoire de Willis par M. Claude Bernard. Paris, 1851. 2 The writer witnessed this experiment, made by M. Bernard, during the summer of 1854. LARYNX. 53 tion made so as to bring into view the glottis, there is found to take place " during normal respiration, a constant and regular movement of the vocal chords, by which the size of the glottis is alternately enlarged and diminished, synchronous with the inspiratory and expi- ratory movements of the chest." These movements are altogether 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, the dilatation being more marked when the breathing is hurried or forced, and on the other hand, marked contraction taking place when the animal whines or cries. These variations as respects the approximation of the vocal chords with the two respiratory acts, and with different respirations, pro- bably 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 laryngis- mus stridulus of children, and occasionally in adults, interfering with inspiration, and occasioning distress in proportion to the degree of obstruction from the narrowing of the orifice of the glottis, and, pos- sibly, proving fatal. The respiratory movements of the glottis are under the control of the recurrent or inferior laryngeal nerves. When these nerves are divided, the glottis remains immovable, neither dilating nor con- tracting. 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 Space.—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 claim a sepa- rate 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, technically called regions. These divisions, although wholly arbitrary and conventional, are extremely convenient, and the student before entering on the study of diseases affecting the respiratory ap- paratus, should make himself familiar, not only with their number, names, and boundaries, but with their anatomical relations respec- tively to the intra-thoracic organs. To these preliminary points this section will be devoted. In determining these topographical sections, the sole end being convenience, simplicity, of course, is to be consulted as much as possible. The number of regions should not be needlessly multiplied. The boundary lines, to be recollected and readily ascertained, should be not entirely artificial, but based, so far as practicable, on natural anatomical divisions. And there is an obvious advantage in desig- nating 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. In many instances it suffices to divide these surfaces into a few fractional parts, after the plan proposed by M. Louis, and followed by other writers. 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 topographical divisions of the chest. 55 the interspace between the fourth and fifth ribs. The lower third is the portion of the chest below the line just mentioned. Posterior Surface.—The upper third comprises the portion 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 localities more circum- scribed than the foregoing divisions. Hence it becomes necessary to subdivide more minutely, into what are more properly termed regions, than the fractional sections already mentioned. The regional subdi- visions which are generally adopted are the following: Anterior Region, a. Post-clavicular, or supra-clavicular.—The space above the clavicle, situated over the projecting portion of the apex of the lung. b. Clavicular.—The space occupied by the cla- vicle, 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 anteriorly occupied by the sternum is divided into a, the upper, and b, 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 Region, 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, b. 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 double. Lateral Region, a. Axillary.—Extending from the highest point in the axilla to a transverse line continuous with the lower 56 ANATOMY AND PHYSIOLOGY. boundary of the mammary region, b. Infra-axillary.—Extending from the axillary region to the lower limit of the chest.1 The relations of these regions, severally, to the organs contained within the chest, are important to be premised. Supposing the divi- sions to be not confined to the surface, but extended to the centre of the chest, what anatomical parts would each section contain ? 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 Region. 1. Supra or Post-clavicular.—Beneath this region lies but a small portion of lung, viz., that part of the apex which projects above the chest, rising 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 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 bronchi, after the bifurcation of the trachea, situated exterior to the pulmonary substance, are also contained in this sec- 1 In designating the limits of the different regions, the author has followed Walshe The divisions and boundaries, however, are essentially those found in other and prior works. anterior region. 57 tion. "The bifurcation takes place on a level with the second rib. From this point the bronchi on the two sides diverge, pursuing direc- tions 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, which are to be studied in this region; and owing to anatomical differences in the bronchi of the two sides, which have been noticed in Section First, it will be seen hereafter that a natural disparity 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 differ. 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 praecordia. Over a triangular space extending from the sternum into the left mammary region, the heart is in contact with the walls of the chest. This triangle 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, i. 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, occa- sions important modifications of the phenomena determined by percussion and auscultation, and disturbs that equality between the right and left mammary regions, as respects the physical signs inci- dent to health, which generally characterizes corresponding localities 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 58 anatomy and physiology. which the over-distended lung covers the heart entirely, or crowding it from its natural situation occupies its place in the praecordia. The impulse produced by the striking of the heart's apex against the walls of the chest falls within the left mammary region. Normally this impulse is seen and felt between the fifth and sixth ribs, about midway between a vertical line passing through the nipple, and another coincident with the left margin of the sternum. The position 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 pleurisy 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 be- comes an important diagnostic sign of pulmonary 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 different persons. The fissure between the middle and lower lobes commences a short distance below, and extends in a similar direction. The portion 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 mammary 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 accounts for certain modifications of phenomena developed by physical exploration. 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 a greater or less extent, with physical explora- tion in this region. anterior region. 59 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, is the liver, covered with the diaphragm. The phenomena determined by physical exploration in health, are quite different from those in other regions including pulmonary substance. These phenomena are some- times attributed to disease by 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 portions of the stomach, spleen, and left lobe of the liver, but the relative proportion of the different parts lying within the limits of the region varies considerably in dif- ferent 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 with gas, oc- casions marked diversities in the phenomena determined by physical exploration of the left infra-mammary 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 respiration developed within the trachea. 7. Upper Sternal.—Beneath the upper 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 bronchial divisions. 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. 60 ANATOMY AND PHYSIOLOGY. II. Posterior Region. 1. Scapular.—The scapula is situated over the superior and pos- terior 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. This region is subdivided into the upper and lower sca- pular ; 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 mammary 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 be- tween 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 affecting (as is usual) the lower lobe in the adult (lobar pneumonitis) 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 lateral region. 61 respiratory sounds developed within the primary bronchi, a matter of interest and importance, as will be seen hereafter. 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 uninte- resting ; 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 dead. By marking with India-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 pictures or diagrams. III. Lateral Region. 1. Axillary.—A section corresponding to the boundaries of this region would contain a portion of the upper lobe of the lungs, with large bronchial tubes. 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. \ PART I. PHYSICAL EXPLORATION OF THE CHEST. PART I. PHYSICAL EXPLORATION OF THE CHEST. CHAPTER I. DEFINITIONS—DIFFERENT METHODS OF EXPLORATION- GENERAL REMARKS. Physical exploration of the chest is the examination of this region by means of certain methods involving principles of physical science, with a view to determine the existence or non-existence, the nature and the situation, of intra-thoracic disease. Limiting attention to the respiratory organs, various changes in their physical conditions are incident to the different diseases to which they are liable. Among these changes, the study of which belongs to morbid ana- tomy, are increased and diminished density of the pulmonary organs; loss of substance, leaving cavities; dilatation or contraction of the air-tubes; reduction in volume and displacement from the presence of liquid in the serous-sacs, etc. Owing to the conformation of the chest, the elasticity of its walls, and the movements which they un- dergo, in connection with the peculiarities in structure of the con- tained organs, air being constantly present, and in motion to and fro with the acts of respiration, the changes just referred to give rise to certain phenomena appreciable by the senses, and these phenomena are distinguished as the physical signs of disease. The discrimina- tion of diseases, so far as these signs are concerned, constitutes phy- sical 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 any deviations from the sounds which are elicited by this process in a condition of health. This method is called per- cussion. 66 physical exploration of the chest. 2. Listening, with the ear applied directly to the chest, or through , a conducting instrument, to discover morbid sounds produced by the movements of the air in respiration, or by the acts of speaking and coughing. This method is called auscultation. 3. Examining the chest with the eye, to see if there are any changes in form or symmetry, and if the visible motions are natural. This method is called inspection. 4. Applying the hand to the chest, to ascertain whether any ab- normal sensations are appreciable by touch, due to the movements of respiration, and more especially the act of speaking. This method is called palpation. 5. Measuring the chest, or parts of the chest, by means of a tape, or graduated measure, 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 styled rational, vital, or physiological symptoms. Each of these epithets, as con- trasted with the term physical, has a certain significance. But the two last are more appropriate than the first, which implies an error, to be noticed presently. The words signs and symptoms, are often used without any adjective, the first to denote the physical and the second the vital or physiological phenomena of disease. It is conve- nient thus to employ these simple terms, and there can be no objection to attaching to each the distinctive sense just mentioned, in conformity with conventional 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, therefore, it may be true that the study of acoustics will be likely to 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 a common impression with those ignorant of the subject, that DEFINITIONS. 67 the signs generally represent uniform and definite morbid conditions ; in other words, that each sign possesses its own special significance; and, therefore, for the practice of physical exploration, that it is simply necessary to be able to recognize and appreciate certain abnormal sounds. According to this view, physical exploration is merely a mechanical art. This is implied when symptoms, as distinguished from signs, are called rational. The inference is, that to determine the value of signs, processes of reasoning are not required: that they express in themselves their full import, and that the ability to discri- minate different diseases thereby depends mainly on manual tact and the cultivation of the senses. The student should, as soon as possi- ble, dispossess the mind of this error. Few signs, individually, are pathognomonic. Their diagnostic signification depends on their com- bination with other signs, and on their connection with symptoms. Hence, something more than delicacy of hearing and skilful mani- pulation is requisite. Thought and the exercise of judgment are needed, not less than in determining the nature and seat of diseases by their vital phenomena. In short, physical exploration developes a series of facts which are to be made the subjects of ratiocination in their applications 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 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 symptoms, 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 affec- tions 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 prac- titioners who rely exclusively on symptoms, which might be easily 68 physical exploration of the chest. avoided by resorting to physical signs. It may not be amiss to cite some illustrations from instances that have fallen under my own observation. Examples of confounding the three affections just named are sufficiently common. Of these affections, pneumonitis and pleuritis are not unfrequently latent, so far as distinctive vital phe- nomena are concerned, and consequently are overlooked. Chronic pleurisy 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 ascertained.1 Yet nothing is more simple than to determine the existence of this affection by an exploration of the chest. Acute pleuritis and pneumonitis are some- times completely masked by the symptoms of other associated affec- tions, and thus escape detection. This is observed in fevers, and when head symptoms become developed, 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 exist- ence. Emphysema is an affection 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 affections erroneously considered to be phthisis, and a still greater number 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 advantages 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 difficulties and liabilities to error arising from ignorance, deception, self delusion, disposition to exaggeration, or desire of concealment, which belong to subjective symptoms. They are available in children too young to give infor- mation respecting their diseases ; in cases of mental derangement, and in the condition of coma. The evidence which they afford of morbid conditions is more positive than that furnished by symptoms. Fre- 1 Vide. Clinical Report on Chronic Pleurisy, by the author. GENERAL RE MARKS. 69 quently in attempting to arrive at a diagnosis by means of the latter, we can only reach an approximation to certainty. In forming con- clusions we are obliged to balance probabilities. This uncertainty, of course, influences the management of disease. But the informa- tion 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 demonstrative, 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 consequence 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 gratification greater than that which he derives from clini- cal 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 exclu- sion of the other. They are not to be disconnected save for abstract consideration. 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 exploration, 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 appa- ratus, it is employed by only a small proportion of medical practi- tioners. Some even now profess to attach but little value to signs; a much larger number practically repudiate them. This fact, how- ever, may be stated, viz., no one who has devoted sufficient attention to the subject to apply successfully the well-established rules of phy- sical diagnosis at the bedside, has ever denied having received great assistance therefrom, or advocated a neglect of them. They who de- preciate and forego the benefits of physical methods of examination, have had little or no experience of their practical application. If 70 PHYSICAL EXPLORATION OF THE CHEST. 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 distin- guish nice shades of difference in sounds ; and in addition to this, extraordinary application and opportunities are supposed to be indis- pensable. The pursuit is generally regarded as extremely compli- cated, requiring an experienced teacher and a large hospital, to be prosecuted with success. These ideas do great injustice to the sub- ject. So far as the more important diagnostic principles are con- cerned, both in their apprehension and application, they are exceed- ingly simple. The points which are abstruse or intricate, as a general remark, are those which are of the least practical consequence. Oral instruction 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 I venture to assert with positiveness, that these advantages, although desirable, are not essen- tial ; and that an intelligent student or practitioner, solely with the aid of books, and with opportunities for observation which may be enjoyed in every village, may, by means of a very moderate amount of exertion, acquire a practical knowledge of physical signs sufficient for ordinary purposes of diagnosis.1 A tithe of the time so often occupied by medical students in becom- ing very indifferent performers on some musical instrument, would 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 qualifications; 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 two 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 opportunities, I desire to express the conviction that, without them, a proficiency sufficient for discrimination in a large proportion of the cases occurring in medical practice, is attainable. GENERAL REMARKS. 71 aspects. The first and more important is the significance and value which belong to them separately and in combination. What are the abnormal conditions which they represent? This question covers all that pertains to the practice of physical diagnosis. In a practical treatise, therefore, 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 our knowledge of signs, as the re- presentatives of morbid changes, obtained? Physical phenomena become signs of disease whenever it is established that there exists a constancy of association of these phenomena with the physical alterations which disease induces. Being uniformly found together, a connection between the two is logically proved, so that the for- mer may be regarded as the indices of the latter. This is the basis of the science of physical exploration. And this constancy of association is determined by clinical observations together with the information derived from post-mortem examinations. Certain sen- sible phenomena 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, whenever certain morbid conditions are ascertained to exist prior to death, we look for the physical phenomena, or signs, which previous observations have shown to coexist with them. In short, the evidence of the value and signifi- cance 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 researches in this direction. Many questions of practical interest and impor- tance are open for investigation by means of the analysis of recorded observation in the living and dead subject. The application of the numerical method to the study of physical signs, so far from having been completed, has hardly been as yet commenced. Much is to be expected from this source which will give greater precision to our knowledge, as well as enlarge its boundaries. Another point pertain- ing to the cultivation of this pursuit, the importance of which does not appear to have been sufficiently appreciated, may be here noticed. I refer to careful and systematic explorations of the healthy chest. The results of such examinations constitute, of course, the point of departure for determining the phenomena of disease. In this way 72 PHYSICAL EXPLORATION OF THE CHEST. only are to be ascertained variations from the phenomena usually observed, which are liable to take place irrespective of disease, i. e. within the limits of health. In subsequent chapters will be adduced results obtained by an analysis of a series of explorations made in subjects presumed to be entirely healthy, the phenomena being recorded at the moment of observation. These researches might be extended with advantage. Our knowledge of healthy physical signs is not yet complete, and in proportion as it is defective are we liable to error in judging of the signs of disease. A second 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 phenomena 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 merely artificial contrivances, in order to imitate the sounds which characterize certain signs, or to prove the correctness of certain hypoy thetical explanations, are to be'received with a certain amount of dis- trust, for it is almost impossible to ascertain and reproduce all the phy- sical elements which are combined in the living body. There is reason to believe that this attempt has given rise to false views, to which re- ference 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 afford 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 experience. In entering on the study of physical exploration the first object should be to become acquainted with the ascertained facts and general principles pertaining to the subject. It is sometimes advised that the student should at once commence clinical observations with- out any previous acquaintance with the signs which characterize disease. This is to place him in the position of the original explorers without, it may be presumed 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. Certain practical points have been GENERAL REMARKS. 73 established. These are to be understood by resorting to oral instruc- tion or books, and as fast as practicable they are to be verified by actual observation. The latter is rendered less difficult by the fact, as will be seen hereafter, that a large share of the signs of disease are exemplified in the living healthy subject. The signs developed by the different methods of exploration are to be studied singly and combined. Isolated from the others, the knowledge per- taining to each has relation to its sensible characters, the manner in which it is developed, its significance and diagnostic value, and the probable explanation of the mode of its production. 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 arrive at positive conclu- sions as to the nature, seat, or stage of diseases. Were it necessary to rely exclusively on the special significance of individual signs, the application of the results of physical exploration to diagnosis would be much more limited than it is. By uniting the information derived from the different methods of examination, its scope is greatly en- larged. Moreover, in determining the existence of individual signs, our observations are rendered positive, or otherwise, by reference to their combinations. The mutual relations, therefore, 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 analogous to syntax. A know- ledge of both is necessary in order to interpret correctly the physical expression of disease. For the successful practice of physical exploration the facts and principles pertaining 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 authori- ties, 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 prac- tise physical exploration, must have noticed that after an inter- mission in its employment for some time, the usual facility and quick- ness in arriving at satisfactory results is temporarily somewhat im- paired. 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. 74 PHYSICAL EXPLORATION OF THE CHEST. In treating of the principles and practice of physical exploration in the following pages, the aim will be to present facts and conside- rations 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 refe- rence 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, also, because my own studies have been chiefly confined to clinical observations. CHAPTER II. PERCUSSION. 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 certain degree and kind of sonorousness is produced when strokes are made in a manner to elicit sound; and various changes in these physical con- ditions incident to disease, occasion corresponding deviations 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. For obvious reasons this mode is objectionable, and is now nearly obsolete. Shortly after the more recent discoveries by Laennec, which served at once vastly to enhance the importance of the method of explora- tion under present consideration, mediate percussion, as it is termed, was employed by M. 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 & pleximeter. The plexi- meter 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 up- right 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 often useful in determining accurately spaces and distances on the chest. Piorry's pleximeter is generally employed in the Parisian hospitals, and to a considerable extent in other countries than France. Other substances have been recommended. A square block of caoutchouc forms a con- venient pleximeter, and is preferred by M. Louis and some others. A circular piece of sole leather, H inches in diameter, fixed in a steel stirrup, so as to be movable on a point connecting the extremities of the 76 PHYSICAL EXPLORATION OF THE CHEST. stirrup; a handle, constructed of wood and steel, attached to the head of the stirrup, the whole eight inches long, devised by Dr. I. Burne, of Ireland, I have found to answer the purpose satisfactorily. Many, however, if not the majority of practitioners who practise physical ex- ploration, use, for the most part, simply the first or second finger of the left hand, the palmar surface being generally 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 applied over the ribs, and in the intercostal spaces. The force with which it is applied can be easily graduated. It renders the operation of percussion less formidable to the patient, and in cases of children especially, this is not a small advantage. It affords information as respects the sense of resistance, which it will be seen presently 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, inflamed from the repeated blows, continued daily, especially when forcible percussion is practised 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 purpose. The latter is termed a percussor. A variety of instruments for making percussion have been contrived. It will suffice to mention some of them, without entering into minute descriptions. A German practitioner, Dr. Winterlich, employs a small steel ham- mer, into which is inserted a piece of caoutchouc, the latter being brought into contact with the pleximeter in making the strokes. Dr. I. Hughes Bennett, of Edinburgh, gives to this instrument a decided preference over the fingers. A similar instrument accompanies the pleximeter of Dr. Burne, save that, instead of caoutchouc, a cone of leather is inserted into the head. Professor Trousseau, of Paris makes use of a slender rod of whalebone, to the extremity of which is fixed a conical piece of caoutchouc. In Dublin, a stethoscope with PERCUSSION. 77 an India-rubber rim surrounding the ear-piece is employed as a per- cussor. This originated with Dr. Marsh. Professor Bigelow, of Boston, recommends a ball of worsted, covered with velvet, to which a handle is attached. Most practitioners, however, are satisfied with one or more of the fingers of the right hand, bent in a half circle; which certainly, in most instances, answers all practical purposes. The mode of performing percussion is a point of practical impor- tance. 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 success depends on a tact to be perfected by practice. The fingers are to be flexed so that their ends shall fall perpendicularly on the pleximeter. 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 pleximeter and withdrawn as it were instantaneously, by a move- ment limited almost entirely to the wrist joint. When a light per- cussion 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 generally recommended to bring the three fingers together as compactly as possible, and support them with the thumb. I find it better to arrange the fingers on a line and percuss without bringing forward the thumb into apposition. With the thumb free, the movements at the wrist are unrestrained, 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 is resorted to in order to develope physical signs with the import of which the practitioner is practically familiar, or whether it be em- ployed merely for form's sake, or to affect an acquaintance with the subject. Rules of manipulation pertaining to the practice of per- cussion, in addition to the foregoing, will be given presently. A mode of practising percussion, involving, for certain purposes, an important improvement, was proposed some time since, by Dr. 78 PHYSICAL EXPLORATION OF THE CHEST. G. P. Cammann,1 and Prof. A. Clark, of New York. The peculia- rity of this mode consists in combining with percussion, another of the methods of exploration, viz., auscultation. Percussion is made with a pleximeter, while the ear is applied to a cylinder of wood, a stethoscope, placed in contact with the chest. This may be distin- guished as auscultatory percussion. Its advantages consist in the better transmission of the sonorous vibrations than when communi- cated through the intervention of the atmosphere, and in the greater distinctness with which differences in the pitch and quality of sounds are appreciated. It is particularly useful in determining the boun- daries 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 pur- poses, the other and simpler modes suffice. 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, first, the phenomena pertaining to health; and, second, those which are to be regarded as the physical signs of disease. Percussion in Health. Percussion made on certain parts of the chest of a person in health, for instance at the summit, in front, developes a resonance which is peculiar. The quality of sound is highly characteristic, and cannot be well described, or illustrated by comparison. This quality, or timbre, is due in a great measure 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 con- trast, 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 ap- preciated by percussing the chest, and afterward the abdomen, pro- vided the stomach or intestines are somewhat flatulent. In the latter instance the sonorousness arises from the presence of gas in a free space of considerable size. This species of resonance, in distinction from that due to the presence of air in the lungs, is called tym- panitic resonance. The same hollow quality of sound is elicited 1 New York Journal of Medicine, July, 1840. PERCUSSION IN HEALTH. 79 for reasons which will be presently mentioned, by percussing certain portions of the thorax in health; and it becomes also, as will be seen hereafter, under certain circumstances, a physical sign of disease. It is thus called in consequence of its type being the sound produced by percussing the abdomen distended by gas, in other words in a tym- panitic state. On the other hand, the sound peculiar to the chest may be distinguished as the pulmonary or vesicular resonance. The words pulmonary or vesicular, indicate the peculiar quality referred to. The latter, vesicular, is perhaps preferable, and I shall therefore employ it. In using the term, however, it is not to be understood that the character 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 distention of the vesicles by air. In addition to its peculiar quality, the vesicular resonance has a certain pitch, and in this respect, compared with most abnormal sounds, it is low or grave. The sound also has a certain duration and degree of intensity. As regards the sonorousness in the four aspects just mentioned, viz., vesicular quality, pitch, duration, and degree of intensity, percus- sion practised in the same manner on the chests of different persons in health, by no means developes identical results. This may be demon- strated by placing a number of persons in a row, and percussing their chests, severally, 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 vesicular quality, in pitch, in duration, and in the degree of intensity. This is owing to differences in the elasticity of the thoracic walls, in the volume of the pulmonary organs, in the amount of muscular and adipose tissues covering the chest, and other circumstances not so easily appreciated. Nor is the percussion sound the same over every portion of the chest in the same individual. In corresponding situations, on the two sides of the chest, however, with certain exceptions, the pheno- mena developed by percussion are usually considered to be identical, or nearly so. This is a very important rule in its bearing on physical exploration. It may be said to be of fundamental importance^ in estimating certain variations from the normal sounds constituting the physical signs of disease, inasmuch as the latter are often deter- mined not so much by reference to an ideal standard of health, as by comparison of one side of the chest with the other side. As respects normal resonance, equality of the two halves of the chest, with some 80 PHYSICAL EXPLORATION OF THE CHEST. exceptions is assumed. Were we not warranted in doing so to an extent sufficient for most practical purposes, it would sometimes be extremely difficult to decide whether or not the phenomena developed by percussion denoted disease; and the same is not less true of other methods of exploration than of percussion. But it is obviously im- portant to ascertain as completely as possible the deviations from this rule of equality, which may exist within the limits of health ; other- wise there is a liability that such deviations may be mistaken for the physical evidences of disease. As already intimated, there is room for investigations with reference to this point. In order to determine to what extent and in what particulars disparity between correspond- ing portions on the two sides may be compatible with health, exami- nations are to be made of the chests of persons, selected for that pur- pose, who are presumed to be entirely free from pulmonary disease; the phenomena must be carefully recorded, and a collection of facts thus obtained, subjected to analysis. I shall give, to some extent, results of such an investigation as regards percussion, and the other methods of exploration, the number of examinations not being large, but suffi- cient to establish certain deviations, and to illustrate the importance of a field of study which is by no means exhausted. We will now proceed to a comparison of the several regions of the chest on the two sides respectively.1 1. Post-Clavicular Region.2—Percussion in this situation gene- rally 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 somewhat tympanitic, and this quality predominates in proportion as the direc- tion of the percussion-strokes is toward the trachea. The resonance in this region is greater in females than in males. It is very difficult to apply above the clavicles the finger used as a pleximeter equally on the two sides; and if an ivory or other artificial instrument be employed, 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, 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 conformation of the chest. Deformi- ties of the chest, either congenital or resulting from disease, will, of course occasion dis- parity between the two sides in the phenomena developed by physical exploration as will be mentioned further on. 2 For the boundaries of the regions, see Introduction, Section II, page 54, et seq. PERCUSSION IN HEALTH. 81 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 dis- ease, 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, important 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 somewhat 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 sound becomes comparatively dull. Equal percussion can be made on the two sides in this region, without difficulty. A slight disparity, however, is not unfrequently appreciable in health, and when the chest appears to be symmetrical, owing, pro- bably, to some difference in the size and curves of the bone. A slight difference in these respects in well-formed chests, is sometimes appa- rent 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 corresponding variation in the percussion-sound of the two sides, either in the post-clavicular or infra-clavicular regions, or in both. 3. Infra-clavicular Region.—Percussion here elicits, gene- rally, 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 disparity in the percussion-sound, taken in connection with other signs, and with symptoms, is held to constitute strong evidence of a deposit of tubercle. With reference to the diagnosis of incipient phthisis, the deviations from the rule of equality at the summit of the chest, incident to health, are highly important to be taken into account. Of twenty examinations of persons apparently free from disease, and whose chests were symmetrical in conformation, in eight the percus- sion-sound was in all respects equal on the two sides, and in twelve, there existed disparity to a greater or less extent. The points of disparity noted were as follows. In ten, the degree of resonance was greater on one side than on the other. In all of these ten instances there existed a greater degree of resonance on the left side. In one instance, however, the resonance was greater on the right 6 82 PHYSICAL EXPLORATION OF THE CHEST. side, save at the portion near the sterno-clavicular junction; at this portion it was greater on the left side. In eleven instances, em- bracing all the ten persons just referred to, and one in addition, the pitch of resonance was somewhat higher on the right than on the left side.1 In one of these cases, the same mentioned above, the pitch was higher at the sterno-clavicular junction on the right and over the rest of the region on the left side. In four instances, it is noted that the vesicular quality of the resonance was greater on the left side, and in no instance was this observed on the right side. Pains were not taken to observe and note this point in all the examinations. The resonance was relatively tympanitic2 in its character on the right side in one instance, and in one, also, on the left side ; with respect to the duration of sound, observations were not made; the disparity in degree of resonance and pitch found in the majority of instances, was generally slight, but sufficient to be dis- tinctly appreciated on repeated careful percussion. It thus appears that in the majority of persons in health, having well-formed chests, there is not an absolute equality in the resonance existing at the summit of the chest in front on the two sides. It appears, also, that, as a general rule, the disparity consists in a greater degree of resonance, more vesicular quality, and, relatively, lowness of pitch, on the left side. The tympanitic quality is occasionally found on one side, which may be either the left or the right. The practical bearing of these facts will appear hereafter; the facts rest on obser- vation, and are independent of any explanation that may be offered. Theoretically, in view of the greater capacity of the right 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 disparity exists in cases in which there is no apparent difference in the muscular covering, in this 1 These results, as respects pitch, differ' very considerably from those obtained in twenty- two examinations made with reference to this point in 1852. (Prize Essay, by author,) In these twenty-two examinations dispaiity of pitch in this region was noted in two instances only. The ratio of instances in which points of disparity are presented would be expected to differ somewhat in different collections of cases, but so great a difference would not have been anticipated. I am disposed to explain it in part by the fact that the more recent examinations were made with a greater closeness of observation, in order to appreciate the slightest ctegree of disparity. 2 By the term tympanitic, I mean a non-vesicular sound, without reference to intensity. PERCUSSION IN HEALTH. 83 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 deaden the sound. On the left side below the lung is situated the stomach, frequently more or less distended with gas, and the effects of this, it may be supposed, is to increase the sonorousness on that side, even at the summit, independent of the transmission of the tympanitic gastric sound which is sometimes ob- served. 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 impor- tant region with reference to the physical signs of phthisis. The normal degree of resonance over the scapula is much less than at the summit in front, for sufficiently obvious reasons. The vesicular quality of resonance is less apparent. A distinct sonorousness, how- ever, exists here, notwithstanding the percussion has to be made on a layer of bone, and a mass of muscle placed upon it. These cir- cumstances do not deaden the sound sufficiently to render the region nearly or even quite unimportant in physical exploration, as stated in a recent work on diseases of the chest.1 On the contrary, percus- sion 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. In thirteen of twenty observations, relative to the comparative resonance in the scapular region, on the two sides of the chest, no disparity was apparent. In four of twenty observations, the reso- nance was less on the right than on the left side. In a single instance the resonance was greater on the right side. In the latter case there was tympanitic resonance in front and laterally. In three instances it was noted that the pitch of resonance was higher on the right side. In two instances this was true of the left side. In both the latter instances tympanitic resonance existed in front on the left side. In two instances the resonance was tympanitic over the left scapula, and in no instance was this noted of the right. Disparity between the two sides thus appears to be present in a less proportion of cases at the summit behind than in front. When pre- 1 Swett on Diseases of the Chest. 84 PHYSICAL EXPLORATION OF THE CHEST. sent, 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. Without having preserved recorded observations, I should say, in general, the degree of sonorousness is greater than in the scapular region below the spinous ridge, although Walshe states that, in this respect, it holds an intermediate place between the infra and supra spinous spaces. The vesicular quality of sound is feeble. The degree of sonorousness is less, and the pitch higher on the right side in some persons, but I have not taken pains to obtain data bearing on the ratio of instances in which disparity in these points is to be observed. 6. Mammary Region.—The mammary region offers marked differ- ences on the two sides, owing to the presence of the upper convex extremity of the liver, covered with lung substance, 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 may be called the line 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 the right auricle and ventricle, occasions diminished sonorousness over a space extending about a finger breadth from the right margin of the sternum. On the left side, diminished resonance exists in the prsecordial space, and over a portion of this space, in which the heart is in contact with the thoracic walls, there is almost complete absence of sonorous- ness. Percussing in a vertical direction from above downward, midway between an imaginary line passing through the nipple, and another line coincident with the left margin of the sternum, diminished 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, reso- nance nearly ceases, in consequence of a portion of the heart in this situation being uncovered by lung. From the fourth to the sixth ribs, 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 tri- PERCUSSION IN HEALTH. 85 angular space, the widest part of which is indicated by a horizontal line touching the fifth rib at a point a little within the nipple. Percuss- ing horizontally from the sternum outward on a line passing through the nipple, resonance is nearly absent to within about a finger's breadth of the nipple. Diminished resonance, however, is appreciable quite to the nipple, and even a little beyond it, 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, absence, nearly or quite, of vesicu- lar resonance. This is the case over the space in which the left lung fails to cover the organ. Second, 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 affections. 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, and the contraction alternating with the two acts. A morbid condition of the lung, consisting in permanent distension of the air- cells (which obtains in emphysema), will, of course, diminish the space over which, in health, resonance is nearly or quite absent. Abnormal resonance in the prsecordia, hence, becomes a physical sign of that affection. On the other hand, atrophy of the lung would have a con- trary effect. Considerable differences as respect the extent to which the resonance is diminished, and also the limits of the two areas are observed in different 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 develope, first, the flatness due to the contact of the heart with the thoracic wall; and, second, the dulness occasioned by the presence of that portion of the organ which is covered by the lung, is somewhat different; and this difference, which involves a rule applicable to the practice of percus- sion in other situations, both in health and disease, may as well be mentioned in the present connection. In determining the space which 86 PHYSICAL EXPLORATION OF THE CHEST. 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 percussing was first pointed out by Piorry. In general, a light percussion 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 of superficial percussion [percussion superfi- cielle); and the second mode he calls deep percussion [percussion profonde). Forcible or deep percussion is necessary to determine the existence and the size of indurations of lung from partial pneu- monia, pulmonary apoplexy, or tuberculous deposit, which are re- moved, to a greater or less distance, from the surface of the lung. Although a portion of the heart is in actual contact with the thoracic walls, the percussion-sound over this space, is rarely totally devoid of resonance, i. e. absolutely flat. This is probably owing to the fact that the percussion, more especially when made on a rib, in consequence of the elasticity of the latter, is not limited in its effects precisely to the point percussed, but extends over a greater or less area, and is thus brought to bear on the lung in near proximity, sufficiently to produce some degree of sonorousness. In this fact may be found an explanation of the superiority of light strokes in ascertaining the condition of parts situated directly beneath the points of the chest on which the percussion is made. As a general rule, the average area of dulness in the prsecordia, may be stated to be about two inches in diameter, measured transversely by a line passing through the nipple. The mammary region affords a degree of resonance considerably less than the region situated above it, the infra-clavicular, for reasons other than those already mentioned. The pectoral muscle diminishes 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, 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 IN HEALTH. 87 percussion."1 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 pleximeter may be used with advantage. With its broad smooth surface the soft parts may be compressed more firmly, and the strokes brought to bear more effi- ciently on the thoracic walls. The left mammary region sometimes 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 naturally present marked disparity as regards percussion-sounds. Over nearly, and in some persons quite, the entire region on the right side, there is absence of sonorousness, owing to the situation of the liver. This fact is not unfrequently overlooked by persons but little accustomed to physical exploration, and the want of resonance attributed to intra-thoracic disease. In- stances 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 flatness, varies considerably 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. Not unfrequently, however, it is over the sixth, and occasionally, as low as the eighth rib. Of fourteen exami- nations made with reference to this point, in nine, hepatic flatness commenced with the seventh rib; in four, with the sixth rib, and in one instance with 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, owing to the play of the diaphragm with the two respiratory 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 former, and its depression with the latter 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 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 1 Swett on Diseases of the Chest. 88 PHYSICAL EXPLORATION OF THE CHEST. to the eighth rib. In the 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 uniformly about 1^ 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 2^ to 5£ 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, notably diminished vesicular resonance, or well-marked dulness, extends up- ward 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 but rarely produced by per- cussing over the liver, due to the presence of gas in the intestinal canal. 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 extends to an extent somewhat variable, generally, according to Piorry, two inches to the left of the median line. Light percussion over this portion elicits a flat sound, or at all events, absence of vesicular resonance. The left boundary of the liver may generally be defined by the percussion-sound. Beneath the left portion of the region 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), be- comes enlarged to a greater or less extent. Frequently, if not gene- rally, the space occupied by this organ, both in health and disease, may be determined by percussion. 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 distension, 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 PERCUSSION IN HEALTH. 89 to the mammary. The sound is characteristic, and may be distin- guished as the gastric tympanitic resonance. It is high in pitch, and often has a ringing metallic tone. These characters are rendered obvious by contrasting 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 generally 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 sub- stances, the percussion-sound is dull or 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 continuous bony covering, devoid of the elasticity belonging to the ribs, emitting an osseous sound when struck, 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 dis- ease 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 prac- tical purposes, it suffices to consider it a modification of tympanitic resonance. Below the point of bifurcation, i. 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 may present more or less of the vesicular quality. The remnant of the thymus gland, and the deposit of adipose substance, however, sometimes render the percussion-sound dull or even flat in this situation. The pre- sence 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 different organs occasions various 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 90 physical exploration of the chest. tact in percussion, however, it is practicable frequently, if not gene- rally, to define the boundaries of the several organs which are embraced in a section of 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 impor- tance 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 characteristic of the organ lying beneath the point percussed. Thus according 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.1 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 convince 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 sup- ported and in sufficient quantity, may also be percussed by aid of a pleximeter, carefully applied to their surface."3 Walshe makes a similar statement.3 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 distin- guished from each other by percussion, or as bone and cartilage differ in this respect, according to Skoda4 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 1 A Treatise on Auscultation and Percussion, by Dr. Joseph Skoda. 2 Translation, by W. C. Markham, M.D., London edition, page 5. 8 Op. cit. * See note to French translation of Dr. Skoda's treatise, by the translator, Dr. F. A. Aran, page 6. percussion in health. 91 of sound in situ by no means hinges upon it. Skoda and Walshe do not deny distinction 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 which 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 distinctive sounds by which the sites of the different organs may be determined and their boundary lines often mapped out. For example, the sound produced by percussing over the liver differs obviously from that elicited over the heart: the latter is less flat and higher in pitch. 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 probably more sharply defined, and appreciated with much greater facility, by employing " auscultatory percussion,?n than by percussing in the ordinary moole. The practice of ordinary percussion, which is more simple, and therefore more readily available, with a view to determine and mark out the bounda- ries 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. To this applica- tion of percussion Piorry has given the title of organographisme. 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 anterior part of the chest, it is here especially that exploration is made for the physical signs of inflammation of the lungs or pneumonia, 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 pul- monary 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 1 See Essay by Dr. Cammann and Clark, previously referred to. 92 PHYSICAL EXPLORATION OF THE CHEST. depressed from one to two inches by a deep inspiration and elevated to a greater or less extent by a forced expiration. Here, 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 ; possibly, also, at the outer side of the lower part of the region, the space occupied by the spleen may in some instances be 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 sixth or seventh 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 percussion-sound may be more or less deadened 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 diagonally is the interlobar fissure, which, although not deter- minable in health, may be traced by means of percussion in disease (pneumonia), 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-thoracic organs embraced within their limits respectively, are nearly similar or sym- metrical on the two sides of the chest: anteriorly, the supra-clavicular and infra-clavicular regions ; posteriorly, the scapular and interscapu- lar regions; laterally, the axillary region. The remainder, viz., the mammary and infra-mammary, the infra-axillary and the infra-sca- pular, present anatomical points of dissimilarity attended by a want of correspondence in the physical phenomena produced by the method of exploration under consideration, 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 percussion in health. 93 as has been seen, yield identical percussion-sounds, but to a certain extent deviations occur entirely compatible with health. In order to settle with precision, numerically, the ratio of instances in which these variations may be expected to be found, an accumulation of further statistical data is necessary. Moreover, these variations appear in some measure to observe certain laws. Knowledge of the variations, and of the laws by which they are influenced, is important in its bearing on the diagnosis of disease, as will be seen hereafter. In instituting comparisons of the corresponding regions of the two sides, hitherto, it has been assumed that the chest is free from dis- parity resulting from deformity or previous disease, in other words, that the two sides are symmetrical in conformation. But instances 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 fundamental importance in physical diagnosis. The most prominent causes of visible altera- tions 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 contraction 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 percussion-sound, 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 general rule, probably, the pitch is lower and the sense of resistance is less in the former case. In old age, the vesi- cular quality of the resonance is impaired by the atrophied con- dition of the lung incident to advanced years, and the sound as- sumes somewhat a tympanitic 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 94 PHYSICAL EXPLORATION OF THE CHEST. contained within the air-cells, and consequently the relative proportion of air and solids, are by no means equal 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 is made at the conclusion of a full inspiration, or a forced expiration. The disparity is not appreciable uniformly in different persons. This fact I have ascertained by noting the results of exami- nations made with reference to the point. When it does exist, it usually consists, contrary to what might perhaps have been antici- pated, and the reverse of what is usually stated in works on physical exploration, in diminished resonance 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 prolonged and maintained—a condition pre- senting physical obstacles to sonorous vibrations more than sufficient to counterbalance the increased 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 after a full inspiration, while on the right side, the opposite effect was produced, and the sound became quite dull after a forced expiration. In view of these variations in a certain proportion of instances incident to different periods of a single act of respiration, in some cases of disease in which it is desirable to observe great delicacy in the cor- respondence of 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 discrimination is important. Certain rules of manipulation, pertaining to the practice of percussion, have already been stated. Others important to be borne in mind remain to be mentioned. These practical rules are PERCUSSION IN HEALTH. 95 equally applicable to examinations of the chest in health and disease; and it will not, therefore, be necessary to recur to this subject in con- nection 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 explore the anterior surface of the chest the position most favorable to elicit sonorousness is standing, the shoulders thrown moderately backward, and the back resting against some firm support; next to this is a sitting posture, the back in like manner supported. 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 dis- posed 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 t\\e 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 posture 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 ex- amination will be most conveniently made in the sitting posture. 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 intensity, if not in other respects. 96 PHYSICAL EXPLORATION OF THE CHEST. 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 vertically, at right angles with the ribs. Whenever careful percussion is required, both positions should be resorted to. In percussing the acromial portion of the infra-clavicular region the most convenient disposition is to place the fingers in a diagonal direc- tion. It is better to place the palmar surface of the fingers in appo- sition 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 inter- costal spaces successively, and to cpmpare the sound elicited from the two sides. As already stated, deviations from healthy sounds are de- termined generally by means of this comparison, and not by reference to any fixed standard. Hence, the differences 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 difference 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 pro- duction of the highest amount of resonance ; then, directly after- ward, on the other side, let the strokes be made with the pulpy por- tion 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 produced, 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 de- tected. A difference 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 suffice to occasion PERCUSSION IN HEALTH. 97 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 by a failure to strike with equal force on corresponding points. That the eye may select points which correspond on the two sides, and the better to secure uniformity in the act of percussing, it is preferable, in cases in which nicety of discrimination 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 offending propriety by uncovering portions of the chest at a time, and not exposing the mammae, which is rarely if ever necessary. In many instances 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 sometimes, at the same time, be obtained by direct- ing attention to the sense of resistance, felt by the fingers when struck. In proportion as the walls of the chest are deprived of their elasticity, 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 percussing 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 dis- parity dependent on deep-seated alterations, forcible percussion is requisite. In connection with this rule, it is to be stated that ordinarily 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 consideration of the student before entering on the study of Percussion in Disease. 7 98 PHYSICAL EXPLORATION OF THE CHEST. After becoming familiar with all that has already been presented relative to percussion, and practically expert by resorting to exa- minations of healthy chests, the knowledge of the morbid signs developed by this method, and its application in the diagnosis of thoracic affections, are easily attained. In fact, to so great an ex- tent may the physical phenomena of disease be studied in health, that, after, such a preparation, the subject offers no difficulties. Percussion in Disease. The various physical changes incident to disease affecting the intra- thoracic organs occasion corresponding modifications of the sound elicited by percussion, and hence, the latter become the signs of the former. The more important of the physical changes incident to different forms of disease, are the following: over-distension of the pulmonary vesicles, involving usually 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 in- creased density of lung, from the deposits of effused blood, serum, coagulable lymph, tuberculous or other morbid products; the pre- sence 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 pleurae, 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 morbid conditions, establishing the relation of cause and effect, depend the significance and value of the former as indices of the lat- ter. Resonance of the healthy chest, has been seen to involve the following elements, viz., a certain amount of intensity, or loudness; a peculiar quality or timbre, characterized as pulmonary or vesicu- lar; pitch, and duration. Morbid deviations from healthy reson- ance are to be analyzed, and studied under the same general as- spects. It is by attention to these different qualities that the signs developed by percussion are recognized, and discriminated from each other. Abnormal sounds, then, we repeat, are distinguished from PERCUSSION IN DISEASE. 99 healthy resonance, and from each other, by variations in intensity, in quality, in pitch, and in duration. Proceeding to a description of the physical signs of disease deve- loped by percussion, the question at once arises, what arrangements 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. Exaggerated Vesicular Resonance.—The term clear is usually employed to express both normal and undue intensity of sonorous- ness. The term is confessedly inappropriate, inasmuch as, strictly, it expresses not intensity, but purity of sound; but the application is sanctioned by usage. Clearness of resonance, however, is an ex- pression equally applied to instances in which the character of sound is changed. To observe precision, therefore, it is necessary to qualify it as vesicular, when the resonance retains the peculiar quality indi- cated by that title. It were better to dispense with the term and de- signate the sound proper to health as normal resonance, and a sound increased beyond the limits of health, but not essentially changed in other respects, as exaggerated vesicular resonance. This will be the designation of the first of the heads under which the physical signs furnished by percussion are to be distributed. 2. Diminished Vesi- cular Resonance.—Diminution of resonance, as a sign of disease, is usually called dulness. A dull percussion-sound generally differs from the normal resonance, at the same time, in quality, pitch, and duration. This will constitute the second division. 3. Absence of Resonance, commonly known as flatness. The type of this sound is that produced when the thigh is percussed. This will make a third division. 4. Tympanitic Resonance.—Under this division I embrace all varieties of sonorousness in which the vesicular quality is wanting. It will include the varieties called by some tubular, amphoric, and the cracked metal sound {bruit de pot fete). Tympanitic resonance usually presents deviations from that of health not only in quality but in intensity, pitch, and duration. Of the foregoing divisions it is perceived that the three first are based on deviations in the intensity of sound, the names denoting dis- tinctions in this character and none other; while the last division is founded on a change in the quality of sound. Deviations in pitch and duration of sound are important, but there is no necessity for consti- tuting separate divisions based thereon, since, with few if any excep- tions, they are always associated with changes in intensity or quality. 100 PHYSICAL EXPLORATION OF THE CnEST. It suffices, therefore, and simplifies the subject, to consider the charac- ters of morbid percussion-sounds which are derived from the attri- butes just named, viz., pitch and duration, as incidental to the several classes embraced in the above arrangement. It seems to me that all the sounds developed by percussion in disease admit of being resolved into four divisions, according to this arrangement, considering varia- tions not expressed by the terms of the classification in the light of incidental characters. Other classes, however, are mentioned by some authors: Skoda, for example, distinguishes certain sounds, as either empty or full. By these terms he intends to express certain dif- ferences conveyed to the ear by the character of sound as to the size of the space in which it is produced, or in other words, the extent of its diffusion. He illustrates the distinction thus : " We do not judge of the size of a resonant body by the strength of the sound which strikes upon the ear ; the slightest vibration of a large bell tells of its magni- tude ; the loudest ringing of a little bell misleads no one as to its small- ness; neither do we judge of the dimensions of bodies, from the pitch of their sounds."1 To make this the basis of a distinct class of sounds seems to me an over-refinement, tending to complicate the subject, and thereby discourage the student. The reality of the distinction, how- ever, may be admitted, and differences in this respect considered, like diversities in pitch and duration, incidental to the sounds arranged in the several divisions that have been adopted. The terms fulness and emptiness are unfortunate, not expressing, except constructively, the meaning attached to them by the translator of Skoda's treatise ; but it would be difficult to fix on other terms which express the dis- tinction more satisfactorily. It remains to consider the phenomena falling under the foregoing clashes severally, and their relations to the different morbid conditions of which they are the signs. 1. Exaggerated Vesicular Resonance.—Increased resonance, the vesicular quality of sound being preserved, is chiefly important as a sign of a single morbid condition, viz., abnormal accumulation of air in the pulmonary cells, constituting pulmonary or vesicular emphysema. The physical change in the lung in this affection ren- ders the fact of an increased sonorousness sufficiently intelligible. The amount of resonance proper to health depends on the presence of air in a certain proportion to the solid parts. When, from disease 1 Op. cit. percussion in disease. 101 the quantity of air is increased, the solid parts remaining the same, or even diminished by the atrophy which may accompany emphy- sema, a greater intensity of the percussion-sound would be looked for. Associated with signs developed by other methods of explora- tion, this is quite distinctive of emphysema. With the exaggerated resonance the vesicular quality is preserved. This fact distinguishes it from the increased sonorousness due to another and quite different affection, viz., pneumothorax, in which an abnormal clearness exists, without the vesicular quality, in other words with tympanitic reso- nance. In emphysematous distension of lung, however, the vesi- cular quality of resonance, although preserved, is more or less dimi- nished, and in proportion as it loses this quality it acquires a tympa- nitic character: this, a priori, would be expected. Moreover, the increase in sonorousness is not proportionate to the degree of enlarge- ment or distension of the air-cells. This interesting fact has been pointed out particularly by Skoda. If the lung become highly emphy- sematous, and the chest considerably expanded in consequence of the greater volume which the lung acquires, instead of being remarkably sonorous the chest may even yield on percussion a dull sound, and under these circumstances the vesicular quality is proportionally less marked. This fact is probably due mainly to the extreme tension of the pulmonary organs and the thoracic parietes. In proportion as exaggerated vesicular resonance preserves the vesicular quality, it may probably be stated as a general rule that the percussion-sound is long in duration and low in pitch. Con- versely in proportion as it loses this quality, and becomes tympanitic in character, it is shorter and higher in pitch. In determining the existence of exaggerated vesicular resonance we should be at a loss in cases in which both lungs are equally affected by emphysema, were we not aided by signs developed by other methods than percussion, and also by symptoms; because we have no fixed standard of natural resonance, and there are wide dif- ferences in different persons in this particular. The evidence afforded by percussion alone is much more complete when the affection is limited to one side, or exists to a greater extent on one side than on the other, which is usually the case. Under these circumstances we have the advantage of a comparison of the two sides. It is needless to add that the natural resonance of different regions on the same side differing considerably in health, it is necessary here, as in other instances, to institute a comparison between corresponding situations 102 physical exploration of the chest. on the two sides. In one situation, however, the effect of emphysema is to render more equal corresponding regions in which there is a disparity in health ; reference is had to the mammary region. The praecordia is naturally dull in consequence of the presence of the heart, which the lung does not completely overlay. But if the left lung become highly emphysematous, the heart is fully covered and removed from the thoracic walls, so that the percussion-sound is abnormally clear in that situation, and it may require forcible per- cussion to discover a disparity between the two sides. Guided by percussion, alone, in cases in which the vesicular reso- nance is greater on one side than on the other, there would be a liability to err in attributing this apparently increased sonorousness to emphysema, when, in fact, it is simply the normal resonance, but relatively greater in consequence of disease seated in the other side, which diminishes the resonance on that side. This error is avoided by resorting to other signs pointing to the side affected. As already stated, exaggerated vesicular resonance is chiefly valu- able as a sign of emphysema. It is altogether probable that when the lung of one side becomes hypertrophied, in other words, acquires an increased expansion in consequence of the lung on the other side being rendered useless by disease, as in cases of chronic pleurisy, the degree of resonance exceeds that belonging to health. It is difficult to determine this fact positively, unless we chance to know the amount of resonance peculiar to the individual before he was attacked with the disease, because we lose the resonance of the diseased side as a standard for comparison. The point, however, possesses little or no importance in diagnosis. The sonorousness of the chest, becomes, of course, greater in pro- portion as the coverings of the thoracic walls are attenuated in the progress of diseases attended by emaciation. But under these cir- cumstances both sides are equally affected; this, in connection with the absence of other signs, suffices to exclude pulmonary disease. 2. Diminished Resonance, or Dulness.—As a sign of disease resonance is much oftener lessened than augmented. Indeed, this is the change which occurs in the vast majority of pulmonary affections. The morbid conditions which occasion it are quite numerous. Under this division, it should be premised, are embraced the instances in which the resonance is less than normal, without being completely abo- lished, and the diminution may have every possible degree of gradation percussion in disease. 103 from the sonorousness of health, to a point at which resonance ceases. The sound is dull until this point is reached, when it becomes flat. Normal resonance is impaired, whenever, from any morbid cause, solids or liquids occupy space within the chest at the expense of the normal quantity of air in the vesicles. This occurs in a variety of diseases, the more important of which 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 quan- tity of the latter, the former not being increased. An obstruction 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 circumstances, may follow. The effect on the percussion-sound is to diminish the normal resonance, which depends, cceteris paribus, on the quantity of air con- tained in the pulmonary vesicles. In the vast majority of cases, however, this effect is due to the increase of the solid contents of the chest, which occupy space to the exclusion of air. b. A thin stratum of liquid between the pleural surfaces, serum, or serum and coagulable lymph, in hydrothorax and pleurisy, may occasion more or less dulness on percussion. This is an infrequent cause, the quantity of liquid effusion and fibrinous exudation gene- rally being so disposed, and in sufficient quantity, to occasion total loss of resonance, or flatness, over a greater or less distance from the base of the chest upward. Instances, however, may occur, in which, from adhesions 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 destroy vesicular resonance. In cases in whiph a considerable 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 vesicular resonance is diminished, the reduc- tion of the lung in volume increasing the proportion of solids to the quantity of air within the cells. At the summit of the chest, there- fore, the percussion-sound is usually dull. But under these circum- stances a sonorousness frequently exists, modified in quality, which will be noticed under the head of Tympanitic 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 104 PHYSICAL EXPLORATION OF THE CHEST. tubes, but to 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 abundant expectoration, the normal resonance is not sensibly impaired. Skoda denies that appreciable dulness ever exists in cases of bronchitis. This assertion is too positive, and does not accord with the observa- tions 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 sufficient degree obtains in some cases at least of pneumonitis, during the first stage, or stage of engorgement,1 and in the hypostatic congestion of the dependent portion of the lungs taking place towards the close of life in various diseases. e. The exudation of coagulable lymph within the air-cells which characterizes the second stage of pneumonitis, or the stage of solidifi- cation, occasions 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 proportionate to the quantity of exudation, occasionally merging into complete flatness. Certain circumstances distinctive of the solidification of the lung, which occurs in the form of pneumonitis usually presented in the adult, viz., lobar pneumonitis, will be noticed under the head of Absence of Resonance or Dulness. /. Effusion of serum within the air-vesicles and areolar tissue of the lungs, is another morbid condition attended by dulness, and in some instances flatness. This condition, never a primitive affection, but generally incident, when it takes place, to disease of heart induc- ing pulmonary congestion, is to be included among the infrequent causes of diminished resonance. g. Deposit of tuberculous matter within the cells is the most fre- 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 inflammation, no solid exudation having taken place. (Hospital Record for April, 1855, cases of Peterson.) The denial by Skoda is not in accordance with the observations of others. PERCUSSION IN DISEASE. 105 quentin its occurrence of the morbid conditions characterized by the change in the percussion-sound under consideration. The mode in which it occasions diminished resonance is the same as in pneumonitis. h. Carcinomatous infiltration of the pulmonary parenchyma, for- tunately extremely rare, will occasion dulness, in the same manner as tuberculous matter. i. Extravasation of blood, constituting pulmonary apoplexy, is another rare form of disease, producing the same effect in the same way. h. 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 diminution or absence of vesicular resonance. In each and all of these various affections, percussion alone deve- lopes nothing beyond the simple fact of the existence of some physical alteration preceding dulness. It affords no information in parti- cular cases, as to which one of the different morbid conditions exists. To determine this point the co-operation of other methods of explora- tion is requisite, taken in connection with symptoms, and the known laws of diseases. In certain instances, 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, espe- cially 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 exists 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 evidence afforded by one only of the methods of explo- ration, or to depend on signs to the exclusion of symptoms. And it is one of the great advantages pertaining to physical diagnosis that phenomena developed by different modes of examination may be brought together, mutually serving to supply deficiencies, correct liabilities to error, and combining to render positive the conclusions therefrom educed. Incidental to diminished vesicular resonance are certain deviations relating to pitch, duration of sound, and the sense of resistance. As 106 PHYSICAL EXPLORATION OF THE CHEST. a general rule, when the solid contents of the chest are increased at the expense of air within the cells, whatever may be the form of dis- ease involving this physical change,not only is the vesicular resonance diminished, but the pitch of the percussion-sound is raised, the sound is shortened in duration, and the sense of resistance is increased. These four deviations generally go together, viz., diminished resonance, elevation of pitch, shortened duration, and greater resistance. This rule is important to be borne in mind in the practice of percussion. A dull vesicular sound, contrasted with a clear vesicular sound, is at the same time higher in pitch, less in duration, and the sense of resis- tance is greater. In the several forms of disease, therefore, which have been enumerated, these changes are united. A point highly important to be understood in connection with this subject is, that vesicular resonance may be diminished or abolished, not involving a corresponding loss, but even with an increased degree of sonorousness: that is, sonorousness may exist to an extent equal to that in health and even greater, but without the vesicular quality, the resonance, in other words, being more or less tympanitic. In the majority of instances in which the solid contents of the chest are increased at the expense of the air in the vesicles, it is probably true that the percussion-sound becomes proportionately dull in every sense, using this term with its ordinary acceptation ; but in a certain ratio of cases it is otherwise. The vesicular resonance is diminished, but in this sense only the sound is dull. The vesicular quality is replaced by a sonorousness, it may be exceeding the normal intensity, and approximating more or less to a tympanitic resonance. Hence, in cases of compression of lung from pleuritic effusion, as already stated, and also in solidification from tuberculous deposit or inflammatory pro- ducts, percussion sometimes elicits an exaggerated tympanitic sound. This point will be considered under the head of Tympanitic Resonance. The fact just stated obviously has an important bearing on the sub- ject under present consideration. The proportion of instances of the forms of disease just referred to, in which the fact exists, remains to be settled by numerical observations. Diminished vesicular resonance, with or without tympanitic sonor- ousness, in the different forms of disease thus characterized, is ascer- tained by contrasting the two sides of the chest; for fortunately the laws governing pulmonary affections do not conflict with making one side a standard of comparison by which to estimate the deviations from health on the other side. With very few exceptions, in cases of pulmo- PERCUSSION IN DISEASE. 107 nary diseases, attended by alterations in the healthy resonance on percussion, either the affection is confined to one side, or is more ad- vanced 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 occurring in practice, 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. Occa- sionally, a delicate comparison is necessary. This is sometimes the case in the early stage of phthisis, when the morbid deposit is in the form of small disseminated tubercles. To appreciate a slight dif- ference 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 possible, the sound elicited on the two sides is to be compared as respects in- tensity, vesicular quality, pitch, and duration. My observations have led me to regard attention to pitch, as particularly useful, in cases in which delicacy of discrimination is required.1 A variation in pitch by one who has what is called a " musical ear," is more easily recog- nized, 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. In cases, therefore, of suspected tuberculosis, it is important to compare the sounds on the two sides as if they were musical notes, in order to determine whether they are in unison, or differ in their diatonic relation to each other. A difference in pitch may then be the only discoverable evidence of dissimilarity, and, in connection with other signs and symptoms, may be entitled to considerable weight in the diagnosis.2 The importance of attention to the pitch of percussion-sounds with a view to greater nicety and accu- racy of discrimination, seems to me not to have been sufficiently appre- ciated by most writers on the subject of physical exploration. A late writer, indeed, whose views have attracted much attention, de- clares that variations in this respect are of little value in practice.3 It is worthy of remark, that in the classification of percussion-sounds by Auenbrugger, variations in this respect occupied the first rank, 1 See Prize Essay by author. 2 This is probably true of the exceptional cases, to be referred to again under another head, in which the percussion-sound over the site of tubercles has a greater degree of sonorousness than belongs to health. See under head of Tympanitic Resonance. » Skoda. 108 PHYSICAL EXPLORATION OF THE CHEST. although with reference to this point, he was misapprehended by his translator and commentator Corvisart,1 a fact which may perhaps serve to account for its having been subsequently overlooked by others.2 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 correspondence 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 dulness, or elevation of pitch, is found on the right side. From this fact it follows that dulness, or elevation of pitch, situated on the right side, are very likely to be due to a natural disparity between the two sides; but situated on the left side, it probably proceeds from a morbid condition. In instituting a very 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 compa- rison is made. It is stated3 that in some cases of slight solidification 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 two sides of the chest is discovered, before concluding it to be a sign of pre- sent 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. Important errors will be likely to be committed without the observance of this precaution. 3. Absence of Resonance, or Flatness.—Complete abolition of sonorousness is incident to certain abnormal conditions. The effect 1 Notes to French edition of Skoda by the translator, Dr. Aran. 2 The importance of attention to variations of pitch in the diagnosis of certain cases of phthisis is emphatically dwelt upon by Dr. Bowditch in his work entitled " The Young Stethoscopist." 8 Dr. Walshe and Dr. J. Hughes Bennett. PERCUSSION IN DISEASE. 109 of percussion is the same as when the thigh is struck. The sound is said to be flat. Perfect flatness on percussion obtains especially when the pleural sac is filled with liquid effusion, either serum, serum and lymph, or pus. If the lung or an entire lobe be completely solidified by the exudation of lymph, or infiltrated tuberculous mat- ter, there may be flatness, but it is rarely the case that sonorousness is so completely extinct as in the former instance. The presence of a small quantity of air in the bronchial tubes, and the proximity of the solidified portion (if the whole lung be not solidified) to another por- tion in which the vesicles contain air, occasion a slight degree of re- sonance, although perhaps so extremely slight as not to be appreciable without comparison with the effect of percussion on a part which is absolutely flat. A large tumor within the chest may occasion flatness. In cases in which flatness, or a degree of dulness closely approxi- mating thereto, exists over a portion of the chest, the discrimination lies between liquid effusion, solidification of lung, and morbid growth. It follows from the statement just made, that the degree of flatness, or, more correctly, the existence or not of positive flatness, as distin- guished from dulness, enters into this discrimination. Displacement of the lung by the accumulation of liquid, or a solid tumor, may occa- sion absence of all resonance, while over lung, be it ever so com- pletely solidified, there is usually only an extreme of dulness. But in making this discrimination, important information is derived from the situation of the flatness, and, in certain cases, the effect of varia- tions in the position of the patient. If the flatness be situated at the superior portion of the chest, the probabilities are vastly opposed to its being due to the presence of liquid, for, excepting in some instances, which must be exceedingly rare, in which liquid effu- sion 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 will extend upward for a distance proportionate to the amount of the effusion. The extreme dulness, or possibly absolute flatness, due to solidification of the lower lobe in pneumonitis, may be ascertained by delineating on the chest its upper boundary, and finding that the line pursues the direction of the interlobar fissure. This is a point pertaining to the physical diagnosis of pneumonitis, to which writers on the subject have not sufficiently adverted. Moreover, the limits of the flatness or dulness incident to that disease, remains unaltered in every posi- tion of the patient. The same remark will apply to tumors, unless, as may happen, and an instance is given by Walshe, they are not 110 PHYSICAL EXPLORATION OF THE CHEST. 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 ascertained 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 direc- tion, the liquid obeying 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 descended, 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 always 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 instances, 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 pleu- ral 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 are apt to be wanting in pleurisy, and hence the test is less frequently available in that affec- tion than in hydrothorax. The discrimination, however, of flatness occasioned by liquid effusion, from that which may be due to solidifi- cation 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 employment of percussion after the rules just given enables the practitioner to determine from day to day, or from week to week, the changes which take place in the quan- tity of liquid effusion. The progress of the disease and the effects of remedies may thus be accurately observed. This is a practical con- sideration of no small importance. With a view to note the increase or diminution of the fluid, the line of flatness, denoting the level of PERCUSSION IN DISEASE. Ill the liquid, while the body is in a vertical position, may be perma- nently 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 flatness, occasion at the same time, and usually in a notable degree, a sense of increased resistance ; in other words, the ribs are less yielding to pressure from without. This sign, cceteris 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. 4. Tympanitic Resonance.—Agreeably to the definition already given, under this head are embraced all kinds of sonorousness which want the special quality or timbre characteristic of the presence of air in cells, which has been distinguished as vesicular resonance. The name implies a drum-like sound, and the type is tlfe sound emitted by the tympanitic abdomen. It is proper to state that the expression is not generally used in a sense so comprehensive. By some writers1 it is limited to exaggerated pulmonary or vesicular resonance. With the French it is considered to denote a clear, intense sound, without necessarily having any special quality or timbre.2 It seems appro- priate, and simplifies the subject, to call the different percussion-sounds tympanitic, which, however they may differ among themselves, agree in this, viz., that they are non-vesicular. The distinctive feature, then, of tympanitic resonance pertains to its quality or timbre. It may have any degree of intensity so long as it possesses the negative distinction just named. It may be louder or clearer than the normal resonance, or, on the other hand, a sound ever so dull, which is not flat, may be tympanitic.3 It presents under different circumstances striking modifications, which are practically not unimportant, but it suffices to consider them as constituting different varieties of tympa- nitic resonance. 1 Walshe, first edition. 2 Dr. Henri Roger, Archives g6ne"rales de me"decine, 1852. 8 Dr. Stokes makes a statement similar to this. Speaking of the difference between the resonance on the left side from the presence of gas in the stomach and that from pneumothorax, he says, " I might say, and stethoscopists will appreciate the distinction, that the one is a tympanitic dulness, the other a tympanitic clearness." Diseases of the Chest, 2d Am. edition, 1844, page 284. 112 PHYSICAL EXPLORATION OF THE CHEST. It has been necessary already to refer to the tympanitic quality of percussion-sounds. The exaggerated resonance of emphysema ac- quires a tympanitic character, but without losing entirely the vesi- cular quality.1 When the tension is great, in some cases of emphy- sema, the sonorousness diminishes, as has been stated already, and the sound is then said by Skoda to be non-tympanitic. But by this expression is meant simply that the loudness and clearness are dimi- nished. Using the term tympanitic as applied to an altered quality of sound, the statement by Skoda is incorrect, inasmuch as with the diminution of sonorousness under these circumstances the vesicular quality is not increased. The tympanitic quality may be combined in every proportion with the vesicular quality of resonance. In per- cussing the chests of different persons in health, there will be found to be marked differences as respects the predominance of one or the other. As a general rule, if not invariably, it may be stated that in proportion as a percussion-sound approximates to tympanitic reso- nance, either in health or disease, the pitch is raised. Finally, over different portions of the chest in the same individual the resonance differs in this respect. In the lower part of the infra-clavicular region, for example, the vesicular quality is marked; while over the scapula it is much less so, showing that this peculiar quality is not altogether independent of the thoracic walls. Frequently over the lower part of the left side, in front, and laterally, and occasionally over the lower part of the right side, the resonance is notably tym- panitic, in the former situation from the presence of gas in the stomach, and in the latter from flatulent distension of the colon. Tympanitic resonance occurs in different forms of disease, and pre- sents certain modifications, which, to some extent, are significant of particular morbid conditions. These modifications, which may be considered as forming several varieties of this division of percussion- sounds, 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 normal resonance, and generally even the exaggerated resonance of emphy- sema, it becomes, combined with other circumstances, a sign quite distinctive of the presence of air or gas in considerable quantity 1 Were it not so desirable as it is to avoid creating distinctions and multiplying names more than is practically essential, I should propose to distinguish a percussion- sound-partly tympanitic and in part vesicular, and apply to it the title of vesiculo-tympa- nitic resonance. I have found this expression convenient in making clinical notes. PERCUSSION IN DISEASE. 113 within the pleural sac. This physical condition characterizes the dis- ease called pneumothorax, or as air and liquid are usually combined in variable proportions, pneumo-hydrothorax. In this affection per- cussion of those portions of chest situated over the space occupied by air, elicits a loud sonorousness totally devoid of vesicular quality and which gives to the mind an impression of a hollow space of con- siderable size filled with air. So far as an idea of size is conveyed, it is what Skoda calls a full, in distinction from an empty sound. An interesting fact pertaining to the sound occurring as a sign of pneumo-hydrothorax has been pointed out by the author just named. When the chest is greatly distended by the large accumulation of liquid and air, the degree of sonorousness is less than when the distension is but moderate. The sound may even become dull. It is stated by Skoda that it becomes non-tympanitic. It is not, how- ever, to be understood by this expression that it acquires the vesi- cular quality of resonance, although the normal resonance of the chest is cited by Skoda as the type of a non-tympanitic sound. It is evident that the quality of resonance must remain tympanitic under these circumstances. It is meant only that it loses its inten- sity. This fact is probably due to the extreme tension of the tho- racic walls. A similar phenomenon, as remarked by Walshe, is observed in a drum. " If a drum be tightened to the extreme 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, gives rise to flatness on percussion below the inferior boundary of tym- panitic resonance, and the relative portions of the surface of the chest over which resonance or flatness are found, will serve to determine the relative quantities of liquid and air. If the pleural surfaces are 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 affec- tion adhesions generally take place to a greater or less extent, the air may be prevented from distending the upper part of the pleural sac. 8 114 PHYSICAL EXPLORATION OF THE CHEST. Under these circumstances, there maybe a liability of attributing the tympanitic sonorousness due to air between the pleural surfaces, to the 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 dimensions of the surface corresponding to the tympanitic resonance be marked on the chest in front, they will be considerably lessened by repeating the examination 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 hydro- thorax, and this will be found to vary with different attitudes, obeying the same rules 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 gene- rally in itself quite conclusive. With an imperfect knowledge of the subject, however, there are liabilities to deception. Emphysema, as has been seen, is attended not only by exaggerated sonorousness, but a quality of resonance approximating to the tympanitic. It does not, however, lose entirely the vesicular quality. It is unaccompanied by the physical signs of liquid effusion, and is distinguished by signs obtained by other methods. The whole of the left side is sometimes rendered 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 tym- panitic resonance is greatest at the lower part of the chest; and diminishes in proportion as percussion is made toward the summit, thus reversing the rule which obtains in pneumo-hydrothorax. A condition more likely to lead into error is ordinary pleurisy, at- tended, as is not unfrequently the case, by a tympanitic resonance, more or less strongly marked, above the level of the liquid, on the surface beneath which is situated the compressed lung. For the knowledge of this important as well as interesting fact, to which allu- sion has already been made, we are mainly indebted to Skoda. He is entitled to the credit of Jiaving pointed out the frequent occur- rence of increased and tympanitic sonorousness over the chest, above the line of flatness denoting the height to which the liquid rises. This subject has also been investigated by Dr. Henri Roger of Paris.1 The latter observer found, that of 51 cases of pleurisy, 41 were characterized by this feature. In these cases the increased tym- 1 Archives G^nerales de M6decine, 1852. PERCUSSION IN DISEASE. 115 panitic resonance was not constantly present, but existed for a greater or less period during the progress of the disease. The fact of the occurrence of this feature was not altogether novel. It had been observed by Dr. Williams. I had noted it as present, in a marked degree, in two cases of chronic pleurisy which came under my ob- servation several years ago.1 In the discovery of its occurrence in a large majority of cases consists the novelty of the point under consideration. This being the fact, it seems surprising that it should have been so long overlooked. An explanation, offered by Dr. Roger, of the frequency of its oc- currence having escaped attention, is that practitioners after making ' the diagnosis of the presence of liquid effusion, have not been in the habit of comparing the two sides of the chest, above the level of the fluid. According to Dr. Roger, the most favorable condition for the sign, is when the quantity of effusion is sufficient to fill a third or half the cavity of the chest, and it does not exist when the quantity is either very small or very large. Dr. Aran, however, has observed it in the early stage of pleurisy, in which the amount2 of effusion was quite small. The rationale of the sign is a matter open for discus- sion. The few remarks pertaining thereto that I shall offer, I will defer till other conditions also characterized by tympanitic resonance have been noticed. Exaggerated and tympanitic resonance exists sometimes over the lower lobes when solidified in pneumonitis. The credit of having first called attention to this fact, is attributed to the late Dr. Graves, of Dublin. On the left side this is not uncommon, and the explana- tion which at once suggests itself, and which is probably applicable to many instances, 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. An exaggerated and tympanitic resonance over the superior lobes in cases of pneumonitis in which the lower lobes are solidified, is not unusual. This has been noticed by several observers. Judging from the results of recent observations directed to this point, I should say this was the rule. This, then, is to be classed among the different morbid conditions in connection with which increased sonorousness with the tympanitic quality is produced, if not uniformly, yet in a cer- tain proportion of cases. 1 See Essay on Chronic Pleurisy, by author. 8 Note to French translation of Skoda's Treatise. 116 PHYSICAL EXPLORATION OF THE CHEST. Belonging to the same category is the occurrence of tympanitic resonance occasionally, more or less intense, over consolidation of the superior portion of the lung from pneumonitis or tuberculosis. This I have repeatedly observed. Skoda has also demonstrated the co-existence of tympanitic resonance with oedema and pulmonary apoplexy, and Dr. Roger has observed it in lobular pneumonia.1 These developments, in a great measure of recent date, are of con- siderable importance in their practical bearing on physical explora- tion. A sonorousness greater than natural and tympanitic in quality, may be present in connection with physical conditions of the parts within the thorax, which a priori would not be expected to give rise to such an effect, and which, in fact, often, if not generally, are accompanied by dulness or flatness. Whether or not we may be able to account for the facts which have been stated, they are established by clinical observation. Irrespective, therefore, of theoretical views relative to their rationale, the facts are to be borne in mind. To repeat them, in general terms,—in cases of pleurisy with effusion, or hydrothorax, the resonance above the level of the liquid is frequently more intense than on a corresponding situation on the non-affected side, and tympanitic in quality; in cases of pneumonitis affecting an inferior lobe, the healthy lung above the limits of respiration generally emits a resonance more or less intense and tympanitic; and over soli- dified lung, not only when the lower lobe is the portion affected, in which case we may suppose a gastric or intestinal sound is transmitted, but also when the solidification is situated in a superior part, be it from tubercle, from extravasated blood, or lobular pneumonitis, an exagge- rated and tympanitic resonance may exist over the situation of the solidified portions. Without attention to these facts, the greater sonorousness on one side existing in connection with the several morbid conditions just mentioned, might possibly lead the observer to conclude that the healthy side, from its being relatively dull on percussion, was the side diseased, the morbid resonance being taken as the standard of health in the individual examined. M. Roger states that he has known of instances in which this mistake was committed. Especially in the diagnosis of early tuberculous disease, it is important to recol- lect that an exaggerated tympanitic resonance at the summit of the chest may attend the presence of tubercles. Such instances are excep- tions to the general rule, stated under another head, that a tubercu- lous deposit occasions diminished resonance on percussion. 1 Dr. Roger, in Archives generates de Medecine, 1852. PERCUSSION IN DISEASE. 117 The rationale of the foregoing interesting and important facts is a matter at present sub judice, and inasmuch as I have no fruits of personal experiments or researches to offer, I shall not engage in a lengthened discussion of the subject. To account for an exaggerated tympanitic resonance under circumstances in which it is clinically exceptional, and apparently opposed to the laws of physics, viz., when the lung is compressed by the presence of liquid, or rendered more dense than natural by solidification, the doctrine has been advanced by Skoda that " if the lung contains less than its normal quantity of air, it yields a sound which approaches to the tympanitic, or is dis- tinctly tympanitic."1 He bases this doctrine on experiments made upon the pulmonary organs in the dead subject, and also removed from the body, taken in connection with the facts pertaining to disease which have been presented. Clinically this doctrine cannot be considered to hold good in the light- of a general law for abnormal sonorousness in cases in which the lungs are to a greater or less extent deprived of their normal quantity of air, in other words rendered more dense by disease, is by no means an invariable sign, but, on the contrary, occurs only as an exception to the general rule. The sign, there- fore, cannot be due simply to the mere deprivation of air, or any constant condition, but to some contingent circumstances. The question, then, is, what are these contingent circumstances? In cases of effusion within the pleura, the natural effect is to condense the lung by compression of the liquid; but it is not certain that in all instances the proportion of air to the solid tissues above the level of the fluid is diminished. By the force of the inspiratory movements causing greater dilatation of the cells, the ratio of air may perhaps even exceed the limits of health. It is not improbable that the origin of the emphysema and dilatation of the bronchiae which sometimes suc- ceed pleurisy may have a date anterior to the absorption of the effused liquid. These are points which claim investigation. But in cases in which abnormal sonorousness at the summit of the chest occurs in connection with solidification of the lower lobe from pneumonitis it is gratuitous to suppose that the relative quantity of air to solid tissues in the upper lobe is diminished. Its occurrence under these circumstances is evidence against the necessity of dimi- nution of air in other instances. Dr. Roger found by experiments that the sound elicited by percussing a lung removed from the body is modified according to the substance on which it rests. Thus on 1 Markham's translation, Am. edition, page 47. 118 PHYSICAL EXPLORATION OF THE CHEST. a bed of muscle or bone it emitted a normal sound, but floating on the surface of a liquid it yielded a tympanitic sound. This fact may be applied to explain the abnormal resonance incident to pleuritic effusion, but not to that found to exist in certain instances over the healthy lung in cases of pneumonia.1 The tympanitic resonance, more or less intense, which is observed over solidified lung at the inferior portion of the chest, especially on the left side, admits of an explanation already stated, viz., trans- mitted sonorousness from the stomach and intestines. When it is pre- sented at or near the summit of the chest, over deposits of tubercle or extravasated blood; or in cases of pneumonitis affecting the upper lobe, some other explanation is requisite. It has been attributed to two incidental circumstances, viz. : 1. The air in the trachea and large bronchial tubes, in consequence of surrounding solidification, may be supposed to give rise to a resonance more or less intense, and of course devoid of the vesicular quality, in other words tympanitic, resembling the sound produced by percussing the trachea: this is the explanation offered by Dr. Williams.3 According to Skoda, direct experiments prove its incorrectness. He does not give an account of the experiments to which he refers; and deductions from experi- ments made out of the body, applied to the parts in situ, are to be received with a certain amount of distrust. The explanation is adopted by so high an authority as Dr. Walshe on subjects pertaining to physical exploration, and it is considered by him adequate in part to explain the tympanitic sonorousness3 which is found at the sum- mit of the chest in cases of pleuritic effusion. An interesting case reported by M. Monneret, of Paris,4 goes to show, that in some in- stances, at least, of the latter description, this explanation may be valid. In this case, a patient at the Hospital Necker, in connection with the physical evidence of liquid in the chest, the percussion-sound at the summit, behind and in front, was persistingly tympanitic and at the same time dull. Paracentesis was resorted to, and a certain quantity 11 have observed in a case of pneumonitis affecting the lower lobe of the right lung the physical signs of well-marked moderate emphysema limited to the upper lobe on the affected side, viz., tympanitic resonance, diminished intensity of the respiratory murmur and increased convexity in the infra-clavicular region. Is not this significant of the condition giving rise to tympanitic resonance at the superior part of the chest on the affected side, both in cases of pleurisy and pneumonitis ? 2 Lectures on Diseases of the Chest. Dr. Walshe attributes the suggestion to Dr. Hudson. s Called by Dr. Walshe tubular. 4 Gazette des Hdpitaux, August 31, 1854. PERCUSSION IN DISEASE. 119 of pus removed. Subsequently there took place perforation of the lung from the pleural surface within. After death, it was found that exactly within the limits of the tympanitic percussion-sound at the summit of the chest, the lung was firmly attached by old adhesions. The reporter attributes the tympanitic resonance in this case to the air within the bronchial tubes modifying the sound in consequence of the close attachment of the lung to the walls of the chest. 2. The second incidental circumstance referred to is emphysema- tous dilatation of the cells in the vicinity of the solidified portions of lung. It is sufficiently intelligible that a tympanitic resonance should exist under these circumstances ; and this is admitted by Skoda. That the air-cells surrounding portions of lung rendered solid by tuber- culous deposits, or other forms of disease, are consequently liable to become emphysematous, is an admitted fact in pathology, and accords with the ingenious theory of the mechanism by which emphy- sema is produced, lately advanced by Dr. Gairdner of Edinburgh.1 It is readily conceivable that the two circumstances just stated, viz., the air contained in the bronchial tubes giving rise to resonance in consequence of solidification of the parts lying between these tubes and the walls of the chest, and local emphysema, may be combined contributing conjointly to render the percussion sound more or less intense and tympanitic. Thus far the expression tympanitic resonance has been considered in a generic sense, as a non-vesicular sound, differing in different in- stances only in intensity. It is occasionally presented with peculiar modifications of quality, which are in some measure significant of a special pathological condition. These modifications may be embraced in two classes, viz., amphoric resonance, and the cracked-metal sound {bruit de pot fete). Amphoric resonance denotes a metallic ringing sound, such as is sometimes elicited by percussing over the stomach, and which may be imitated by striking the cheek when the jaws are moderately separated and the integument rendered somewhat tense, as is done in 1 The second explanation will hardly apply to cases in which the entire upper lobe is solidified in pneumonitis, and under these circumstances I have repeatedly noted the presence of tympanitic percussion-resonance. There seems in such cases to be no alter- native but to adopt the explanation of Dr. Williams. That the tympanitic resonance in such instances is not transmitted from the stomach (on the left side) is probably proved by this fact, which I have repeatedly noted, viz., the pitch of the tympanitic sound at the summit, and that of the gastric tympanitic sound at the lower part of the chest, may present a marked disparity. 120 PHYSICAL EXPLORATION OF THE CHEST. the trick of imitating the pouring of liquid from a bottle. The per- cussion-sound occasionally assumes this peculiar intonation in pneumo- hydrothorax ; and possibly also in cases of solidification from inflam- mation or tuberculous deposit. But in the vast proportion of the instances in which it occurs it is occasioned by a tuberculous excava- tion of considerable size, and, of course, more or less empty. Although not an infallible sign of a cavity, the evidence is very nearly conclu- sive if it be confined within a circumscribed space, at the summit of the chest. Piorry calls it a " water-sound," under the supposition that air and liquid contained in a cavity are necessary for its pro- duction. This opinion, according to Skoda, is disproved by experi- ments. The cracked-metal sound, as the title implies, resembles that pro- duced 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 children, pro- ducing 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. Several observers have noticed it in children at the summit of the chest in thoracic affections without excavation, and even when no pulmonary disease existed. Two striking instances have fallen under my own observation. In one, a child five years of age the sign was marked in the left infra-clavicular region, and after death there was found an abundance of tuberculous deposit without excavations, but lying directly beneath the left bronchus, was a mass of tuberculous matter, the largest collection found anywhere being about the size of an English walnut. In the other case alluded to, the child was reduced to extreme emaciation, but without cough or other symptoms of pulmonary disease. The sign in the latter case was so well marked that the patient was several times presented to a medical class to illustrate the peculiar character of the cracked-metal resonance. The production of this sound is now generally attributed to the air being suddenly and forcibly expelled from a cavity commu- nicating with the bronchiae by several free openings, precisely as the blow on the knee expels the air between the palms in the experiment mentioned 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 demonstrate the production PERCUSSION IN DISEASE. 121 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. Percus- sion 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 in which consolidation of the lung existed. 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 denoting 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 associa- tion with other signs. It would be an error to suppose that either of the preceding varieties of tympanitic resonance is found, save in a very small proportion 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 conditions may be essential, the importance of which is not so appreciable. Cavities resulting from circumscribed gangrene, or abscesses in connection with pneumonitis, do not embrace the necessary physical conditions, and the signs are therefore chiefly significant of tuberculous excavations. They may occur in connection with pouch-like enlargement of the bronchiae. It would also be an error to infer that whenever a cavity gives rise to well-marked tympanitic resonance on percussion, the sound is necessarily either amphoric or of the cracked-metal character; a tympanitic, i. e. a non-vesicular resonance, may be elicited over a cavity without any special modification of the quality of the sound. Under these circumstances, how is a cavernous resonance to be dis- tinguished 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 affords, it would certainly be difficult, if not impossible, to make the discrimi- nation. If a distinct tympanitic resonance, with no peculiarity of character, be found over a circumscribed space, at the summit of the 122 PHYSICAL EXPLORATION OF THE CHEST. chest on one side, the sound elicited around the border of this space being dull, the evidence thus derived solely by percussion of the exis- tence 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 tympa- nitic resonance is sometimes present, and at other times absent; the 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. Occasionally a tympa- nitic 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 emission of puruloid matter by 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 auscultation. So far as percussion is concerned, indeed, the results of percussion are much oftener negative than otherwise, owing to the cavities being more or less filled with liquid, or other circumstances not being favorable for the production even of simple tympanitic resonance. Summary. The abnormal sounds developed by percussion are distinguished from each other, and from the normal thoracic resonance, by varia- tions in timbre, or quality, in intensity, in pitch, and in duration. For practical purposes it suffices to arrange them into divisions based on differences in intensity and in quality; variations in pitch and duration furnishing incidental characters. Thus arranged, the several classes of abnormal sounds are as follows: 1, exaggerated vesicular resonance; 2, diminished resonance; 3, absence of resonance; 4, tympanitic resonance. 1. Exaggerated vesicular resonance is characteristic of vesicular emphysema. It is highly distinctive of that affection, unless the distension of the cells and expansion of the thoracic walls be very great, when the sonorousness may be diminished. Exaggerated re- sonance from emphysema retains the vesicular quality distinctive of summary. 123 normal resonance, but this quality may be diminished more or less, and the sound approximate in timbre to the tympanitic. In propor- tion as the latter alteration takes place, the pitch is raised. 2. Diminished resonance, or dulness, occurs, as a general rule, when a thin stratum of liquid removes the lung a short distance from the chest; when the pulmonary substance is condensed by pressure of liquid effusion within the pleural sac, or, more rarely, by fluids in the bronchial tubes, by serous effusion within the cells or areolar tissue, and by vascular engorgement; by tumors encroaching on the thoracic space, and by deposit of solid products within the lungs, viz., coagulable lymph, tubercle, carcinomatous matter, and a bloody clot; cceteris paribus, the degree of dulness is in proportion to the extent to which the air-cells are compromised, and the relative quantity of air to the solid parts reduced. Important exceptions to this rule are observed. In a large proportion of cases of pleural effusion, the per- cussion-sound above the level of the liquid, for a variable period during the progress of the disease, is exaggerated, and in its charac- ter tympanitic. The same is true of the percussion-sound over the healthy lobe on the side in which the lower lobe is solidified in pneu- monitis. A tympanitic resonance is propagated from the stomach and intestines in cases of solidification of the lower lobes, more espe- cially the left lobe. It accompanies also, sometimes, partial solidifi- cation from tubercle, or other deposits at the summit of the chest. Whenever the sound becomes dull, the pitch is raised, and the dura- tion shortened. The pitch is also higher when it becomes tympanitic. The diseases in which diminished resonance occurs, with the excep- tions just stated, are pleurisy and hydrothorax, above the level of the liquid ; pneumonitis ; oedema of the lungs ; great congestion; pulmo- nary apoplexy; carcinoma, and tuberculosis. 3. Absence of resonance, or flatness, is occasioned by an accumu- lation of liquid in the pleural sac, and exists below the level of the liquid; sometimes by complete solidification in pneumonitis, and by tumors, or morbid growths. An increased sense of resistance, under these circumstances, is marked. • 4. Tympanitic resonance embraces all abnormal sounds (exclusive, of course, of flatness, which is, strictly speaking, absence of sound), which are non-vesicular. It exists in the most marked degree in cases of pneumo-hydrothorax. But in this affection, if the walls of the chest are distended so as to be made quite tense, the sound may become dull, although in character still tympanitic. The sound 124 PHYSICAL EXPLORATION OF THE CHEST. transmitted from the stomach or intestines, when percussion is made over solidified lung, is purely tympanitic. The sonorousness some- times existing over condensed lung, or lung solidified by morbid deposits, at the summit of the chest, is also more or less tympanitic. A tympanitic resonance may also be developed by percussion over tuberculous excavations. In the latter case it is circumscribed in extent. Tympanitic resonance, under these circumstances, occasion- ally presents a ringing metallic intonation, and it is then called amphoric resonance. This modification is sometimes observed when sonorousness exists over solidified lung. Another modification is a cracked-metal sound {bruit de pot fete), sometimes produced by per- cussing over a cavity of considerable size, superficially situated, having rigid walls, and communicating freely by several orifices with the bronchial tubes. The same peculiar sound, however, has been repeatedly observed in children at the summit of the chest, being caused by the forcible expulsion of the air from the bronchial tubes. 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 pereussione thoracis Humani ut signo abstrusos interni pectoris morbos detergendi.1 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, M. Piorry, of Paris, is by far the 1 One cannot avoid an emotion of sorrow at the thought that Auenbrugger, who de- voted 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. history. 125 most prominent. Mediate percussion was introduced by him. He is the author of several works on the subject.1 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 situa- tion 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 ade- quate to most of the objects to be attained by percussion, originated with Drs. Cammann and Clark, of New York. 1 Traite" de la Percussion mediate, Paris, 1828, and Du Proc^de ope"ratif de la Per- cussion, Paris, 1831. The views of M. Piorry are also embodied in a more recent work, by one of his pupils, M. Maillot, Traiti 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 by percussion, 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 manipulations of the listener, while in auscultation they result from the actions, either instinctive or voluntary, of the patient. The explorer, in the one case, is an active agent in originating the impressions received through the sense of hearing; in the other case he is little more than a passive recipient. Another point of dif- ference 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.1 In immediate ausculta- tion, the sounds are received by the ear placed in immediate contact with the chest. Mediate 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, which is to be preferred ? Each mode has its peculiar ad- vantages, and neither should be adopted to the exclusion of the other. Immediate auscultation is the simpler mode; it is in most cases prac- 1 These terms were first employed by Laennec, and subsequently borrowed and applied to percussion by Piorry. auscultation. 127 tised 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 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 alone 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 patients is often not a trifling objection ; and with females, 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 contact with the chest. With the stethoscope, the area whence the sounds are transmitted is more circumscribed, and this is an important advan- tage under some circumstances, as in seeking for the auscultatory signs of an excavation, or of tuberculous consolidation contained within narrow limits. In some cases in which the surface of the chest has been rendered very irregular by injuries, or deformities, 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. Laennec appears to have regarded it in the light of an ear trumpet rendering sounds more audible than they appear to the unassisted ear. It is simply a conducting medium. It does not augment sonorous vibrations. And the glory which will ever attach to the name of Laennec, as has been justly remarked, is in no measure derived from the in- vention of the stethoscope, but solely from the discovery of auscul- 128 PHYSICAL EXPLORATION OF THE CHEST. tation. A great variety of stethoscopes are in use. Almost every one who has bestowed special attention on this branch of practical medicine, seems to have felt it incumbent to originate an instru- ment 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 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 conducting power, indeed, is of less con- sequence than might be at first imagined, provided the sounds are fairly transmitted; for intensity, as a general remark, is of less value than other features by which auscultatory signs are recognized and discriminated, and often it is of very little account whether the phe- nomena due to respiration are strongly or feebly conveyed to the ear, if they are distinctly appreciable. The first stethoscope constructed by Laennec was composed of three quires of writing paper rolled compactly in the form of a cylinder and secured by paste. After- ward 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 competent authority.1 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 gene- ral principles to be observed in its construction. Some (Hughes, Wat- son, and Blakiston) prefer solid wooden cylinders. Most of the in- struments, however, in common use are perforated 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 enclosed within the canal passing through the cylinder. Of the different kinds of wood, either cedar or ebony is usually selected from their lightness and straightness of fibre. The instrument 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 1 Dr. J. Hughes Bennett. AUSCULTATION. 129 accurately adjusted to the chest. Six to ten inches are the limits of a convenient length. The end applied to the ear (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 stethoscopes are faulty in these points; the aural extremity is too small, and the con- cavity 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 material 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 end applied to the chest (pectoral extremity), should be trumpet 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. With these few 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 which a particular instrument is employed; and it is undoubtedly true that a stethoscope defective in certain points of construction will be pre- ferred by one accustomed to its use, over another which is in reality superior, but to which he is not habituated. Flexible stethoscopes are used to some extent, and by some pre- ferred to the wooden cylinder. Their introduction in this country is due to Dr. Pennock, of Philadelphia. 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 extremity consists of a metallic cone, and to the aural extremity a tube is attached, also of metal, which is introduced within the exter- nal ear. The chief recommendation of a flexible stethoscope is that it admits of application to different parts of the chest, without the necessity of much change of position on the part either of the patient 9 130 PHYSICAL EXPLORATION OF THE CHEST. or operator. In some instances this is an important desideratum. The instrument is a sufficiently good conductor of the thoracic sounds. A disadvantage of it is, that the pectoral extremity requires to be held in apposition to the chest with one hand, and the aural extremity kept within the ear by the other hand. Sounds produced by the con- traction of the muscles of the hands, and by friction on the instru- ment, are apt to be commingled with those received from the chest. A little practice, however, enables the listener to disconnect 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 a stethoscope with a number of gum-elastic tubes, by means of which several persons may auscultate simultaneously. Dr. Marsh, of Cincinnati, has invented and patented an instrument with two tubes. A peculiar feature of the latter is a gum-elastic membrane stretched across the pectoral extremity. I cannot speak of this instrument from any practical knowledge of it. Quite recently a flexible stethoscope on a novel plan has been in- vented by Dr. Cammann, of New York. It consists of a bell-shaped pectoral extremity, made of ebony, and 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 each side at the same time. The sounds are thus received through both organs of hearing, and other sounds than those transmitted by the instrument are excluded. In the construction of this instrument the agency of the column of air in conducting the thoracic sounds is supposed to be 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 by means of this instrument with great intensity ; and are rendered distinct when scarcely appreciable by the naked ear, or with the ordinary cylinder. In the latter respect it serves virtually to enlarge the application of auscultation by developing positive results in cases in which, by former modes of examination, the signs are negative. It also renders auscultation available to those whose sense of hearing AUSCULTATION. 131 is impaired. Conducing, however, in a striking degree to the inten- sity of sound, the quality and pitch are altered, as indeed, is stated by the inventor. In making trial of the instrument, I have found it more difficult to institute comparisons as regards quality and pitch of sound than with the ear alone, or the ordinary stethoscope ; but with reference to differences of intensity, and in rhythm, it admits of a wider application than the common modes. It renders distinctly audible, also, morbid sounds in some instances in which they are too obscure to be studied satisfactorily without its aid. For comparison of the two sides of the chest as respects the resonance produced by the act of speaking, it is exceedingly well adapted. With these advantages the invention is entitled to be considered a valuable contribution to the means of physical exploration. In using the instrument it is to be borne in mind that it conducts sounds pro- duced exterior to the chest in no less a degree than those emanating from within the thorax. The slightest friction of any substance upon it gives rise to a loud sound. The pectoral extremity must be applied to the naked skin to avoid this source of extrinsic sounds. It is intended to be a self-adjusting stethoscope, but in order to keep it firmly and equally applied, I have found it necessary to hold the pectoral extremity between the fingers ; this is a source of extrane- ous sounds which by practice are to be guarded against as much as possible, and recognized when they are produced.1 , With the aid of an assistant, or of the patient himself, in keeping the pectoral extremity of this stethoscope to the chest, it must be admi- rably suited for auscultatory percussion, as proposed by its inventor in connection with Prof. Clark. In the performance of auscultation certain rules are to be observed, the more important of which may be here stated. Whenever practi- cable, 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, 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 1 Dr. Cammann's stethoscopes are manufactured and sold by Messrs. George Tieman & Co., No. 63 Chatham St., New York. 132 PHYSICAL EXPLORATION OF THE CHEST. patient be confined to the bed, the chest in front may be examined in the recumbent posture, and afterward, if the disease be not accom- panied by extreme debility, he may be raised, and supported 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 ver- tical position of the body 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 the flexible stetho- scope. It rarely occurs, however, that when a careful examination of the back is desirable, a favorable position is impracticable. 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 alter- nation. So far, however, as concerns the transmission of sounds, this is not necessary. A single thin covering of cotton or linen offers little or no obstruction, nor is it a serious hindrance to deter- mining often with sufficient accuracy the particular parts of the chest to be examined in succession. Several thicknesses, or a thick woollen article of dress, interferes with the appreciation of auscultatory pheno- mena. 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 or stethoscope. In immediate auscultation a soft napkin, or handkerchief, may be interposed between the skin and the ear, in order to obviate the disagreeable circumstances often atten- dant on applying the head to the naked surface. A regard for delicacy prevents complete exposure of the chest of the female. The portions, however, most important in cases in which a minute and visual 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 properly regulated, especially if the chest be exposed. This is important not only to obviate the liability of the patient suffering 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 murmur, it might be supposed to ema- nate from within the chest. The position of the explorer should be one favorable for listening with attention, and which may be main- tained for some time without fatigue or discomfort. If he assume a constrained posture his mind will be diverted from the object of AUSCULTATION. 133 the examination to his own sensations, and he will be unable to re- serve 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 in- duces a temporary congestion, which dulls the sense of hearing. It is not uncommon to see practitioners 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 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 imme- diate auscultation, or the use of the wooden cylinder. With a flexible stethoscope from one to two feet in length, the explorer may remain sitting by the side of the patient, the latter lying, or seated, as the case may be. This is one of the recommendations of this instrument to be placed against its disadvantages. The ear is to be pressed against the chest, or on the cylinder, with a certain amount of force. If the pressure be made too lightly the sounds are not transmitted, or an unnatural character may be com- municated 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 that incident to cer- tain morbid conditions, constituting the physical sign called aegophony. On the other hand, if too great force be applied, pain may be occa- sioned sufficient to disturb the respiratory movements, or the expan- sion of the chest may even be mechanically impeded. Attention to this point, with practice, will enable the auscultator to hit the medium between the two extremes. If the cylinder be employed, the pec- toral 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 in- strument, which is to be kept in place by means of pressure with the ear alone. Non-observance of this rule is one of the circumstances by which a mere formalist in the practice of auscultation may be detected. In practising 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 134 PHYSICAL EXPLORATION OF THE CHEST. habit of mental abstraction, and the power to concentrate the attention exclusively on the thoracic sounds, are not generally acquired with- out 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 dif- ferences in this respect that some persons become much better auscultators than others. Every one accustomed to physical explo- ration must have observed that the facility and satisfaction with which examinations are made, differ considerably 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, therefore, 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 acoustic phenomena revealed by auscultation relate to the respiration, the voice, and the act of coughing, the latter being comparatively of little consequence. In listening tOj the respiratory sounds, the manner in which the patient breathes is a matter of im- portance. 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 unsatisfatory, or even prove abortive. In persons of great nervous impressibility it is frequently necessary to wait until calmness is restored before proceeding with, or completing an exploration. As justly remarked by Fournet, the manner and bearing of the physician have much to do with this point. If he wear a solemn mien, and favor by his looks or actions the idea that the operation is one of formidable import, he will be less successful than if he manages to divest it of repulsive features. With reference to this end immediate auscultation, in which no instruments are exhibited, is to be preferred, whenever the object can be equally well attained by that mode. It is generally desirable to cause the patient to breathe with more than ordinary force in the progress of the examination, and it is sometimes extremely difficult to effect this object satisfactorily. He accelerates the respiration, or takes a deep inspiration and holds his breath, or in different ways alters the rhythm of the respiratory acts. The end de- sired is simply to render the breathing somewhat more intense without AUSCULTATION. 135 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 respiratory phenomena are not ap- preciable except the force of the breathing be voluntarily or involunta- rily 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 person examined, for sounds emanating from the thorax. The patient should be instructed to avoid making labial sounds, which by entering the ear not applied to the chest, tend to distract the attention, if they do not lead to the error just mentioned. In auscultating the voice, the plan usually adopted is to cause the patient to count from one to five, repeating these numbers as often as may be requisite, being careful 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. Hence here, as in the practice of percussion, a comparison is instituted between the two sides of the chest. The laws of disease, in a large proportion of cases, permitting one side of the chest to retain the phenomena of health, enable us to judge of morbid phenomena by means of a want of correspondence be- tween 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 com- parison, well-marked physical signs of disease. But in certain in- stances, as will be seen hereafter, a close comparison of corresponding points of the two sides is very necessary in determining the exis- tence 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 enuncia- tion 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 identical as possi- ble, etc., are points not to be overlooked when nicety of discrimination is involved in the diagnosis. 136 PHYSICAL EXPLORATION OF THE CnEST. Finally, to employ auscultation successfully, the explorer must be qualified by knowledge and practice to appreciate the sounds incident to respiration and the voice, in the different aspects in which morbid deviations from health are liable to be presented; he must be pre- pared, in other words, to recognize the morbid phenomena which may exist, and to do this he must make himself conversant theoretically, and as far as opportunities are offered practically, with the facts and principles which have been established by the labors of those who have devoted attention to the subject. Otherwise he is met by all the difficulties which the pioneers in the cultivation of this field of research were obliged to encounter; 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 become a proficient in physical exploration. In the study of auscultation, as of percussion, the point of departure for investigating the signs of disease is an acquaintance with the phe- nomena 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. But there is an additional reason why the study of the auscultatory phenomena pertaining to the respiratory system in health is to be commended to the student's careful attention before he enters on the subject of the signs of disease, viz.: by means of this preparatory knowledge he is at once qualified to appreciate some of the more important of the morbid sounds. Incongruous as it may at first appear, it will be found to be true, that certain of the most valuable of the physical signs involved in diagnosis, may be studied in persons entirely free from disease. This fact will appear in the sequel. In treating of Auscultation in Health we are to consider the phenomena incident to respiration, to the voice, and to the act of coughing. We will consider these phenomena under separate heads. AUSCULTATION IN HEALTH. 137 PHENOMENA INCIDENT TO RESPIRATION. These phenomena are by no means the same in all parts of the respiratory apparatus, and it is highly important to study them in different portions of this apparatus separately. The respiratory sounds are widely different, according to the sources whence they are supposed to emanate. As distinguished by their origin, either in the air-vesicles, or different parts of the air-tubes, they may be arranged into three classes, viz. : 1. Those situated in the trachea, and in this class may be included laryngeal sounds; 2. Those produced within the larger bronchi; 3. Those originating in the smaller tubes and vesicles. The phenomena thus incident to tracheal, bronchial, and vesicular respiration are to be investigated separately, and contrasted with each other. 1. Tracheal Respiration.—To auscultate the trachea the ste- thoscope 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 inspi- ration 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 distinguished as a tubular sound. This term tubular it is convenient to use by way of distinction. Occa- sionally the sound has a ringing, metallic quality. The respiratory and the expiratory tracheal sound present some differences, and merit sepa- rate 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 quite intense with ordinary breathing, but it always becomes much more so when the force of the breath- ing 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 regards intensity, it is frequently, but -not generally, more intense in ordinary respiration, but almost in- variably in these cases becomes less intense than the expiratory sound in forced breathing. In duration the inspiratory sound falls a little short of the period occupied 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 138 PHYSICAL EXPLORATION OF THE CHEST. 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- siderably with different 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, with a few exceptional or doubtful instances, more acute than the inspiratory sound with ordi- nary respiration, and this is uniformly the case when the respiration is forcibly increased. It presents oftener than the inspiration the quality called metallic. In duration, in the great proportion of in- stances, it 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 expira- tory, like the inspiratory sound, quickly attains its maximum of intensity, but instead of preserving the same intensity, it gradually becomes 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 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 1 In order to appreciate this point of distinction in anticipation of the consideration of the vesicular respiration, the student may compare the two by listening to the respiration with the ear applied to the chest after auscultating the trachea. AUSCULTATION IN HEALTH. 139 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 com- parative 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 concern- ing 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, 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 diminu- tion 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 in part due to the greater force of this act; but in part, probably, to the greater contraction of the glottis by the approximation of the vocal chords, which recent obser- vations have shown to take place with expiration, the space between the chords dilating regularly with inspiration. This approximation is greater in proportion as the respiration is forced, a fact which corresponds with the more marked elevation of pitch under these cir- cumstances. (Introduction, pages 33 and 53.) The tone and intensity of the tracheal respiration, may be readily ! Ex. gr. Barth and Roger,« Sur le larynx meme le murmure varie encore; il ressemble a l'espece de souffle que determinerait l'entree de l'air dans une cavite" plus large; outre sa rudesse, il prend un caractere caverneux beaucoup plus marque" et constitue le bruit respiratoire larynge." Op. cit. p. 36. 140 PHYSICAL EXPLORATION OF THE CHEST. 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 establish- ing types of cardiac bellows murmurs, has been long since pursued by Bouillaud and Hope. Following Skoda, the letters ch, soft, will re- present a tracheal sound. The pitch and loudness may be varied by graduating 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 respiratory sounds incident to the trachea. The tracheal respiration may be heard with distinctness, and some- times with considerable intensity, when the stethoscope is placed on the neck behind, over the cervical vertebrae. 2. Bronchial Respiration.—The normal bronchial respiration is the sound supposed to be produced within the bronchial tubes on either side prior to their entering the lungs. The points where either the stethoscope or ear is to be applied, in order to observe the phe- nomena incident to this portion of the respiratory apparatus, are in front, between the second and third ribs, close to the sterno-clavicular junction; and behind, in the interscapular space, on a line with the spinous ridge of the scapula. Applied over the upper part of the ster- num in front, as directed by some authors, the sound must necessarily come mainly from the trachea. In fact, it is not probable that in the situations lying directly above the bronchi, the respiratory sounds are purely bronchial in their origin. The tracheal respiration may be heard there in some, if not in a greater or less degree, in most persons. Generally, also, the vesicular respiration emanating from the air-cells, modifies, to a greater or less degree, the character of the sound. The normal bronchial respiration is thus, in reality, a mixed respiratory sound, and the differences which are to be noted in different individuals, are to be explained, in a great measure, by the combination, in varying proportions, of the three varieties, viz., tracheal, bronchial, and vesicular respiration. The study, however, of the auscultatory phenomena, in the situations named, is of much interest and impor- tance, not only in order to become conversant with the sounds proper to those portions of the chest, but because they furnish types of phenomena incident to disease in other situations. It will be seen, hereafter, that the different grades of what is distin- guished as the normal bronchial respiration, when present in portions AUSCULTATION IN HEALTH. 141 of the chest other than the points where they belong in health, may constitute significant indications of morbid conditions. The student, therefore, by impressing on the memory, and verifying by practice on healthy individuals, the characters and diversities which belong to the normal bronchial respiration, is acquiring knowledge which will be directly available in diagnosis. The previous study of the tracheal respiration will prepare for that of the bronchial, the two being, as will be perceived, analogous, and often, if not generally, essentially identical. Directing attention first to the anterior surface of the chest, if the ear be applied near the sterno-clavicular junction, a respiratory sound, differing in several important features from that heard over the remainder of the chest (vesicular respiration), is heard in the vast majority of cases. To indicate the several points of difference would require an anticipation of the description of the vesicular respi- ration. The two kinds of respiration will be fully contrasted when the latter is considered. But in describing the former it will be ne- cessary to imply knowledge of the fact that the bronchial, as well as the tracheal respiration, differs from the vesicular in a tubularity of character, as distinguished from what will be called a vesicular quality, and in greater altitude of pitch. Other distinctive traits need not now be alluded to. The following account will be based in part on examinations of twenty-three persons in health, made several years ago, in order to study the characters of the normal bronchial respira- tion ; and more especially on another series of twenty-four exami- nations made recently for the same purpose. In both series the memoranda were noted at the instant of observation, and the facts afterward analyzed. In almost every instance a bronchial sound of respiration was dis- coverable, both in front and behind, at the points mentioned,1 on both sides of the chest. In several instances2 a respiratory sound was either absent or scarcely appreciable, except when the force of breathing was voluntarily increased, and in the degree of intensity marked difference existed in different persons. It was not appre- ciable with the cylinder in all instances in which it was discoverable, and even well developed, by employing immediate auscultation,3 a fact 1 Absent in 7 of 47 cases in front, and 2 of 36 cases behind. These 9 cases all are within the first series of examinations. By employing Cammann's stethoscope a sound could probably have been discovered in every instance. These examinations were made before that stethoscope was invented. 2 Six of 24 cases in front, and 9 of 22 cases behind. 3 This fact was noted as follows : In front, of 24 cases, on both sides of the chest, in 142 PHYSICAL EXPLORATION OF THE CHEST. which goes to show that by immediate auscultation the tracheal sound is transmitted, since the stethoscope circumscribes the space whence the sound is conducted, while the ear applied directly to the chest derives it from a wider circuit. In a single instance the sound was appre- ciable with the cylinder and not by immediate auscultation. In two instances it was heard distinctly with Cammann's instrument, when not appreciable either with the ear alone or the ordinary stethoscope. In every instance, either in front or behind, in which the bronchial respiration was compared with that over other parts of the chest, for example, the middle of the infra-clavicular, and in the infra-scapular regions, it was found more or less deficient in the vesicular quality, in other words approximating to the purely tubular character of the tracheal respiration, also uniformly higher in pitch, and differing frequently in other characters.1 The bronchial respiration is heard in some persons with both re- spiratory acts, and in some with the inspiration only. In these points striking differences are observable. Marked disparities are also frequently found to exist between the two sides of the chest in the same person. The readiest way to present an idea of these variations will be to give, as succinctly as possible, the result of the analysis of the examinations already referred to. Limiting the analysis to the twenty-four recent examinations, of this number the bronchial re- spiration was heard near the clavicular sternal junction with the act of inspiration only, on both sides of the chest, in twelve instances, leaving the same number of instances in which it was heard both with inspiration and expiration. Behind, in the upper part of the interscapular space, of twenty-two examinations, it was heard with the inspiration alone, on both sides, in seven; leaving fifteen instances in which it was heard with both respiratory acts. According to these examinations, then, an inspiratory and expiratory bronchial sound on both sides of the chest will be found, in front, in the pro- portion of one half, and behind, in the proportion of two-thirds of persons free from disease. 3 cases ; on the right side, 2 cases; on the left side 1 case. Behind, of 22 cases, on both sides, 3 cases. 1 In making this statement, I am compelled to differ from authorities on the subject of physical exploration so distinguished as Barth and Roger. These writers say (Traite" Pratique dAuscultation, etc., 1854, page 33): "Il ne faudrait pas croire que cette respiration bronchique existe toujours en ces points, et se distingue nettement de la respiration des autres regions: tres-souvent l'oreille la plus exerce"e ne saisit pas de difference sensible." AUSCULTATION IN HEALTH. 143 As respects this point, the two sides are by no means uniformly in correspondence. The inspiratory sound, in a certain proportion of cases, is alone heard on one side, while the inspiratory and expiratory are heard on the other side. This dissimilarity, however, is subject to a rule which, so far as my examinations go, is invariable, viz., a sound accompanies both acts of respiration, not infrequently on the right side only, and this is never observed on the left side. In eight of the twenty-four examinations, a sound accompanied both acts on the right side, in front, while an inspiratory sound alone existed on the left side. This was true of the back in three of the twenty-two examinations ; neither in front, nor behind, did a sound with the two acts exist on the left side, and not on the right in a single instance. It remains to ascertain the results of the analysis as respects other characters of the bronchial respiration, and to institute a comparison between the two sides, in front and behind, as regards intensity of the respiratory sound, disparity in pitch of sound, and the relation of the expiration to the inspiration in intensity, duration, and pitch. We will direct attention now to these several points. Limiting the attention first to the inspiratory sound, in some in- stances the intensity appeared equal on the two sides, but in other instances a marked disparity was apparent. The enumerations with respect to this point are as follows : In front, of ten instances in which a disparity of the inspiratory sound was obvious, the intensity was greater on the right side in six and on the left side in four. Behind, of five instances, the intensity was noted greater on the right side in two and on the left side in three. Thus there is no rule restricting the existence of greater intensity of the respiratory sound to either side ; but, so far as these few observations go, the inten- sity is a little oftener greater on the right side in front and on the left side behind. The sum total of the instances, in front and behind, in which the intensity was greater on the right side, is thus eight; and on the left side seven. These results accord in a striking man- ner with those obtained by an analysis of the previous series of ex- aminations. Of the latter, the intensity was greater on the right side in five of nine instances, and on the left side in four.1 Comparing the inspiratory sound on the two sides as regards pitch, in a few instances it is noted that no difference was apparent, but in ' See Prize Essay on Variations of Pitch, etc., Transactions of Am. Med. Association, vol. v., page 84, et seq. 144 PHYSICAL EXPLORATION OF THE CHEST. a large proportion a disparity was obvious. A fixed rule evidently governs this disparity: of twenty instances in which it was observed near the sterno-clavicular junction, in nineteen the pitch was higher on the right side, and in a single instance only on the left side. At the upper part of the interscapular space, in all of nine instances, the pitch was higher on the right side. The results are in accordance with those obtained by the former analysis. The latter developed in twenty examinations, elevation of pitch on the right side in fifteen, no difference in this respect being appreciable in the remaining five.1 Practically, then, it may be assumed that a disparity in pitch exists in the larger proportion of instances, and that the pitch is almost invariably higher on the right side. In tubular character, or in deficiency of vesicular quality, a con- trast was observed between the two sides. In this respect the results show an invariable rule, viz., whenever a disparity exists between the two sides, the greater tubularity of sound is found on the right side. This was noted in thirteen instances in front and in three behind. The foregoing results relate to the inspiratory sound. Directing attention secondly to the expiratory, the relative intensity of the latter to the former is the first point which suggests itself. In a small number of instances, it is noted that the expiration was more intense than the inspiration. The number of instances is five ; but it is highly probable that attention was not given to this point in all the exami- nations. So far as these few observations go, they point to a rule, viz., when the intensity of the expiratory, as compared with the inspiratory sound, is decidedly greater, and confined to one side, the right side is the one presenting this contrast. In all of the five cases in which the fact was noted, it was on the right side. Comparing the pitch of the expiratory with that of the inspiratory sound, the results are more striking. In a very few instances (three) the expiratory sound was lower in pitch than the inspiratory. In each of these instances it was observed on the left side. In every other instance in which the presence of an expiratory sound was noted, it was higher in pitch than the inspiratory. An expira- tory sound higher in pitch than the inspiratory, on the right side, was noted in twelve instances, viz., nine in front, and three behind. In several instances in which this contrast between the two sounds existed on both sides, it is stated to have been much more marked See Prize Essay. AUSCULTATION IN HEALTH. 145 on the right side. The difference in this respect was sometimes very striking. The expiration was in some instances observed to be longer than the inspiration. This was oftener noticed on the right side. And in every instance in which attention was directed to the point, a brief interval separated the sound of inspiration and expiration. These re- sults are in accordance with those obtained by the previous analysis.1 In view of the foregoing results, the following is a summary of the descriptive facts and distinctive characters pertaining to the normal bronchial respiration, as heard at the sterno-clavicular junction in front, and the upper part of the interscapular space behind. In most persons a respiratory sound may be discovered and studied in these situations, if the force of respiration be increased, by auscultating with the ordinary stethoscope; in a still larger number this is practi- cable by immediate auscultation, and in nearly every individual, pro- bably, by means of Cammann's instrument; of a given number of individuals, in one-half we may expect to hear an inspiratory and expiratory sound in front; and in two-thirds behind. When a sound with both respiratory acts is found on one side, and not on the other, it is invariably on the right side. When there is a difference of intensity in the respiratory sound between the two sides, the greater degree of intensity is found sometimes on the right, and sometimes on the left side, the proportion of instances being not far from equal. The pitch of the inspiratory sound is generally greater on the right side, and almost never on the left side. In some instances also the in- spiratory sound is more tubular in character on the right than on the left side. The reverse of this is not observed. The expiratory sound is sometimes more intense than the inspiratory. When this is more marked on one side than on the other, it is on the right side. The same remark will apply to prolonged expiration. The pitch of the expiratory, as compared with the inspiratory sound, is higher. To this rule there are occasional exceptions, occurring only on the left side. A striking contrast between the two sounds in pitch is cha- racteristic of the bronchial respiration of the right side. When the sounds are heard with the two respiratory acts, a brief interval occurs between them. These facts are interesting and important to the student of physical exploration, as already stated, in the first place showing that the phe- nomena found at certain portions of the chest in health, together with 1 Prize Essay. 10 146 PHYSICAL EXPLORATION OF THE CHEST. the variations and the disparity between the two sides of the chest in these portions, which are not to be considered evidences of disease ; and, in the second place, exemplifying in the healthy chest the varieties of the bronchial respiration so-called, occurring as the signs of morbid conditions. In the latter respect it will come up for con- sideration under the head of Auscultation in Disease. On reviewing the elementary characters of the normal bronchial and the tracheal respiration, and instituting a comparison between them, it will be perceived that in the more important of these cha- racters they bear to each other a close resemblance. Both are de- ficient, but the tracheal more completely, in a peculiar distinctive quality, which will presently be seen to characterize the vesicular respiration. Both are high in pitch compared with the vesicular respiration. The expiratory sound in each (with a very few excep- tions in the case of the bronchial respiration on the left side), is higher in pitch than the inspiratory. Frequently in the bronchial, as in the tracheal, the expiratory sound is more intense and longer; and an interval separates the two sounds in both cases. The chief points of difference are the greater intensity of the tracheal sound, its purely tubular character, and the constant presence of an expiratory sound. As already remarked, it may be doubted whether the normal bron- chial respiration is exclusively bronchial, i. e. produced solely within the bronchial tubes; but it is a combination of a bronchial sound with the tracheal, modified more or less by the vesicular respiration. The sound frequently appears to come from a distance. This was noted in several of the examinations, especially with respect to the expiratory sound. The loud expiratory sound is probably derived chiefly from the trachea. On the other hand, the want of complete tubularity, greater in some instances than in others, may be attribu- table to an admixture of sound from the proximate air-vesicles. 3. Vesicular Respiration.—The sound incident to respiration heard over the chest elsewhere than upon the upper part of the sternum, at the sterno-clavicular junction, and in the upper part of the interscapular space near the spinal column, is called the pulmo- nary 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, pro- bably, in certain parts of the chest, to transmitted tracheal respi- AUSCULTATION in health. 147 ration. It is, however, true, that the predominant and distinguish- ing character of the vesicular respiration originates within the vesi- cles and capillary tubes. The expressions are therefore sufficiently appropriate, and the term vesicular is selected as the most dis- tinctive, and the one generally adopted. This appellation originated with Andral. 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 respiration from the tracheal and bronchial; 2. The variations in characters 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 and bronchial.' 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. The region most convenient for this purpose is the summit of the left lung a little below the clavicle, midway between the acromial and sternal extremi- ties. We will proceed, then, to institute a comparison between the characters of the vesicular respiration in the situation just mentioned, and those pertaining to the tracheal respiration. The tracheal respiration is selected in preference to the bronchial for the compa- rison, because, the contrast being stronger, the distinctive traits of the vesicular respiration are exhibited in bolder relief, and thereby rendered more clear and impressive. On auscultating the summit of the left side, at the point mentioned, either immediately, or with the stethoscope, a sound more or less intense is generally found to accompany the inspiratory act. Com- paring this sound with that heard over the trachea, 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 148 PHYSICAL EXPLORATION OF THE CnEST. which acts noiselessly; to softly sipping the air with the lips, etc. These comparisons are but rudely approximative, 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 per- cussion, is that peculiar kind of sound, not suggesting a priori to the mind the existence of cells, but due in a great measure, at least, to the cellular construction of the lungs. In what manner is this vesi- cular quality of sound generated ? I shall not discuss this, more than other questions relating to the physical mechanism by which auscul- tatory phenomena are produced. It is generally attributed, after Laennec, to the friction and vibrations caused by the air driven into the cells by the inspiratory act. May not the peculiar quality be owing to the separation of the walls of the cells and capillary tubes, which, to a greater or less extent, come into contact, and, owing to the moisture of the tissues, are slightly adherent during the collapse of the lung incident to expiration ? We shall see hereafter that this is the most rational explanation of an important and highly distinctive physical sign of disease. Whatever be the rationale, the distinctive quality of the vesicular respiration belongs to the inspiratory, and not to the expiratory sound. The inspiratory sound is somewhat longer in duration than the tracheal. Like the tracheal it is continuous, augmenting in intensity from its commencement to its termination, and ending rather abruptly. It is decidedly lower in pitch than the tracheal inspiration. According to Skoda, the average pitch of the vesicular inspiration may be represented by the consonant v or b, whispered. In a certain proportion of instances, an expiratory sound is appre- ciable. This was the case in fifteen of twenty-four examinations; no sound of expiration being discovered in the remaining nine instances. In this respect the vesicular respiration presents a striking point of contrast with the tracheal, the act of expiration constantly developing a sound within the trachea. The difference is not less striking in other respects. The expiration, when present in the vesicular respi- ration, is nearly or quite continuous with the sound of inspiration; not succeeding after a brief, but distinct interval, as in the tracheal respiration. This statement holds good, except when the person AUSCULTATION IN HEALTH. 149 examined, increasing voluntarily the force of the respiratory move- ments, 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 unfrequently 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,1 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 expiratory sound on the left side, cer- tainly in the great majority of instances, is lower than that of the in- spiratory. It is represented, according to Skoda, by a sound falling between the whispered consonants / and h. Here, too, the rule is the reverse of that which governs the tracheal respiration. In the latter, the pitch of the expiratory sound is usually higher than that of the inspiratory. These, then, are the several points of contrast between the tracheal and the vesicular respiration; and it is to be borne in mind that precisely the same points of contrast exist between the vesicular and the bronchial respiration, the only difference being that in the latter case they are exhibited in a less striking degree. To recapitulate: the distinctive characters of the tracheal and the bronchial 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 and Bronchial Respiration. Vesicular Respiration. Inspiration. Inspiration. 1. Tubular in quality. 1- Vesicular in quality. 2. In duration falling somewhat short of 2. Longer in duration. the inspiratory act. 3. High in pitch. 3. Low in pitch. 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 accuracy, but it is not a matter of practical moment. 150 PHYSICAL EXPLORATION OF THE CHEST. Expiration. Expiration. 1. Uniformly present in tracheal respira- 1. Absent in about one-third of the case3. tion. 2. Generally more intense than the inspi- 2. Intensity much less than that of the ration. inspiration. 3. As long or longer than the sound of 3. Much shorter than the sound of in- inspiration. spiration. 4. Higher in pitch than the inspiration. 4. Lower in pitch than the inspiration. 5. The inspiration and expiration sepa- 5. The inspiration and expiration conti- rated by an interval. nuous. As already stated, the foregoing points of contrast are applicable to auscultation in disease, for in connection with certain morbid con- ditions, it will be found that the vesicular respiration gives place to the tracheal or bronchial, and the latter then become physical signs of these morbid conditions. The vesicular respiration presents marked differences in different persons, not only of the same age and sex, but apparently with chests similar in conformation. This statement is applicable not alone to the respiratory sounds pertaining to the summit of the left side, but to the thoracic regions in general. In intensity it is very far from being uniform. In some persons it is with difficulty appreciable, and in some cannot be heard even when the force of the respiration is voluntarily increased. In others it is loudly developed. Between these extremes there is every grade of intensity. In the same person the murmur often differs considerably in intensity with different respi- rations, with some being perhaps full and loud, while with others it is feeble, and sometimes inappreciable, these fluctuations being observed in the space of 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 respiration compared with tranquil breathing, do not show any change except in an increased intensity. It is heard with greater intensity by immediate, than by mediate auscultation, provided the ordinary cylinder be em- ployed ; but with Cammann's stethoscope, the intensity is much greater than when the ear is placed in direct apposition to the chest. It may be distinctly appreciated with Cammann's stethoscope, when it is not heard with the ordinary cylinder or the naked ear. The expi- ratory sound, which, as has been seen, is present in some persons and absent in others, varying also in its relative duration, is sometimes discovered by immediate auscultation, when it is not heard with the cylinder; and in some instances may be rendered distinct by Cam- AUSCULTATION IN HEALTH. 151 mann's instrument, when it is inappreciable by the ordinary stethoscope or the ear alone. My recorded examinations of healthy chests con- tain illustrations of these facts. Sex and age exert a decided influ- ence on the intensity of the vesicular respiration. In early life the intensity is marked, so that a morbidly intense vesicular murmur, after Laennec, is frequently distinguished as puerile respiration. In old age, on the other hand, the intensity is diminished, a change to be attributed, according to Andral, 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 respi- ration. In females, as a general remark, the respiratory sounds are more intense than in males. This is true more especially of the vesicular respiration at the summit of the chest. In other respects than intensity, differences are to be 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 developed by percussion 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, generally, 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 tubular or blowing, resembling the tracheal in quality, but differing in its want of intensity and lowness of pitch. It remains to consider the variations in characters of the vesicular 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. Comparing first the two sides, the summit of the chest claims attention more especially, because slight deviations from correspon- dence in this situation are of great importance in their bearing on the diagnosis of tuberculous disease; and, moreover, anatomically, there is greater equality at the upper part of the chest, than at the middle or lower portion, in consequence of the presence of the heart 152 PHYSICAL EXPLORATION OF THE CHEST. and other organs, which encroach more or less on the thoracic space, rendering the two sides more or less unequal. Besides, the diseases seated in the lower and middle portions, pneumonia, pleurisy, etc., do not generally require so nice a comparison of the two sides as is frequently involved in the diagnosis of tuberculous disease, which affects by preference the superior part of the lungs. For the reasons just stated, the question in how far the two sides of the chest are in unison as respects the phenomena developed by auscultation, has an important practical relation, and it is highly desirable to determine what points of disparity may occur in this situation within the limits of health, in order that they may not be mistaken for the signs of disease. It is stated by Fournet as a conclusion based on repeated examinations of the chest in persons apparently free from thoracic disease, that the respiratory sounds at the summit on the two sides are absolutely identical, and hence, that any disparity is a just ground for assuming the existence of disease.1 The observations of others have shown this conclusion to be erroneous. Dr. Gerhard,2 of Phila- delphia, was the first to direct attention to the frequent existence of disparity between the two sides, consisting, according to him, in a greater intensity of the respiratory sound on the right side, which he attributed to the larger size and relative shortness of the right pri- mary bronchus. Subsequently M. Louis, in a series of examinations of persons free from pulmonary disease, found a certain proportion of instances in which an expiratory sound exists on the right side and not on the left; and that when it exists on both sides it is often more intense and prolonged on the right side. In the twenty-four examinations to which I have already referred, attention was paid, among other points, to the one under consideration; and an analysis of the phenomena recorded at the instant of observation, shows dif- ferences between the two sides of the summit in intensity, the amount 1 " J'ai choisi, dans des salles de militaires ceux qui avaient toutes les apparences de la same" la plus robuste, et qui avaient 6te" amends a l'h6pital par des maladies tout-a-fait etrangeres aux organes thoraciques; j'ai bien constate" chez eux qu'en effet, dans l'<}tat normal, les bruits respiratoires se faisaient entendre absolument 6gaux de l'un et de l'autre cote\ II resulte de la que toutes les fois qu'une difference existera entre les bruits des deux sommets de la poitrine, cette difference pourra, en regiegenerale, eHre attribuie a une itat pathologique."—Recherches sur VAuscultation, etc. t. 1, p. 64. The italics are the author's. Walshe also says, " The characters of the inspiration-sound do not differ in the corre- sponding points of the two sides of the chest to any appreciable amount." Ed. of 1854, page 93, English Ed. 2 The Diagnosis, Pathology, and Treatment of the Diseases of the Chest, by W. W. Gerhard, M.D., etc., 1846. AUSCULTATION IN HEALTH. 153 of the vesicular quality, and the pitch of the inspiratory sound, as well as in the relative development, duration, and pitch of the sound of expiration. - The results of the analysis are as follows : 1. Inspiratory Sound.—In sixteen of twenty-four cases, more or less difference as respects intensity between the two sides was appre- ciable. In all but one of these sixteen instances the inspiratory sound was more intense on the left side. This result is in direct opposition to the statements of some authors ;' but the matter is purely one of observation, and as the comparisons were made with care, and with no expectation of ariving at such a result, I am bound to assume its correctness. I can only account for the opinion of observers that the inspiratory sound on the right side is frequently more intense than that of the left, by supposing that elevation of pitch has been mistaken for increased intensity. The disparity in intensity was in some instances very marked. An inspiratory murmur was occasion- ally tolerably developed on the left side, and scarcely audible on the right. A striking difference was also in some cases observed in the effect of forced respiration on the intensity of the inspiratory sound, the intensity on the left side being proportionately increased, without any augmentation on the right side. In the relative amount of vesicular quality a difference was appre- ciable in a large proportion of the cases. And in all the instances in which a disparity in this particular existed, the greater amount of vesicular quality was on the left side. This was true in fourteen of twenty-four examinations of different individuals. The disparity in some instances was slight, but in several strongly marked; in not one instance was the vesicular quality greater on the right side. Compared as respects the pitch of the inspiratory sounds, a differ- ence was apparent in a large majority of the observations. Exclud- ing a few cases in which attention was not directed to this point, of nineteen examinations, the pitch was higher on the right side in twelve, and no disparity was appreciable in seven; in not a single in- stance was the pitch higher on the left side. The difference here as with respect to the preceding characters, was in some instances striking, and in other instances slight. This numerical result does not vary much from that obtained by an analysis of the series of previous examinations. The latter numbered fifteen, and of these fifteen examinations the inspiratory murmur was higher in pitch 1 Gerhard, Barth and Roger. 154 PHYSICAL EXPLORATION OF THE CHEST. on the right side in eleven, and no disparity was observed in the remaining four. So far as the data just presented, then, furnish ground for deduc- tions, a disparity between the inspiratory sounds at the summit of the chest in front, exists in a large proportion of individuals free from all symptoms of thoracic disease, this disparity pertaining to the inten- sity, vesicular quality, and pitch. Variations in these three charac- ters obey certain rules, viz., the greater relative intensity is almost uniformly on the left side. The same rule holds good with respect to a greater relative amount of the vesicular quality. On the other hand the greater elevation of pitch is always on the right side.1 2. Expiratory Sound.—Facts relative to the intensity of the ex- piratory sound on the two sides are contained in the notes of nine examinations. Of these nine comparisons, in three instances an ex- piratory sound was appreciable on the right side, and none on the left side; in two the development on the right side was greater than on the left, and in three, the intensity seemed equal on the two sides. In several instances the expiratory sound on the right side was prolonged, sometimes being nearly or even quite as long as the inspi- ratory ; on the contrary the expiratory sound, when present on the left side, was always short, never exceeding one-third of the duration of the inspiratory. It is noted in several instances that the expira- tory sounds on the right side seemed distant from the ear. In several instances, on the right side, a brief interval separated the sounds of inspiration and expiration. In every instance, on the other hand, on the left side, the two sounds were continuous. The pitch of the expiratory sound was higher than that of the inspiratory on the right side in eleven instances, and on the left side in a single instance. It was lower on the left side in six, and on both sides in four instances. According to the foregoing results, an expiratory sound exists on the right side in a certain proportion of cases in which none is appre- ciable on the left side. It is frequently prolonged on the right side, appears distant, and is separated from the inspiratory sound by an interval, and is higher in pitch. The facts presented in the foregoing comparative account of the summit of the chest in front, may be seen at a glance by reference to the subjoined table. 1 The relative duration of the inspiratory sound on the two sides is another point of comparison, to which attention was not directed in making the examinations. AUSCULTATION IN HEALTH. 155 Comparison of Right and Left Infra-clavicular Regions. Whole number of examinations twenty-four. Inspiratory Sound. Right. Left. Greater intensity in 1 case. Greater intensity in 15 cases. Vesicular quality more marked in no Vesicular quality more marked in 14 case. cases. Higher pitch of sound in 12 of 19 exami- Higher pitch of sound in no case. nations. Expiratory Sound. Right. Left. Present on this side, and not on left side, Present on this side, and not on right side, in 3 cases. in no case. More intense on this side in 2 cases. More intense on this side in no case. Prolonged in several cases. Prolonged in none. An interval between the sounds of in- The two sounds continuous. spiration and expiration in several cases. Pitch higher than that of the inspiratory Pitch higher in 1 instance. sound in 11 instances. Pitch lower than that of inspiration in 4 Pitch lower in 10 instances. instances. Reviewing the facts pertaining to both the inspiratory and the expiratory sound, it is perceived that the several elements which have been seen to compose the bronchial respiration are manifested at the summit of the chest, in front, on the right side. This is a practical conclusion arrived at by means of the foregoing analysis. Assuming this conclusion to be correct, its importance will be appa- rent hereafter, in connection with the diagnosis of tuberculosis of the lungs in the early stage. In that .connection, without knowledge of the facts which have been presented, it can hardly be otherwise than that error of diagnosis will be committed, by mistaking for the physical signs of disease, the several characters of the bronchial respiration which may exist at the summit of the right chest, not pro- ceeding from a morbid condition. I am free to state that my own experience would supply illustrations of error from this source. The post-clavicular region may be examined by auscultation, the stethoscope being requisite in this situation. The caution inculcated by Laennec, 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 develope an arterial bruit which 156 PHYSICAL EXPLORATION OF THE CHEST. is to be distinguished from a respiratory sound by observing that it is synchronous with the pulse, and persisting when the movements of respiration are voluntarily arrested. The vesicular respiratory 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 observations. In a single instance in which the phenomena were recorded, care being taken not to incline the stethoscope toward the trachea, the inspira- tory sound was more intense on the left side, and no sound of expira- tion appreciable on that side; but on the right side, after an interval, a well-marked expiratory succeeded the inspiratory sound, and higher in pitch. Passing, next, to the upper portion of the chest behind, over the scapula above the spinous ridge, owing to the difficulty of applying the ear directly, the stethoscope is preferable. With the wooden cylinder a respiratory sound is heard sufficiently to study its cha- racters and institute a comparison between the two sides in only a certain proportion of cases. With Cammann's instrument it is some- times rendered distinct when it is scarcely appreciable with the ordi- nary stethoscope. This instrument was used by me here, as in other situations, in but a portion of the examinations made with a view to study the phenomena incident to auscultation in health. The results developed by the analysis of these observations would probably have been to some extent different had it been uniformly employed in con- junction with immediate auscultation, and the use of the wooden cylinder. The facts pertaining to the respiratory sounds in the upper scapular region on the two sides contained in twenty-one examinations are exhibited in the following table: Comparison of Right and Left Tipper Scapular Regions. Inspiration. Absent on both sides in 5 cases. Right. Left. Sound indistinctly appreciable in 7 in- Sound indistinctly appreciable in 10 in- stances, stances. Intensity greater in 1 case of 7, in which Intensity greater in 3 cases. the sound was more or less developed by forced respiration. Pitch higher on this side in 2 cases. Pitch higher in no case. Vesicular quality more marked in no Vesicular quality more marked in 2 case. cases. AUSCULTATION IN HEALTH. 157 Expiration. Right. Left. Expiratory sound, absent in 7 cases. Expiratory sound absent in 10 cases. Indistinctly appreciable in 4 cases. Indistinctly appreciable in 5 cases. Prolonged in 5 out of 6 examinations Prolonged in no case. made with respect to this point. More intense than the sound of inspira- More intense than sound of inspiration tion, and higher in pitch in 5 cases. and higher in pitch in 1 case.1 It follows from these results that while an inspiratory sound is absent on both sides in an equal proportion of cases, viz., about one- third, the sound of expiration is oftener absent on the left than on the right side; both the inspiratory and expiratory sounds are oftener very feeble on the left side, but when tolerably developed the inspi- ratory sound on the left side is apt to be more vesicular and more intense than on the right, while the latter is apt to be higher in pitch; and the sound of expiration on the right side in a certain proportion of instances is prolonged, more intense than the inspiratory, and higher in pitch, this being very rarely the case on the left side. Ac- cording to these results the disparity frequently existing between the two sides, corresponds with that observed at the summit and in front. More or less of the elements of the bronchial respiration, in other words, are occasionally manifested on the right side. The respiratory sounds when heard over the upper scapular region are not only less intense than in front of the summit of the chest, but the vesicular quality is less marked, and they convey to the mind the impression of greater distance from the ear. In examining the scapular region below the spinous ridge, imme- diate auscultation is available. A respiratory sound is appreciable here in a larger number of instances than above the ridge, and is more intense when present in both situations. It is, however, consi- derably less intense in the cases in which it is fully developed than in the infra-clavicular region. Here, also, as above the spinous ridge, the vesicular quality is less marked, and the sound seems farther removed from the ear. An analysis of the observations recorded with reference to a comparison of the two sides gives the results exhi- bited in the following table : ' In this case the contrast with the inspiration in these respects, was less than on the right side in the same case. 158 PHYSICAL EXPLORATION OF THE CHEST. Comparison of Right and Left Lower Scapular Regions. Number of Examinations twenty. Inspiration. Absent on both sides in 1 case. Too indistinct to compare in 4 cases. Right. Left. More intense in 2 cases. More intense in 8 cases. Vesicular quality more marked in no case. Vesicular quality more marked in 6 cases. Pitch higher in 7 cases. Pitch higher in no case. Expiration. Presence noted in 7 cases. Right. Left. Present only on this side in 4 cases. Present only on this side in no case. More intense than inspiration in 3 cases. More intense than inspiration in no case. Higher in pitch than inspiration in 4 cases. Higher in pitch than inspiration in no case. Noted lower in pitch than inspiration in 1 Noted lower in pitch than inspiration in 3 case. cases. These results correspond with those presented in the previous tables. The inspiratory sound is oftener more intense and more vesicular on the left side, but wherever a disparity in pitch is ob- servable, it is higher on the right side. An expiratory sound is some- times present on the right, and not on the left side. The reverse is not observed. It is sometimes more intense than the sound of inspi- ration on the right side, but this does not occur on the left side. It is generally higher in pitch than the sound of inspiration on the right side, and this does not occur on the left side; on the other hand, it is distinctly lower in pitch in some instances on the left side, and rarely on the right side. In short, irrespective of disparity between the two sides as regards intensity, the respiratory sound on the right side presents in a certain proportion of cases more or less of the characters of the bronchial respiration. 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, which, as already intimated, have not escaped the attention of observers, 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 re- spects 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 pro- AUSCULTATION IN HEALTH. 159 bable 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 compressing al- ternately the right and the left bronchus with the finger. Compar- ing 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 possible 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 per- ceive 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 inconsis- tent with the fact that the inspiratory sound on the left side is fre- quently 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 in some instances 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. In the infra-scapular region a respiratory sound is almost uni- formly appreciable. It is generally well developed, and frequently with forced breathing becomes intense. Here, as in other situations, a very marked difference in intensity is often observed between the sounds developed by ordinary and forced breathing: with the latter, in some instances, they are quite loud, when with the former they may be scarcely heard. As a general rule, the intensity is greater than in the lower scapular region; the vesicular quality is also more appa- rent, and the pitch somewhat lower. This rule is not without excep- tions. The intensity in a small proportion of instances is about equal 160 PHYSICAL EXPLORATION OF THE CHEST. in the scapular and infra-scapular regions; so, also, the vesicular quality and pitch. In one of the examinations which I have noted, the in- tensity was in a marked degree greater below, than over the scapula. The person examined was a female. The subjoined table exhibits the results of a comparison of the two sides as respects the respiratory sound observed in this region. Comparison of the Right and Left Infra-scapular Regions. Inspiration. Present in all of 21 examinations. Right. Left. More intense in 1 of 14 examinations. More intense in 5 of 14 examinations. Vesicular quality more marked in none Vesicular quality more marked in 2 of of 11 examinations. 11 examinations. Pitch higher in 4 of 13 examinations. Pitch higher in none of 13 examinations. Expiration. Of 17 examinations present in 5 and absent in 12. Right. Left. Present only on this side in 1 of 5 cases.1 Present only on this side in 1 of 5 cases. 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. Oc- casionally 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. A single exception to this rule was noted 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 sounds to be transmitted in the healthy chest to the ear applied below the scapula,—a fact important to be remembered, since these sounds in that situation in the vast majority of cases is evidence of disease. Passing to the front of the chest, it will suffice to notice the respi- ratory phenomena furnished by auscultation in the mammary and infra-mammary regions under the same head. An inspiratory sound is almost uniformly appreciable in these regions, but differing considerably in intensity in different individuals. ' In this case it is noted that the sound was distant and high in pitch ; an intense expiratory sound existed in that case over the scapula. AUSCULTATION IN HEALTH. 161 Of 23 recorded examinations in which more or less of the respiratory phenomena were noted, in no instance was an inspiratory sound in- appreciable. Instances, however, are occasionally met with. The intensity is less than at the summit, with very few exceptions. This was true in all but two of sixteen observations made relative to this point. In one of these two instances the greater development in the mammary region was confined to the right side; and in the other instance the inspiratory sound at the summit was extremely feeble. The pitch is uniformly lower. Of eighteen observations this was true without an exception. The vesicular quality is, at the same time, more marked. The latter, and lowness of pitch, are correlative traits. In these three points of view, viz., diminished intensity, 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 noted in several instances. It is to be explained by the disparity which has been seen to exist at the summit in a certain proportion of individuals as regards intensity, pitch, and vesicular quality. Supposing the inspiratory sounds at the middle and lower portions of the chest to be equal, a comparison with the sounds at the summit will, of course, not give identical results if the two sides at the summit differ. Another explanation, applicable to a certain extent in some instances, is, that the sounds over the middle and lower portions on the two sides are not equal. The latter is true, but of a very small propor- tion of cases save with respect to intensity. Of twelve comparisons of the two sides, in five the intensity appeared somewhat greater on the left, and in two on the right side. With a single exception, in which the pitch appeared a little higher on the right side, there was no disparity in pitch or vesicular quality between the two sides. In the course of my examinations I attempted in several instances to determine whether there was an appreciable difference in the pitch, intensity, or vesicular quality of the inspiratory sound over the upper lobe on the left side, or the middle lobe on the right side, and the small portion of the lower lobe extending in front. I endeavored, in other words, to define the situation of the interlobar fissure by a change in the vesicular murmur. In one instance, and one only, I appeared to succeed. In that instance the person was a good subject for this experiment, the vesicular respiration being unusually well developed. Passing the stethoscope downward on a vertical line falling about half an inch within the nipple, on the left side, between 11 162 PHYSICAL EXPLORATION OF THE CHEST. the fourth and fifth ribs, the characters of the inspiratory sound abruptly changed, the pitch especially becoming lower, and the intensity lessened. The same abrupt change was discovered on the right side. An expiratory sound is very rarely appreciable in the mammary and infra-mammary regions. Its presence is noted in two only of thirteen examinations, the records of which contain information on this point. In one of these two cases it was only appreciable with Cammann's instrument, not by immediate auscultation, or the ordinary stethoscope. The number of instances in which it was appreciable would have perhaps been greater had Cammann's instrument been employed in a larger proportion of the examinations. It was used in a little less than one-half of the cases only. In both instances in which an expiratory sound was present, the pitch was distinctly lower than that of the inspiratory. It is unnecessary to introduce a table exhibiting the results of a comparison of the two sides of the chest, as respects the respiratory phenomena, observed in the mammary and infra-mammary regions, for the disparity noted, as has been seen, with a single exception, consists in a greater intensity of the vesicular murmur on the left side in a certain proportion of cases, and on the right side in a smaller proportion. In the axillary and infra-axillary regions, an inspiratory sound, especially with forced breathing, is often heard with as much and even more intensity than over any other part of the chest: of thirteen examinations, in none was the respiratory murmur absent. Its absence, however, in these regions would not necessarily denote disease more than in other situations where it is generally present. 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 deposit; and in other instances when no cause is apparent and it can only be attributed to a peculiarity of constitution. As in other situations the intensity differs considerably in different persons. The intensity is generally less in the infra-axillary, than in the axillary region, and the pitch somewhat lower. Careful comparison of the two sides, according to my observations, shows some points of disparity in the larger proportion of cases. Thus, of twelve exami- nations, 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 AUSCULTATION IN HEALTH. 163 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 instances than over the middle and lower portions of the chest in front or behind. Of nine examinations its presence is noted in five, and its absence in four. It was present in the axilla in some instances and not in the infra-axillary region. It was lower in pitch than the inspiratory sound save in one instance, and in this instance it was higher on the right side and lower on the left. 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 respi- ratory apparatus; and the vocal, as well as breathing sounds may be arranged according to their situation, into 1st, those produced within the larynx and trachea ; 2d, those heard over the large bronchi; and 3d, those emanating from the chest generally. The healthy pheno- mena in these several 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 respiratory phenomena, variations within the limits of health exist in different individuals, and in the same individual in cor- responding 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 phenomena incident to the voice in health, therefore, merits close attention, preparatory to entering on the subject of aus- cultation 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 164 PHYSICAL EXPLORATION OF THE CHEST. 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 imme- diate auscultation. Phenomena are made distinct by this instrument, in some instances, in which without it they are too feeble to be appre- ciated. The general rules and precautions to be observed in the practice of auscultation are alike applicable to the investigation of vocal and respiratory phenomena. These need not be repeated. We may cause the patient to speak by addressing to him questions while the ear is applied to the chest; but a better mode is to request him to count 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. It is also desirable often to observe the effect of articula- ting in a whisper. In treating of the auscultation of the voice in health, I shall adopt the same divisions as in treating of the respiratory sounds, and consider under distinct heads the tracheal voice (including the laryn- geal), the bronchial voice, and the normal vesicular vocal reso- nance. And I shall present under these general divisions of the sub- ject the results of analysis of observations made in a certain number of persons supposed to be free from diseases affecting the respiratory organs, in the manner pursued in treating of the phenomena incident to respiration. It is evident that upon results thus obtained must be based accurate knowledge of the phenomena pertaining to, and com- patible with, a condition of health; and this knowledge, it is equally evident, is the true point of departure for determining morbid signs by clinical observations. 1. Tracheal Voice ; (Laryngeal Voice ; Tracheophony; Laryn- gophony).—If the stethoscope be placed over the trachea just above the sternal notch, and the person desired to count in a moderately loud tone, the ear of the auscultator receives a combination of sensations resolvable into several different elements. The voice occasions a strong resonance, accompanied by a concussion or shock, and, also, by a fremitus or thrill. The articulated words are sometimes trans- mitted so as to be heard almost as clearly as when received from the lips; in other instances they are conveyed with more or less indistinct- ness, and occasionally are inappreciable. The resonance, the shock, the fremitus, and the complete or incomplete transmission of sounds auscultation in health. 165 are the several elements which compose the mixed sensations embraced under the head of the tracheal voice. It will facilitate a clear appre- hension of the vocal phenomena incident to the auscultation of dif- ferent parts of the respiratory apparatus, and not less to morbid con- ditions, to consider the tracheal voice as thus made up of different constituents. All these elements, in the great majority of instances, will be found to enter into the tracheal voice, the differences in dif- ferent individuals consisting in variations in the degree, absolute and relative, which they present. The resonance and shock and fremitus are generally strong. Of twenty-two examinations it is noted that these elements were strongly marked in eighteen ; considerably so in three, and moderate in one only. 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. Yet they do not involve precisely 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 expira- tion in connection with its partial, sudden arrest by the act of speaking, and the fremitus to the vibrations of the tracheal tube, in conjunction 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 a painful intensity, in some instances being quite unendurable; the articulated voice, however, is not conducted much better through this instrument than through the ordinary cylinder. The transmission of sounds 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 physical sign called Pectoriloquy. Pecto- riloquy is said to be perfect when the articulated sounds are distinctly heard with the ear applied to the chest mediately or immmediately. It is imperfect when the words are indistinctly heard. The types of perfect, and 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 166 physical exploration of the chest. proportion of cases, however, in which perfect pectoriloquy is repre- sented by the tracheal voice is small. Of twenty-three examinations the articulated voice was distinctly transmitted in only four; being more or less indistinctly appreciable in the remaining nineteen. The degree of indistinctness varied considerably in the nineteen cases. It is evident from these results that the transmission of the articulated voice 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 base voice, which is most favorable for the elements just mentioned, does not render the pectoriloquous element more strongly marked. A clear sharp voice is probably best trans- mitted, but I have not noted observations with respect to that point. 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 resonance, shock, or thrill. These three elements are either wanting, or compara- tively slight; but the whispered words are transmitted in some instances perfectly, and in other instances incompletely. This is identical with what is called whispering pectoriloquy, when whis- pered 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 voice comes from the chest. From its derivation it signifies chest-talking. In connection with perfect or incomplete transmission of speech is a strongly marked 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 souffle or blowing sound is also appreciable in some instances when words are spoken aloud. Its intensity is irrespective of the perfect transmission of the articulated voice. It is sometimes intense when the transmission of the voice is quite imperfect. Whispered words are oftener distinctly transmitted than words spoken aloud. Of twenty observations the transmission was perfect in five, in three it was quite imperfect, and in twelve, although not perfect, it was less imperfect than when the words were 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 AUSCULTATION in health. 167 the marked differences, compared with the tracheal, which the student is led to expect from the writings of some authors; and in some instances^ the sounds in both situations are very nearly if not quite identical. As a general rule, the shock and vibration commu- nicated 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 transmission of the articulated voice is oftener perfect, and generally less incomplete. Of eighteen comparisons with reference to the latter point, in no instance was the pectoriloquous element more marked over the trachea; in six instances there was no obvious dif- ference between the tracheal and laryngeal voice in this particular, and in twelve instances the transmission was decidedly more complete over the larynx. 2. Bronchial Voice ; Normal Bronchophony.—Applying the stethoscope, or the naked ear, to the chest at the points where the normal bronchial respiration is to be sought for, viz., in front near the sterno-clavicular junction, and behind, in the interscapular space, on a line with the spinous ridge of the scapula, the phenomena atten- dant on the act of speaking constitute what is distinguished as the > bronchial voice, or normal bronchophony. It differs greatly from the tracheal voice or tracheophony, but the difference consists mainly in the characters of the latter being but partially present, and with a much less degree of intensity. A certain amount of resonance characterizes the bronchial voice, and this varies considerably in its intensity in different persons. In some persons it is quite strong, in others almost inappreciable, and it may present every grade of inten- sity between these extremes. Other things being equal, it is stronger in proportion to the power of the voice and gravity of its tone. It is better appreciated and its intensity is greater by immediate than by mediate auscultation. It is rarely, if ever, the case that the ear re- ceives a shock or concussion, such as is felt when the stethoscope is placed over the trachea. A fremitus or thrill is either absent, or, if present, is generally slight; but in some instances it is well-marked. The articulated voice is very rarely transmitted. Whispering pecto- riloquy exists in a small proportion of cases. The results of an ana- lysis of fifteen observations relative to the transmission of the voice are, that in nine instances pectoriloquy, perfect or imperfect, did not exist; in but one instance were spoken words conveyed to the ear, 168 PHYSICAL EXPLORATION OF THE CHEST. and in this instance in the interscapular space only; in two instances whispering pectoriloquy was perfect, and in three instances imperfect. A souffle or blowing sound was observed in some instances to accom- pany the utterance of words spoken aloud, and in a large proportion of instances whispered words. These, then, are the characters of normal bronchophony contrasted with tracheophony: A resonance less in degree, and differing widely in different persons; absence of shock or concussion; a fremitus or thrill present in a certain proportion of cases, and less marked; words spoken aloud transmitted only as an occasional exception to the general rule, and whispering pectoriloquy, perfect or imperfect, existing in a small number of instances. Comparing the two sides of the chest in front and behind, an obvious disparity exists in a large majority of cases. This is seen by the following table giving the results of a series of observations relative to this point: Comparison of the Right and Left Side of the Chest, as respects Normal Bronchophony. Front. Right. Left. Resonance greater in 19 of 23 examina- Resonance greater in none of 23 exami- tions. nations. Back. Right. Left. Resonance greater in 13 of 22 examina- Resonance greater in none of 22 exami- tions. nations. It thus appears that excepting a very small proportion of instances the vocal resonance is greater on the right side in front, and in a ratio of more than one-half it is greater behind, while a greater degree of resonance is never observed on the left side either in front or behind. In some instances a resonance exists on the right side and none is appreciable on the left. This was observed in two instances in front, and in two instances behind. The difference between the two sides in the cases in which it was perceived on both, was sometimes slight, but in some instances strongly marked. It was generally more apparent on immediate auscul- tation, than with the ordinary cylinder ; and was rendered still more apparent by Cammann's stethoscope. 3. Normal Vesicular Vocal Resonance.—I adopt the title vesicular vocal resonance to distinguish the sound occasioned by the AUSCULTATION IN HEALTH. 169 voice when the ear is applied over the chest elsewhere than at the situations where the bronchial voice, as well as the normal bronchial respiration, is to be sought for, viz., at the upper part of the intersca- pular space behind, and near the sterno-clavicular junction in front. The title is to be preferred, not so much from its intrinsic appropriate- ness, as for the sake of uniformity, the respiratory sounds heard over the chest, with the exception just mentioned, being called vesicular. The vocal sounds cannot with strict propriety be called vesicular, inasmuch as the air-vesicles have no agency in their production. In its present application the term simply denotes that the sound is that heard over all those portions of the chest beneath which the air- vesicles predominate over the bronchial tubes, obstructing the trans- mission of the sonorous vibrations, which may be either conducted by the latter from the larynx, or possibly reproduced within them. The same objections are applicable equally to the term pulmonary, which by some writers is used to distinguish the vesicular respiration. The vesicular vocal resonance presents important distinctive traits when contrasted with the tracheal or bronchial voice, more especially the former ; certain differences are frequently observed when corre- sponding 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. The vesicular vocal resonance is to be considered under these three points of view. First, as contrasted with tracheophony and normal bronchophony, the vesicular resonance is generally much weaker; in other words, it has much less intensity. It differs from the former, especially, in not being constantly present; not unfrequently over portions of the chest no resonance is appreciable, at least with the ordinary stethoscope, and immediate auscultation; and in some persons it is absent over the entire chest. The sound, in general, seems farther removed from the ear. It is rarely accompanied by a sense of concussion or shock. It is less frequently attended by fremitus or thrill, but in some in- stances, in certain parts of the chest, the latter concomitant is strongly marked; and it is sometimes present in a degree which is out of proportion to the amount of resonance. Transmission of the articulated voice, in other words pectoriloquy, does not occur in con- nection with normal vesicular resonance, save as a very rare anomaly. Imperfect whispering pectoriloquy is occasionally observed; and not very unfrequently, in some parts of the chest, the act of speaking in a whisper occasions a souffle or blowing sound, resembling that 170 PHYSICAL EXPLORATION OF THE CHEST. which attends the tracheal and the bronchial voice. These are the important points distinguishing the phenomena embraced under the appellation of the normal vesicular resonance from those emanating more directly from the larynx and trachea, and the larger bronchial divisions. The vesicular vocal resonance presents in different individuals in health, even greater variations in degree than the vesicular respira- tion, due to differences in power of voice, gravity of tone, and other circumstances 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 intensity is 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 generally done by instituting a comparison of corresponding situations on the two sides of the chest, taking advantage of the laws of disease, in conformity with which, happily, for the most part, either it is 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 provided the conformation be symmetrical, the two sides of the chest furnish the same phenomena on auscultation. Theoretically this may be assumed, and as already remarked, it is a fundamental principle in physical exploration. Its importance in diagnosis is made at once apparent by this statement, viz., if the two sides are found to be free from any disparity as respects the normal phenomena obtained by physical exploration, the evidence is conclusive against the existence of intra-thoracic disease. But we have seen that, as regards pheno- mena incident to respiration, this rule is practically not without fre- quent and striking exceptions. The same fact will be found to hold good with respect to the phenomena incident to the voice. Hence, it is sufficiently obvious that to avoid the error of mistaking normal differences for the signs of disease, it is highly important to become acquainted with the nature and extent of the deviations from equality which are liable to occur within the limits of health. Fortunately these deviations are found generally to observe certain laws, the knowledge of which will secure against error of diagnosis, which would be unavoidable if such laws did not exist. Proceeding to consider the vesicular 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 AUSCULTATION IN HEALTH. 171 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 be entirely free from any disease of the respiratory apparatus. Directing atten- tion first to the summit of the chest, the different regions will be noticed in the same order as under the head of vesicular respiration. Infra-clavicular region.—Vocal resonance is rarely absent in this region. Of twenty-three examinations it was appreciable in all, but varying widely in degree, being in some instances slight and scarcely appreciable, and in other instances the varied intensity indicated by the terms moderate, considerable, strongly marked, etc. A thrill, more or less in degree, in some instances accompanied the resonance, and was sometimes more marked than the resonance. Pectoriloquy did not exist in any instance. Imperfect whispering pectoriloquy is noted in one instance. A souffle frequently accompanied whispered sounds. The results of a comparison of the two sides of the chest are exhibited in the following table : Comparison of the Right and Left Infra-clavicular Regions. Right. Left. Vocal resonance greater in 20 of 24 ex- In none of 24 examinations. aminations. Imperfect whispering pectoriloquy in 1 In no case. case. Souffle with whispered words confined In no case. to or more marked on this side noted in 4 cases. Greater thrill noted in 2 cases. In no case. It thus appears that in a very large proportion of the persons examined relatively to this point, viz., in 20 of 24, the vocal reso- nance was distinctly greater in the right than in the left infra-clavi- cular region ; there being no obvious disparity in the remaining four cases. These results are opposed to the opinion of Fournet1, pro- fessedly 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 appears to be 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, 1 Op. cit. page 152, torn. 1. 172 PHYSICAL EXPLORATION OF THE CHEST. and was confirmed by the researches of Louis.1 It is usually attri- buted to the larger size of the right bronchus. As regards the amount of disparity noted in the records of the ex- aminations, it differed considerably. In a few instances a resonance was distinct on the right side, none being appreciable on the left. In some instances the difference was slight; in other instances more strongly marked, and occasionally the contrast was striking. The comparisons were made in every instance with the ordinary stethoscope, and by immediate auscultation; and in about half the examinations Cammann's instrument was used in addition. Scapular region.—Vocal resonance is generally more or less marked in this region: of twenty-three observations in no instance was there absence of resonance on the two sides. It is habitually less in intensity than at the summit of the chest in front. It is in some instances more marked above, and in other instances below the spinous ridge. Of twelve examinations relative to that point, in pre- cisely the same number of instances, viz., in six, the resonance was greater in the upper as in the lower scapular space. The intensity is almost uniformly greater on the right side. This was true in twenty-two of twenty-three observations. The disparity between the two sides in different persons varies, in some being slight, in others strongly marked. The intensity of the resonance on both sides, also, here as in front differs considerably in different individuals. A thrill accompanies the resonance in some instances, but less frequently than in the infra-clavicular region. Pectoriloquy, perfect or imperfect, with words spoken aloud or whispered, was not present in any instance ; but with whispered words a souffle was occasionally observed, oftener on the right side. Infra-scapular region.—In a large majority of cases the vocal resonance in this part of the chest is greater than over the scapula: it was so noted in fifteen of nineteen examinations, in the remaining four instances the resonance being greater 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 in- tensity varies in different individuals. In much the larger proportion of instances, also, there is greater resonance on the right than on the left side. This was observed in seventeen of twenty examinations, no disparity being apparent in the remaining three. A thrill some- 1 Recherches sur la Phthisie, 1843, p. 533. AUSCULTATION IN HEALTH. 173 times accompanies the resonance, and occasionally a slight souffle when words are whispered. Mammary and infra-mammary regions.—The resonance in these regions is uniformly less than at the summit of the chest in front: of fourteen examinations it is so noted in all. It is also habitually greater on the right than on the left side. This is noted in fourteen of sixteen examinations, there being no disparity in two instances. A thrill accompanies the resonance in some persons. A souffle with whispered words is not noted in any instance. The statement by some writers that the intensity of vocal resonance diminishes regularly from the summit of the chest downward is not applicable to all persons. It is sometimes greater over the lower than over the middle third of the chest, but these instances are exceptions to the general rule. The difference in intensity between the resonance over the upper third, and the two inferior thirds of the same side, is in some in- stances much more marked on one side than the other, owing not only to the disparity existing between the inferior thirds, but to the fact that a disparity exists at the summit. Axillary and infra-axillary regions.—In the axillary regions the resonance is usually greater in intensity than over the middle and lower thirds of the chest in front; and in some instances it is quite equal to that of the infra-clavicular region. The intensity is less in the infra-axillary than in the axillary region. In some instances the difference is slight, in others considerable. A thrill attends the re- sonance in some persons in both regions, but oftener in the axillary. In both the resonance is habitually greater on the right side : of nine comparisons, in eight this disparity was obvious, the resonance seeming to be equal in the single exceptional instance. In view of the importance, with reference to the diagnosis of dis- ease, of the differences existing more or less frequently between corre- sponding regions on the two sides of the chest, the following con- densed abstract of the foregoing facts pertaining to the respiration and voice is appended: BRIEF SUMMARY OF FACTS Relating to disparity between corresponding regions on the two sides of the chest, in healthy individuals, as respects the phenomena incident to respi- ration and the voice. 1. Infra-clavicular regions.—More or less of the characters of 174 PHYSICAL EXPLORATION OF THE CHEST. the bronchial respiration generally present on the right side. Greater intensity and more strongly marked vesicular respiration often observed on the left side. Vocal resonance greater on the right side in the larger majority of instances. 2. Scapular regions.—Respiration more vesicular and intense in some instances on the left side; and frequently presenting characters of bronchial respiration on the right side. Greater vocal resonance habitually on the right side. 3. Infra-scapular regions.—The intensity and vesicular quality sometimes greater on left side ; the pitch frequently higher on the right, and rarely on the left side. The vocal resonance generally greater on the right side. 4. Mammary and infra-mammary regions.—Greater intensity of \he respiratory sound on the left side in a ratio a little less than one-half, and on the right side in a ratio of one-sixth. Vocal reso- nance habitually greater on the right side. 5. Axillary and infra-axillary regions.—Respiratory sound more intense on either side in an equal ratio; the characters of the bron- chial respiration presented on the right side in a small proportion of cases. Vocal resonance habitually greater on the right side. 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 disease, 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, con- stitute 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. AUSCULTATION IN DISEASE. 175 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 ascertain the connection between individual morbid sounds and the physical conditions of which, in consequence of this connection, they are the signs : 3. To explain, as far as practicable, the manner in which morbid physical conditions give rise to the phenomena embraced 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 attention. As already remarked, knowledge of physical signs, their significance and value in diagnosis, is not dependent on our ability always to furnish a complete exposition of the mechanism 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 conditions, by virtue of which the former repre- sent the latter; but with our present knowledge, this branch of the subject of physical exploration contains many points not fully settled. In a work intended to be practical, it would be out of place to dis- cuss opinions and theories relating to questions which are as yet open for speculation ; and I shall therefore content myself with giving, as concisely as possible, different views, without attempting a full consideration 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 re- spiratory sounds more or less, and variously, modified; Second, 176 PHYSICAL EXPLORATION OF THE CHEST. new or adventitious sounds, having no existence in the healthy chest. Of the phenomena embraced in the first of these two classes, a large proportion are represented by types existing in health; and with these the student who has studied faithfully normal respiratory sounds is already familiar. They are to be found in different parts of the respira- tory apparatus when entirely free from disease, and they become signs of abnormal conditions by a change of location. The phenomena embraced in the second class have no counterparts among the sounds incident to normal respiration, and pertain exclusively to the changes produced by disease. We will consider these two divisions separately. 1. Modified Respiratory Sounds.—Limiting the attention to the vesicular murmur, exclusive of the tracheal and bronchial respiration, the changes which it undergoes in connection with different forms of disease, on analysis, are resolvable into various kinds of aberration. Its intensity may be increased, or diminished, or it may be suspended. Its quality may be altered, the vesicular character giving place, partially or completely, to tubularity of sound. The pitch may be raised, and perhaps in some instances 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, etc. It is, however, unnecessary 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 severally, comprising more or less of the foregoing aberrations, is important to a clear apprehension of the subject. And for all practical purposes the following arrangement suffices.1 1. Modifications of the intensity of the vesicular murmur, consist- ing of a, increased intensity; b, diminished intensity ; c, suppressed respiration. 2. Modifications of the quality of the respiratory sounds, associated generally with aberrations in pitch, duration, and rhythm. This division will consist of a, bronchial respiration; b, broncho-vesicular, commonly called rude respiration; c. cavernous respiration. 3. Modifications of rhythm, consisting of a, shortened inspiration ; b, prolonged expiration ; c, interrupted inspiration or expiration. ' This division accords with the arrangement by Barth and Roger. The subdivisions differ from those which they adopt. AUSCULTATION IN DISEASE. 177 I shall consider all the physical signs derived by auscultation which consist of modified respiratory sounds, as embraced under the forego- ing 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 Respiration.—The respiration is simply increased in intensity, or exaggerated, whenever the loudness of the murmur is augmented, the normal characters, in other respects, remaining unchanged. The sound may be 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 the por- tion of lung affected, but from the 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 increased 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 vicariouSj or supplementary, and has been called by some writers supplementary respiration. Laennec applied to it the title of puerile respiration, from its resem- blance to the naturally loud respiration incident to early life. Hyper- vesicular respiration 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 evidence of the ex- istence of disease in the opposite side, but it does not afford any information as to the particular form of disease which is present. The pulmonary affections with which it is oftenest associated, and in 12 178 PHYSICAL EXPLORATION OF THE CHEST. the most marked degree, are pneumonitis and pleuritis. In the former of these affections, occurring in the adult, at least an entire lobe is rendered, for a time, nearly or quite incompetent to take part in haematosis, in consequence 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. 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 respi- ration. Considerable deposit of tubercle on one side may produce it; and also solidification from extravasated blood, carcinoma, etc. Undue dilatation of the air-cells, or emphysema, limited to one lung, is another affection to be enumerated in the same category. It is stated by Fournet1 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, surrounding a mass of tubercle he thinks the vesicular murmur is rendered unduly intense, and, indeed, he asserts that an abnormally increased vesicular murmur in the surrounding healthy portion of lung is greater in proportion to its proximity to the point of local disease. He cites an instance in illustration of this opinion, and in which advantage of the fact was taken in arriving at an early diagnosis. A patient attacked with all the symptoms of pneumonitis, presented no physical signs of disease save exaggerated respiration on one side of the chest; in a short time the exaggerated respiration was replaced by the physical signs of pneumonitis. The explana- tion offered by Fournet is, that the inflammation attacked first the central portion of the lung, giving rise, while centrally situated, to exaggerated respiration in the healthy vesicles surrounding the affected portion, and afterward extended to the exterior. Whether the principle laid down by the author just named be correct or other- wise, is not easily determined, nor is it of importance with reference to diagnosis, excepting in such an instance as he has cited; for, assum- ing that the vesicular murmur does become more intense in the healthy lung surrounding a diseased portion, for example in tuberculous dis- ease, 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 respiration. In cases of solidifica- tion of an entire lobe from pneumonitis, according to Fournet, the ' Recherches Cliniques, etc. AUSCULTATION IN DISEASE. 179 vesicular murmur proceeding from the other lobe or lobes of the affected side is exaggerated, and in a more marked degree than that proceeding from the healthy side. Without having taken pains to analyze a series of observations with respect to this point, 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. This is found to be true in a case of pneumo- nitis under observation at the very moment that I am penning these remarks. When the vesicular murmur is abnormally exaggerated, the dura- tion of the inspiratory sound, as a general rule, is somewhat in- creased. This is because the murmur is heard during the entire act of inspiration, while, 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 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,—a prominent feature, as will be seen hereafter, of the bronchial respiration. In simple exag- gerated respiration the expiratory sound is lower in pitch than the inspiratory, and 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 dif- ference I cannot conceive that the two need ever be confounded, an error which Barth and Roger state is liable to be committed. An exaggerated vesicular murmur approaches nearer to a cavernous, than to a bronchial respiration ; but the coexisting symptoms and signs, in connection with the fact that it is not circumscribed within a limited space, as is the cavernous respiration, suffice for discrimina- tion. An abnormal intensity of the vesicular murmur is attributable, 180 PHYSICAL EXPLORATION OF THE CHEST. 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 drawn 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 suspect a series of observations would show to be true, viz., that in these affections the exaggerated 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 diminish, than to increase the intensity of the vesicular murmur. Feeble or weak respiration is an abnormal modification of very frequent occur- 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 aber- ration would not fall under the present head, but under those belonging to other divisions of abnormal sounds. In duration, the inspiratory sound is frequently shortened when its intensity is ab- normally 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 characterized by feeble respiration, it is frequently present and pro- AUSCULTATION IN DISEASE. 181 longed, the diminution of intensity being less marked than in the inspiratory sound. Except in this affection (emphysema), an ex- piratory sound is rarely heard, and is not prolonged, provided the modification 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-distending 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 respecting the 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 loudness of the vesicular murmur by reducing the quantity of air which pene- trates the cells. Laryngeal affections, for example, croup, oedema, spasm of the glottis, vegetations which contract the calibre of the canal in this situation, involve this result. The space within the trachea may be reduced, in like manner, by inflammatory deposits, or morbid growths. These causes will diminish the murmur equally on both sides of the chest. An obstruction, however, may be seated in one of the large bronchi, and then the effect upon the respira- tory sounds will be limited to the corresponding side. This obtains when a foreign body is lodged in one of the bronchial divisions, which occurs oftener on the right side. A foreign body within the air-passages sometimes changes its place, being at times thrown upward into the trachea, and occasionally transferred, alternately, from one of the bronchi to the other. The abnormal feebleness of the vesicular murmur, under these circumstances, will be variable in degree, at different times, and present itself now on one side, and now on the other side of the chest. This intermittence and altera- tion afford evidence that the physical sign is due to a movable 182 PHYSICAL EXPLORATION OF THE CHEST. foreign body, and hence, is a point of importance in the diagnosis. The location 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 pulmonary 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 bronchitis, generally, the bronchial tubes on both sides are equally affected (this being one of the symme- trical diseases), when the obstruction depends on swelling of the membrane, the effect on the vesicular murmur is usually 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 products of inflammation, it may be limited to one side, or be greater on one side than on the other, the effect on the respiratory sound, of course, corresponding. Spasm of the bronchial muscle 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 tumor, 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 discrimination between these various causes is to be made, if practicable, by means of the symptoms and circumstances associated in individual cases. The diagnosis is not always easy, and sometimes impracticable. b. 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, pneu- monia, extravasation of blood, oedema, etc., the physical sign inci- dent to respiration may be simple feebleness of the vesicular murmur. Generally, however, in. these affections, either the respiratory 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 respiratory acts taking place imperfectly, and hence the physical conditions for the production of the vesicular murmur are impaired. An abnormally AUSCULTATION IN DISEASE. 183 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. Pro- longed 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 obstruction 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 abnormally clear. This alone would suffice for the discrimination between these two kinds of vesicular obstruction. 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 through the sense of hearing, in other instances than this, will be found to furnish an attribute to 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 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 effect on the respiratory sound will be manifested 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.1 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 will render 1 That a thin stratum of liquid may be equally diffused over the lung, as contended by Woillez, may fairly be doubted. 184 PHYSICAL EXPLORATION OF THE CHEST. the respiratory sound abnormally feeble. For example, in a case of incomplete general paralysis, which recently came under my observa- tion, the respiratory muscles were in a measure involved. The respi- ratory movements were wanting in strength, and the vesicular murmur was correspondingly feeble on both sides. In cases of hemiplegia, this effect obtains on the paralyzed side. In pleurisy, before effusion has taken place, and in pleurodynia, the pain occasioned by the expan- sion 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 additional cause already mentioned, incident to the first at a later period. The movements of the chest on one side may be restrained mechanically, in consequence of permanent contrac- tion as the sequel of chronic pleurisy, of morbid pleuritic adhesions, of injury to the thoracic walls, and deformity. Whenever by any of the modes just named the vesicular murmur is rendered abnormally feebler on one side of the chest, the respiratory sound on the other side is likely to become exaggerated, and the con- trast between the two sides is thereby enhanced. It is needless to state that in order to judge of abnormal feebleness 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 determined by comparison of corresponding regions of two sides of the chest. In drawing inferences from the results of this comparison, it is sometimes highly important to bear in mind the fact, that in a certain proportion of individuals in good health and with chests well formed, a natural dis- parity exists as regards the intensity of the vesicular murmur. This fact has appeared in the portion of this chapter devoted to the results of 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 tuberculous disease, a disease in which in certain cases few and slight deviations from equa- lity of the two sides at the summit of the chest, are justly regarded as highly significant. The results of examinations of the healthy chest not only enforce the caution just given, but lead to another very important consideration. In much the larger proportion of in- stances of relative feebleness of the vesicular murmur on one side compatible with health, it is observed on the right side. It follows from AUSCULTATION IN DISEASE. 185 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, in a considerable proportion of cases it is 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 suppressed when no sound whatever is appreciable by auscultation: the re- spiratory acts take place without giving rise to any audible phenomena. This effect may be produced by each of the four modes which have been seen to occasion abnormal feebleness of the respiratory murmur: their operation being pushed to a certain extent, the sound is abolished. Suppression is therefore liable to occur in connection with any of the various morbid conditions which induce feebleness of respiration. This being the case, it is only necessary under this head to repeat an enu- meration of the affections which were mentioned in connection with the modification last considered. Obstruction of the larynx from inflammatory exudation, oedema- tous infiltration, vegetations, spasm, or the presence of a foreign body, may extinguish all sound over the entire chest. A foreign substance lodged in one of the bronchi may produce this effect on the corre- sponding side, giving rise to exaggerated respiration on the other side. Absence 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 cir- cumstances 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 other tumor, on a bronchial tube, may be sufficient to produce complete absence of sound. In some cases of pneumonitis, tuberculosis, pulmonary apoplexy, oedema, etc., the respiration is suppressed. The vesicular murmur is generally abolished in connection with these affections over the solidi- fied 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 respiration. In some cases of emphysema no respi- 186 PHYSICAL EXPLORATION OF THE CHEST. ratory sound is appreciable. In this affection the inspiratory sound may be suppressed, and the expiratory, more or less prolonged, remain. The expiratory sound is also alone appreciable under other circumstances, which will claim notice 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 sound of respiration is gene- rally extinct. Finally, from contraction, deformity, injury, or paralysis, the move- ments of the chest may be insufficient to produce a respiratory 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 pneumonia, emphysema, pleurisy, or pneumothorax. Of course no inference can be drawn from the isolated fact that there is no respiratory sound, as to which of these several affections 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 much difficulty. In point of frequency, absence of respiratory sound oftener proceeds from liquid effusion within the chest than from any other morbid condition. The respiration will be feeble or suppressed in certain cases of dis- ease 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 affect 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 mainly to deviations from healthy respiration 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 gene- rally, also, with abnormal changes in pitch, duration, and rhythm. This class of modifications embraces signs of great importance in physical diagnosis. AUSCULTATION IN DISEASE. 187 4. Bronchial respiration.—Under the head of bronchial respira- tion, I embrace all sounds which, in addition to this title, are called blowing and tubular, exclusive of cavernous respiration, to which the former of the two terms last mentioned will equally apply. Laennec described a blowing respiration distinct from the bronchial and cavernous. In this he is followed by Walshe and others. For all practical purposes it suffices, and, indeed, as it seems to me, with sufficient intrinsic propriety, to consider both as essentially the same species of modification, presenting in several particulars, as will be presently seen, variations in different cases. This view of the sub- ject is sanctioned by high authority.1 The appellation bronchial respiration imports that the sound corre- sponds to that heard over the sites of the bronchi in the healthy chest. The term, however, has a more comprehensive signification. It includes sounds analogous to those produced within the larynx and trachea. A morbid bronchial respiration may be defined to be a re- spiratory sound resembling or identical with the normal bronchial or the laryngo-tracheal respiration, supplanting the vesicular murmur in a part of the chest to which this murmur belongs in a healthy condition—in other words, elsewhere than at the upper portion of the sternum, and on either side, near the sterno-clavicular junc- tion, and at the upper portion of the interscapular space, these being the situations where the normal bronchial respiration is to be sought for. With this definition, the student familiar with the characters which distinguish the tracheal and bronchial sounds from the vesicular murmur, which have been considered fully under the head of Auscultation in Health, will have no difficulty in understand- ing and in 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 descrip- tion already given of the tracheal and bronchial sounds contrasted with the vesicular murmur. The distinctive characters are as fol- lows : An inspiratory sound, tubular or blowing, in place of the peculiar character to which reference in the foregoing pages has frequently been made under the name of the vesicular quality; shorter in duration, 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 1 Barth and Roger. 188 PHYSICAL EXPLORATION OF THE CHEST. the inspiratory sound after an interval, owing to the fact just stated, that the inspiratory sound ends before the completion of the respira- tory 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 refer- ence 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 vesicular respiration, the latter are reproduced in this connection. They are as follows: An inspiratory sound characterized by the vesicular quality; lower in pitch than the tracheal or bronchial in- spiration. An expiratory sound, when present, much shorter in duration, less intense and lower in pitch than the sound of inspira- tion. Contrasted with the vesicular respiration, the bronchial is said to be characterized by greater hardness and dryness. These terms, although in vogue since the time of Laennec, do not seem to me to express properties of sound, of which, in this comparison, the mind receives a very distinct idea. The distinctions pertaining to intensity, rhythm, quality, and pitch, are much more definite, and are sufficient of themselves for the discrimination. I shall therefore dispense with the use of the former terms after this allusion to them. They appear 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 affections to which it is incident, but in different cases of the same disease. It is not to be distinguished practically by its in- tensity so much as by the other characters which belong to it, 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 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, like that pro- duced by blowing through a tube of metal, and hence called a metallic intonation. It is oftener marked in the expiratory than in the inspi- ratory sound. The normal tracheal respiration occasionally presents AUSCULTATION IN DISEASE. 189 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 others of the ordinary characters 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 the normal bronchial sounds. Both the inspiratory and expiratory sounds 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 some- times, 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 auscul- tator 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 possibly of the cavernous respiration. In some instances in which this is strongly marked, the illusion is almost complete, and, quoting the language of Laennec, " it is only from the absence of the feeling of titillation and of warmth or coldness which a blast of air so impelled must neces- sarily 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 walls of the chest. It is impor- tant to be borne in mind that not only is the bronchial respiration incident to 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 coexists with 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 successive respira- tions, always, however, preserving certain characteristics. Skoda contends that it is an intermittent sign, frequently ceasing for a series of inspirations, and then reappearing. This does not, however, accord with the experience of others, the latter, so far as my observa- tions go, being correct as the general rule. Its occasional cessation and reappearance after coughing and expectoration, is a fact which I have distinctly observed. 190 PHYSICAL EXPLORATION OF THE CHEST. With what physical condition of the lungs is the bronchial respira- tion associated ? This question may be explicitly answered. It is inci- dent to abnormal density of the pulmonary structure. Whenever the bronchial respiration is present it denotes increased density of lung.1 The converse of this, however, is not true, viz., that whenever the density of lung is increased it gives rise to bronchial respiration. The sign always denotes the morbid physical condition just stated, but as will be seen presently, the physical condition may exist without giving rise to the sign. Increased density of lung is incident to diseases which induce condensation by pressure. This effect follows the accumu- lation of liquid within 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, oedema, 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 important with reference to their diagnosis. Before directing further attention to it in connection with these affections respectively, we will inquire how does the increased density of lung incident to different forms of disease give rise to a bronchial respiration ? To this inquiry 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 the normal bronchial respiration, which, owing to conditions of disease is transmitted to the ear, disconnected from the vesicular respiration. The bronchial respiration appears in connection with physical condi- tions which involve suppression of the vesicular murmur. In health, the latter, as it were, stifles any 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, in the opinion of Laennec, are sufficient to account for the bronchial respi- 1 As an apparent exception to this statement, dilatation of the bronchiae might be cited. Dilatation is, however, as will be seen hereafter, always associated with in- creased density of lung. AUSCULTATION IN DISEASE. 191 ration, the source of the sound, according to him, being the large and small bronchial tubes. The sufficiency of this explanation has been called in question, in consequence of the bronchial respiration incident to disease being sometimes more intense than even the tracheal sounds; and, differing from the tracheal and normal bronchial respirations, 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 solidi- fied, 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, how- ever, 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 gene- rate a tubular sound, is assumed rather than established. The move- ments of the chest on the affected side, in cases of pneumonitis, with solidification of one or more lobes, are not much, if at all, diminished either in power or extent; and it seems altogether probable that, not- withstanding the comparative incompressibility of the lung, the bron- chial tubes remaining unobstructed undergo alternate contraction and dilatation.1 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 develope an exaggerated sound therein, although repudiated by 1 That air circulating in the bronchial tubes does play a part in the mechanism, would seem to be a rational inference from the fact, that the removal of mucus by expectora- tion is sometimes observed to be followed at once by the reappearance of the bronchial respiration, which, immediately before had been found to be absent. 192 PHYSICAL EXPLORATION OF THE CHEST. high authority, is not disproved, and seems rational.1 With regard to the greater intensity of the bronchial than the tracheal respira- tion, in some cases, and variations in pitch, it is certain that differences as respects these characters, do exist in a certain proportion of cases. A morbid bronchial respiration is sometimes not only more intense than the sound emanating from the trachea of the same person and at the same time, but notably 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 and normal bronchial respi- ration present in contrast with the vesicular murmur, they belong equally to the bronchial respiration incident to disease. The latter, when strongly marked, as, for example, frequently in cases of pneumo- nitis, is identical with the sounds heard over the trachea as regards tubu- larity, duration of the inspiratory and expiratory sounds, the rhyth- mical succession of the latter, and their relative intensity and pitch, these constituting, as has been seen, the traits by which these sounds are distinguished from the vesicular murmur. This being the case, in the production of the bronchial respiration incident to disease, the tra- cheal and normal bronchial respiration, it is reasonable to infer, must either be reproduced within the bronchial tubes, or conveyed to the ear by conduction. Circumstances incidental to their manifestation in disease produce in certain cases the variations in quality, pitch, and intensity to which reference has been made. According to Skoda, the sounds may be reproduced. He 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 vibration consonating with those caused by respira- tion 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 the corresponding strings of another instrument in its vicinity are struck. This fanciful hypothesis, which appears to be readily re- ceived by many, I shall notice somewhat more fully in connection with the explanation of vocal signs. The simple fact that the loud- ness of the bronchial respiration of disease is often 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 1 This view is advocated by Dr. Gerhard. Diseases of the Chest, 1846. AUSCULTATION IN DISEASE. 193 consonating sound is always in unison with the primitive sound. Without denying that sonorous vibrations within the pulmonary 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 circumstances in which, according to Skoda, the principle of consonance is particu- larly applicable, viz., when the bronchial respiration incidental to disease is intensely developed. Regarding, then, the bronchial respiration as consisting of trans- mitted sounds, they are produced within the trachea, the bronchi, and probably also within the subdivisions of the latter, and are conducted by solidified lung to the ear of the auscultator. In what proportion they are due, respectively, 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 stetho- scope 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, how- ever, of the sounds generated within the trachea, and the bronchi, as in the conditions of health, will not suffice to explain the intensifi- cation of sound which sometimes characterizes the bronchial respira- tion in disease, nor the disparity in pitch which is observed. These differences 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 unyielding by surrounding solidification, according to Four- net, Barth and Roger, and others, are reinforced and strengthened by reverberation, and thus acquire an increased intensity. Other phy- sical 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 bronchial respiration being more intense than the tracheal with ordinary breath- ing 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 subject of auscultation in health, that the intensity of the tracheal sounds is greatly increased 13 194 PHYSICAL EXPLORATION OF THE CHEST. 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 pulmonary organs, but the proper standards of comparison are the tracheal sounds of the patient which are incident to the same circumstances under which the morbid bronchial respi- ration is observed. Some of the circumstances accounting for differences in different cases, as regards the intensity of the bronchial respiration are obvious. 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 inten- sity will be greater than if the continuity be interrupted 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. With the same amount of solidification, the greater the proximity to the larger tubes, the louder will be the sound; hence, the bronchial respi- ration is mo*re 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 through the lung, 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 instances, 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 circumstances involved in its development and transmission. The affection in which the bronchial respiration is most constantly present, as well as oftenest intense, and in the union of its general distinctive characters most complete, is pneumonitis. As this affection in the adult generally is seated in the inferior lobe, and extends over the entire lobe, a well-marked bronchial respiration conjoined to dulness on percussion over the lower scapular and infra-scapular regions, in conjunction with the symptoms of intra-thoracic inflamma- AUSCULTATION IN DISEASE. 195 tion, 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 respiration to the bronchial 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 has been previously determined by percussion, auscultation, in the way just mentioned, will afford confirmation of its correctness. 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 inspiratory sound will 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. In the form-of pneumo- nitis peculiar to children, lobular pneumonitis, in which the inflamma- tion invades irregularly distributed and isolated lobules of both lungs, the bronchial respiration is less marked, and for other reasons, more appropriately considered hereafter, this sign is much less available in diagnosis. Next to pneumonitis in the frequency with which the bronchial respiration is associated, is tuberculosis. A mass of tubercle, situated at the summit of the chest, in proximity to some of the large subdi- visions of the bronchi, may give rise to a well-marked, and sometimes an intense bronchial respiration, rarely, however, so intense as may attend 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 connection with a tuber- culous deposit, the respiratory sound, although distinctly modified, is not sufficiently so to constitute a well-marked bronchial respiration, and the modification will fall under the head to be next considered. In oedema of the lungs the bronchial respiration is occasionally present, but not often strongly marked, never presenting the intensity and metallic quality observed in some cases of pneumonitis. The 196 PHYSICAL EXPLORATION OF THE CHEST. same is true of pulmonary apoplexy and carcinoma of the lungs. These forms of disease, more especially the two last, are extremely rare, and their diagnosis involves, 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 Dieu and La Gharite, 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 co-existence in them being the rule according to Dr. Swett.1 Occurring in pleurisy, it is due to condensation of the lung from compression by the liquid effusion 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 surfaces. 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 cases, certainly among adults, suppression of respiration over the chest, below the level of the liquid effusion, characterizes cases of pleurisy. 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 a degree of compression sufficient for the development of a well-marked bronchial respiration, is hardly compatible with life. As already stated, compression of the pulmonary parenchyma by other causes than pleuritic effusion may give rise to the bronchial respiration. Barth and Roger state that in two instances it was observed by them in connection with an accumulation of fluid within the pericardial sac, the non-existence of liquid in the pleural cavity, and of pneumonitis, or solidification from other disease, being deter- mined by autopsical examinations. It is evident that a tumor deve- loped within or extending into the chest may produce the same effect. 1 Diseases of the Chest, etc. AUSCULTATION IN DISEASE. 197 Abnormal dilatation of the bronchial tubes is to be added to the foregoing list of affections giving rise to the bronchial respiration. It is difficult to determine how much influence is to be attributed to the dilatation, since it is generally associated with more or less induration of the pulmonary tissue surrounding the dilated tubes. From the relations which have thus been seen to subsist between bronchial respiration and different pulmonary affections, pneumonitis and tubercle more especially, it is sufficiently apparent that it is a highly important physical sign, holding very frequently a prominent place among the phenomena involved in diagnosis. Practical ac- quaintance with its distinctive characters is therefore indispensable to the skilful 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 auscultation in health, as in disease. 5. Broncho-vesicular, or rude respiration.—The abnormal modifica- tion commonly called rude respiration, I have ventured to designate by a new title, viz., broncho-vesicular, an appellation expressing both the character and source of the sounds, while the term rude, in this ap- plication, is not only indefinite, but even its correctness admits of ques- tion. A bronchial respiration we have seen to be characterized, first and specially, by the absence of the vesicular quality, which is re- placed by a tubular or blowing sound; now, in certain forms of disease, the respiratory sound presents the tubular or blowing and the vesi- cular qualities, 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 respiration. If the reader will take the trouble to consult different works on 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 difficult 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 an imper- fectly developed bronchial respiration, which in the process of certain diseases, as will be seen presently, it may both precede and follow. Decomposed by analysis it consists of the same elementary charac- ters as the bronchial respiration, the chief points of difference being that the vesicular quality, although impaired, is not lost. 198 PHYSICAL EXPLORATION OF THE CHEST. In describing the distinctive characters of the broncho-vesicular respiration, as contrasted with a healthy vesicular murmur, the in- spiratory and expiratory sounds 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; a healthy vesicular murmur, or an approximation thereto, being presumed to exist on one side. This comparison is necessary in judging of this modification more than in determining the presence of a bronchial respiration, for the characters in the latter are more distinct. As remarked under the head of Auscultation in Health, in quality, as well as in intensity of the normal respiratory sounds, marked differences exist in different individuals. The natural respira- tion in some persons, compared with that in others, might be called in some particulars broncho-vesicular. The intensity of the inspiratory sound in the broncho-vesicular respiration may be greater or less than in the vesicular. The inten- sity does not furnish a distinctive feature. It is frequently shorter in duration than the vesicular, the sound ending before the close of the inspiratory act; in other words being unfinished. It has less of the vesicular quality, and more of the bronchial or tubular, as the title 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.1 I am persuaded, however, that practical auscultators have been accustomed to recognize, unconsciously, what they have called a rude respiration, in a great measure by its difference in pitch. I say unconsciously, for it is evident that sounds may be discriminated practically, without a full knowledge of the special characters by which they are distinguished, this being obtained by careful and accurate analysis. In comparing sounds on the two sides of the chest which differ but slightly, it is easier to appreciate a variation in pitch than a difference in the amount of vesicular quality, although, pro- bably, each involves the existence of the other. The expiratory sound may be present or absent. It is much oftener present than in healthy vesicular murmur. It may be pre- sent without any sound of inspiration. It is oftener prolonged, being nearly or quite as long as the sound of inspiration, when both are 1 On Variations of Pitch, etc., Prize Essay. Transactions of Am. Medical Association, 1852. AUSCULTATION IN DISEASE. 199 present, 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 identity with the bronchial respiration. This holds good still farther. The expiratory sound is higher in pitch, and fre- quently more intense than the inspiratory. It was observed by Jackson (who first called attention to the importance of the expira- tory sound in physical diagnosis), and the fact has been confirmed by Fournet and others, that in the development of the rude respiration the morbid alteration generally first appears in the expiration. It becomes more intense and prolonged. The change in pitch, becom- ing higher than that of the inspiratory sound, reversing in this respect the condition of health, appears to have escaped observation. This change 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 respiration: Inspiration presenting vesicular and tubular qualities mixed; short- ened in duration ; pitch raised ; intensity variable ; sometimes alone present. Expiration, oftener present; frequently existing alone; prolonged; occurring after an interval; pitch higher than that of inspiration and oftener more intense. Keeping in view these distinctive characters, it is not difficult to determine clinically the existence or non-existence of the modifica- tion under consideration. It should be discriminated readily from exaggerated or puerile respiration, after a little experience in physi- cal exploration ;l for, in the latter modification, there is no change in 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. But if an inspiratory sound be alone present, the mixed quality and the elevation of pitch pertaining to the bron- cho-vesicular respiration suffice to mark the distinction. It may be in some instances a matter of question whether the respiration be broncho-vesicular or bronchial; but this is a point practically of little or no consequence, since the one merges insensibly into the other, 1 " La distinction n'est pas toujours 6 vidente entre la respiration rude et les formes de la respiration dite puirile, etc." Barth and Roger. Op. cit. Other writers make a simi- lar statement. 200 PHYSICAL EXPLORATION OF THE CHEST. 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 to which broncho-vesicular respi- ration is incident, the respiratory sounds assume more or less of its character in some cases of emphysema. But in the great majority of instances it is connected with increased density of the lung, either from compression or morbid deposits. The conditions, in other words, are identical with those which give rise to the bronchial respi- ration ; and the physical principles involved in its mechanism are the same, the only difference being that the vesicular murmur is par- tially, 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 early, when the quantity of liquid is small, the lung being subjected to moderate pressure, and again late in the process of these affections, when the liquid has been considerably reduced in quantity by absorption. In pneumonitis it may also be present at different epochs, first indicating a small amount of lym- phatic exudation, and, afterward, its removal in a great measure ; in the former instance giving place to, and in the latter succeeding the bronchial respiration. In general terms, it may be a sign of any of the several ^affections named, provided the condensation or solidification of lung be not sufficient to extinguish the vesicular murmur, in which case either the bronchial respiration appears, or all respiratory sound is suppressed. The broncho-vesicular respiration is important, as a physical sign, chiefly in the diagnosis of pulmonary tuberculosis in its early stage. In this relation it is frequently a sign of great value. When the amount of tuberculous deposit is small, so far as the phenomena determina- ble by auscultation are concerned, this is the modification 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 the several characters which distinguish this sign from the healthy vesicular murmur are by no means invari- AUSCULTATION IN DISEASE. 201 ably present. More or less of these characters may be absent, as is the case with the bronchial respiration. The distinctive traits are nevertheless sufficient for its recognition. For example, an inspira- tory sound only may be appreciable. If it be less vesicular, higher in pitch, and shorter in duration, together with a greater or less de- gree of intensity than the inspiratory 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, it is perhaps oftener the case that the sound of expiration exists alone, or at all events the distinc- tive characters may be more strongly marked by the presence of an expiratory sound on one side and not on the other, or a prolonged expiration on one side, in either case more intense than the sound of inspiration and higher in pitch, the reverse being the case on the opposite side, if an expiratory sound be appreciable on that side. These characters, irrespective of the inspiratory sound, denote a broncho-vesicular respiration. In the diagnosis of tuberculous disease, before attributing to a morbid source the sign under consideration, we are always to inquire whether the phenomena may not be incident to a healthy condition; in other words, whether the points of disparity, which may be ob- served, do not rank among the variations which are frequently found in persons free from all 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-vesicular respiration. It has been seen under the head of Auscultation 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 assistance in settling the question just mentioned. If the reader will refer to the comparisons of the regions at the summit of the chest in health, as respects the phenomena incident to respiration, he will see 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- 202 PHYSICAL EXPLORATION OF THE CHEST. tion of the latter with greater intensity and elevation of pitch, are points of disparity peculiar to the right side. In other words, a 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 modification of the respiratory sound being due to disease, pertains to its presence on the right side of the chest. A well-marked broncho-vesicular respiration on the right side may not indicate more than a natural disparity. To be considered a morbid sign, 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 diagnosis. On the left side, however, the probabilities of the sign being due to a normal disparity are very few. In this situation, it is almost of itself positive evi- dence of a tuberculous deposit, when other circumstances create a suspicion of the existence of phthisis and it is of vastly less importance, with reference to the diagnosis, that it be associated with other signs, and with symptoms denoting the existence of tuberculous disease. 6. Cavernous respiration.—The term cavernous imports modifica- tions of the respiratory sounds due to the presence of caverns or exca- vations within the chest. The formation of cavities of greater or less size, belongs to the natural history of tuberculosis of the lungs espe- cially ; they result from the production of abscess, as a very rare termination of pneumonitis; also from circumscribed gangrene, and from perforation establishing a fistulous communication between the bronchial tubes and the pleural sac. The cavernous respiration con- sists of the sounds caused by the entrance, with the act of inspira- tion, of air into the cavities incident to the several affections just named, and its expulsion with the act of expiration. Laennec de- scribed this sound as resembling that of the bronchial respiration, but distinguished by the air seeming to penetrate a larger space than that of a bronchial tube. The difference 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 advocates this view. The laryngotra- cheal sounds are frequently referred to by writers on this subject, as offering equally a type of the bronchial and cavernous respiration. This view does not seem to me to be correct. The cavernous respi- ration, I think, is a distinct modification, and, when well-marked, is AUSCULTATION IN DISEASE. 203 discriminated from the bronchial 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 never 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-vesi- cular, in other words blowing or tubular. It conveys to the ear the idea of a hollow space. The difference in this respect, between it 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, com- pared with that of the tracheal or the bronchial respiration either of health or disease. An expiratory sound may be present, and if so, judging from a limited number of observations, the pitch is lower than that of inspiration.1 Finally, it is evolved more slowly than the bronchial respiration; in other words, it does not so promptly accompany the beginning of the successive respiratory acts. Of the descriptive characters just mentioned, those which are specially dis- tinctive, as contrasted with the bronchial respiration, relate to pitch of sound. The inspiratory sound is lower in pitch than in the bron- chial respiration. The sound of expiration is lower than that of in- spiration, the reverse obtaining in the bronchial respiration. This statement is based on a few observations, in which the phenomena were noted during life, the existence of cavities in the situations where these characters of the respiration had been studied,2 being demonstrated after death. In determining, clinically, the existence of the cavernous respira- tion, other circumstances than its intrinsic characters are to 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 completely filled with liquid morbid pro- ducts. Occurring, in the vast majority of the instances in which 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, to be noticed hereafter, viz., pectoriloquy, gurgling, and metallic tinkling. 1 Vide cases in Appendix to Essay by the author, on Variations in Pitch, etc. 2 Essay on Variations in Pitch, etc. 204 PHYSICAL EXPLORATION OF THE CHEST. 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 con- tents 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 openings will affect the sign; in the first place, directly, the intensity of the sound, other things being equal, being proportionate to the freedom with which the air is admitted to the cavity; and, in the second place, indirectly by favor- ing the removal of the liquid contents by expectoration. The open- ing or openings, are liable to become temporarily or permanently obstructed. Their form and size sometimes are such, that the cur- rent of air in passing to and fro, gives rise to adventitious sounds, which render the cavernous respiration inappreciable. The bronchial tubes leading to the cavity must be unobstructed, and free from loud adventitious sounds, which are frequently 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 expira- tion ; 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 respiration will be marked in proportion to its magnitude. The presence of the sign will depend on the situation of the cavity. Situated 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 pulmonary 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 cavernous re- spiration, but in other instances it drowns the latter and prevents it from being appreciated. In consequence of its dependence on so AUSCULTATION IN DISEASE. 205 many contingencies, it is only in a small proportion of the cases in which a cavity or cavities exist, that auscultation succeeds in disco- vering a well-marked cavernous respiration; and frequently in the instances in which it is discoverable, it is found only after repeated explorations. Fortunately, as a physical sign, it is of less import- ance practically than other signs involved in the diagnosis of the affections to which the formation of cavities is incident. A successful search for a cavity requires considerable care and patience. The object is to localize within a circumscribed space a non- vesicular respiration, with an inspiratory sound low in pitch, evolved somewhat slowly, and an expiratory sound, if present, lower in pitch than the inspiratory. Perhaps, to these differential characters should be added a certain hollow quality, giving the idea of air entering into a cavity, which constitutes the distinctive feature, according to most of the writers who recognize a cavernous sound intrinsically distinct from the bronchial. 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 expiration compared with the inspiration, has not to my knowledge, been before pointed out. As I have been careful to state, this relation, as regards pitch of the inspiratory and expiratory sounds, is based on a few observa- tions only, in which, however, the results were positive. If this rela- tion be uniform, it must be considered to constitute 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, formerly 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 blowing sound being restricted within a circumscribed space, is by no means reliable as suf- ficient evidence that the respiration is cavernous. They, who con- sider the bronchial 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 circumscribed within narrow limits; hence, errors of diagnosis are necessarily incident to reliance on this point. Fournet confesses that he has fallen into this error. He says : " Dans ces cas, il est facile de prendre le caractere bronchique, pour le caractere caverneuse: je m'y suis d'abord trompe' quelquefois......j'dtais e'tonne', a l'autopsie de ne pas rencontrer la plus petite trace de cavernes." Op. cit. p. 101. I have known mistakes arising from this source to 206 PHYSICAL EXPLORATION OF THE CHEST. be committed by experienced auscultators. Taken, however, in con- nection 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 comparison1 may be made of the sound at this point with that heard over portions of the chest where the vesicular quality is distinctly preserved. To determine that the pitch is lower than that of the bronchial respiration, in cases of tuberculosis, the sound at a suspected 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 comparison 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 one of the cases in which I succeeded in localizing a cavity, the following interesting circumstance was noticed. At the begin- ning 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, the blowing quality being still preserved. The inspiration was fol- lowed 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.2 This instance exemplified a combination of the cavernous and bronchial respiration. Of the several affections in which a cavernous respiration may be observed, tuberculosis, as already remarked, is the one in which it 1 There will be a liability, in certain cases, without due attention to the vesicular quality, to mistake an exaggerated vesicular respiration for the cavernous. I have cau- tioned against this liability in another work (Prize Essay), yet it has been illustrated in a case which recently came under observation, in which all the external characters of advanced phthisis were presented, and the exploration was limited to the summit of the chest. The patient had double pleurisy, with considerable effusion in both pleural cavities; under these circumstances, the superior costal respiratory movements were strongly marked, the percussion resonance was tympanitic, and on auscultation, an intense inspiratory sound was heard, followed by a prolonged expiration, lower in pitch than the sound of inspiration. The respiratory sounds were manifestly not bronchial, and were incorrectly supposed to be cavernous. An autopsy disclosed double pleurisy with effusion, and a few small disseminated tubercles. 2 Vide Appendix to Essay on Variations in Pitch, etc. AUSCULTATION IN DISEASE. 207 occurs in the vast majority of instances. All the other affections are extremely rare. In circumscribed gangrene and abscess moreover, the conditions required for the production of the sign, are much more unfrequently combined than in the cavernous stage of phthisis. Skoda states that in the few instances in which an excavation results from pneumonitis, 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. In pneumo-hydrothorax the pleural sac, which may be more or less circumscribed by morbid adhesions, con- stitutes 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 which a cavity may be formed within the chest, viz., by means of a pouch-like dila- tation of a bronchial tube. This is exceedingly unfrequent, but it is to be borne in mind as a possible condition giving rise to the sign under consideration. In view of the vastly greater ratio of tubercu- lous 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 tuber- culous 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 but a small proportion of the cases in which cavities exist. Tuber- culous excavations are very frequent. They are found after death in most subjects dead with phthisis, and the prevalence of this fatal dis- ease in all countries is well known. Yet it is rather rare in cases of advanced phthisis, to be able to discover a well-marked cavernous respiration, 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 respiration only serves to confirm its correctness. Moreover, in each of these affec- tions, excepting, perhaps, pouch-like dilatation of the bronchia, the signs and symptoms, irrespective of cavernous respiration, are suf- ficient to render the diagnosis easy and positive, so that the latter is redundant, and except as a matter of scientific interest, hardly com- pensates for the pains necessary to discover it. 208 PHYSICAL EXPLORATION OF THE CHEST. ■ An abnormal modification of the respiratory sound, called amphoric respiration or metallic echo, is by some writers considered a distinct physical sign. It is incident to a cavity equally with the cavernous respiration, and both are sometimes combined, although the mechanism of their production is not the same. But for all practical purposes it suffices to regard the amphoric, as a variety of the cavernous respi- ration. If a person blow gently into an empty vessel, for example a decanter, or water-croft, 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 blowing respiratory sound presents a silvery or metallic tone it is said to be amphoric. A still more perfect imitation is afforded by blowing into a fresh bladder, after it is inflated to a considerable degree of tension, while in contact with the ear. This peculiar 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, but according to Barth and Roger is most apt to attend the act of inspiration.1 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 respiration. The special conditions which it requires are, a cavity of considerable size, of course free from liquid contents, partially or entirely, and the walls of the cavity sufficiently firm not to undergo complete contraction and dilatation with the alternate acts of inspira- tion and expiration. In some instances a partial displacement of air takes place in consequence of a certain amount of collapse and ex- pansion of the walls of the cavity, and then, there may exist a true cavernous respiration with the amphoric sound superadded. The amphoric respiration may occur in connection with any of the affections which give rise to cavities. It is exceedingly rare, however, 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 very unfrequent phenomenon in tuberculous disease. The conditions are most likely to exist in pneumo-hydrothorax; and hence, when the sign is present it gene- 1 Dr. Walshe states the reverse of this, viz., that it especially accompanies expiration. Fournet makes the same statement. AUSCULTATION IN DISEASE. 209 rally denotes that affection. It is stated by Skoda that for the pro- duction of an amphoric sound, a free communication between the bronchial tubes and the pleural sac or a pulmonary excavation is not necessary. He thinks that the sonorous vibrations may be communi- cated 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 decanter 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-hydrothorax, or the existence of a large cavity within the lungs. Its absence, however, is not evidence that one or the other, or both morbid conditions do not exist. This remark, which is applica- ble to ordinary cavernous respiration, is still more so to the amphoric variety. Considering its infrequency, and in view of the fact that the diagnosis of the affections, in connection with which it occurs, is in no wise dependent 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 the subdivisions of the class of auscultatory phenomena embracing ab- normal modifications in quality, pitch, etc., of the normal respiratory sounds. In place of a summary of the distinctions which have been described in the preceding pages, the subjoined tabular view is ap- pended, by means of which the reader may review, at a glance, the distinctive characters pertaining to the three forms of morbid respira- tion just mentioned, and compare them with the characters which belong to the healthy vesicular murmur. Tabular View of the Distinctive Characters pertaining to tlie Different Abnormal Modifications in Quality, Pitch, etc., of Respiratory Sounds. Normal Vesicular Murmur. Inspiration. Expiration. Vesicular in quality. Low in pitch. Short in duration, averaging about l-5th Longer than expiration as 5 to 1. length of inspiration. Less intense than the inspiration. Often absent. Pitch lower than that of inspiration. Inspiration and expiration continuous. 14 210 PHYSICAL EXPLORATION OF THE CHEST. Bronchial Respiration. Inspiration. Expiration. Tubular in quality. Pitch raised. Short- Prolonged ; frequently as long or longer ened in duration. Rapidly evolved. than the inspiration. Generally more in- tense than the expiration. Rarely absent. Pitch higher than that of the inspiration. An interval between inspiration and ex- piration. Sometimes present without in- spiration. Broncho-vesicular Respiration. Inspiration. Expiration. Tubular and vesicular qualities mixed. Prolonged. Generally more intense than Pitch raised. Duration frequently short- the inspiration, and the pitch higher. Usual- ened. ly present. Pitch somewhat higher than that of inspiration. An interval between inspiration and expiration. Sometimes present without inspiration. Cavernous Respiration. Inspiration. Expiration. Blowing or non-vesicular in quality. Feeble. Frequently absent.^) Pitch Pitch low. Slowly evolved. lower than that of inspiration. The remaining division of the modifications in quality, etc., of re- spiratory sound comprises those relating to rhythm. The subdivi- sions under this head, save one, are among the constituent elements of modifications included under other divisions, and have been already considered. A brief notice of them will therefore suffice in the pre- sent connection. The modifications in rhythm which are of import- ance 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, bron- chial, and broncho-vesicular respiration. 7. Shortened inspiration.—Abnormal shortening of the inspiratory sound, occurring as one of the elements entering into modifications which have been considered, is of two 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 time before any sound is appreciable. The healthy vesicular murmur is heard in health with an intensity increasing from the beginning to the end of AUSCULTATION IN DISEASE. 211 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 extending more and more towards the end of the act of inspiration, until the sound entirely disappears. The duration 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 before the close of the act. The inspiratory sound in this case, is said to be unfinished. The differ- ence 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 distinction is involved in the foregoing, viz., a shortened bronchial or unfinished inspiration is, at the same time, notably changed in quality and pitch; a shortened vesicular or de- ferred inspiration offers much less change in other respects. To treat 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 sounds. 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, entirely 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 importance of its abnormal modifications escaped the attention of the illustrious discoverer of auscultation. His observations of the phenomena of disease referable to modified respiratory sounds, were confined to those produced by the inspiratory act. The honor of having first called attention to the value of the expiration in physical diag- nosis belongs to an American physician, arrested by the hand of death at the threshold of a career of useful labor in behalf of medi- cal science. In 1833, Dr. James Jackson, Junr., of Boston, at that time prosecuting his studies in Paris, communicated a paper 212 PHYSICAL EXPLORATION OF THE CHEST. to the Societe Medicate 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 com- mencement 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 modifica- tions just mentioned, to perceive the importance of the abnormal changes in duration as well as in the intensity and pitch of the sound of expiration. 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 varia- tions in pitch, are important to be considered in connection with pro- longation of the inspiratory sound. Thus, in bronchial respiration, the expiration, while it is increased in length, is more intense and higher in pitch than the sound of inspiration. The same difference holds good, to a greater or less extent, in broncho-vesicular respira- tion. On the other hand, in cavernous respiration, the expiratory sound is more feeble and lower in pitch than the sound of inspiration. In exaggerated respiration, the expiration is also less developed than the inspiration, and the relatively lower pitch which exists in normal respiration is preserved. The same is probably true of the prolonged expiration in emphysema; at all events, it does not present the eleva- tion of pitch which characterizes the expiratory sound in bronchial respiration.1 These variations in the pitch of the expiratory sound have hitherto been but little studied, and their significance has, there- fore, not been sufficiently appreciated. They appear from the facts just stated to sustain relations to the differences in the physical con- ditions under which the duration of the expiratory sound is increased, which it is both interesting and important to note. When the pitch is raised in the bronchial and the broncho-vesicular respiration, the pro- longation is due to increased density of lung; while in exaggerated 1 The prolonged expiration in emphysema often assumes a high-pitched tone in con- sequence of co-existing bronchitis. Under these circumstances it ceases to be, properly considered, a modified respiratory sound, but becomes ar&le. This distinction is to be observed in verifying by observation the statement made above. AUSCULTATION IN DISEASE. 213 respiration there is no morbid change in the part of the lung whence the sound emanates, but simply an increased functional activity, and under these circumstances the pitch is not raised, but continues as in health, lower than that of the inspiration. In emphysema, owing to the diminished elasticity of the lung, the cells collapse and expel their contents more slowly than in health. In this case the pitch is not notably, if at all raised. The same will be true when the pro- longation is due simply to any obstruction to the passage of air from the cells to the larger bronchial tubes. If this view of the subject be correct, and observations will, I believe, be found to confirm its correctness, the pitch of sound, taken in connection with increased duration, affords a means of determining whether the latter is an indication of tuberculous or other morbid deposit, or only of a retarda- tion of the reflux current of air from the cells. A prolonged expiratory murmur in some instances is the sole or chief alteration of the respiration which an examination of the chest dis- closes, the inspiratory sound not presenting any distinct morbid change in vesicular quality, intensity, pitch, or duration. Now, what is the diagnostic value of a prolonged expiration under such circumstances? The importance of this question relates to its practical bearing on the diagnosis of incipient phthisis. Is a prolonged expiration under the circumstances assumed, to be regarded as a sign of tubercle ? 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 inci- dent to the expiration. On this point, the observations of Dr. Theo- philus Thomson are interesting.1 This author states that among 2000 consumptive patients, a prolonged expiratory 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 render the diagnosis positive ; and, hence, Dr. Thomson is led to conclude that a prolonged expiratory murmur frequently takes precedence of other characteristic signs; an opinion according with that advanced by Jackson, in his memoir on this subject. But a prolonged expiratory murmur is found to exist frequently in the healthy chest. This is shown by the results of a series of examinations given under the head of Auscultation in Health. A certain allowance is to be made for this fact, which was not ascer- tained when Jackson first called attention to the importance of the ex- ' Clinical Lectures on Pulmonary Consumption. 214 PHYSICAL EXPLORATION OF THE CHEST. piration 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 a natural peculiarity. The sub- jects were the out-patients of an hospital, and it is not stated how large a proportion remained under observation till the evidences of tuberculous disease were unequivocally declared. A naturally pro- longed expiration, however, occurs only on the right side. The ques- tion whether it be natural 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 sig- nificance 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 tubercu- lous disease, and, if not natural, probably denotes emphysema. The more circumscribed 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 the normal bronchial 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 account. If the pitch be not raised, it indicates only obstruc- tion, 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 con- junction with other signs, however, and with symptoms, observing the cautions just mentioned, it is entitled to considerable weight. In a large proportion of cases, it is associated with more or less of the other characters of the bronchial, or the broncho-vesicular respira- tion, of which modifications, when it co-exists 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- AUSCULTATION IN DISEASE. 215 ceived several names, such as jerking, wavy, cogged-wheel.1 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 vari- ous affections, which may be arranged into two classes, according to the mode in which they produce this phenomenon. In one of these classes the interruption takes place in consequence of a corresponding want of continuousness in the expansive movements of the thoracic walls. This occurs in pleurisy, pleurodynia, and intercostal rheu- matism, in consequence of the pain occasioned by expanding the chest. The patient instinctively, as it were, shrinks from the move- ments necessary to haematosis, and hence an irregular series of efforts instead of a steady expansion. Thus produced, an interrupted in- spiratory 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 ex- pansion of a portion of the lungs. Partial obstruction of a bronchial tube, either from spasm, tuberculous deposit, or bronchitis confined within circumscribed limits, is probably competent 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 pul- monary disease. I met with it in two of twenty-four examinations. I have observed it on the healthy side in lobar pneumonia. Incident to health, it is sometimes a transient or intermittent peculiarity, but in some instances is persistent. In health or disease it is oftener observed on the left, than on the right side, and is rarely found, ex- clusive 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 1 Called by Laennec inspiration entrecoupee, and by French writers of the present day respiration saccadie. 216 PHYSICAL EXPLORATION OF THE CHEST. obstruction caused either by the pressure of the tubercles on the bronchial tubes, or by circumscribed bronchitis ; and in other instances to mechanical restraint exterior to the lungs, such as is incident 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 con- nection with other forms of disease. Dr. Theophilus Thomson, who has made this sign the subject of special statistical research, recorded 105 cases in which it was found to be present.1 Of these cases, in 32 there were grounds, irrespective of this sign, for suspecting tuberculous disease. Of the remainder, many were entirely free from other evidences of any affection of the lungs. Dr. Thomson adds that in several instances he has watched the persistency of this sign for years without its becoming complicated with any other indi- cation 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. 2. Adventitious Respiratory Sounds.—Thus far, in treating of the phenomena incident to respiration, the abnormal sounds which have been considered are modifications of those which pertain to the respiratory apparatus in health. It remains to consider certain phe- nomena which have no existence in the healthy chest, and are there- fore distinguished as new or adventitious sounds. The greater part of, these sounds originate either in the air-tubes, the vesicles, or within cavities formed in the lungs. Some are produced exterior to the pulmonary organs between the pleural surfaces. The latter are termed attrition or friction sounds. Different names are employed to designate the former. Laennec applied to them the word rdles, which is still in vogue with the French, and also with medical writers, and in conversational language, to a considerable extent in other countries than France. Other names by which they are collectively distinguished are rhonchi and rattles. The two latter terms are not 1 Op. cit. p. 161. auscultation in disease. 217 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 substitute 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 rdle 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.1 Proceeding at once to a consideration of the rales, the points to be first settled are, the number which are to be recog- nized as constituting individual signs; the method of classification, and the appellations by which they are to be distinguished severally from each other. Laennec determined the rales by their audible characters, and designated them after resemblances to other well- known sounds. Most of the rales discovered by him are still recog- nized, and the same appellations are generally retained. Andral proposed to divide the rales after their anatomical location in the air- tubes, vesicles, 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.2 As a basis of classification this is convenient and advantage- ous. The appellations, however, in common use since the time of Laennec will continue to be employed, and they are so interwoven in medical literature that it would be undesirable to endeavor to substi- tute 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 bronchi, and the subdivisions of the latter. Those produced within the larynx, trachea, and two bronchi, may be arranged into one class, and em- braced 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 ineffectual, from blunted perception and 1 If the French term rale be adopted, it should, I think, be anglicised, and I shall here- after 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 accorded 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. 218 PHYSICAL EXPLORATION OF THE CHEST. defective muscular power. The tracheal rales are therefore charac- teristic of the moribund state, or indicate generally that this state is nigh at hand. Constituting what is popularly known as the " death rattle," 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 sec- tions of the air-passages when there exists contraction at the glottis from spasm, oedema, exudation of croup, etc.; or when, from the pressure of a tumor, the presence of a foreign body, morbid deposits or growths, the calibre of the tube is sufficiently 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 represent, 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, may be useful in determining the precise seat of an ob- struction. Rales produced within the larynx or trachea may be pro- pagated to the chest and heard in the latter situation. It is, there- fore, necessary sometimes to auscultate the larynx and trachea in order to determine whether sounds heard over the chest are trans- mitted 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 pulmonary subdivisions of the bronchi 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 bronchial rales are subdivided into two varieties, called the sibilant and 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 some- times distinguished as the vibrating rales. Most of the moist bron- chial rales are usually styled mucous rales, the liquid concerned in their production being generally mucus. They are, however, pro- duced equally by other fluids, viz., pus, softened tuberculous matter, AUSCULTATION IN DISEASE. 219 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 bronchial tubes in which the sounds are produced. In contrast with the term vibrating, applied to the dry rales, the moist are sometimes palled bubbling rales. A moist rale produced in the minute bronchial divisions, but not in the capillary bronchiae, is distinguished as a sub-crepitant rale. The significance of this title is derived from resemblance to a sound pro- duced within the vesicles, to which reference will shortly be made. The sub-crepitant is an important variety of the moist bronchial rales. The only rale positively 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 considera- ble size. By some, however, it is considered as simply a variety of mucous rale. 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. Table showing the Number, Names, and Anatomical Situations of the Pulmonary Rales. 1. Bronchial. ( 1. Sibilant rale. a. Dry, or vibrating. ^ 2< Sonorous rale. r 1. Coarse mucous rale. b. Moist, mucous, or bubbling. -} 2. Fine mucous rale. I 3. Sub-crepitant rale, 2. Vesicular. 1. Crepitant rale. 3. Cavernous. 1. Gurgling rale. 4. Indeterminate. 1. Rdle crepitant sec d grosses bulks, of Laennec. 2. Pulmonary crumpling. 3. Pulmonary crackling. 220 PHYSICAL EXPLORATION OF THE CHEST. 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 cha- racterized by its apparent dryness and elevation of pitch. With this definition, notwithstanding its diversities, it is appreciated without difficulty. 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, fre- quently, 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. The sibilant rale is produced within the smaller branches of the bronchial tubes. This is the rule, with perhaps exceptional instances in which it originates in the larger bronchiae in consequence of their calibre being diminished by morbid changes. Laennec attributed its production to the space within the tubes becoming contracted at cer- tain points by swelling of the mucous membrane. From its varia- bility, however, and the fact that it frequently disappears after an act of coughing, it is probably due in many if not most instances, to tenacious mucus adhering to the walls of the tubes with sufficient firmness to occasion a partial obstacle to the current of air, and give rise to sonorous vibrations without 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 adhe- sive. The swelling of the membrane, greater in some portions than AUSCULTATION IN DISEASE. 221 in others, reducing thereby the capacity of the tubes, not uniformly, but irregularly, may, it is probable, give rise to dry rales, which, under these circumstances, are more persistent. Spasm of the muscular fibres also induces the requisite physical conditions. So, also, pres- sure of a tumor on the tubes, diminishing their size, and changing their direction, but not sufficiently to produce obstruction. In the majority of instances a sibilant rale is a sign either of catarrh or bronchitis seated in the smaller tubes. If it be heard more or less over the chest on both sides, associated with certain symptoms, febrile movements, etc., the evidence is very strong of the early stage of capillary bronchitis occurring as a primitive affection; for 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 contingent affection. On the other hand, if it be confined to one side of the chest, it may be due to bronchitis occurring as a secondary affection, for example, in connection with pneumonitis or pleurisy. If it be restricted to a circumscribed space at the summit of the chest on one side, taken in connection with other facts, it inferen- tially points to the existence of phthisis; for circumscribed capillary bronchitis rarely occurs except in the immediate vicinity of a tubercu- lous deposit, and it is at the summit of the chest, near the apex of the lung, that this deposit takes place. The sign is present in a marked de- gree in asthma proceeding from spasm of the bronchial tubes, generally associated with pulmonary catarrh or bronchitis; and it is still more marked if the catarrh or bronchitis occur in connection with emphy- sema. Under the circumstances last mentioned, it is most prominent in the expiration, owing to the same causes which occasion a prolonged expiratory murmur, viz., impaired elasticity of lung, and the neces- sity of increased muscular power to expel the air from the over-dis- tended cells. Although, therefore, the presence of the sign gene- rally denotes inflammation of the mucous membrane lining the smaller tubes, or irritation bordering on an inflammatory state, the diagnosis would often be incomplete were not other signs taken into account, as well as symptoms which disclose the coexistence of other affec- tions, viz., pneumonia, pleurisy, 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 pertain- ing solely to the bronchial tubes. 2. Sonorous rale.—This expression, which the French apply to all the dry bronchial rales, by English writers is limited to those dis- 222 PHYSICAL EXPLORATION OF THE CHEST. tinguished 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 de- marcation between the sibilant and sonorous rales cannot be defined in words, nor is it necessary to make the distinction with rigorous exactitude in practice. Sonorous rales are due to the same physical conditions as the sibilant, the only difference as regards their produc- tion pertaining to location. They proceed from the larger bronchial tubes. In their audible characters they are not more uniform than the sibilant rales. Among the diversity of sounds to which they may be compared are the snoring of a person sleeping, heard at a dis- tance, the humming of a musquito, the cooing of a pigeon, a note of a bass-viol or bassoon, etc., etc. The tone is oftener more dis- tinctly musical than that of the sibilant rales. 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 variableness 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, or both acts. When confined to one, it is more apt to be produced by expi- ration, in this particular differing from the sibilant rale. Sonorous rales denote either pulmonary catarrh, or bronchitis, affecting the larger bronchial tubes; which may be primary affections or complications of other diseases, viz., pneumonitis, tubercle, emphy- sema, etc. The coexistence of other morbid conditions is to be determined by the associated signs, in conjunction with symptoms. Occurring in connection with other diseases which are oftener limited to one side of the chest than primary catarrh or bronchitis, it will be confined to the side affected; and hence, when present on both sides, it is presumptive evidence that the bronchial affection is primary. The sonorous and sibilant rales 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 alternating at irregular intervals with successive acts of respiration in the same situation; or, again, both appreciable at the same instant, sometimes commingled together, and sometime* succeeding each other at differ- ent periods of a single respiration. When combined, it is evidence AUSCULTATION IN DISEASE. 223 that the bronchial affection is seated both in the larger and smaller tubes. The sonorous, like the sibilant rale, is especially marked in cases of pulmonary catarrh or bronchitis occurring in connection with emphysema. It is in such cases that the sounds are sometimes so intense as to be heard at a distance. On applying the ear to the chest in the early part of these affections, or 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 continuous, not only during the two acts of respi- ration, but uninterrupted by the intervals between successive respira- tions, the contraction of the lung prolonging the sounds with expira- tion after the visible expiratory movements have ceased. In the progress of catarrh and bronchitis they diminish, or cease entirely, becoming merged in the moist rales to be presently considered. The discrimination of both species of the dry rales from other Sounds emanating from the chest is attended with no difficulty. A mere description of their characters suffices for their recognition when heard for the first time. They are quite unlike any of the modifica- tions of the natural respiratory sounds, and are distinguished 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 bronchial catarrh or inflammations, affec-: tions of frequent occurrence. As denoting these affections, their sig- nification is almost positive; and if they are present extensively on both sides of the chest, together with the negative evidence afforded by the absence of the signs of other diseases, the diagnosis is com- plete. Pulmonary catarrh and bronchitis, however, not unfrequently occur as complications of other diseases. Under these circumstances the former are oftener confined to one side of the chest, or still more circumscribed, while the reverse is the rule when these affections are idiopathic or primary. But the fact of their existence as complica- tions is to be established by the concomitant signs and symptoms of the co-existing diseases. 3. Mucous rales.—The mucous rales are the moist bubbling sounds produced in any portion of the bronchial tree except the minute branches, the sounds in the latter situation constituting the sub-crepi- tant rale. The term mucous is here used in a generic sense to com- prehend sounds, essentially similar in character, which 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 224 PHYSICAL EXPLORATION OF THE CHEST. tubercle, and serum. Whenever either of these fluids is contained within the bronchial tubes, the currents of air with the respiratory acts, together with agitation of the liquid, cause explosive bubbles, which give rise to sounds more or less intense. These sounds have a bubbling 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 re- spects viscidity, etc., doubtless affect somewhat the character of the sound. The variations, however, due to this source are not sufficiently 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 abundance, is contained in the bronchial tubes. Generally the kind of liquid is determined demonstratively by an examination of the matter of expectoration. The mucous rales may be imitated by blowing through a tube intro- duced 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 bubbling sounds differ perceptibly according to the dimensions of the bronchial sub- divisions in which they are produced. This has been shown by ex- periments in which, after death, sounds differing according to the size of the tubes are produced by injecting fluids into different sections of the bronchiae, and afterward introducing currents of air by infla- tion.1 These differences are expressed by the adjectives coarse and fine; and the different degrees of coarseness and fineness are expressed approximately by words of quantity, sueh as very, considerable, mode- rate, etc. These expressions are sufficiently precise for practical pur- poses. The coarsest mucous rales, then, are produced in the largest bronchial tubes; they lose this quality gradually in the subdivisions of these tubes, until in the smaller ramifications before reaching the minute branches, they assume the quality of fineness; and this fine- ness merges into the still finer sub-crepitant rale. It would be diffi- cult 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 consequence in diagnosis. 1 Barth and Roger. AUSCULTATION IN DISEASE. 225 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 of the chest to another part; occurring not with each respi- ration, 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. Finally, they may exist on both sides of the chest, or on one side only, or in a circumscribed space on one or both sides. In the great majority of cases mucous rales constitute the physical sign of pulmonary catarrh or 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 intense in proportion to the extent to which the irritation or inflammation pervades the bronchial mucous membrane, and the abundance of the mucus secreted in consequence. If fine and coarse rales are intermingled, which is not infrequently the case, it is evidence that the affection of the membrane is not con- fined to the larger tubes, but extends to those of smaller size. In the progress of the affections just mentioned, 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. In view of the fact that bronchitis and pulmonary catarrh affect 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 one or the other of these affections 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 larger number of bronchial subdivisions, the greater amount of inflammation in this situation, and also 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 irrespec- tive of any affection of the tubes themselves. Thus, pus in this situation 15 226 PHYSICAL EXPLORATION OF THE CHEST. 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 haemoptysis, or pulmonary apoplexy, or serum in bronchorrhcea 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 espe- cially if they are either present on one side only, or persistingly more marked on one side than on the other, they constitute a sign significant of phthisis, like the dry rales, particularly the sibilant, under similar conditions, and for the same reason, viz., they indicate a bronchitis confined to a small section of the bronchial tubes. Thus restricted, the disease is never primitive, but dependent on a prior local affection, which affection, 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 progress, being produced not alone by bronchitis occurring as a complication, but by the presence of liquid derived from tuberculous excavations. Moreover, the bubbling and agitation of the liquid con- tents of small cavities occasion 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 dis- ease prior to the stage of softening and excavation. 4. Sub-crepitant rale.—By some writers, all the moist bronchial rales are embraced under this title;l and, on the other hand, the sub-crepitant might with propriety be regarded as a variety of mucous rale. A reason for making it a separate physical sign is, that ap- proximating in certain of its characters to the rale produced 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 mucous and the crepitant rales. It is distinguished from the mucous rales by its greater degree of fineness. It is produced in the minute bronchial ramifica- tions, but not in the capillary bronchi. Its locality accounts for its being finer, that is, for the bubbling being smaller than other bronchial rales. The bubbling character of sound is however preserved; the sensation conveys the idea of the presence of a liquid in tubes of small dimensions. The bubbling sound is generally unequal; in • Barth and Roger. AUSCULTATION IN DISEASE. 227 other words, it seems to be made up of bubbles uniformly small, but of different volumes. 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 or with both. It may continue during the whole duration of the in- spiratory or the expiratory sound, or be heard only during a small portion of one or both of the respiratory acts. In its persistence it presents somewhat of the irregularity and want of uniformity which characterize the mucous rales, but its variable- ness is less marked. These few points are important to be borne in mind with reference to its distinctive characters as contrasted more particularly with the crepitant rale. The sub-crepitant rale attends those affections 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, haemop- tysis, and pulmonary apoplexy. The sub-crepitant rale, therefore, is liable to occur in each of these diseases. So far as the audible characters pertaining to the rale are concerned, it is impossible to determine there- by the%nature of the liquid giving rise to the bubbling sound. This as- sertion is in opposition to the views of Fournet, who describes a dis- tinct rale for each of the several affections just named. In this he is not followed by other auscultators, who regard the rale as essen- tially 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 intrinsic differences in the characters pertaining to sound, but on other circumstances 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 affection be not confined to the minute branches, also with the sonorous and mucous rales. Capillary, as well as ordinary bronchitis, affecting, when primary, both sides of the chest, the rale will be present on the two 228 PHYSICAL EXPLORATION OF THE CnEST. sides, and especially at the base of the chest behind. This is an im- portant diagnostic point, inasmuch as the other affections to Avhich 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 con- clusive evidence of capillary bronchitis, as distinguished from pneu- monitis, 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, ex- clusive of the characters distinguishing the crepitant from the sub- crepitant rale. In capillary bronchitis the percussion-resonance con- tinues clear, while in pneumonitis it becomes dull. In the former the sub-crepitant rale continues, and is replaced by the vesicular murmur; in the latter it soon diminishes or ceases entirely, and generally gives place to the bronchial respiration. These circumstances will aid in arriving at a positive conclusion in instances in which, judging from the intrinsic characters 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 propor- tion 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 circum- stances it constitutes the rhoncus crepitans redux, or returning crepi- tant rale of Laennec. In pulmonary oedema the sub-crepitant rale is due to the presence of serous fluid within the minute bronchial branches. Occurring in connection with this rather rare form of disease, it is usually limited to one side of the chest; is present on the posterior surface; accom- panied with more or less dulness on percussion, and found in connec- tion with the ulterior morbid conditions upon which the production of oedema depends, viz., disease of heart, more especially 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 pneumonitis, in addition to the characters distinguishing the sub-crepitant and crepitant rales, enable us to exclude the latter affection. In phthisis a sub-crepitant rale may be due to circumscribed capil- lary 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, AUSCULTATION IN DISEASE. 229 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 situa- tion at the summit of the chest, within a circumscribed space. With these conditions, a sub-crepitant rale is strongly indicative of the ex- istence 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 expectorated ; or it coagulates, constituting apoplectic extravasation; both results doing away with the physical conditions necessary to develope the rale under consideration. The sub-crepitant rale is an important physical sign. From the mucous rales it is distinguished chiefly by the sensation which it con- veys of a finer bubbling sound. The characters which will be pre- sently found to mark the distinction from the crepitant rale are, the sense of a liquid, inequality in volume of the bubbles, its presence some- times with expiration, as well as inspiration. In some instances the approximation is so close to the crepitant rale that, it must be con- fessed, judged by intrinsic characters, it would not be easy practically always to make the distinction. 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 capillary bronchi are such that they can hardly be isolated from each other; and, in fact, the physical conditions giving rise to the crepitant rale pertain equally to both. The character of the sound is well expressed by the term crepitating. Laennec compared it to the noise produced by salt in a heated vessel. Barth 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 230 PHYSICAL EXPLORATION OF THE CnEST. after a description of its characters, with the comparisons just men- tioned, the student will have no difficulty in recognizing it the first time it is presented to his notice. As already stated, it bears a re- semblance to the sub-crepitant rale. The two rales approximate in their audible characters, but usually they are readily distinguished by their intrinsic differences alone, and always with the aid of col- lateral 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 crepitant rale is a true crepita- tion, while in the sub-crepitant rale it is a fine bubbling, approaching to a crepitating character. With the common idea that in both in- stances 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 production, it is included in the divi- sion of moist rales. Laennec, however, 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 con- nection with the diagnosis of pneumonia, 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 considerably in calibre. The equality of the multitude of 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 crepitating sounds are rapidly evolved, occurring, as it were, in puffs, resembling the noise produced by ignition of a small train of gunpowder, 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 AUSCULTATION IN DISEASE. 231 changing with different respirations, save in intensity, and this is • usually proportionate to the force with which respiration is performed. It is sometimes developed by forced breathing when it is not other- wise appreciable. It is not suspended by coughing and expectoration. On the contrary, after an act of coughing, the respiratory movements immediately succeeding being more forcible, it becomes more intense. Finally it is heard with the inspiratory act exclusively. This is cer- tainly the rule, and the exceptions, if they exist, are extremely rare. This last point, to which attention was first called by Dance, is emi- nently 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.1 Laennec regarded the crepitant rale as almost pathognomonic of the early stage 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 the early stage of pneumonitis. Moreover, it is very rarely the case that it is absent during the career of that disease. The opinion of Skoda is in opposition to the latter state- ment. 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 asser- tions enunciated by that writer. It is at variance with 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 numerical 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 invari- ably present is undoubtedly true, but the experience of most ausculta- tors is united on the fact of its existence being the rule in the lobar form of pneumonitis. In the lobular form of children the rule does not hold good. Not only, therefore, is it, as originally claimed by 1 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. Barth and Roger state this liability to error, as follows: " Il est un autre bruit qui pourrait facilement induire en erreur une oreille peu exerce'e: le frottement pleuretique est parfois construe- par une serie de petits craque- ments successifs, par une espece de crepitation in6gale, que le rapproche du veritable rhonchus crepitant. C'est sans doute cette variete" de bruit qui a fait dire qu'il existait un rale crepitant dans la pleure"sie." P. 149. 232 PHYSICAL EXPLORATION OF THE CHEST. the founder of auscultation, almost pathognomonic when present, but its constancy makes it reliable as a diagnostic criterion. It is usually discovered shortly after the attack of pneumonia 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. In quantity and intensity, however, different cases differ. When abundant, it is heard during nearly the whole of the inspiratory 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 inspiratory sound. Occasionally it is deve- loped 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 pneumonia, 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 exis- tence on one side of the chest is an important diagnostic circum- stance ; for pneumonitis, in the vast majority of cases, is confined to one side. On the contrary, capillary bronchitis as uniformly affect- ing both sides equally, the sub-crepitant rale is heard on both sides. This distinction, aside from the distinctive characters pertaining to the crepitant and the sub-crepitant rales respectively, suffices, in general, for a differential diagnosis. A rale, concerning which 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 crepitant rale. Pneumonitis may be complicated with general bronchitis. This coincidence is not frequent, but of occasional occurrence. The vesi- cular rale and the bronchial rales, will then be likely to be variously AUSCULTATION IN DISEASE. 233 combined. Capillary bronchitis and pneumonitis are sometimes as- sociated. 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 inspiration, the former during the first part, and the latter at the close of the act. The returning crepitant rale, rdle crepitant de retour, described by Laennec as characterizing the resolution of pneumonitis, occurs in only a certain proportion of cases. It denotes the presence of liquid in the smaller bronchial branches, and is a sub-crepitant rale. This, in fact, with our present knowledge of the two rales, is a fair infe- rence from the description by Laennec. The occurrence of the sub- crepitant rale at this stage of pneumonitis has already been men- tioned. In the vast majority of cases, the crepitant rale denotes pneumo- nitis. It is not, however, true that it never occurs in any other affec- tion. It has been observed in oedema, and possibly in haemoptysis. 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 haemoptysis, the expectoration of blood settles the diagnosis. Moreover, in this case the rale will be found at the summit of the chest in front, and not on the posterior surface, as in the larger pro- portion of cases of pneumonitis, haemoptysis being generally incident to tuberculous disease. The differential diagnosis of pneumonitis and oedema, is to be based on the associated circumstances which will usually suffice for discrimination without much difficulty. (Edema is comparatively rare. It 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 in- vades an entire lobe, and in the great majority of instances, an infe- rior lobe. When situated toward the apex of the lung, and extending 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, with 234 PHYSICAL EXPLORATION OF THE CHEST. the conditions just stated, becomes a sign of 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 production of the mucous and sub-crepitant rales, the difference 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 exclusively the act of inspiration, militate strongly against the doctrine commonly held. To meet these objections, Dr. Walshe suggested 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 Dr. Carr, of Canan- daigua, N. Y. Dr. Carr attributes the production of the sound to the abrupt separation of the walls of the cells, which had become adherent by means of the mucus, or the viscid exudation incident to the early stage of inflammation.1 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, wThile 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 exu- dation within the cells and minute bronchiae belongs among the local phenomena of the disease; and as it is not readily removed by ex- pectoration, but accumulates till the cells ar*e filled, and the lung solidified, the constancy of the rale for a certain duration is intel- ligible. Its occurrence with inspiration only, is fully explained'by this theory. The conditions for the production of the sound are 1 New explanation of the crepitant rhonchus of pneumonia, by E. A. Carr, M,D.— American Journal of Medical Sciences, October, 1842. AUSCULTATION IN DISEASE. 235 only present after the lungs have collapsed with expiration, at the moment when the agglutinated walls of the vesicles are separated with the expansion of the lung by the inspiratory act. Adopting Dr. Carr's explanation, it would be expected, as observation shows it to be true, that the sound would be present in the early stage of pneumonitis, the air in this stage still entering the vesicles, and sub- sequently 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 cha- racterizes all the cells in the early stage, explains the persistence of the rale in some cases during the second stage of pneumonitis, and its being developed, under these circumstances, 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 haemoptysis, in which the crepitant rale is observed. In these affections the vesicles contain a glutinous liquid, although in a less marked degree than in pneumonitis ; and we can readily understand that the necessary phy- sical conditions are present sometimes, but not constantly, on account of the greater facility with which the liquid escapes from the cells into the bronchial tubes, giving rise to the bubbling rales—the sub-crepi- tant 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. 6. Cavernous Rale, or Cfurgling.—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, and therefore it is entitled to a separate place among the phenomena of auscultation. 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 236 PHYSICAL EXPLORATION OF THE CHEST. 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 description is embraced in the term gur- gling. It may be compared to the sudden commotion which occurs from time to time, when a liquid is brought nearly to the point of ebullition. 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 pro- duce 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 respi- ration is momentarily suspended, and is synchronous with the pulse. This curious fact has been repeatedly noticed when the cavity 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 former 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. 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 partially 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 commu- nication, and the bronchial tubes themselves, must not be obstructed AUSCULTATION IN DISEASE. 237 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, with- out success. The value of the sign in diagnosis, therefore, is alto- gether 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 loudness 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 called1 cavernulous, and supposed to indicate the existence of small excavations. This distinction, however, is clinically unimportant. As has been stated, a well-marked cavernous rale at the summit 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 the bronchiae. 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 diagnosis of each of these affections must, however, be based mainly on other signs. The infrequency with which this rale is discovered, the diffi- culty in many instances of discriminating between it and coarse mucous rales (the two being, moreover, frequently commingled), to- gether 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 a variety of adventitious sounds, not clearly referable to either of the foregoing divisions, and of which the situations, as well as the man- ner of production, are matters of doubt. Notwithstanding this un- certainty 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. (1.) Laennec described a distinct sound which he designated by the somewhat contradictory phrase, " Dry crepitant rale with large bub- bles" (rale crepitant sec d grosses bulles). This sound, according to Laennec, " conveys the impression as of air entering and distending ' This title was first applied by M. Hirtz, of Strasbourg. 238 PHYSICAL EXPLORATION OF THE CHEST. lungs which had been dried, and of which the cells had been very un- equally dilated, and resembles the sound produced by blowing into a dried bladder." He regarded the sound thus described as character- istic of emphysema of the lungs. Most auscultators, 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 em- physema, do not establish its connection with any such sign. It is probable, that in instituting this rale, Laennec was influenced by preconceived notions. Having established a moist crepitant rale, he was led theoretically to assume the existence here, as in other instances, of a dry crepitant rale. At all events, if a rale, such as Laennec described, exists, in view of the difficulty of appreciating it, and its indefinite signification, it is practically unavailable in diag- nosis. Pulmonary crumpling.—Under the title of froissement pulmo- nale, rendered as above, Fournet1 embraced a variety of sounds not bearing to each other close resemblance, save that, according to this observer, an impression is conveyed to the mind of the auscultator 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 ; another is like the sound produced by blowing upon tissue-paper. These sounds, differ- ing so much in their audible characters, admit of being classed to- gether 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 originate 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 1 Op. cit. AUSCULTATION IN DISEASE. 239 are properly varieties of the same sign, and of any hypothesis as to their mode of production. Fournet states, that he has observed a bruit de froissement in the proportion of about one-eighth of persons affected with phthisis. Occurring at the summit of the chest, fre- quently, if not generally limited to one side, and confined within cir- cumscribed limits, a rale resembling either of the sounds above de- scribed, belongs among the numerous and varied physical signs which, from their situation and limitation, taken in connection with symp- toms, 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. Pulmonary crackling.—A crackling sound, presenting certain varieties (rdles de craquement), like the preceding, has been particu- larly described by Fournet, and is recognized as a distinctive ausculta- tory sign by most writers on the subject of physical exploration. The varieties of this sound are arranged in two classes, viz., dry crack- ling and moist crackling. Like the so-called crumpling sounds, they belong among the physical signs of phthisis, and are entitled to con- siderable weight in the diagnosis of that disease. Their diagnostic significance, like that of several other signs of tubercle already men- tioned, depends on their being observed at the summit of the chest within a circumscribed space. 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 exclusively with inspiration. The mechanism of the sound is generally consi- dered 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 presence of a small quantity of glutinous exudation.1 The sound is occasionally observed during a few respirations in the healthy chest. In the twenty-four examinations to which reference was made under the head of Auscultation in Health, I met with it in two instances, hi both of transient duration. It is a sign of rather frequent occurrence in the early stage of phthisis; and, under these circumstances, is usually 1 This explanation accords with the description of the character of the sound by Fournet: "Il consiste dans une sensation toute particuliere de rupture," etc. 240 PHYSICAL EXPLORATION OF THE CHEST. 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 instances. 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 differs from dry 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 crackling in regular suc- cession, and the uniform relation of each to a different 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 Indications of the Different Rales. Sibilant. Sonorous. Dry sound, high in pitch; whistling, Dry sound, grave in tone. Oftener hissing, or clicking; sometimes musical. musical than the sibilant; louder and stronger. Variable in continuance, intensity, into- Variable in continuance, intensity, into- nation, and situation. Suspended by cough- nation, and situation. Suspended by cough- ing, ing. Present with inspiration, or expiration, Present with inspiration and expiration, or both; oftener with inspiration. oftener the latter, and with both, If present on both sides, indicative of If present on both sides, indicative of primitive bronchitis or catarrh affecting the primitive bronchitis, or catarrh, or of bron- smaller tubes, or of bronchial spasm. chial spasm. Confined to one side, indicative of catarrh Confined to one side, indicative of secon- or bronchitis complicating pneumonitis or dary bronchitis, or catarrh. pleurisy. AUSCULTATION IN DISEASE.- 241 Limited to a circumscribed space at the summit of the chest, indicative of tubercu- losis. 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 they are produced. Variable in continuance, intensity, situa- tion, and degree of coarseness. Suspended by expectoration. Present with inspiration, or expiration, or both. Coarse and fine rales often combined. If present on both sides at the inferior posterior portion of chest, indicative of second stage of primitive bronchitis or catarrh ; the coarseness or fineness denot- ing extent of bronchial tubes affected. Confined to one side indicative of secon- dary 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 ad- vanced. May be associated with sibilant and sonorous rales. 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 the early stage of pneumonitis; frequently continuing through the disease, or giving place to a sub-crepitant rale. Occurs occasionally in oedema, and haemoptysis. Limited to a circumscribed space at the summit of the chest, indicative of tubercu- losis. Limited to a circumscribed space at the summit, indicative of tuberculosis. Often associated with the sibilant and mucous rales. 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 ex- pectoration. Present with inspiration or expiration, or both. If present on both sides at posterior in- ferior part of chest, indicative of primitive capillary bronchitis. Occurs in pneumonitis, at period of reso- lution ; also in oedema, and pulmonary apoplexy, or haemoptysis. Limited to a circumscribed space at the summit of the chest, indicative of tubercu- losis. Cavernous. A moist sound, conveying the impression of very large bubbles, and the agitation of a mass of liquid (gurgling), occasionally synchronous with the heart's impulse. Present with inspiration, or expiration, or both, especially with inspiration. Sometimes accompanied with metallic reverberation. Generally situated at the summit of the chest. Alternating or combined with cavernous respiration. Ceases and returns at irregular intervals. Indicative of tuberculous excavations; cavities following abscess, circumscribed gangrene, and pouch-like dilatation of bronchial tubes. 242 PHYSICAL EXPLORATION OF THE CHEST. Indeterminate. 1. Rale crepitant sec d grosses bulles. 2. Pulmonary crumpling. 3. Pulmonary crackling. Attrition or pleural friction-sounds.—With the act of inspi- ration the thoracic space is enlarged mainly by depression of the diaphragm, and the elevation of the ribs. The lung expanding to fill the augmented capacity of the chest, moves in a vertical direction downward, while the walls of the chest ascend; and hence results, of necessity, a certain degree of friction of the pleural surfaces, 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 rendered 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 titles attrition or friction sounds. The me- chanism 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 diagnostic 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 relations, so distinct and impor- tant as to claim separate consideration. A delicate grazing is one variety, occurring when the opposing movements are not forcible, or the physical conditions are not the most favorable for the production of sound. Another variety is a more distinct rubbing, chiefly denot- ing greater force of attrition. A greater degree of harshness of sound, dependent on greater roughness of the pleural surfaces, con- stitutes the variety called rasping 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 furnishing any special indications as respects either the nature or degree of the disease. The grazing and rubbing sounds, which are the varieties ordinarily presented, may be exactly imitated by placing the palm of the left hand over the ear, with firm pressure, and moving slowly auscultation in disease. 243 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 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 succeeding each other with more or less rapidity, resembling in this particular, 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 pro- longed 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 membranes, situated on the pleural surfaces, become infiltrated with serum. Under these circumstances a sound may be produced, which Walshe characterizes as squashy. 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. An instance has fallen under my knowledge in which it was so intense as to be a source of annoyance to the patient, during convalescence from pleurisy. 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 occasionally 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 appreciable at a greater or less distance from its source. The situations 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 mentioned. The sound always appears to be superficial, not emanating from beneath the super- ficies 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 instances, a friction-sound is heard with each successive respiration, but oftener it is variable in this re- 244 PHYSICAL EXPLORATION OF THE CHEST. spect, accompanying some respirations, but being absent in others. It is sometimes,appreciable only with forced respiration, and, on the other hand, it has been observed to be strongest when the breathing was tranquil. The sound has been observed to be increased when firm pressure is made with the stethoscope. It is also variable in duration. It may be transient, or it may continue in a greater or less 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 alternations may occur more than once in the progress of the same disease. Finally, if a friction- sound be strong, and especially if it be rough, it is perceptible to the touch, on placing the hand over the side, as well as to the sense of hearing; and in this way patients themselves become aware of a rubbing movement 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 distin- guish it from other adventitious sounds. As already stated, some- times, when interrupted and limited to inspiration, it may be mistaken for a crepitant rale. The instances, however, in which this resem- blance 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 deter- mining the existence of a friction-sound, in all cases we are aided by the coexistence of other signs, and of symptoms 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, in addition to that produced by respiration, will be found to be synchronous with the beating of the heart, or the pulse, and will continue when the respiratory movements are voluntarily sus- pended. The concurrence of a cardiac friction-sound, gives rise to the question whether it be of pleural or pericardial origin; and the set- tlement of this question clinically, must be attended with considerable AUSCULTATION IN DISEASE. 245 difficulty. In general terms, if it have been preceded, or if it be accompanied by the signs and symptoms of pericarditis, it is in all probability pericardial; but if it be unattended by other evidences of an affection of the pericardium, and there are present the evidences of disease affecting the pleura, it may be suspected to have connec- tion with the latter. 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 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 emphysema, were also affected with pleurisy ; and it is remarkable that its connec- tion with the latter affection should not have presented itself to the reflections of the discoverer of auscultation. Subsequent observations have shown that in the interlobular, as well as the ordinary form of emphysema, and also in that variety in which air-vesicles 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 even frequently present in that affection, and, indeed, 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 with each other. In the early period of the disease it is due to the presence of coagulable 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 exuda- tion 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 possesses any importance as a sign to be relied upon in the diagnosis prior to the occurrence of effusion. The latter takes place so 1 Vide Fournet, p. 210. 246 PHYSICAL EXPLORATION OF ME CHEST. quickly after inflammation is established, that generally the pleural sur- faces are already separated before patients come under observation. In hospital practice this is almost uniformly the case. Instances, how- ever, are occasionally observed in which, notwithstanding a conside- rable, or even large accumulation of liquid in the pleural sac, a fric- tion-sound is apparent. Dr. Stokes was the first to report a case of this description, 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 may obtain anteriorly, while the whole posterior surface of the lung is sepa- rated 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 ob- served. Of the instances in which a friction-sound occurs in pleu- ritis, in by far the larger proportion it appears in a later stage, after absorption. The pleural surfaces coming again into contact, are roughened by semi-organized 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 affection, but simply denote differences pertaining to the disposition of the mor- bid matter, 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 pro- bably oftener and with greater intensity, by the contact of the dia- phragmatic 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.1 But even after absorption a friction-sound is of rare occurrence in pleuritis. This is probably 1 Sibson's Medical Anatomy. AUSCULTATION IN DISEASE. 247 owing to the fact that adhesions of the pleural surfaces generally take place directly they are brought into contact. It is, however, not im- probable 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 favorable 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 as respects the diagnosis which it is to be presumed has been already made, it is yet of utility 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 thickness of the layers of morbid deposit, percussion and the auscultation of the respiratory sound may be insufficient to determine the fact that the liquid is ab- sorbed. 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 pleuro-pneumonitis it is occa- sionally 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. Occurring 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 suffi- cient to give rise to a strongly marked sound of attrition. Fournet gives an instance of this kind; and a striking case was reported several years ago by Prof. Lawson.1 Second, It is due to intercurrent pleurit% confined to a circumscribed space, situated over the tubercu- lous deposits. Successive attacks of pleuritis, attended by the exu- dation 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 almost 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- 1 Western Lancet, Cincinnati, Oct. 1850. 248 PHYSICAL EXPLORATION OF THE CHEST. 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 absence is not entitled to any weight as negative evidence; but when present, it is a sign of considerable diagnostic importance. Occurring 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 precludes the con- tinuance 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 different kinds. These affections are, however, very infrequent; and in its diagnostic rela- tions 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 asso- ciated witj. symptoms leading to the suspicion of tuberculosis, it is highly significant of that affection. And if it be found under circum- stances in which neither pleurisy nor tubercle are evidencecfcby asso- ciated signs and symptoms, it proceeds from emphysematous tumors or other affections, the nature of which may not be determinable.1 The discovery of a pleural friction-sound as a physical sign, was made by M. Honore', a contemporary with the discoverer of auscul- tation.2 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, however, as already stated, failed to perceive its connection with 1 Dr. Walshe states that intra-thoracic friction is sometimes simulated by the move- ments of the scapula in breathing. 2 Vide Treatise on Mediate Auscultation, etc., by Laennec. AUSCULTATION IN DISEASE. 249 pleurisy, 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 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 consist of the characteristics of the normal bronchial and tracheal or laryngeal voice, transferred to situations where they are not found in a healthy condition. This class of signs will constitute one division of the morbid phenomena inci- dent to the voice, comprising exaggerated vocal resonance and bronchophony. Under this head are comprehended all abnormal modifications, in which the intensity of the normal vesicular vocal resonance is morbidly increased, or gives place to a sound not only more intense than belongs to health, but presenting other of the characters which pertain to the normal bronchial, tracheal, or laryn- geal voice. It suffices for all practical purposes to include simply exaggerated resonance and bronchophony, in a single division; and although, strictly speaking, there is an inaccuracy in applying the term bronchophony to a sound more intense than the normal bron- chial, and even the tracheal or laryngeal voice, it is admissible for the sake of convenience, and is sanctioned by conventional usage. It would be not less inaccurate to designate an intense vocal sound in any part of the chest, by the terms tracheophony or laryngophony, although identical in character to that observed on auscultating the larynx or trachea. The signification of the term bronchophony is extended by all writers to embrace sounds, the intensity of which equals and sometimes exceeds the tracheal and laryngeal voice. It is usual, also, to make a distinction between exaggerated vocal reso- nance and bronchophony, the former expression denoting simple increase of the vesicular resonance, and the latter in addition to intensity, alterations in other particulars of the vocal sound. The distinction, as will be seen, is a valid one, but I can see no prac- tical advantage in treating of them under distinct heads, and, there- fore, with a view to simplify the subject, I have included both in the same division. To distinguish the gradations of bronchophony, 1 Vide Barth and Roger. 2-30 PHYSICAL EXPLORATION OF THE CHEST. the terms weak and strong, may be employed. The expression, weak bronchophony, denotes that the distinctive characters are but little or moderately marked; and the bronchophony is said to be strong, when, in intensity and other features, it is considerably or extremely marked. To indicate different degrees of simply exagge- rated vocal resonance, adjectives of quantity, such as little, moderate, much, great, etc., are sufficiently exact for all practical purposes. The normal vocal resonance may not only be increased to a greater or less extent, but on the contrary, diminished and suppressed. Morbid changes in this direction will constitute another division of vocal signs, which may be distinguished by the simple expressions 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 distinct physical sign, called pectoriloquy. This will claim separate consideration, and constitutes the third of the divisions of abnormal vocal phenomena. A fourth vocal sign consists of a partial transmission of the voice, elevated in pitch, and tremulous; which, after Laennec, is called, from its resemblance to the bleating of the goat, cegophony. Agreeably to the foregoing divisions, the phenomena incident to the voice in disease may be arranged under four heads: 1. Exaggerated resonance and bronchophony. 2. Diminished and suppressed vocal resonance. 3. Pectoriloquy. 4. JEgophony. Of these four classes of signs, the two first are by far the most important in a practical point of view; in other words, the objects to be attained by ausculta- tion of the voice with reference to diagnosis, chiefly relate to the increase or diminution of the normal vesicular vocal resonance. Now to determine, in individual cases, whether the normal vesicular vocal resonance be increased or diminished, it is necessary to know what is the normal amount of vocal resonance. It has been seen that this varies considerably in different persons, so that neither the amount proper to any single individual, nor the mean intensity of a series of examinations, will serve as a standard for comparison. Here as in other instances, it is necessary to judge of an abnormal deviation by comparing one side of the chest with the other. But in instituting this comparison, an important consideration is to be taken into account, AUSCULTATION IN DISEASE. 251 viz., it has been seen that in health, there does not exist perfect cor- respondence between the two sides of the chest as respects the degree of the normal vocal resonance. Happily the variations in the two sides are found to observe a certain rule, which must be borne in mind, in order to avoid attributing to disease what may be due to a disparity entirely compatible with health. 1. Exaggerated Vocal Resonance, and Bronchophony.— After the foregoing remarks, a brief description of the characters distinctive of these vocal signs will suffice. With the ear applied to certain parts of the healthy chest, for example, the infra-clavicular region, in front, or the infra-scapular, behind, the act of speaking generally occasions a certain diffused, dull resonance, the sound ap- pearing to come from a distance, and accompanied with a feeble vibration or thrill. This is the normal vesicular vocal resonance. Now this normal resonance may be rendered by disease more intense, 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, diffused, and dull. If, however, well marked bronchophony become developed, not only is the resonance usually greater, but the sound acquires a certain concentration and clearness ; the voice seems to be near the ear, while the accompanying vibration may or may not be proportionally great. The distinction, thus, between simply exaggerated resonance, and well-marked morbid bronchophony, is real, and the two signs may be clinically discriminated from each other without difficulty. It is not therefore strictly correct to say that they are essentially identical, the difference consisting only in the degree of intensity of the reso- nance. But it is true that both may proceed from similar physical and pathological conditions ; and that, in diagnosis, their significance is not materially different. 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. Hence, it is not very essential, practically, to observe always with precision the distinction; and for this reason I do not give to each separate consideration. The vibration or thrill, it is important to note, does not always increase in a uniform ratio to the exaggeration of the resonance, the clearness and concentration of the sound, and the ap- parent proximity to the ear, pertaining to the thoracic voice. In 252 PHYSICAL EXPLORATION OF THE CHEST. strong bronchophony, the ear sometimes receives a shock or concussion, like that felt in auscultating the trachea or larynx, which may even be painfully intense. In other instances, the fremitus seems to be not greater than belongs to health. The sound sometimes has a metallic, ringing tone. Occasionally it is somewhat tremulous. The latter is peculiar to the aged. In degree, both exaggerated vocal resonance and bronchophony present, in different cases of disease, great varia- tions. The intensity of the thoracic voice may exceed that of the normal laryngeal or tracheal. This is a fact not only interesting, but important in its bearing on the explanation of the mechanism by which morbid bronchophony is produced. Another fact, also interest- ing, and in the same point of view important, is, the pitch of sound is not in all instances identical with that of the normal laryngeal or tracheal voice. Both the foregoing facts are sufficiently attested by observations, but they are to be regarded in the light of exceptions to the general rule. Finally, abnormal intensity of the thoracic voice continues, certainly in the large majority of cases, constantly; that is, it is always found on auscultation, so long as the pathological conditions of the lung to which it is incident continue ; in other words, it is not an intermitting sign, like the bronchial rales, now present, and now absent, but steadily presisting for a certain period, in this respect resembling the crepitant rale and the bronchial respiration. This last statement is in direct opposition to the opinion of Skoda, who main- tains that the alternate absence and presence of the thoracic voice is a well-known and a common occurrence, and that bronchophony may appear and disappear several times in the course of a few minutes.1 The question is one to be settled purely by observation, and the experience of others does not sustain Skoda's assertion. Intermit- tency 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 accuracy 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 bronchophony, practically, involves no difficulty. It is sufficiently easy to determine, on comparison of the two sides of the chest in corresponding situa- tions, a disparity in the degree of resonance, and the several charac- ters pertaining to bronchophony. There is no liability of confound- 1 Translation, by Markham. Am. ed. page 68. AUSCULTATION IN DISEASE. 253 ing these with other signs. The only error to be guarded against is, attributing to disease differences between the two sides which exist normally. Under the head of Auscultation in Health it has been seen that normal differences are observed in a large proportion of persons. They observe, however, a regular law, viz., the greater relative in- tensity is on the right side; and this is frequently found to be the case over all the regions on this side, but it is especially marked at the summit in front. Exaggerated vocal resonance may be said to exist naturally at the superior anterior portion of the right chest, in a large number of individuals, amounting, in some instances, to bron- chophony. 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; while a slightly greater resonance on the left than on the right side, is highly significant of a morbid condition. The coexistence of other signs incident to the same physical conditions, is a safeguard against the mistake of con- founding morbid with natural variations. The physical condition of which exaggerated vocal resonance and bronchophony are the signs, in the great majority of the cases of disease in which either is present, is increased density of the pulmo- nary structure. They occur in the different affections which give rise to the broncho-vesicular and the bronchial respiration, and are generally found in combination with these signs. Bronchophony is more uniformly present, and is most 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 surface of the chest on one side, the seat of the inflammation, in the adult, being the inferior lobe, save in a small proportion of cases. It is in pneumonitis espe- cially that the bronchophony is strong or intense, the voice seeming to be very near the ear, attended by concussion or shock, the pitch sometimes notably higher than on the unaffected side, and the sound occasionally somewhat metallic in its tone. As respects the loudness of resonance, however, and the presence of the other characters, 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, probably exerts an influence on the intensity of the sign; but with reference to this 254 PHYSICAL EXPLORATION OF THE CHEST. point, different observers entertain discrepant opinions. Laennec, Fournet, C. J. B. Williams, and Hughes, regard a treble voice as favorable for transmission throughout the chest, and, hence, broncho- phony, other things being equal, is stronger in females and children than in males. Barth and Roger, and Walshe, on the other hand, think that a grave tone conduces to a greater development of the sign, and that it is most likely to be marked in males and adults. The strength of the resonance will be proportionate to the power of the voice, irre- spective of its pitch or special quality. These, and other circum- stances, such as the thickness of the muscular and adipose layers covering the chest, affect, of course, the resonance in health as well as that incident to disease. The difference of opinion among dif- ferent observers just referred to, is perhaps due to their attention not being directed to the same elements of those entering into the thoracic voice. 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 probably greater when the pitch of the oral voice is high. Bronchophony is not present in all cases of pneumonitis, and in some instances the vocal resonance "is not even exaggerated, so that absence of either or both of these signs, by no means affords positive evidence against the existence of the disease. They are present, however, in a greater or less degree, in the great majority of instances. They may be present without being associated with bronchial respiration, and in such instances they are highly important with reference to the question of solidifica- tion. 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 a resonance exaggerated, or to bronchophony, which is strong in proportion to the quantity of tubercle, the degree of solidity which it induces, its extension to the superficies of the lung, and its proximity to the larger bronchial tubes. It is sufficiently intelligible that these circumstances will affect the amount of exaggeration, or the intensity of the bronchophony, in addition to the strength and cha- racter of the voice of the individual, etc. Owing to the diversity pertaining to the physical conditions favorable for the production of these signs, different cases of tuberculous disease differ greatly as respects their presence and their prominence. Even an exaggerated resonance may not be appreciable in some instances in which a con- AUSCULTATION IN DISEASE. 255 siderable 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. It is probable, also, that accumulation of mucus or other morbid products in the bronchial tubes may occa- sion the temporary suspension of the thoracic voice. Its presence, therefore, as necessary to the diagnosis, is much less to be counted on even 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 proportion of the cases of the latter disease. Hence its value is less in phthisis. 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 the lower or upper lobes, being usually limited to a cir- cumscribed area. These are distinctive features of the signs as inci- dent to tubercle ; but the history and symptoms, in conjunction with all the physical signs, rarely render it a difficult problem to decide between 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, and even bronchophony, alone, are not evidence of the presence of the deposit of tubercle; while a slight exaggeration on the left side, in itself, is sufficient ground for 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 even bronchophony. Under these circumstances the latter is very rarely marked, and frequently both are absent. So true is this, that in a case of pleurisy with effusion, strong bronchophony should occasion suspicion of solidification of lung from some cause, in addition to reduction of its volume by com- pression ; in other words, it would denote either coexisting tuberculosis or pneumonitis. Excepting some instances in which the lung is re- tained in contact with the walls of the chest by adhesions, the effect of the accumulation of liquid is to remove it to the upper and poste- 256 PHYSICAL EXPLORATION OF THE CHEST. rior part of the chest. Bronchophony or exaggerated resonance, if either exists, will then be heard at the summit, in front or behind. It is sometimes limited to the site posteriorly of normal bronchophony, viz., over the upper part of the interscapular space, but is, by no means, constantly present even in that situation. Over the portion of the chest corresponding to the space occupied by the liquid, the resonance is not exaggerated certainly in the vast majority of cases, and this is to be taken into account in determining the fact of pleu- ritic effusion; while existing over the inferior part of the chest, it indicates the presence of solidified lung. Serous infiltration or oedema occasions increased density of the lung, and may give rise to exaggerated resonance. Marked broncho- phony, however, is very rarely, if ever, developed 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, the typhoid material, syphilitic induration, and also in cases of extra-pulmonic morbid growths, exaggerated 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 affections, 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 the exagge- rated 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 re- ferred to), we may infer the existence of some one of the affections just enumerated. In determining which one of these several affec- tions exists, in individual cases, we are to be guided by the circum- stances associated with the physical signs; for example, the expec- toration of blood in pulmonary apoplexy, and of fetid matter in gangrene ; the pre-existence of typhoid disease, or syphilis, etc. It has been stated that, of the instances in which the signs under consideration occur, in the vast majority, the physical condition is increased density of lung. As an exception to this rule, exaggerated resonance and even bronchophony have been sometimes observed in an affection characterized by abnormal rarefaction of lung, viz., emphysema. Their occurrence, however, is exceptional as regards the AUSCULTATION IN DISEASE. 257 physical signs of that affection,—the rule being a degree of vocal resonance not exceeding, and frequently falling below that of health. To the fact of their occasional presence in a marked degree in em- physema—a fact not generally stated by writers on physical explo- ration—Dr. Walshe has particularly called attention.1 Dilatation of the bronchial tubes is another morbid condition in which exaggerated vocal resonance and bronchophony occur. In this rare lesion, the dilated bronchiae are surrounded, to a greater or less extent, with condensed or indurated lung, so that it is difficult to say what is the relative proportion of the exaggerated resonance or bronchophony, which is fairly attributable to the enlarged calibre of the tubes. Bronchophony is not constantly associated with the lesion, and is present in different instances with variable degrees of intensity, sometimes being very strongly marked, when the dilatation coexists with considerable induration of the surrounding lung. The mechanism of bronchophony, as of some other physical signs, offers scope for much theoretical 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 relates to the availability of the sign in the diagnosis of diseases. To this part of the subject, therefore, as in other instances, I shall devote but little space, referring the reader who may desire a more extended consideration of it, to works which professedly treat at length of the physical principles involved in the production of auscultatory phenomena. Laennec attributed the phenomena per- taining to the thoracic voice, to the greater conducting power of lung, when its density is increased. According to this explanation, the vibrations of the vocal chords, and of the air within the larynx, are propagated 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 found there are certain difficulties which it does not fully meet, and it has been attempted by Skoda to disprove altogether its correct- ness, and to substitute another theory, to which reference has been made in treating of bronchial respiration. The theory of Skoda attributes bronchophony, as well as the bronchial respiration, to the 1 Op. cit. 17 258 PHYSICAL EXPLORATION OF THE CHEST. reproduction of sonorous vibrations within the bronchial tubes, in accordance with the musical principle of consonance. The bronchial tubes, according to him, take no direct part in the mechanism ; 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 consonating sounds are slight, owing to the smaller bronchial tubes being membranous, and the want of firmness in the surrounding parenchyma; 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 developed1 under these circumstances. In support of this theory, it is assumed by Skoda that bronchophony is absent whenever the bronchial tubes are ob- structed, 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 it is certainly not so dependent on the presence or absence of mucous secretions in the smaller subdivi- sions of the bronchiae, as Skoda assumes. Its constancy in cases characterized by cough and abundant expectoration is incompatible with that position. This consideration alone renders the theory of consonance inadequate, in itself, to account for the phenomena of bronchophony. In disproval of Laennec's doctrine of conduction, Skoda declares, as the result of experiments on hepatized lung re- moved from the body, that the conducting power is less than that of healthy lung; and that, hence, if exaggerated resonance depended on conduction alone, it should exist in health rather than when the pul- monary structure is solidified by disease. 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 dis- tant. 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 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. 259 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. Dr. Walshe has found that different speci- mens of hepatized lung do not conduct sound equally, a fact ac- cording with the variations in the intensity of vocal resonance, which are clinically observed in different 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 during life, and another person listen to the chest, there is often nearly complete absence of sound. Here are the physical conditions for consonance, provided the bronchial tubes are unobstructed. Skoda endeavors to explain the non-production of sound in this experiment, by assuming that, after death, the smaller tubes are always filled with fluid; but, accord- ing to Walshe, close examination 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 untenable. A consonating sound always sus- tains a fixed harmonic relation 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 consonating vibrations are imagined to take place. Finally, a consonating 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, there- fore, is at variance with the laws of acoustics.1 The doctrine of Laennec, which, as has just been seen, is by no 1 The author would express his indebtedness for the foregoing points, to the admi- rable work of Dr. Walshe (edition for 1854); to which also.he would refer the reader desirous of a fuller consideration of the subject. 260 PHYSICAL EXPLORATION OF THE CHEST. means disproved, nevertheless fails to account for all the phenomena of bronchophony. As already remarked, the thoracic voice has been observed to be intense, when the lung, instead of being condensed, is actually rarefied, viz., in emphysema. Moreover, 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 inadequate to explain the variation of pitch some- times observed between the laryngeal and the thoracic voice. The vocal sounds must be, in certain instances, at least, in some way reinforced within the bronchial tubes, and also receive there modifications of its quality and 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 reverberation probably take place, constituting what is distin- guished 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.1 With the fore- going brief discussion, which, in view of the practical objects of this work, has been perhaps already too extended, I leave the considera- tion 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 knowledge of the latter being based solely on clinical and autopsical observations. An incidental phenomenon which was noticed in treating of healthy vocal resonance, is of interest and importance in connection with bronchophony as a sign of disease. I refer to a souffle or blowing sound accompanying words spoken aloud, but which is apt to be obscured by the resonance and vibration, and is therefore more satis- factorily observed when words are whispered. In cases of pneumo- nitis or tuberculosis, if the naked ear or stethoscope be applied over the solidified lung, the other ear being closed (a precaution always to be employed in auscultating for vocal resonance), and the patient requested to count in distinct and tolerably loud whispers, a bellows sound, more or less loud, will be found to accompany each enunciated numeral. On comparing the result of the same procedure on the ' For a full exposition of the principles of conduction, union-resonance, and echo, so far as they relate to this subject, the reader is referred to the treatise by Dr. Walshe. AUSCULTATION IN DISEASE. 261 healthy side in a corresponding situation, a sound in the latter in- stance will either be entirely wanting, or it will be notably more feeble, and also lower in pitch. A relatively intense and high-pitched souffle, accompanying the act of whispering, is thus a physical sign having the same significance as bronchophony, and the bronchial respiration. In the character of the sound it is analogous to the latter. This sign is not only worthy of attention, as co-operating with bronchophony and bronchial respiration, and thus serving to confirm their validity, but it may be strongly marked in some instances in which the other signs just mentioned are imperfectly developed. In the latter point of view, it deserves more consideration than it has received from writers on physical exploration. In conclusion, the phenomena which have been presented under the head of exaggerated vocal resonance and bronchophony, taking into consideration, in individual cases, the situation in which they are observed, the space over which they are found to extend, their inten- sity, and their conjunction with other physical signs together with symptoms, are often of considerable value in diagnosis. 2. Diminished and Suppressed Vocal Resonance.—The effect of certain morbid conditions is to diminish or suppress the normal vocal resonance. If, therefore, it be apparent that the resonance proper to any part of the chest in health is lessened or absent, evi- dence is thereby afforded of the existence of some one of the morbid conditions which are known to produce this effect. 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 between the two sides in a large number of individuals, and also 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 dis- parity 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 exaggera- tion on the other side. In the one case, the disease is seated in the Bide in which the resonance is relatively less; in the other case, the affected side is that on which the resonance is relatively greater. 202 PHYSICAL exploration of the chest. Without the co-operation of other signs, or of symptoms, it would 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 emphysema, certain cases of solidification, obstruction of one of the large bronchi, the presence of abundant liquid effusion, and of air in the pleural sac. Of these several conditions, in the two first, viz., emphysema and solidification, the normal resonance is diminished, not uniformly, but in a certain proportion of cases only. In emphysema, diminution is the rule, but in some exceptional instances the resonance is notably increased. In solidification, the resonance is generally increased. It is in connection with this condition, as has been seen, that exaggerated vocal resonance and bronchophony occur in the great majority of instances. As exceptions to the gene- ral rule, however, an opposite effect is sometimes induced. Cavities filled with liquid products also occasion a notable diminution of reso- nance within a circumscribed space corresponding to the side 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 circula- tion of air is cut off. In pleuritis, hydrothorax, and pneumo-hydro- thorax, 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 men- tioned, 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, are feeble and distant. Absence of vocal resonance, or 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 this application that the sign possesses clinical value; and inasmuch as the diagnosis of these affections is usually not attended with difficulty, diminution and suppression of vocal resonance are to be ranked among the signs of minor importance. Nevertheless, in accumulating evidence in order to arrive at a conclusion with the utmost positive- ness, a feeble and distant vocal sound on the affected side, or the absence of resonance, is a point entitled to weight, and should not be overlooked. auscultation in disease. 263 3. Pectoriloquy—Cavernous and Amphoric Voice.—The dis- tinctive characteristic of pectoriloquy, as the name imports, is the transmission, not simply of vo.cal sound, but speech: the articulate words are appreciated by the ear applied to the chest. This cha- racteristic is sufficient to distinguish it from bronchophony, but, as will be presently seen, there is not much practical advantage in re- garding it as a distinct physical sign; and at the present time some writers treat of it as a modified form or variety of bronchophony.1 It is accompanied by bronchophony in a certain proportion of cases, but not invariably. The type of pectoriloquy is to be found among the phenomena incident to the voice in health. With the stetho- scope placed over the trachea or larynx, the ear, in a small propor- tion of instances, receives with distinctness the words enunciated 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 practi- cally, by auscultating the trachea and larynx of different individuals. This phenomenon 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, as regards its audible characters, together with so limited an application in its diagnostic significance, Laennec was influenced by the desire manifested in other instances to establish for each particular lesion a special physical sign. Taking his own de- scription 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. According to him, bronchophony is, in fact, pecto- riloquy, whenever, from its situation, the general symptoms, and the 1 Walshe, Skoda. 264 physical exploration of the chest. progress of the disease, it may be deemed to proceed from a cavity.1 Observations since the time of Laennec have abundantly disproved the hypothesis of the transmission of speech, even when most com- plete, being always due to the presence of a cavity ; and, at the pre- sent time, pectoriloquy, be it ever so perfect, has not the significance which it possessed in the estimation of the illustrious founder of aus- cultation. The physical condition, irrespective of excavation, to which pecto- riloquy is sometimes incident, is solidification of lung, either from inflammatory or tuberculous deposit. Exaggerated vocal resonance, to a greater or less extent, coexists. Under these circumstances the sign is, in fact, incidental to bronchophony. The other signs indica- tive of solidification will be associated with it, viz., notable dulness on percussion, and the bronchial respiration. In both forms of dis- ease, but more especially in pneumonitis, the pectoriloquy will be diffused, i. e. heard over a considerable space. In connection with crude tubercle, the situation in which it is found is at the summit of the chest; and it is most apt to occur in pneumonitis affecting the upper lobe. It is by no means frequently present in the affections just mentioned, 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 seldom that well-marked pectoriloquy is developed in the pro- gress of phthisis. Its occurrence cannot therefore be counted on as evidence that the disease has advanced to the stage of excavation. 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 fre- quently exists in the vicinity of the excavations ? The circumstances on which this discrimination is to be based are not so much any peculiarities of character, as its intermittence when due to a cavity ; its being limited to a circumscribed space, and associated with other physical signs indicative of excavation, viz., tympanitic resonance on 1 Vide Treatise on Diseases of the Chest, etc. Translated by Forbes, page 39, New York edition, 1830. auscultation in disease. 265 percussion, with, in some instances, the bruit de pot fete, and the cavernous respiration, alternating Avith gurgling rales. If these cir- cumstances were not conjoined, in many if not in most instances it would not be easy to determine whether the pectoriloquy be or be not cavernous. The point, happily, is one of clinical curiosity, rather than of much practical importance. Cavernous pectoriloquy requires the conjunction of several conditions. The cavity must be of consi- derable 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 structure 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 when it is empty. The space within the excavation must not be intersected by parenchymatous bands. The infrequency with which these seve- ral conditions are united, accounts for the absence of the sign, as a general rule, even when cavities exist, and for its being transient or intermittent in cases in which it may be sometimes discovered. In by far the greater proportion of the instances in which cavern- ous 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. It may also occur in some cases of perforation of the lung, establishing a commu- nication between the bronchiae and the pleural cavity, giving rise to pneumo-hydrothorax. In that rare lesion in which a pulmonary cavity is simulated, or rather virtually exists, viz., pouch-like dilata- tion of the bronchiae, pectoriloquy may be strongly 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 which the same title 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, while ordinary pectoriloquy may be due to solidifica- 266 physical exploration of the chest. tion, it has a positive diagnostic value in the rare instances in which it is heard. It occurs not only in pulmonary excavations, but in cases of pneumo-hydrothorax, with a fistulous communication between the bronchial tubes and the pleural sac. The characteristic sound is not necessarily accompanied by the transmission of speech. An amphoric voice, therefore, may with propriety be regarded as a sign distinct from pectoriloquy. It is so regarded and treated of under a separate head by some writers.1 It suffices, however, for all practical purposes to notice it thus incidentally and briefly in the present connection. Pectoriloquy does not sustain any constant relation to the intensity of thoracic resonance and the associated thrill, nor is it dependent on the loudness of the oral voice. The speech may be distinctly trans- mitted without being associated with the phenomena combined in well- marked bronchophony, and also when the patient is unable to speak except feebly, or only in whispers; in some instances the words ema- nating from the chest have been observed to be even louder and more distinct than when received from the mouth. The transmission of whispered words is distinguished as whispering pectoriloquy, which is regarded by Walshe as highly distinctive of a cavity. My own ob- servations lead me to a different conclusion. I have repeatedly found well-marked whispering pectoriloquy over solidified lung; and, with- out having analyzed cases with respect to this point, I should say that it is oftener met with than the transmission of words spoken aloud. This accords with the results obtained by auscultation of the voice in health, viz., whispered words are oftener transmitted over the trachea, larynx, and bronchi; and in a single instance, imperfect whispering pectoriloquy was observed in the infra-clavicular region, while in no instance were words spoken aloud even partially trans- mitted. The mechanism of pectoriloquy claims but a few words, inasmuch as the physical principles involved are probably 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 rein- forced by reflection from the walls of the excavation, and possibly, also, to some extent, by consonance, according to the theory of Skoda. 1 Barth and Roger. « Vide Auscultation of the Voice in Health, page 168. auscultation in disease. 267 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 between the cavity and the bronchial tubes, but that the necessary sonorous vibra- tions may be excited within the former, provided a thin layer of tissue only intervenes. Barth and Roger concur in this opinion. Pectoriloquy is an interesting physical sign, from the fact that it was the first observed by Laennec, and led to the application of auscultation to the investigation of pulmonary diseases. As respects its value in diagnosis, since it has been ascertained to accompany bronchophony in a certain proportion of cases of solidification, and to occur very infrequently in connection with cavities, it cannot be con- sidered to possess much practical importance. Barth and Roger propose to dispense with the use of the term pectoriloquy, and under the title of cavernous voice to include only the instances in which speech is transmitted from cavities. But so far as the sign alone is concerned, it cannot be determined whether it proceed from a cavity or not. This point is to be settled, not by the evidence received through the sense of hearing, but by reasoning on the circumstances with which the sign is associated. In other words a cavernous voice, exclusive of the amphoric voice, does not exist as a distinct physical sign. The distinction is consequently arbitrary. The reality of pectoriloquy, that is, the transmission of speech, as distinct from bronchophony, even when the two are associated, as is frequently but not invariably the case, is unquestionable. Its distinctive character is very clearly defined. It has therefore just claims to be recognized as an individual physical sign, although, as has been seen, it repre- sents anatomical conditions precisely opposite in character. Its pathological significance is always to be determined by the part of the chest in which it is situated; the extent of surface over which it is heard; its constancy or persistency; and the other physical signs together with the symptoms which accompany it. 4. iEGOPHONY.—The modification of the thoracic voice thus en- titled, has given rise to much discussion respecting its pathological significance, as well as its mechanism. Limiting the attention almost exclusively 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 268 PHYSICAL EXPLORATION OF THE CnEST. 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 sufficient 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 is observed, owing to the adequateness of other signs to the diagnosis; 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 aegophony are, a peculiar tremulousness of the vocal sound, the pitch being elevated above that of the oral or laryngeal voice. With these characters it frequently bears a striking resemblance to the bleating cry of the goat, and this similarity is expressed in the etymology of the word aegophony, which was employed to designate the sign by Laennec. In its audible character, however, it is by no means always uniform. In some in- stances a sound is produced which was compared 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 de polichinetle. The force of the last illustration will be less generally 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 suffi- cient to say that the vocal resonance becomes aegophonic whenever the sound is interrupted or tremulous, and the pitch more or less acute ; and that these distinctive traits may be presented in various degrees and proportions from strongly marked, pure aegophony, down to the slightest modification in these particulars. The two elements which thus enter into the composition of the aegophonic voice may not be present in an equal ratio. The sound resulting from their combination is by no means uniform. It may be feeble or strong. It may be so faint as to be scarcely appreciable, or the sign may be asso- ciated with exaggerated vocal resonance or even bronchophony. It may exist in every degree as respects intensity. The tremulousness may be strikingly marked, or just perceptible, with every intermediate shade. The pitch may be slightly or considerably raised. The bleating, vibrating intonation, accompanies the vocal resonance, but AUSCULTATION IN DISEASE. 269 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 aegophonic sound, as each word or syllable is pronounced, follows the articulation like an echo. The impression of distance is another feature belonging to aegophony; 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 characters, other distinctive traits relate to the situation where it is usually heard, the extent of its diffusion, etc. JEgophony 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 re- ference 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 ;x but in a case of chronic pleurisy cited by Laennec, it lasted for several months. In the pro- gress of the same disease, viz., pleurisy, 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 articulated 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 reproduced immediately after coughing and expectoration. 1 Barth and Roger. 270 PHYSICAL EXPLORATION OF THE CnEST. Laennec regarded aegophony 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 much less than was supposed by the founder of auscultation. 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 aegophony from bronchophony and pectoriloquy; and, also, by the importance wrhich 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 aegophonic intonation. At all events, it is certain that well-marked aegophony, so far from being constantly or generally present in pleurisy, is one of the rarest of the physical signs, 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 associated 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 pleurisy, the hemorrhagic variety of the disease, empyema, pneumonitis with liquid effusion, and hydrothorax. Even in the time of Laennec, the uniform dependence of aegophony 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 at- tached to it by Laennec, and declares that he has met with it both in simple pneumonitis, and tubercular infiltration. Such instances, if they exist, are certainly exceptional. Without denying their occur- rence, 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 effusion, may be the explana- tion in some cases.1 The sharp tremulous character of the oral voice 1 Normal aegophony, 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 AUSCULTATION IN DISEASE. 271 may, also, account for its occasional apparent manifestation. Bron- chophony, and the normal thoracic voice, assume frequently an aego- phonic character in the aged of both sexes, but especially in females. Moreover, with reference to this point, a distinction is to be made between distinctly marked aegophony, and a slightly aegophonic cha- racter 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 aegophony 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. Observations also have sufficiently esta- blished that, in general, it demands for its production a small or 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 compression of the lung, interposing a thin stratum between the pulmonary surface of the thoracic parietes, appears to furnish the necessary physical conditions. In the progress of pleurisy, 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 pleurisy, 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 aegophony (Sgophonie de retour, cegophonia redux), thus furnishes evidence of the progress of the disease toward morbid sign which, excepting some rare instances of hydrothorax, is limited to one side. But the character of the oral voice will be apparent. Moreover, the other physical signs of pleuritic effusion will be wanting. 272 PHYSICAL EXPLORATION OF THE CHEST. 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 aego- phony, 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 on the surface of the chest, and finally disappearing after the whole of the fluid contents of the chest had been withdrawn.1 The fact of aegophony 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 effusion 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 aegophony; flatness and the absence of respiration existing at the lower part of the chest.2 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 aegophony 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 1 Barth and Roger, op. cit. p. 202, edition of 1854. * Fournet, op. cit. AUSCULTATION IN DISEASE. 273 after death. The shifting of the seat of the aegophony, 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 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 aegophony, or a substitution of simply exagge- rated resonance or bronchophony, provided the lung be partially solidified. These phenomena have been repeatedly observed, but by no means uniformly in the cases in which aegophony occurs, which accords with the well-known fact, that it is only in a small 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 pleurisy. 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 aegophony is exceedingly rare. It is not, however, very uncommon for the thoracic voice to assume more or less of an approximation toward aegophony. Under these circumstances there is usually exaggerated vocal resonance or bronchophony; these signs, in other words, become aegophonic.1 Intensity of the thoracic voice, with an aegophonic modification, is to be regarded as diagnostic of solidified lung conjoined with pleural effusion, the vocal resonance in simple pleurisy or hydrothorax being rarely much exaggerated. 1 It has been proposed by Dr. Christophe to distinguish a sound intermediate between aegophony and bronchophony by the title of agony—a diminutive of segophony. There is not, however, sufficient practical importance in the distinction to warrant the intro- duction of a new technical term. 18 274 PHYSICAL EXPLORATION OF THE CHEST. The mechanism of aegophony 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 offered. The other aegophonic 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 mouth-piece 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 unsatisfactory, but of the various substitutes that have been proposed, no one has suffi- ciently commended itself to be generally adopted. The true rationale is yet to be established; and here, as in other instances in which the physical principles involved in the mechanism of signs are undeter- mined, the question is one of speculative rather than practical interest. In conclusion, from the facts contained in the foregoing account of aegophony, 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. More- over, 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. Never- theless, as stated at the outset, in view of the infrequency of its occur- rence in connection with the pathological condition which it repre- sents when it does occur, its brief duration, and, in general, the suffi- ciency 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 exploration, 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 AUSCULTATION IN DISEASE. 275 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 autophonia.1 What- ever clinical value attaches to autophonic phenomena, of course 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, etc. 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 appreciablex 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 special 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. Summary of Facts Pertaining to Vocal Signs.—The normal thoracic vocal resonance in connection with certain morbid conditions may be increased or diminished, and may also present abnormal phenomena as regards quality, pitch, etc., of sound. The various deviations from health are arranged in four divisions, viz., exagge- rated vocal resonance and bronchophony; diminished and suppressed vocal resonance; pectoriloquy, including amphoric voice, and aego- phony. In exaggerated vocal resonance, the diffused, dull, distant resounding of the voice, accompanied with more or less vibration or thrill, which constitute the characters of the normal vocal resonance, are increased in intensity, without any notable alteration in other respects. In bronchophony there is, in addition, an abnormal con- 1 From atirds and tpuvhv. 276 PHYSICAL EXPLORATION OF THE CnEST. centration and clearness of the vocal sound, the voice seeming to be near the ear. The vocal resonance may be slightly, moderately, considerably, or greatly exaggerated. Bronchophony, also, in differ- ent morbid conditions, may be more or less marked. If slightly or moderately marked it is called weak, and if it have considerable or great intensity, it is called strong bronchophony. Strong broncho- phony may exceed in intensity the sound heard over the trachea or larynx. 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 resonance, does not necessarily increase in proportion to the abnormal strength of the bronchophonic voice. Exaggerated vocal resonance habitually exists on the right, contrasted with the left side of the chest, and the thoracic voice at the summit of the right chest, in front, may even be bronchophonic without denoting disease. Exaggerated vocal resonance and bronchophony, represent almost invariably morbid conditions, accompanied by in- creased density of lung. They occur in connection with the same conditions which 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 broncho- phony is observed. Situated at the summit of the chest on one side within a circumscribed area, making due allowance for a normal degree of disparity, if the comparatively greater intensity be on the left side, 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 exaggerated resonance, situated over a part of the chest corresponding to the space occupied by the condensed pulmonary structure; and this situation, save in some exceptional instances, will be at the superior part of the chest. If strongly marked bronchophony exists under these circumstances, there is reason to suspect that the density of lung involves something more than compression, viz., solidification, either from inflammation or crude tubercle. Exaggerated vocal resonance may also, in connec- tion with other signs, together with symptoms, denote carcinoma of the lung, melanotic deposit, extravasated blood or apoplexy, gan- grene, serous infiltration, or extra-pulmonic morbid growths. It is rare that well-marked bronchophony exists in connection with these several affections. As an exception to the rule that exaggerated vocal resonance and bronchophony denote increased density of lung, both have been observed in cases of emphysema. Their occurrence, AUSCULTATION IN DISEASE. 277 however, in the latter affection is altogether exceptional, the normal resonance, as a general rule, being diminished. Dilatation of the bronchiae, accompanied with surrounding solidification, furnishes condi- tions calculated to give rise to strongly marked bronchophony. Inci- dental to bronchophony, especially when words are whispered, a souffle or blowing sound, more or less intense, and high in pitch, is a highly distinctive sign of solidification. It is analogous to the bronchial respiration, and is marked in some cases of solidification in which the latter is obscure or absent. 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 some instances of solidification of lung. Pectoriloquy is the transmission, more or less completely, of articu- late words through the chest to the ear of the auscultator. This sign may be present, when various circumstances favorable to its pro- duction 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 the lung, in the second stage of pneumonitis, and from crude tubercle. When due to a tuberculous cavity, the space in which it is heard is circumscribed, situated, in the vast majority of cases, at the summit of the chest, and it is associated with the cavernous respiration and rales. In connection with pulmonary cavities arising from abscess or circum- scribed gangrene it is seldom present, the several circumstances necessary for its production rarely concurring. It is rarely heard, even when tuberculous cavities exist, the various incidental con- ditions upon which it depends, being either permanently wanting, or only transiently present. A cavernous voice sometimes has a ringing, metallic 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 an event incidental to pecto- riloquy, but it may or may not coexist with transmission of speech. Strictly, it is a sign distinct from pectoriloquy, and is more signifi- cant of a cavity than the latter. The transmission 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 extin- guished. Whispering pectoriloquy, however, may accompany solidi- 278 PHYSICAL EXPLORATION OF THE CHEST. fication of lung, as well as an excavation. An amphoric vocal sound is more apt to occur in a pleural cavity, in pneumo-hydrothorax, than in tuberculous excavations. Ordinary pectoriloquy may be present in the affection just mentioned. It may also be well-marked in pouch- like dilatation of the bronchiae, a lesion of very rare occurrence. iEgophony is characterized by a peculiar tremulousness, together with acuteness 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 circumstances. Morbid aegophony may be strongly marked, or the thoracic voice may be slightly aegophonic, 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, however, 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 pleurisy, hydrothorax, and occasionally to empyema and pneumo- nitis. If it be sometimes observed in connection with solidification, without liquid effusion, as held by some, these instances are rare ex- ceptions to the general rule. In the vast proportion of the instances in which it is observed, it is incident to simple pleurisy ; but is seldom discovered even in that affection, owing to the precise amount of liquid requisite for its pro- duction 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 connec- tion 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 bronchophony. Although very rarely well marked in cases of pneumonitis, it is not uncommon for the bronchophonic voice, in that affection, to present slight tremulousness, with eleva- tion of pitch, in other words to manifest an approximation to aego- phony. In cases of pleurisy the sign has been observed to shift its seat in the progress of the disease, following the increase, on the one hand, and the diminution on the other hand, of the quantity of liquid effusion. AUSCULTATION IN DISEASE. 279 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. Nevertheless, 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 invo- luntarily takes a deep inspiration preparatory to the act, and at this moment the respiratory murmur may 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 coughing an ob- struction 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 respi- ration is thus determined. Instances occasionally occur in which it is difficult to decide from the characters pertaining to the sound whether a rale emanates from the bronchiae 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 compared 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 prac- tically important, may be arranged into two classes, viz., 1. Bronchial Cough; 2. Cavernous Cough. 1. Bronchial Cough.—The tussive sound is bronchial, or, as it is also termed, tubular, when, in place of the feeble, short, diffused sound, unaccompanied by much, if any, impulse or shock, constituting the tussive phenomena heard over the chest in health, the ear receives, 280 PHYSICAL EXPLORATION OF THE CHEST. a concussion more or less forcible, together with a blowing sound, more or less intense, prolonged, concentrated, elevated in pitch, con- veying the impression of nearness. These characters are similar to those which belong to the phenomena produced normally within the trachea by the act of coughing. The analogue of the bronchial or tubular cough is the bronchial respiration, and it is usually associated with exaggerated vocal resonance or bronchophony. The characters which have just been mentioned are in fact identical with those which belong to the expiratory sound in the bronchial respiration. They may be strongly marked in some cases in which the bronchial respi- ration is feeble, and hence the tussive sign may be valuable, not only as confirming, but as a substitute for the latter. It represents precisely the same physical conditions as the bronchial respiration and bronchophony. The bronchial cough, therefore, occurs especially in the second stage of pneumonitis; next in frequency and promi- nence, in connection with crude tubercle; also in pleurisy over the lung rendered dense by compression, in apoplectic extravasation, oedema, and dilatation of the bronchial tubes, etc. The mechanism of its production involves the same physical principles as the bronchial expiratory 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 approximated, and the blowing sound transmitted with greater intensity to the ear of the auscultator in consequence of the density of the intervening pulmonary structure. 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, probably always lower in pitch than the expiratory sound in the bronchial respiration, or the souffle accompanying whispered words; and conveying the impression of its being produced within a hollow space. These cha- racters, 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 in nine cases in ten pulmonary excavations are due to tuberculous dis- AUSCULTATION IN DISEASE. 281 ease, 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 cavernous from a bron- chial blowing, taken in connection with the intrinsic 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 simple cavernous respiration : the latter is its analogue. The one may be well marked, when the other is not distinctly appreciable. A caver- nous 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 instance. The circumstances which are favorable to the presence of both are identical, viz., in addition to emptiness of the cavity, its size, commu- nication with the bronchial tubes, the latter being unobstructed, superficial situation, etc. The second variety is amphoric cough. A cavernous cough be- comes amphoric when it has a ringing, metallic tone, resembling that which constitutes a variety of the respiratory and vocal sounds to which the same title is applied. An amphoric cough may be imitated by coughing over the mouth of an empty vase. 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 caver- nous 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 loud splashing sound is fre- quently 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 tuberculous cavity of con- siderable size. It will be likely to alternate 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. 282 physical exploration of the chest. 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 pos- sess a significance almost pathognomonic; and its distinctive charac- ters 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 which a grain of sand is dropped;" and, again, to the " vibration of a metallic wire touched by the finger." Other illustrations employed by different writers, are the tinkling of a small bell; shaking 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, clear, abrupt, short, silvery tone. There is no difficulty 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, but following in quick but irregular succession. As already stated, the sign may accompany respiration, speaking, and coughing. It is oftener pro- duced by the two latter than by the first, and more especially attends the act of coughing. The act of deglutition may also occasion it. This fact was first noticed by Dr. Charles T. Hildreth, of Boston,1 in 1841. It has since been confirmed by other observers. 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 consequence of a change of position, from the horizontal to the vertical. When it accompanies respiration, it is more apt to be produced by the inspira- tory than the expiratory act, although it may be present with either, or both. It occurs at the close of inspiration, the tinkling sounds 1 Vide Descriptive Catalogue of the Anatomical Museum of the Boston Society for Medical Improvement, page 124. AUSCULTATION IN DISEASE. 283 frequently being continued into the expiration. Sometimes when it is not heard with ordinary breathing, it becomes developed by a forced inspiration. It rarely accompanies each successive act of respiration, but is heard at irregular intervals. It is important 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 respira- tion. Its situation is commonly at the middle 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 progress of the same dis- ease 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 different cases differs. It may be transient, or persist for a long time. In constancy it is also variable. Sometimes it appears, ceases for a time, and is again reproduced ; or, it comes and goes at irregular intervals. The sound in some instances appears 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 varying circumstances connected with the physical conditions upon which the sign is depen- dent. In determining the presence of this sign, there is scarcely a possi- bility of confounding it with any other of the auscultatory phenomena. The only liability to error arises from the fact that a metallic tink- ling sound, as already intimated, is occasionally produced within the stomach, and transmitted, so as to be apparent on auscultating the inferior portion of the left chest. Mere gastric tinklings, however, are never so frequently repeated or persisting as are generally those produced within the chest. They occur irrespective of either respi- ration, voice, or cough, and this alone suffices for the discrimination. Moreover, the associated signs and symptoms will 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 contends that the presence of liquid is not essential—an opinion he is in a 284 PHYSICAL EXPLORATION OF THE CHEST. measure bound to entertain for the sake of consistency with his pecu- liar 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 all the cases in which the sign is pre- sent with very rare exceptions.1 Subsequent observations have shown that it is not indispensable, although much more favorable to its pro- duction 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 essen- tial conditions, viz., the existence of a space of considerable size con- taining air and liquid, are furnished in pneumo-hydrothorax and pul- monary 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 proportions of liquid and air happen to be favorable. From the infrequency 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 ma- jority of cases, if not without exceptions, proceeds from tuberculous disease. Hence, in the few instances in which it is due to this cause, 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 generally present in cases of that affection. This fact, taken in con- nection with its extreme 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 dif- fused more or less over the chest. But dependence on this sign exclusively is never necessary, the concomitant signs, denoting pneumo-hydrothorax, being quite distinctive, as has appeared from the phenomena incident to percussion and auscultation, which have been.already considered. 1 Vide op. cit., Am. Ed. of Forbes's Translation, Edition of 1830, pages 526 and 60. AUSCULTATION IN DISEASE. 285 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 physical signs is not dependent on our ability to adduce all the physical prin- ciples which their production involves. Different writers may differ widely as respects the latter, but there is very little room for dis- crepancy of opinion concerning the pathological or anatomical rela- tions 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. Laen- nec 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 which 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, but without giving any special rationale. 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 injecting, in small quan- tities 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 experiments reported by Dr. Jacob Bigelow, of Boston,1 Dance, Fournet, and Barth and Roger, in France,2 is, that the air, finding its way 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 intro- dnced through an opening into the chest, and carried below the sur- face of the liquid, air blown through the instrument produced an exquisite metallic tinkling at the explosion of each bubble, resembling ' Vide American Journal of Med. Sciences, 1839, and a recent volume by Dr. Bige- low, entitled Nature in Disease, etc. 8 Vide Treatises by Barth and Roger, French edition of 1S54, and by Fournet. 286 PHYSICAL EXPLORATION OF THE CHEST. the sound heard during life. This result obtained only when a few ounces of liquid were contained within the chest. If the quan- tity was increased by injection to the amount of two or more quarts, a bubbling sound was alone produced. Tinkling also was produced by repeating Laennec's experiment, viz., letting 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.1 " 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.2 Barth and Roger, on repeating the experiments made by Dr. Bigelow with a bladder, found the same results.3 This explanation, it is obvious, will only apply to the instances in which a communica- tion exists between the cavity and the bronchial tubes, or externally by means of an opening through the thoracic walls. It is difficult also to understand the persistency of the sign when thus produced, since the accumulation of air above the level of the liquid must soon establish an equilibrium of pressure between it and the external atmosphere, so that bubbles would no longer rise and explode in the manner described. 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.4 A sufficient amount of agitation, it may be imagined, takes place with respiration, but more especially with the acts of speaking and coughing. Again, experiments appear to show that the bursting of bubbles of mucus at the opening of a fistulous orifice situated above the level of the liquid, may occasion a sound resembling, but not absolutely identical with metallic tinkling.5 Without citing other 1 The bladder or stomach employed in these experiments should be recent. 2 Op. cit. t. 1, page 378, et seq. 3 0p. cit, ed. of 1854, page 239. 4 Vide Dr. Bigelow's experiments, op. cit. 5 Vide experiments by Bigelow, Fournet, and Barth and Roger. AUSCULTATION IN DISEASE. 287 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.1 Either explana- tion, 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 conditions upon which it depends. Adopt- ing 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 communica- tion 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 circum- stances, 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 mem- branes 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 communication with the bronchiae, 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 proportionate quantity of the latter. The orifice, also, or the bronchial 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 circumstances will serve to explain the variations in 1 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 satis- factory than to the explanation of other auscultatory phenomena. 288 PHYSICAL EXPLORATION OF THE CHEST. quality, intensity, situation, 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 by some writers it is regarded as essen- tially similar to the three signs last mentioned.1 The pathological and diagnostic relations are the same. As respects the audible cha- racters, however, an analogy only exists; there is by no means an identity. Moreover, different physical conditions are involved, cer- tainly in the great majority of instances. Metallic tinkling, with very 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 opening 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 espe- cially 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; while, certainly in the large proportion of instances, the liquid plays an important role in the production of metallic tinkling. Amphoric respiration, voice, and cough, demand only a space of considerable size filled with air. Metallic tinkling, occasioned, as has been seen, generally 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 excep- tional mode mentioned, in a cavity containing nothing but air. These statements are shown to be correct by facts detailed 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 operation of paracentesis, and with a recent bladder or stomach partially filled with liquid, whenever air was blown through a tube, introduced into the cavity and carried above the level of the liquid, a sound analogous to the 1 Walshe, Skoda. AUSCULTATION IN DISEASE. 289 amphoric respiration was heard on applying the ear to the chest, or to the distended membrane; and never the metallic tinkling, except- ing saliva was carried into the tube, producing bubbles at its ex- tremity. Although, therefore, this sign is so often associated with the amphoric modifications of respiration, voice, and cough, the phenomena cannot be properly considered as essentially the same. Summary. Metallic tinkling requires, as a general rule, with perhaps some rare exceptions, a cavity of considerable size containing air and a certain quantity of liquid. In the vast proportion of cases the cavity in which it occurs communicates 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 affection, and is found frequently to co- exist or alternate with amphoric 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 praecordial region, the extent of their diffusion and their intensity 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 appre- ciable. If, therefore, they are discovered to be more intense 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 force 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 considerably 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 19 290 physical exploration of the chest. chiefly with reference to the diagnosis of tuberculous disease, that this sign possesses clinical value. In that connection it is worthy of attention. The deposit of tubercle probably renders the portion of lung affected, a better conductor of the sonorous vibrations 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. The examples just cited in illustration, are actually presented in some instances of phthisis. 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 praecordia, and even more intense 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 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, which concur to establish the diagnosis of that affection. To constitute this a sign of tuberculosis, 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 front or behind. 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 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 AUSCULTATION in disease. 291 certain distance from the praecordia, 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 consi- derably 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 posterior surface of the left chest, the right side remaining in a normal condi- tion in this respect. Without knowledge of the fact that the trans- mission 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 praecordial region is an effect of emphysema affecting the left lung. The enlarge- ment 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 praecordia with less intensity than in a normal condition. Abnormal diminution of the sounds of the heart in the praecordia, in connection with undue clearness 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 inten- sity to different portions of the chest, but they may emanate from other situations than the praecordia, in consequence of displacement of the heart. This will be found to enter into the history of pleurisy with large liquid effusion, and of pneumo-hydrothorax. Finally, a bellows arterial sound is sometimes heard within a circumscribed space at the summit of the chest on one side, not transmitted from the heart, but limited to the subclavian artery, probably 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 intermittency, and his having observed it to subside after copious haemoptysis, and leeching in the subclavian or axillary regions.1 Whatever may be the expla- 1 Stokes on the Chest, American edition, 1844, page 3S5. 292 PHYSICAL EXPLORATION OF THE CHEST. nation, the occasional occurrence of a bruit de soufflet, 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 important to be borne in mind. 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 insignificant had been its results, that the honor of the discovery justly belongs to Re'ne' 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 same year was published the great work entitled " De VAuscultation Mediate, ou Traite du diagnostic des Maladies des Poumons et du Coeur, fonde principalement sur ce nou- veau moyen d'exploration." In the introduction to this work, Laennec announces the discovery, and relates the circumstance which led to it in the following words : " In 1816, I was consulted by a young woman laboring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just men- tioned being rendered inadmissible 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 im- pression of sound when conveyed 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. 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 AUSCULTATION IN DISEASE. 293 the action of the heart, but of every species of sound produced by the motion of all the thoracic viscera, and, consequently, for the explora- tion of the respiration, the voice, the rale or rhonchus, and perhaps even the fluctuation of fluid effused in the pleura or pericardium. With this conviction I forthwith commenced at the Hospital Necker a series of observations which have continued to the present time. The consequence 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 prominent, and calculated, perhaps, to render the diagnosis of the diseases of the lungs, heart, and pleura, as decided and circum- stantial as the indications furnished to the surgeon by the introduc- tion of the finger or sound, in the complaints wherein these are used."1 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 vastly 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 call the new method by the title of 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 was the science of auscultation perfected in the hands of its founder, that a considerable portion remains to the pre- sent 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 instance of a discovery of equal importance in which so little was left by the discoverer to be performed by others. Moreover, as an ex- ception to the general rule, the gratification was accorded to Laennec of witnessing the acknowledgment of the value of his discovery, and its adoption by the most intelligent of his contemporaries. Never- theless, the labors of those who have devoted attention to the culti- vation of this department of medical science, since the discovery by Laennec, have by no means been without useful results. Some errors 1 Forbes' translation. 294 PHYSICAL EXPLORATION OF THE CHEST. have been corrected, auscultatory phenomena have been studied in new aspects, important parts have been added, and, in short, the physical diagnosis of thoracic affection has been rendered more easy and pre- cise by contributions to our knowledge from various 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 ocular examination of the chest, in order to discover deviations from sym- metry, or any abnormal appearances, as regards size and form, and also visible alterations of the natural movements incident to respi- ration. 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 exploration, this method should generally be first employed, because its results are to be taken into account in estimating the importance which belongs to 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 exa- mination without offence to modesty, different sections may be in- spected separately. The lower portion of the chest anteriorly, including the mamma, may be covered, while the upper part is exposed; and afterward the upper part, with the mamma, 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, or sitting, or standing. When circumstances render it practicable and proper, the last-men- tioned 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 afterwards on each side, obtaining a view in profile. The anterior and posterior surfaces 296 PHYSICAL EXPLORATION OF THE CHEST. of the chest are to be inspected, observing the same precautions. The examination of the posterior surface, especially, is most conve- niently 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. In- attention to this point may affect materially the results of the exami- nation. In the size, configuration, &c, of the chest, considerable differences are observed in different persons free from thoracic disease. It is impossible to fix upon a normal standard, which shall serve as^i criterion by which to estimate either the existence or the degree of abnormal deviations. The physical signs furnished by inspection, as a general rule, are determined by observing a want of correspon- dence between the two sides. Taking advantage of the fact that, for the most part, intra-thoracic diseases 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 symmetrical (which, with certain excep- tions, 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 characterized 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 connection 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 perfect 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. Woillez1 found, of 197 subjects in good health, and without spinal curvature, that in 47 only was the symmetry in all respects absolutely perfect. A projection of the left side in front, either at, or above, or below the nipple, existed in the proportion of 26 per cent. An anterior projection on the right 1 Op. cit. INSPECTION. 297 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 by M. Woillez, while it is very rarely noticed on the left side. Variations, due to slight spinal cur- vature, are exceedingly common. The majority of persons, especially laborers and mechanics, are not altogether 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 curvature of the spine is also very common with females. Want of harmony between the two sides, not suffi- ciently marked to be observed without careful examination, may occa- sion an appreciable disparity as respects the signs furnished by percussion and auscultation, and, hence, the importance of first com- paring closely by inspection wherever it is important to institute a close comparison by means of the other methods 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 affections of an anterior date, more or less remote, which have left permanent effects on the con- formation 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 under two heads, viz., enlargement and contraction; each admitting of subdivision into general and partial. The enlargement or contraction is general when the dimensions of the whole of at least one side of the chest is either increased or diminished. Partial enlargement or contraction is 298 PHYSICAL EXPLORATION OF THE CHEST. when there is either a projection or depression of a portion of the chest on one or both sides. General enlargement of the chest occurs 1st, in consequence of aug- mented volume of the pulmonary organs, or 2d, from the accumula- tion of liquid, or air, or both, within the pleural sac. The enlarge- ment from either of these causes, produces changes in the relations 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 enlargement, 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 both lungs are emphysematous, the chest remains expanded as it is by a deep inspiration. The enlargement, however, is usually most marked at the superior and middle portions of the chest; the reverse of this, as will be seen presently, obtaining 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 lobe; and, second, the action of the diaphragm incident to the labored respiration occasioned by the disease, offers an obstacle to the enlargement of the inferior portion of the chest. The latter, indeed, may appear to be contracted, from the greater relative dilatation of the superior and middle portions. It is rarely the case, when the en- largement from emphysema is general, i. e. affecting more or less one chest at least, that the side is regularly dilated. The emphysema being usually more marked at some parts of the lung than at others, the surface of the chest presents a corresponding inequality. In this respect the enlargement from emphysema differs from that due to liquid in the pleural sac, the expansion in the latter being more re- gular. Moreover, the enlargement from emphysema is never so great as that not infrequently observed from pleural effusion. If the em- physema affect both lungs, the two sides of the chest will of course be enlarged. And if both lungs are equally augmented, it is diffi- cult to determine to what extent the dimensions are increased, not having the advantage of a comparison of the two sides with respect INSPECTION. 299 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 observations show that the left lung is more prone to a greater rela- tive amount of augmentation than the right.1 Dilatation of the chest from emphysema is oftener limited than general, so that the anato- mical 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 emphyse- matous condition. This obtains especially in bronchitis affecting the smaller bronchial tubes (capillary bronchitis); and it has been ob- served, in a marked degree, in the bronchitis complicating typhoid fever.3 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 pleurisy, 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 haematosis 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 un- usual activity of respiration, also produce the same result. In simple 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 enlargement, 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 the chest occurs most frequently, and is most marked. Universal, and not infrequently great dilatation on one side, is an important physical sign in chronic pleurisy with abundant effusion, and in pneumo-hydro- 1 Racle. Op. cit. 2 Traite" de Diagnostic Medical, par le Dr. Racle. 1854. 300 PHYSICAL EXPLORATION OF THE CHEST. thorax. General enlargement in these affections is always confined to one side. An accumulation of liquid, or air, in both pleural cavi- ties, sufficient to dilate the two sides, would 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 emphysema, 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 pleurisy, render the discrimination sufficiently easy. In emphysema, the percussion-resonance is never lost, and is generally abnormally clear, with a quality more or less approximating to the tympanitic. In pleurisy, with abundant liquid effusion, the percussion-sound is flat. 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 ausculta- tory signs, viz., metallic tinkling and amphoric respiration, in connec- tion with the symptoms and history, the differential diagnosis does not involve much difficulty. The expansion of the thoracic walls, if it be considerable, 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 protuberant. It has been asserted that the effect on the intercostal spaces is charac- teristic of enlargement from the pressure of liquid or gas, in distinc- tion from that due to the augmented volume of the lung.1 The inter- costal depressions, however, may be effaced in cases of emphysema. The error of supposing otherwise has perhaps arisen from observa- tions having been confined to the lower part of the chest, where the depressions are most conspicuous in health. Liquid effusion oblite- rates the depressions in this situation, the distension 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. But it is undoubtedly true, that, at the superior portion of the chest, the intercostal depressions, in persons in whom they are normally visible in these situations, may 1 Dr. Stokes. INSPECTION. 301 be diminished or lost in consequence of the pressure of emphysema- tous lung. Partial enlargement is incident to most of the anatomical conditions 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 oftener partial than general. It occasions undue prominence over a portion of the chest corre- sponding to the seat of the affection, and proportionate in amount to the extent of the affection, with diminution or obliteration of the intercostal depressions. Affecting the superior portion of the lung on one, or more commonly on both sides, but greater on one side than on the other, a characteristic appearance is an abnormal 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 subjacent lung. The evidence derived from percussion and auscultation suffice to correct this error. The physical evidences of the morbid 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 which 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 enlarged from the accumulation of the liquid. Unless the quantity of effusion is large, the dilatation is partial, and situated inferiorly, in this re- spect contrasting with enlargement from emphysema in the majority of cases of the latter affection. The contrast as respects the signs derived from percussion and auscultation, however, generally serve to distinguish these affections from each other as broadly as possible. In pneumo-hydrothorax the quantity of liquid at the bottom of the chest may be sufficient to occasion manifest enlargement when no obvious disparity exists above. 302 PHYSICAL EXPLORATION OF THE CHEST. Pneumonitis affecting a single lobe sometimes gives rise to an appreciably increased fulness of the part of the chest situated over the solidified lung, but the enlargement is apparent in only a small proportion of instances. Various conditions additional to these may produce partial enlarge- ment, the more important of which are as follows : (1.) Circumscribed pleurisy, a collection of liquid sufficient to occa- sion bulging, being confined within a limited area by adhesions of the surrounding pleural surfaces. Cases of this description are some- times 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.1 (2.) Enlargement of the spleen. Marked projec- tion of the lower portion of the left side is sometimes due to this ana- tomical 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 protru- sion of the lower left ribs. (4.) Enlargement of the liver, from tumors, abscess, or hypertrophy. In this case, of course, the partial enlarge- ment of the chest will be situated on the right side. (5.) Liquid effusion within the pericardium, and enlargement of the heart. The praecordial portion of the chest may be rendered abnormally promi- nent 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 attributed to the hypertrophy of the heart in the instances in which it has been observed in connec- tion with that affection. (6.) Aneurismal and other intra-thoracic tumors. (7.) According to Dr. Chambers, 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 confirmation. Variations in size and form, the reverse of those just considered, may also, as has been stated, be general or partial. When contraction is general, i. e. affecting one or both sides, the relations of the component parts of the chest are analogous to those incident to a forced expiration. 1 Essay on Chronic Pleurisy, by Author. INSPECTION. 303 The upper ribs are more widely separated, while the lower are ap- proximated to each other, and the space below the xiphoid and between the lower costal cartilages is diminished. General contraction of one side is presented in a striking degree after recovery from chronic pleurisy. 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 assume, after the liquid is absorbed, 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, there- fore, forces the thoracic walls to accommodate themselves to the diminished bulk of the pulmonary organ; the reduced dimensions compared with the other side (the latter becoming increased in size) are sufficiently obvious on inspection, but the altered relations of dif- ferent 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 nipple 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 pleurisy, 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, pro- vided the pleural cavity does not contain liquid effusion or air, is of ne- cessity accompanied by a contraction of the chest exactly proportioned to the extent to which the pulmonary organ is reduced in bulk. Col- lapse, from obstruction of one of the main bronchi, involves an amount of general contraction corresponding to the diminished volume of the lung. Condensation from inflammatory exudation within the air-vesi- cles, remaining after the removal of this exudation, leads to some re- duction of bulk, and hence contraction is sometimes observed to follow the resolution of simple pneumonitis, and is general if the inflamma- tion 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 dis- 304 PHYSICAL EXPLORATION OF THE CHEST. ease induces a shrinking of the lungs, and a corresponding diminu- tion of the size of the chest; and this effect follows long confinement to the bed with any disease.1 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 matter ; but they are found more frequently, and in a more marked degree after softening and excavation have taken place. In connection with the changes by which cavities are formed, their rationale is suffi- ciently 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 retained 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 important by way of preparing the observer to estimate correctly morbid ap- pearances. Incidentally, in connection with the physiological facts relating to this subject, allusion has already been made to the more prominent of those aberrations of the respiratory movements which constitute physical signs of disease. Abnormal frequency of the respiration 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 respiration implies a morbid 1 Vide Sibs'on's Medical Anatomy, Fasciculus 1. INSPECTION. 305 condition seated in the nervous system, the respiratory function being affected secondarily, or symptomatically. Increased frequency is incident to various affections compromising the function of haematosis, such as pleurisy, pneumonitis, phthisis, and in a notable degree to capillary bronchitis. The number may be increased from the healthy average, ranging between 14 and 20 per minute, to 40, 50, and even 60. Abnormal frequency of the respirations does not neces- sarily 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 general rule, four strokes 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 presumed to exist whenever an increase in the number of respira- tions 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 move- ment is somewhat shortened, as a general rule, whenever dyspnoea exists, the want of fresh supplies of atmospheric 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 lessened ; hence it is more quickly performed. This occurs in cases in which pain is produced by a full or deep inspiration, as in pleurisy or pleurodynia. The patient instinctively represses the inspiratory movements, and thus, as far as possible, consistently with the intro- duction of sufficient air for haematosis, shortens the duration of inspira- tion. An abrupt arrest of inspiration, with manifestations of acute pain, is a sign highly distinctive of the affections just named. The inspira- tion is also shortened by an obstruction in the larynx, which arrests 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 prolonged in emphysema, owing to the impaired con- tractility of the lung; in bronchitis attended with obstruction of the smaller bronchial tubes ; and in spasm of the muscular fibres entering into the bronchiae, constituting nervous asthma. The prolongation is 20 306 PHYSICAL EXPLORATION OF THE CHEST. great when the three morbid conditions just mentioned are combined, which is not unfrequently the case. Under these circumstances, 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 slow- ness which increases until the act is completed. Obstruction 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 obstruction seated in the smaller bronchial tubes. Dr. Sibson's observations show this to be a point of distinction.1 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 inspiration, will be marked and extensive in proportion to the degree of obstruc- tion. If the obstacle to the entrance of air be slight, the lower portion of the sternum only falls backward. The collapsing move- ment extends over the sides in proportion to the difficulty attending the ingress of air; and, in extreme cases, the entire thoracic walls are contracted, excepting the ribs to which the diaphragm is attached. Owing to the action of the diaphragm, the latter are still moved out- wardly.3 An exception to the effect on the chest just stated, occurs when, from old age, the costal cartilages have become rigid and un- yielding. 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 1 On the Movements of Respiration in Disease. 2 Ibid. INSPECTION. 307 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 farther divisible into the superior and the inferior costal type. The combination of these several types, and their relative predominance, respectively, in other words, different 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, which involves chiefly, and sometimes almost exclusively, the abdominal type. In cases of peritonitis, in which the play of the diaphragm occasions acute pain, the respiratory move- ments are in a great measure restricted to the thoracic walls: the breathing is costal. The same effect is produced by mechanical ob- struction to the descent of the diaphragm from ascites, pregnancy, tympanitis, or abdominal tumors. On the other hand, in cases of pleuritis, 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 pleurisy, 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 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 respi- ratory movements, constitutes, in some instances, important diagnos- tic evidence of disease. In the dilatation of the chest on one side from large liquid effusion, the movements on that side are notably dimi- nished, and may be almost null, whilst, on the opposite side, they are supplementary increased. A similar disparity, but never to the same extent, exists in some cases of emphysema, in which the affec- tion is either confined to, or is more marked, on one side. The same 308 PHYSICAL EXPLORATION OF THE CHEST. contrast exists in pneumo-hydrothorax. In simple pneumonia, affect- ing 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 symp- tom is not present. This was denied by Laennec; but a careful com- parison of the two sides, in a series of cases, must convince any one of the correctness of the statement.1 A local disparity at the summit of the chest is sometimes a highly significant sign of tuberculous dis- ease. The superior costal movements, owing to pleuritic adhesions, or other causes, in some instances, are notably less on the side in which a tuberculous deposit exists, than on the opposite 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 ex- ploration for evidence for or against the existence of tuberculous 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 symmetrical in conformation, this may be assumed; but in making examinations of persons presumed to be free from disease, I have, in a few instances, observed a slight disparity in that situation, as well as at the lower part of the chest. In view of these occasional exceptions to the general rule, a disparity in mobility, as an isolated sign, should be distrusted; but, associated with other signs, it is entitled to consider- able weight. Finally, a marked disparity in the movements of the two sides obtains in cases of hemiplegia. Summary. The phenomena determined by inspection embrace morbid appear- ances pertaining, (1), to the size and form of the chest; and, (2), to 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 during respiration is of very little utility. INSPECTION. 309 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 the pleural cavity. To the former of these anatomical conditions is due the en- largement, in cases of emphysema, which may affect both sides of the chest. Enlargement of the chest from emphysema is most marked at the superior and middle portions of the chest; and the surface rarely presents a uniform regular dilatation. General enlargement on both sides is observed in some cases of bronchitis. A more fre- quent anatomical condition, giving rise to general enlargement, is the accumulation of liquid in the pleural sac in cases of chronic pleurisy. General enlargement from this cause is necessarily confined 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 pleurisy, wherethey are normally most conspicuous, viz., the anterior and lateral portions at the lower part of the chest. In this situation they are rarely effaced by the pressure of an emphysematous lung so as not to be marked with inspiration; but they may be diminished or lost over the superior portions in cases in which they are normally apparent in that situa- tion. General enlargement of the chest may also proceed from pneumo-hydrothorax, and, in a slight degree, from simple pneumo- nitis affecting an entire lung. Partial enlargement, oftener than general, is incident to emphysema, pleurisy, pneumo-hydrothorax, and pneumonitis. It is also incident to circumscribed collections of liquid; enlargement of the spleen; distension of the stomach; aug- mented 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 reco- very from chronic pleurisy. It results from collapse of lung following obstruction of the bronchus leading to it; and accompanies in a slight degree the diminished volume succeeding pneumonitis affecting an entire lung, and also coexists 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 more frequent and more marked in an advanced period of the 310 PHYSICAL EXPLORATION OF THE CHEST. 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 haematosis, and is therefore observed in pleurisy, pneumonitis, phthisis, and especially in capillary bronchitis. Occurring oftener than in the ratio of one to four beats of the heart, pulmonary disease of some kind is generally indicated. The inspira- tion is shortened, as a general rule, in dyspnoea. It may be arrested before the act is completed by an obstruction of the windpipe, and is voluntarily arrested in consequence of pain in pleuritis and pleuro- dynia. 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 proportionably 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 later- ally 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 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 pre- vented mechanically in tympanitis and ascites, by tumors, and in pregnancy. Abdominal or diaphragmatic respiration is marked when the thoracic movements occasion suffering in pleuritis or pleurodynia, and in paralysis of the costal muscles. In health, the type of respi- ration in the male is chiefly abdominal, but whenever the breathing is labored, the inferior and costal types are also manifested. When the chest on one side is greatly dilated in chronic pleurisy, the side affected is nearly immovable, the movements on the unaffected side being supplementarily increased. The same disparity, but in a less degree, is exhibited in cases of emphysema in which the affection is limited to or more marked on one side. It is also 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 hemiplegia, the movements of the chest on the paralyzed side of the body are diminished, and those on the opposite side increased. INSPECTION. 311 History. Inspection was doubtless resorted to, in the investigation of diseases, 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, has led practitioners to employ, to a much greater extent than previously, and with vastly more advantage, this method of examination. The value of results obtained 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 respiratory movements, with greater accuracy than can be determined by the eye. For this end, measurements are resorted to. These constitute a distinct method of examination, called mensuration. For ordinary clinical purposes, in other words, with reference to diagnosis, the practical value of this method is very limited. It is rarely im- portant, because the information obtained by inspection is sufficiently exact, and in some instances, even more satisfactory. The two ob- jects for which mensuration is employed, viz., to determine 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 opposite 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, it may be doubted whether partial enlargements or con- tractions on one side are not generally more satisfactorily appreciated by comparison with the eye. I have had no practical experience in MENSURATION. 313 the use of callipers, and so far as my knowledge extends, they are rarely made use of even by those who devote special attention to physical exploration. A difference between the two sides in any of the diameters, sufficient to become an important physical sign, is ap- parent on careful examination and comparison by inspection. It is chiefly in noting facts for analytical investigation, that an exactness of measurement in this or other modes, which can be expressed nu- merically, is desirable. 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 prac- tice. 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 effusion, etc.; and, on the other hand, contraction, incident to re- covery from pleurisy, tuberculosis, etc. Another application of mensuration consists in measuring distances 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, equi- distant from the centre of the sternum. Enlargement of one side in connection with morbid conditions which have been already men- tioned, removes the nipple on the affected 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 diminished when the chest is con- tracted. 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 compa- rative 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 be- tween the two sides, as respects the points just mentioned, in figures ; but so far as concerns the bearing of the facts on diagnosis, such pre- cision is superfluous. The facts, as estimated by the eye, are suffi- ciently exact. 314 PHYSICAL EXPLORATION OF THE CHEST. Another mode of practising mensuration, consists in measuring the horizontal circumference of the chest, and comparing the two 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 vertebrae with ink, or by insert- ing a pin. The point meeting the extremity fixed at the centre of the sternum is also marked. The data for determining the circum- ference of the whole chest, and that of each side are in this way ob- tained ; and since, practically, the chief object 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 ex- ceeds 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-circumfe- rence at each side is sometimes measured separately ; but a difficulty in the way of accuracy arises from the liability of the chest not being equally expanded while the measurements 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. A better 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 this simple plan (attributed by Dr. Walshe to Dr. Hare) is, that it may be applied while the patient is recum- bent. The point of junction being fixed over the spine, and the two tapes brought forward, the circumference of each side is shown by a glance at the centre of the sternum. Of the convenience of this plan I can speak from my own experience. Comparison of the semi- circular 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 difference 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 MENSURATION. 315 normally unequal. In the majority of persons the right semi-circum- ference 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 latter is found to occur oftener among left-handed persons. Owing to these natural differences, the fact of a disparity as shown by the results of mensuration, if it be but small or moderate, does not necessarily denote disease. To become a morbid sign it is to be taken in connec- tion 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 circumstances 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-cir- cumference of the side affected, and under these circumstances the latter must be determined by inspection, or by the callipers. The advantage of circular measurement does not relate to the determina- tion 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 increase at different periods in the same case. This object has reference mainly to a single disease, viz., chronic pleurisy, 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 accumulation 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 sta- tionary. 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 pleurisy, are measurably applicable to pneumo-hydro- thorax, and to some extent to emphysema. The progress in the slow expansion of the chest after the contraction which immediately 316 PHYSICAL EXPLORATION OF THE CHEST. follows the removal of liquid effusion, may also be determined, from time to time, by measurements, with greater precision than by means simply of ocular examinations. The foregoing remarks have related to a comparison of the two sides of the chest, by means of which, 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 healthy limitation, 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 dis- parity between /the sides is the point to be considered. The researches by M. Woillez, however, have led to some interesting results as re- spects the changes in the general capacity of the thorax which are to be observed during the career of acute diseases. These results, ex- pressed as concisely as possible, are as follows r1 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. These 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. These alterations in capacity are accompanied by proportion- ate modifications of the elasticity of the thoracic walls. The elasticity diminishes as the enlargement increases, and again, gradually 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 1 Traite" de diagnostic medical, par Racle. MENSURATION. 317 size takes place prior to the complete development of the eruption. Particular causes, affecting the 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 enlarge- ment of the chest, and the diminished elasticity, are attributed by M. Woillez, to pulmonary congestion accompanying the development and career of acute affections. These changes in the size of the chest, revealed by mensuration, he regards as evidence that pulmonary con- gestion 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 frequency of the pulse; and it is affected neither by blood- letting, nor gastro-intestinal evacuations, nor by any course of alimen- tation. 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. Progressive 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 oscillations in the amount of pulmonary congestion appear to occur, giving rise to variations in the thoracic capacity. But, as a general rule, in- creasing enlargement of the capacity of the chest denotes a progres- sive development of the disease, a stationary condition of enlarge- ment indicates a persisting acuteness, and a decrease in the dimen- sions of the chest often precedes the symptoms and other signs which afford evidence of commencing resolution of the malady. These con- clusions, purporting to have been deduced from a series of measurements 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 im- portant results respecting the actual and relative extent of the motion of different parts of the chest in health, with the peculiarities incident to sex, age, etc.; and, also, the effects of different forms of disease, in modifying the normal respiratory movements. The more important 318 physical exploration of the chest. of the facts deduced by Dr. Sibson have been already referred to in the introduction to this work, and under the head of Inspection, in the preceding chapter. Dr. Sibson's ingenious instrument, however, only measures the forward movements of the chest. It does not show the actual amount of expansive motion. 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. I cannot, however, speak of the merits of either from personal experience. Their value chiefly relates to scientific researches, in which it is convenient, and indeed important, to express the results of observations with numerical exactness. For ordinary clinical objects, this is not necessary. It suffices 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 re- ference to the respiratory movements, is even less essential, and less resorted to, than with reference to deviations in size. Ocular exami- nations, comparing carefully the two sides of the chest, enables the observer to distinguish, without difficulty, an amount of abnormal alteration in the respiratory movements, sufficient to constitute them physical signs of disease. When it is desired to confirm the evidence which the eye discovers by resorting to measurement, Dr. Quain's stethometer is doubtless applicable and convenient. To measure par- tial 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 in- spiration, and next after a forced expiration. If the circumference of the two sides, when fully dilated, and subsequently when contracted, be obtained, the simple rule of subtraction gives the range and expansi- bility at the part of the chest where the circular measurement was made. The expansibility of each side being in the same way ascer- tained, a comparison of the two sides, as respects the amount, of course gives the extent to which the movements on one side are ab- normally diminished, or on the other side increased, or, again, what is oftener the case, diminished on one side, and, at the same time, in- creased on the other side. The effect of disease on the respiratory movements is most strikingly exemplified in cases of chronic pleurisy with large effusion. As stated by Walshe, the difference between the mensuration. 319 fullest expiration and the fullest inspiration on the side affected, may not exceed one-sixteenth of an inch, while the other side, in conse- quence of its movements being supplementarily increased, may show a difference of two and a half inches,—an extent as great as the move- ments 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 con- nection with mensuration, would involve a repetition of the facts contained in Chapter IV, to which 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 no- ticed 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 power, 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 Mr. 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 the extent of its progress; but this evi- dence cannot be much relied upon, owing to the influence of circum- stances other than pulmonary lesions. The spirometer employed by Dr. Hutchinson is so cumbrous an 320 PHYSICAL exploration of the chest. 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 stop-cocks; and by an orifice at the extremity of the meter, also regulated by a stop-cock, its con- tents may be expelled. The patient breathing into the reservoir with as prolonged an expiration as possible, the air is retained by closing the stop-cocks. 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, alte- rations in the extent of respiratory movements. Partial enlargement or depression is measured by means of callipers ; general enlargement or contraction, is determined by comparing the horizontal semi-cir- cumference 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 researches involving observa- tions recorded for analytical investigation, it is convenient and impor- tant to employ the instruments just mentioned, expressing results in figures; but, in general, alterations in size may be ascertained suffi- ciently for diagnosis, by inspection. Clinically, the advantage of mensuration with reference to comparison of the dimensions of the two sides, relates to variations taking place at different periods in the same case, these variations sometimes being important to be consi- dered in connection with therapeutical agencies; and, thus restricted mensuration. 321 pleuritis with effusion is the affection in which this method of explo- ration is particularly useful. According to the researches of M. Woillez, mensuration practised daily during the career of acute dis- eases, shows first a progressive enlargement of the whole thorax during the development of the disease; 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 alterations is accounted for by M. Woillez on the hypothesis of pulmonary congestion existing as an important element of all acute affections. Abberrations of the respiratory movements are determined by the chest-measurer, and by the stethometer. The first measures the extent 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 with the eye suffices for that purpose. To institute a com- parison between the two sides as respects the relative extent of gene- ral 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 thequantity of air which can be expelled by a single prolonged expiration; the results of this method of mensuration are, however, in a great mea- sure, dependent on circumstances affecting muscular power, irrespec- tive of the condition of the pulmonary organs ; and the degree of the vital capacity of different individuals is found to differ widely in health. It is rarely, therefore, that positive information respecting the ex- istence of pulmonary disease is to be obtained from this source, in cases in which symptoms and other signs fail to indicate 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 disease does not exist; or, if the amount of vital capacity proper to an individual in health 21 322 PHYSICAL EXPLORATION OF THE CHEST. be known, and it be found that this amount is not diminished, it may be fairly presumed that the pulmonary organs are sound. History. The remarks made under this head, in connection with the subject of Inspection, Chapter IV, are equally applicable to mensuration. 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 instances it furnishes signs of considerable importance. In general, the evidence of disease which it affords is auxiliary to or confirmatory of information, more positive and complete, 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 examination 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 suffer- ing 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 exami- nation. Information on this point, it is true, may be obtained, inci- dentally, in practising percussion; but in order that the attention shall not be divided between two objects, it is useful to make pressure with express reference to the sense of resistance. The elasticity 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. 324 PHYSICAL EXPLORATION OF THE CHEST. By passing the hand over the thoracic surface, we are aided in judging of the nature and extent of changes in form and size incident to disease. Inequalities, due to depressions or projections, are some- times better appreciated by the touch than by inspection. By the touch, it is ascertained whether enlargement arises from a morbid condition exterior to the walls of the chest, for example, oedema, or abscess, or whether it be intra-thoracic. If the latter, the sensations communicated to the hand sometimes afford important information as to the character of the disease. A circumscribed enlargement, pro- duced by an aneurismal tumor, may be accompanied by a pulsation, which, in connection with other signs, serves to establish the diag- nosis. It is important, however, to remark, that a circumscribed pulsating tumor may be caused by a collection of pus beneath the skin, communicating with an accumulation within the chest by means of a perforation through the thoracic wall. 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 wall, the pus being retained entirely within the pleural cavity. These instances have given rise to a variety of the affection called " pulsating empyema."1 Under these circumstances, the heart's impulse, communicated to the purulent 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 connection with a large cerebri- form tumor, springing from the posterior mediastinum, and dis- placing the upper lobe of the left lung.2 In the latter instances, it is doubtful whether the pulsation was the transmitted cardiac impulse, or whether it was due to arterial throbbing of the parts within the chest. The last is the explanation adopted by Dr. Stokes. These different morbid conditions, under which an abnormal pulsation, cir- cumscribed or diffused, is discovered by palpation, are to be discrimi- nated, by calling to our aid, in addition to symptoms, the associated signs determined by the several methods of exploration. Fluctuation is occasionally distinctly felt in cases of chronic pleurisy, or empyema, in the distended intercostal spaces. I have met with an instance in which it was well marked over a large excavation in a 1 Vide Walshe on Diseases of the Lungs, etc., second London edition, 1854, page 396. 2 Stokes on the Chest, second American edition, 1844, page 280. PALPATION. 325 patient extremely emaciated. The concussion produced by liquid within a superficial cavity thrown with force against the thoracic walls by the act of coughing, is sometimes very plainly perceptible 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, the two sides can be accurately compared with respect to their rela- tive width, and the relation of the ribs in 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 effusion, the lower intercostal spaces are widened, and those between the upper ribs narrowed. The ribs, under these circumstances, on the affected side, will be found to remain comparatively motionless during the movements of respiration on the affected side, while, on the opposite side, those situated at the lower portion of the chest manifestly be- come 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 charac- terizes the affected side in cases of chronic pleurisy, or empyema, with notable dilatation of the chest, is appreciated by the touch better than by the eye. In the same manner, tactile examination serves to distinguish the comparatively unequal enlargement due to emphy- sema. 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 examining the female chest, if sensitiveness on the score of delicacy precludes a satisfactory exami- nation by inspection, palpation may be employed as an alternative. The respirations may be conveniently enumerated by means of pal- pation. In one respect this method has an advantage over inspection, 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. The situation of the apex impulse of the heart is sometimes an important point in the diagnosis of affections pertaining to the pulmo- nary organs. In large pleuritic effusions, and in some cases of em- 326 PHYSICAL EXPLORATION OF THE CHEST. physema, 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 somewhat 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 late- rally 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 effusions 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 attended with diminution of the bulk of the lung, viz., after absorption of inflamma- tory exudation, collapse or atrophy, and in cases of tuberculosis involving considerable destruction of the pulmonary substance. Absence of the heart's impulse, owing to its 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 organ is depressed, so that its impulse is transferred to the epigastrium. Finally, vibratory motions of the walls of the chest accompanying the act of speaking, and, under certain circumstances, respiration, constitute physical signs, possessing, in some cases, considerable im- portance. 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 communicated to the thoracic parietes, give rise to a thrilling sensation, called the vocal 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 infra- mammary region ; ceasing below the line of hepatic dulness ; slight, if appreciable behind, over the scapulae ; generally felt, and sometimes well 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 percussion, is found to present great varia- tions in degree in different individuals entirely free from pulmonary disease. In some persons it is strongly marked ; in others moderate, in others slight; 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 intensity. In general, the fremitus is notably PALPATION. 327 stronger in persons whose voices are powerful and low in pitch. It is therefore oftener, present, and is apt to be intense in adult males, than in females and children, 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 reso- nance, it has already been incidentally noticed. As already remarked in that connection, the vocal fremitus does not sustain any fixed rela- tion to vocal resonance. 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 intensity of the fremitus, in health or disease, is affected by posi- tion. 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 exception 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 account 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, there- fore, the voice, by means of palpation, furnishes physical evidence of disease. An increase of the vocal fremitus occurs in solidifi- cation of lung, especially from inflammatory exudation and tuber- culous deposit; less frequently and in a less degree, in connection with oedema, extravasation of blood, or carcinoma. Dilatation of the bronchial tubes contributes to its intensity. Bearing 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 equivo- cal 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. Existing in the left infra-scapular and infra- axillary regions, it is one of the signs indicative of consolidation from pneumonia. It becomes a valuable sign of the second stage of pneu- monia in some instances in which exaggerated vocal resonance, and even the bronchial respiration, are deficient. 328 PHYSICAL EXPLORATION OF THE CHEST. The normal vocal fremitus is diminished or suppressed, as the rule, whenever the lung is removed from the thoracic walls by the accu- mulation of liquid or gas within the pleural cavity. Some exceptions to this rule, as with respect to the absence of vocal resonance and re- spiratory sound, under similar circumstances, have been observed. Generally, in cases of pleurisy 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 pleurisy, the vocal fremitus is increased at the sum- mit of the chest, over the lung condensed by compression, while it is feeble or null below the level of the liquid. In emphysema, the vocal fremitus is generally diminished, but, ac- cording to Walshe, this rule is not without exceptions, and the fre- mitus may even be increased. As already remarked, the normal vocal fremitus on the right side ceases below the line of hepatic dulness. 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. Certain motions of the chest, perceptible on manual examination, are occasionally incident to the respiratory movements. The bron- chial rales, both dry and moist, i. e.'the mucous, sonorous, and sibi- lant, and the gurgling incident to cavities, sometimes cause a vibra- tory thrill, appreciable on application of the hand. This is called the rhonchal fremitus. In some of the instances in which a pleural fric- tion-sound is present, the rubbing of the roughened surfaces 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 absorption 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. 329 Summary. Palpation furnishes information respecting the degree, situation, and extent of soreness of the chest; the degree of elasticity of the thoracic walls; the changes in form and size ; inequalities of the sur- face ; the condition of the intercostal spaces, and the amount of con- vergence or divergence of the ribs in respiration. In some instances, determining the existence of fluctuation, it esta- blishes 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 different situations, in this respect. It affords 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 different forms of disease. It is frequently increased in cases of solidification, especially from inflammatory exudation, and from tu- bercle. An increased amount of fremitus, situated on the left side, according to the part of the chest at which it is observed, is a signi- ficant sign of either phthisis, or pneumonia. Diminished or sup- pressed fremitus is incident to diseases in which the lungs are removed from contact with the thoracic walls, viz., pleurisy with effusion^ 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 generally 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 pleurisy, generally after the removal of the liquid effusion. 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 effusion, was first pointed out by M. Reynaud. CHAPTER VII. SUCCUSSION. Sudden agitation of the body, under certain circumstances of disease, 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 backward and forward. This method of examination is called Succussion. A splashing noise is the only physical sign de- veloped by this method ; and, as just stated, it has a special significa- tion, representing, in the vast majority of the cases in which it occurs, a particular form of disease, viz., pleurisy with perforation, 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. It is analogous to the gurgling occasionally produced in large pulmonary excavations by the impulse of the heart, and more especially, by acts of coughing. The conditions requisite for the production of the sign, are a cavity of large dimensions, partially filled with liquid, and partially with air or gas. These conditions obtain in pneumo-hydrothorax. In that affection, 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 bron- chial tubes, or externally through the thoracic walls, suffice for its manifestation. The sign would be entirely pathognomonic, except that it is sometimes observed in cases of a very large tuberculous ex- cavation. It is obvious 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 extremely infrequent), the sign belongs exclusively to pneumo-hydrothorax. SUCCUSSION. 331 The intensity of the splashing noise, and the facility with which it is produced, vary considerably in different cases. It may not be ap- parent save when the ear is either in contact with, or in close proxi- mity to the chest; but in some instances, it is sufficiently 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 gallop, 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., pro- duced 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, probably 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 sometimes has a high-pitched ringing character, and 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 sufficiently clear without resorting to this method of examination. 332 PHYSICAL EXPLORATION OF THE CHEST. Summary. Frequently in cases of pneumo-hydrothorax, and occasionally in cases of phthisis with a very large excavation, succussion occasions a splashing noise, produced by the agitation of liquid in a space of con- siderable size, partially filled with air or gas. Owing, however, to the sufficiency of other signs, in connection with symptoms, this method of exploration is of trifling value with reference to diagnosis. 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 presence of air or gas. He regarded it as a sign of empyema. Its patho- gnomonic significance has been established by modern investigations. CHAPTER VIII. RECAPITULATORY ENUMERATION OF THE PHYSICAL SIGNS FURNISHED BY THE SEVERAL METHODS OF EXPLORATION. I. Percussion. 1. Exaggerated vesicular resonance. 2. Diminished vesicular resonance. 3. Absence of resonance. 4. Tympanitic resonance. a. Amphoric. b. Cracked-metal. (Bruit de pot fele.) II. Auscultation. phenomena incident to respiration. A. Modifications of the Intensity of the Vesicular Murmur. 1. Increased intensity of vesicular murmur. 2. Diminished intensity of vesicular murmur. 3. Suppressed respiration. B. Modifications of the Quality, etc., of 'Respiratory Sounds. 1. Bronchial respiration. 2. Broncho-vesicular (rude) respiration. 3. Cavernous and amphoric respiration. C. Modifications of the Rhythm of Respiratory Sounds. 1. Shortened inspiration. 2. Prolonged expiration. 3. Interrupted inspiration or expiration. D. Adventitious Respiratory Sounds. 1. Dry, vibratory, bronchial rales (sibilant and sonorous). 334 PHYSICAL EXPLORATION OF THE CHEST. 2. Moist, bubbling, bronchial, or mucous rales (coarse and fine). 3. Sub-crepitant rale. 4. Crepitant rale. 5. Gurgling. 6. Indeterminate rales. a. Crumpling. b. Crackling. * 7. Friction or attrition-sounds. PHENOMENA INCIDENT TO THE VOICE. 1. Exaggerated vocal resonance and bronchophony. 2. Diminished and suppressed vocal resonance. 3. Pectoriloquy and amphoric voice. 4. iEgophony. PHENOMENA INCIDENT TO THE ACT OF COUGHING. 1. Bronchial cough. 2. Cavernous cough and amphoric cough. 3. Metallic tinkling. PHENOMENA INCIDENT TO THE CIRCULATION. 1. Abnormal transmission of heart-sounds. 2. Arterial bellows-murmur. III. Inspection. A. Morbid Appearances pertaining to the Size and Form of the Chest. 1. Enlargement. a. General. b. Partial. 2. Contraction. a. General. b. Partial. B. Morbid Appearances pertaining to the Respiratory Movements. 1. Abnormal frequency of the respirations. recapitulation of physical signs. '335 2. Shortened inspiration. 3. Prolonged expiration. 4. Abdominal or diaphragmatic respiration. 5. Costal or thoracic respiration. 6. Exaggerated superior costal respiration. 7. Respiratory movements on one side diminished or suppressed. 8. Respiratory movements on one side exaggerated. 9. Disparity in the superior costal movements between the two sides. IV. Mensuration. 1. Alterations in size and form enumerated under the head of Inspection. 2. Alterations in respiratory movements enumerated under the head of Inspection. V. Palpation. 1. Tenderness on pressure. 2. Increased or diminished elasticity of thoracic walls. 3. Abnormal inequalities from depression or projection. 4. Pulsation from cardiac impulse or arterial throbbing. 5. Fluctuation. 6. Abnormal conditions pertaining to intercostal spaces. 7. Disparity between the two sides in expansibility, general or local. 8. Abnormal situation of heart's impulse. 9. Exaggerated vocal fremitus. 10. Diminished or suppressed vocal fremitus. 11. Rhonchal fremitus. 12. Pleural rubbing. VI. Succussion. 1. Splashing. CHAPTER IX. CORRELATION OF PHYSICAL SIGNS. Of the various morbid conditions to which the respiratory organs are subject, each gives rise, almost invariably, to a group of physical phenomena. As with symptoms, so with signs, a greater or less number accompany individual diseases; and hence, they are rarely presented to the clinical observer isolated, but in certain combina- tions. In the diagnosis of intra-thoracic affections, it is seldom if ever the case that exclusive reliance is to be placed on a single sign, more than upon a separate symptom; but the discrimination of one affection from another involves collective physical not less than vital evidence. Very few, if any, of the physical indications of pulmonary disease are pathognomonic. As a general rule, their diagnostic im- portance is in a great measure derived from union with each other; and this aggregation of different signs, while it is often essential to diagnosis, always renders it much more exact and positive. A group of signs, no one of which by itself would be reliable, sometimes points to the nature and seat of a disease with greater precision than the most distinctive characteristic taken singly. To cite an illustration of this truth, the existence of tuberculous disease may be established by a series of phenomena, each of which, without the others, would possess trivial importance; but, collectively, they render the diag- nosis as complete as possible. On the other hand, let one of the most significant of the physical signs be selected, for example metal- lic' tinkling: guided by it exclusively, there would be a liability to error, for, although in the immense majority of the cases in which it is marked, it indicates pneumo-hydrothorax, it may occur in connec- tion with a large pulmonary excavation, and is simulated by sounds produced within the stomach. The accumulated evidence, in the first instance, overbalances the weight to be attached to the single sign, for reasons not unlike those which give to an abundance of circum- stantial proof in courts of law greater force than belongs to the strongest direct testimony of a single individual. Again, not only correlation of physical signs. 337 are physical signs individually insufficient as diagnostic criteria, but the same sign may be incident to different affections. The bronchial respiration, for instance, belongs equally to the semeiological history of pneumonitis and tuberculosis. Absence of respiratory sound occurs in cases of emphysema and in cases of pleurisy,—two very dis- similar forms of disease. The significance of particular signs, in such instances, depends in a great measure on the combinations in which they are found. Thus, absence of the respiratory murmur in emphy- sema is associated with an abnormal clearness of percussion-reso- nance ; on the other hand, in pleurisy, it is accompanied by flatness on percussion. The significance of the respiratory sign in these two instances is borrowed from the coexisting signs, the latter, it will be observed, being exactly opposite in their character. It is unnecessary to adduce farther illustrations to show the impor- tance of studying not only physical signs separately, but their mutual relations, by which they are united in groups or combinations, in connection with different morbid conditions. These relations have already, in the foregoing pages, to some extent been incidentally noticed, and hereafter, in treating of the diagnosis of individual diseases, the manner in which the physical phenomena furnished by the several methods of exploration are grouped will necessarily be considered. But, before entering on the second part of this work, there will be an advantage in devoting some attention to the correlation of physical signs; in other words, taking up, seriatim, certain im- portant phenomena pertaining to physical exploration, and enumerat- ing those with which each is found to be correlatively associated in clinical observation. To this object the present chapter will be de- voted. What are the different groups or combinations formed by the union of physical signs in consequence of their pathological affinities? and what are the morbid conditions which these different groups or combinations of signs represent ? Although the answers to these questions involve to some extent a recapitulation of facts already pre- sented, and also an anticipation of points which are hereafter to be con- sidered, the student will not find it a useless expenditure of time to bestow some attention on the correlation of physical signs, in order to become more familiar with what may be termed the rules of syntax regulating the language of physical exploration, and as preliminary to the department of the subject which remains to be considered, viz., the diagnosis of particular diseases. To consider all the physical phenomena, respectively, which are 22 338 physical exploration of the chest. furnished by the several methods of exploration, would involve need- less and tedious repetitions. It will suffice to take up the individual signs belonging to percussion, and to auscultation so far as concerns respiratory and friction sounds. An enumeration of the signs sus- taining correlative relations to these, will be found to embrace the more important of the phenomena pertaining to auscultation of the voice, and to the remaining methods of exploration. Of the respira- tory signs, I shall omit those consisting in abnormal modifications of rhythm, because the two first, viz., shortened inspiration and pro- longed expiration, in the great proportion of instances, are merely elements either of the bronchial or the broncho-vesicular respiration, and the third modification, viz., interrupted respiration, belongs in the category with certain other phenomena, viz., the rales, which, it will be seen, cannot be said to have any correlative signs. Exclusive, then, of the modifications of rhythm, I shall proceed to take up, in the order in which they were enumerated in Chapter VIII, the phe- nomena furnished by percussion, and by auscultation so far as it re- lates to respiratory and friction sounds, presenting, briefly, the groups or combinations into which they respectively enter, by virtue of their relations to similar anatomical conditions of disease. Signs correlative to those furnished by Percussion. 1. Exaggerated Vesicular Resonance.—Occurring in conse- quence of the activity of the lung on one side being supplementarily increased, the correlative sign pertaining to auscultation is an exagge- rated vesicular murmur. Under such circumstances, however, these signs are not intrinsically morbid. They are physiological phe- nomena exaggerated, but not to a point to be in themselves patho- logical, and they denote intra-thoracic disease, not at the portion of the chest corresponding to the situation where they are observed, but, inferentially, at another part, and generally on the opposite side. A correlative sign obtained by inspection and mensuration is increased extent of the respiratory movements. The pathological relation of exaggerated resonance to emphysema is more direct and important. The morbid condition in this affection consists in an abnormal accu- mulation of air, generally within the pulmonary cells, in some rare instances in the interlobular and sub-serous areolar tissue. The cor- relative sign derived from auscultation is directly the reverse of that correlation of physical signs. 339 in the previous instance, viz., diminution of the respiratory murmur, amounting sometimes to suppression. This combination is highly significant. Other auscultatory signs are frequently associated, but they are incident, not purely to the emphysema, but to coexisting affections, especially bronchitis. This remark applies to the bron- chial rales so often present in cases of emphysema. Associated signs, determined by inspection, are thoracic enlargement, general or local, corresponding to the extent of the emphysematous dilatation; dimi- nished respiratory movements ; obliteration of intercostal depressions; diminished obliquity of the lower ribs; divergence of the lower, and convergence of the upper ribs, if the emphysema be general. The relation of exaggerated resonance to emphysema is the rule; but occasional exceptions are present in cases of great tension of the thoracic walls from the pressure of an over-distended lung. In these exceptional instances the resonance may be diminished in place of being exaggerated. The vesicular quality of resonance in cases of emphysema is rarely if ever lost, but it is more or less diminished. It is vesiculo-tympanitic. In proportion as the intensity of resonance is diminished by tension, the vesicular quality is impaired, and the tympanitic predominates. Exaggerated percussion-resonance incident to the temporary em- physematous condition which sometimes obtains in bronchitis, pul- monary catarrh, and bronchial spasm, involves, as correlative signs, the adventitious sounds which pertain to these affections, viz., the dry and moist bronchial rales. 2. Diminished Vesicular Resonance.—In the exceptional in- stances of emphysema in which this modification of percussion-reso- nance occurs, the correlative signs will, of course, be the same which, in the majority of instances of that affection, are combined with exagge- rated resonance. Commonly the affections to which diminution of resonance is inci- dent are those involving either liquid pleural effusion, viz., pleurisy and hydrothorax; or increased density of lung from deposit of liquid or solid matter, viz., pneumonitis, tuberculosis, oedema, pulmonary apoplexy, carcinoma, etc. The correlative signs in these two classes of affections are far from identical; nor are they uniform in the different affections included in the same class. In pleuritic effusion sufficient to diminish but not abolish the vesicular resonance, correlative auscultatory signs are, diminished 340 physical exploration of the chest. respiratory murmur, and in some instances aegophony. Correlative signs determined by palpation are, diminished or suppressed vocal vibration, and increased force of resistance to pressure. In solidification from pneumonitis and tuberculosis, the correlative auscultatory phenomena, in the majority of instances, are more or less of the characters of the broncho-vesicular, or of the bronchial respiration, together with exaggerated vocal resonance, or broncho- phony, and increased vocal fremitus. Exceptional instances are not very infrequent in which, instead of these signs being associated, the respiratory sound is abolished and the vocal resonance and fremitus not increased. The latter constitute the rule, rather than the ex- ception, in the other affections involving abnormal density of lung, viz., oedema, pulmonary apoplexy, carcinoma, etc. A correlative sign in cases of oedema, and, less constantly, in cases of pulmonary apoplexy, is the sub-crepitant rale. The crepitant rale is generally associated with diminished percussion-resonance in pneu- monitis, but the converse does not hold good to the same extent; in other words, the crepitant rale often appears before the percussion- resonance is sensibly diminished. Diminished respiratory movements may be combined in all the affections named, but oftener in pneumonitis and tuberculosis. In- creased force of resistance on pressure, and diminished elasticity, is a correlative sign common to all the varieties of solidification. 3. Absence of Resonance.—The anatomical conditions giving rise to diminished resonance may be sufficient to abolish it, rendering the percussion-sound flat. Absolute flatness being in the great majority of instances due to the presence of a considerable quantity of liquid in the pleural cavity, the correlative auscultatory signs are absence of respiratory sound, and of vocal resonance, with notably diminished elasticity of the thoracic walls. This combination of signs is highly diagnostic; yet the rule is not without exceptions, diffused bronchial respiration being associated with flatness in some cases of large effu- sion. Absence of vocal fremitus is another correlative sign. If the amount of effused liquid be great, inspection and mensuration furnish important associated signs, viz., enlargement of the chest; obliteration of the hollows between the ribs; divergence of the lower and con- vergence of the upper ribs; comparative immobility; elevation of the shoulder; widening of distance between the nipple and the median line; depression of the liver, and removal of the heart from correlation of physical signs. 341 its normal position. Fluctuation is occasionally appreciable. This collection of signs incident to enlargement of the chest, may, how- ever, to a considerable extent, be reversed, in combination with flat- ness on percussion over the greater part of the chest. Absorption of the liquid effusion, inducing contraction, may take place, but not sufficiently to permit a return of percussion-resonance, with reappear- ance of respiratory sound, vocal resonance, and fremitus. Then, in connection with diminished size of the affected side, there will be convergence of the lower ribs, and divergence of the upper; depres- sion of the shoulder, and narrowing of the distance between the nipple and the median line. Obliteration of the intercostal hollows and comparative immobility will be likely to continue. Flatness on percussion may accompany abundant tuberculous deposit, the second stage of pneumonitis, and other affections involving abnormal density of the pulmonary substance. The facts pertaining to correlative signs which have been stated under the head of dimi- nished resonance, or dulness, incident to pulmonary solidification, will be equally applicable, and need not be repeated. 4. Tympanitic Resonance.—The signs associated with the differ- ent varieties of tympanitic resonance differ widely, according to the diversity of anatomical conditions represented. In the affection which presents, more than any other, a resonance purely tympanitic, strongly marked and diffused, viz., pneumo-hydrothorax, the correlative pheno- mena derived from auscultation are, the characteristic vocal, tussive, and respiratory sign, metallic tinkling ; feebleness or extinction of the vesicular murmur ; blowing and amphoric respiration, occasional and irregular ; absence of vocal resonance. Inspection and mensuration furnish the group of appearances incident to enlargement from liquid effusion. Palpation discloses absence or marked diminution of the normal vocal fremitus. Succussion developes the sign incident almost exclusively to this affection, viz., splashing. Tympanitic resonance, circumscribed in extent at the summit of the chest, sometimes metallic or amphoric, and occasionally present- ing a cracked-metal modification—these circumstances denoting its connection with a spacious pulmonary cavity, superficially situated, with rigid walls and free from liquid contents—exists in combination with cavernous respiration, presenting sometimes an amphoric intona- tion, alternating with gurgling ; occasionally splashing, with the act of coughing, and metallic tinkling; pectoriloquy in some instances; 342 physical exploration of the chest. local depression or flattening at the summit of the chest, and deficient expansibility. Occurring, as an exception to the general rule, over lung solidified by inflammatory exudation, it is combined, of course, with the various phenomena incident to that anatomical condition. When presented in pleurisy, situated above the level of the liquid effusion, and also over the healthy lung in cases of pneumonitis, it cannot be said to have any definite correlative signs, irrespective of those which pertain to the diseases of which it is an incidental feature. Signs correlative to Sounds furnished by Auscultation. 1. Increased Intensity of Vesicular Murmur.—Proceeding always from hyper-activity of respiration induced supplementarily in a portion of the pulmonary apparatus, the correlative signs are exagge- rated percussion-resonance, and increased respiratory movements. The remarks made under the head of Exaggerated Vesicular Resonance are here equally applicable. 2. Diminished Intensity of Vesicular Murmur.—The pheno- mena associated with this sign are quite opposite in their character, corresponding to differences in morbid conditions which present a contrast equally striking. Abnormal feebleness of the vesicular murmur may be due to the removal of the lung at a certain distance from the thoracic wall. This removal is caused by the presence, in some cases, of air or gas; in others, by a stratum of liquid or solid matter, and sometimes by air and liquid together, in the pleural cavity. In the first instance, a correlative percussion-sign is tympanitic resonance; in the second instance, it is absence of resonance, or flatness.; and in the third in- stance, both are conjoined, i. e. tympanitic resonance exists above the level of the liquid, and flatness below this level. The presence of air and liquid, constituting pneumo-hydrothorax, is, however, very rarely characterized by simple feebleness of the respiratory sound; either the latter is abolished, or presents the cavernous or amphoric modifi- cation. Correlative signs incident to this affection are metallic tinkling and a succussion-sound. Diminution of the respiratory motions, of vocal resonance, and fremitus, are common to the three morbid conditions just mentioned. correlation of physical signs. 343 Again, feebleness of respiration, without change in quality or rhythm, occurs in a certain proportion of cases of solidification from tubercle, inflammatory exudation, oedema, etc. On the other hand, it is incident to emphysema, bronchitis, and partial obstruction at any point in the air-passages. In these two classes of morbid conditions the correlative percussion-signs are precisely reversed. In the first class it is combined with diminished resonance, or dulness ; in the second, the clearness of the percussion-sound is either undiminished or exaggerated. The anatomical condition in both instances is marked by the combination. Exclusive of the cases in which the lung is removed by liquid or solid matter, air, or gas, from the thoracic wall, feebleness of the respiratory murmur, combined with dulness on percussion, as the rule, denotes increased density of the pulmonary organ ; combined with normal resonance, it indicates that the density is neither increased nor diminished; combined with exaggerated resonance, it is evidence of the abnormal rarefaction of the lung, pertaining to emphysema and some cases of bronchitis. Other signs existing in combination serve to establish the distinction as respects the anatomical condition. In cases of solidification, in Avhich the effect on the respiratory sound is simply to diminish its intensity, the vocal resonance may be exag- gerated, and even bronchophony may be present. In cases of rare- faction, this occurs only as rare exceptions to the general rule. The same remark will apply to vocal fremitus. Diminished respiratory motions may accompany both anatomical conditions. Enlargement of the chest, and its attendant phenomena, determined by inspection, mensuration, and palpation, pertain to emphysema. Diminished elas- ticity of the thoracic walls belongs to the former anatomical condition (increased density); increased elasticity to the latter (rarefaction). 3. Suppressed Respiration.—Abolition of the sound of respira- tion, occurring in connection with the same diversity of morbid con- ditions as diminished intensity of the respiratory murmur, presents similar combinations with other signs. Accumulation of liquid or gas, or both air and liquid, within the pleural sac, in sufficient quantity to render respiration inaudible, gives rise, in the first instance, to flatness on percussion; in the second instance, to tympanitic resonance ; and in the third instance, to tym- panitic resonance above and flatness below the level of the liquid. Diminished respiratory movements, together with absence of vocal resonance and fremitus, are common to the three morbid conditions, 344 PHYSICAL EXPLORATION OF THE CHEST. and, in addition, first in the order of time, are presented the pheno- mena attending enlargement of the chest, which need not be again enumerated; and, second, the reversed phenomena following absorp- tion of the fluid, sufficient to induce contraction, but not to permit reappearance of the respiratory sound. In the cases of solidification from tubercle, inflammation, oedema, etc., in which suppression occurs, it is combined with notable dulness on percussion, as the rule, and with a clear tympanitic resonance, as an exception to the rule. Exaggerated vocal resonance, or bronchophony, and increased vocal fremitus, may exist in combination, together with diminished respiratory movements. On the contrary, in the cases of emphysema, in which the respiratory sound is lost, exaggerated per- cussion-resonance, with more or less of the tympanitic quality (vesi- culotympanitic resonance), is the associated sign as the rule, dulness being observed, as an exception to the rule, in some instances in which the tension of the thoracic wall, from distension, is very great. In the former anatomical condition (solidification), the elasticity of the parietes of the chest is notably diminished ; in the latter (rarefac- tion), the elasticity is increased. In connection with the suppressed respiratory sound incident to emphysema, the vocal resonance and fremitus are not exaggerated, save in some rare exceptional instances, the reverse being true, as already mentioned, of solidification. 4. Bronchial Respiration.—The bronchial respiration represents solidification of lung, except when it occurs in connection with dilated bronchial tubes, increased density of the pulmonary parenchyma, in the latter case, being superadded. The correlative signs, therefore, are those which have direct relation to pulmonary solidification, as it exists more especially in tuberculosis and pneumonitis, the bronchial respiration being much oftener present and more strongly marked in these, than in other affections in which the density of the lung is in- creased, viz., oedema, extravasation of blood, etc. The group of signs has been already given in connection with diminished vesicular per- cussion-resonance, and diminished or suppressed vesicular murmur, when these signs are due to the same anatomical condition, i. e. solidification. The associated signs, when the bronchial respiration exists, are much more uniform than those presented in combination with dulness or flatness on percussion, or with suppressed or dimi- nished respiration, owing to the fact, that the anatomical condition represented, in the vast majority of instances, by the bronchial respi- correlation of physical signs. 345 ration, is the same, while the signs last mentioned are incident to ana- tomical conditions different, and, indeed, opposite, in their character. Dulness on percussion, exaggerated vocal resonance, or broncho- phony, increased vocal fremitus, diminished respiratory movements, increased force of resistance to pressure, are the signs sustaining a correlative relation to the bronchial respiration.1 5. Broncho-vesicular Respiration.—Representing slight or moderate increase of the density of lung, the correlative relations of this modification of the respiratory sound, are essentially similar to those belonging to the bronchial respiration. The difference is, the signs which may be associated are less frequently present, and, when present, are less marked. Dulness on percussion is comparatively slight, and may not be appreciable ; the vocal resonance and fremitus may not be obvious, and, if apparent, are weak ; the respiratory move- ments are, perhaps, not sensibly diminished, or, if so, in a small de- gree ; and impairment of the elasticity of the thoracic walls is either not determinable, or feeble. 6. Cavernous and Amphoric Respiration.—Correlative cavern- ous signs form a group, each preserving always its significance, and not occurring in connection with other anatomical conditions. Actually, however, they are rarely combined, and, indeed, it is impossible for all of them to be present simultaneously, since some can only be pro- duced when the cavity is empty, and others only when it is more or less filled with liquid. The correlative signs requiring an empty space, are the cavernous respiration, pectoriloquy, and circumscribed tympanitic percussion-resonance, inclusive of the metallic modifica- tion, and the cracked-metal sound. The correlative signs requiring the presence of liquid, are circumscribed dulness on percussion, gurgling, splashing with the act of coughing, and occasionally metal- lic tinkling. The two series of signs may occur in alternation. Both are incident to pulmonary cavities, tuberculous or otherwise, inclusive of pouch-like dilatation of the bronchial tubes; and, also, in the 1 Under the head of Correlation of Physical Signs, I design to embrace only those which sustain toward each other direct relations. The signs incident to pleuritic effu- sion in the instances in which bronchial respiration exists over the compressed lung, are indirectly related, and therefore, not included among those to which the term cor- relative is applied. For the same reason, I do not enumerate among correlative signs those supplementarily induced by various affections in parts of the lungs more or less remote from the situation of the disease. 346 PHYSICAL EXPLORATION OF THE CHEST. pleural space, in connection with perforation, or, in other words, in pneumo-hydrothorax. In the latter affection, the cavernous respira- tion oftener presents the amphoric character; and the associated signs differ from those pertaining to pulmonary cavities. The per- cussion-resonance is more constantly tympanitic, is not circumscribed, but more or less diffused. Liquid, in greater or less quantity, is always present, and hence, flatness coexists with tympanitic reso- nance, the former situated above, and the latter below the level of the liquid. Metallic tinkling is generally observed, while in pulmo- nary cavities it is of rare occurrence. The succussion-sound is com- mon, which is exceedingly infrequent in cavities formed within the lungs. The phenomena attendant on enlargement of the chest, are generally present in cases of pneumo-hydrothorax, and absent in intra-pulmonary excavations. 7. Adventitious Respiratory Sounds, or Rales.—The adven- titious sounds, or rales, may be considered under one heading, for, ex- cepting a single species, viz., gurgling, they resemble each other in not sustaining toward other signs any fixed correlative relations. In this respect, they offer a striking contrast to the signs already enumerated. The moist and dry bronchial rales, including the sub-crepitant, gene- rally represent pulmonary catarrh or bronchitis. They constitute all the positive or direct physical signs belonging to these affections. Other signs, it is true, are frequently found associated with them, but in such instances, pulmonary catarrh or bronchitis are superadded to other affections. The connection is one of coincidence, not of a pathological relation. This deficiency of correlative signs has a positive and important bearing on diagnosis. The presence of the bronchial rales, taken in connection with the absence of abnormal percussion-sound, or other signs, establishes the existence of the diseases which they represent, disconnected from other affections. The crepi- tant rale represents, in the great majority of the instances in which it is observed, pneumonitis. Pneumonitis during its career presents, as has been seen, a group of correlative signs ; but the crepitant rale, strictly speaking, cannot be considered to stand in a correlative re- lation to any of them, for it is developed often prior to their appear- ance, and although it very frequently persists after other signs have appeared, this is by no means uniformly the case. Moreover, in a certain proportion of cases, it does not appear during the course of the affection. In the instance of this disease, as of bronchitis, the correlation of physical signs. 347 absence of coexisting signs is an important point, for, in connection with certain symptoms, it may denote the existence of pneumonitis, not advanced sufficiently to give rise to the pathological changes represented by associated signs. This point may have a material influence on the therapeutical management of the disease. The in- determinate rales, although often combined with other physical phe- nomena, and deriving much of their diagnostic significance from the combination, have, nevertheless, no fixed or definite correlative signs. In other words, there are no signs involving the coexistence, even in a considerable proportion of instances only, of the indeterminate rales. 8. Friction-Sounds.—These resemble the foregoing rales in not sustaining definite correlative relations to other signs. They differ, however, in this respect, viz., clinically, they are very rarely found isolated; they are associated with signs to which they do not stand in a fixed or uniform relation. The associated signs are different, ac- cording to the different circumstances under which the friction-sounds are developed. Representing, in the great majority of instances, pleuritis, they may or may not be associated with the physical evi- dences of a certain amount of liquid effusion. Occurring either at the commencement or at a late period in the career of the disease, they may or may not be accompanied by the phenomena pertaining to contraction of the chest. Being incident not only to simple pleu- risy, but occasionally to pleurisy developed as a complication of tuberculosis and pneumonitis, they may be found in combination with the groups of the physical signs representing the latter affections. PAET II. DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. V PART II. DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. PRELIMINARY REMARKS. The diagnosis of diseases affecting the organs of respiration in- volves the practical application of the principles which it has been 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 importance 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 discrimi- nation of intra-thoracic affections is always to be based on the com- bined 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 diseases, I shall not disconnect entirely 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 Diagnosis I shall adduce symptoms and pathological laws which are to be associated with the phenomena furnished by physical exploration in the discrimination of the disease. The diseases affecting 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. BRONCHITIS—PULMONARY OR BRONCHIAL CATARRH. Bronchitis, 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 affects them and the larger subdivisions also. In the great majority of cases the disease is presented in the first form, and, consequently, this may be distinguished as ordinary bronchitis. The second form is generally called capillary bronchitis. This title im- plies that the inflammation is seated in the capillary bronchial tubes, which is not the fact; the smaller ramifications are affected, but not the terminal twigs of the bronchial tree, or bronchioles, which are, properly speaking, the capillary tubes. This form offers 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 diseases, seated either in the pulmonary organs, or elsewhere. Important points of difference pertain to this distinction. The affection 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 invariably as a complication of some other antecedent pulmonary disease. Farther divisions were formerly made, based on the predominance 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 modi- fications of the disease, are deemed insufficient grounds for multiply- ACUTE BRONCHITIS. 353 ing nosological distinctions. The occurrence of a 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 development 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 sometimes condensation of pulmonary lobules proportionate to the number and size of the 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 pertaining to the' disease. Clearness of the percussion-resonance is a fundamental point in the diagnosis. As the rule, it holds good that the resonance continues vesicular and undiminished, and it is sometimes increased. The exceptions to this rule are very infre- quent. Moderate dulness, situated at the posterior and inferior part of the chest, has been observed as the result of the accumulation 23 354 DISEASES OF THE RESPIRATORY ORGANS. within the bronchial tubes of the liquid products of inflammation, toward the close of the disease in fatal cases characterized 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 invalidating the rule. In the vast majority of the instances in which the resonance on percussion is found to be diminished, the bronchial affection is a com- plication of some other pulmonary disease. The existence of bron- chitis having been determined by symptoms, laws, and positive signs, the fact of the percussion-sound remaining clear serves to establish its idiopathic character. With an unimportant exception, auscultation furnishes all the posi- tive physical 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 contained in the bronchial tubes becomes more abundant and less viscid. Both de- scription of rales may be afterward commingled in varied proportions. The varieties of the dry and moist rales, with their distinctive fluctua- tions as respects intensity, persistency, etc., have been already fully described, and it is unnecessary to reproduce in this connection details relative to these points. It will suffice to mention the fol- lowing practical considerations. The dry rales alone do not consti- tute adequate proof of the existence of bronchitis, for contraction of the bronchial tubes from spasm, with, and even without, simple irrita- tion of the mucous membrane, suffices for their production. Nor do bubbling rales, of themselves, invariably denote the disease, for they may proceed from blood, pus, as well as serum and mucus, within the tubes, without necessarily involving bronchial inflammation. If, how- ever, the two classes of sounds occur in succession, or if they are found to be commingled, the diagnostic evidence either of bronchitis or bronchial catarrh 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 reso- lution. 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 ACUTE BRONCHITIS. 355 rale, the latter heard especially with inspiration, render it probable that the bronchial inflammation extends over a considerable area, em- bracing 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 extends be- yond 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 exa- mination. The different varieties may be presented in succession, 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 is frequently abnormally loud, the expiration being somewhat prolonged, as in exaggerated respiration ; the sound is also rough or harsh. This increased inten- sity and roughness of quality may persist, if the characters of the 356 DISEASES OF THE RESPIRATORY ORGANS. vesicular respiration are not masked by the presence of the rales. These modifications of the respiratory murmur are observed espe- cially at the superior portion of the chest. In some cases of bron- chitis the murmur is heard throughout the continuance of the disease, apparently not materially modified as respects either its intensity or character. This is true of certain cases in which the inflammation is not severe, confined to the larger tubes, unaccompanied by much swelling of the membrane, and the secretion of mucus slight. The vesicular murmur is diminished oftener than exaggerated during the progress of bronchitis, and not unfrequently it is suppressed partially or generally over the chest. Partial suppression may be caused by plugging of certain of the larger bronchial tubes with tenacious mucus, interrupting the passage of air 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. It is conceivable, indeed, that 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 marked 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 preced- ing this act it had not been appreciable,—a fact often observed in auscultating patients affected with this disease. This suggests a procedure which should be resorted to, in order to determine whether the diminution or suppression proceed from the presence of liquid products, viz., requesting the patient to make a voluntary effort of coughing, and auscultating 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 mucous membrane may be sufficient to diminish, and even abolish, the vesicular murmur, in cases in which the inflammation extends to ACUTE BRONCHITIS. 357 the smaller bronchial tubes. Marked diminution or suppression of respiratory sound generally over the chest, under these circum- stances, is evidence of the extent of the bronchial inflammation. The emphysematous dilatation of the air-cells is another circumstance tending to enfeeble the vesicular murmur. As regards the other methods of exploration, inspection and palpa- tion 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 notably labored or 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 fre- mitus may in some instances be felt, which is incident to the bron- chial 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 phy- sical exploration, is generally unattended with difficulty. Prior to the discovery of auscultation, it was confessedly impracticable, in many instances, to discriminate between inflammations affecting 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 contributed to the more successful study of the semeiological history of these different affections ; so that at the present time, the diagnostic 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 uncertain without the aid of exploration. Cases of pneumonitis and pleuritis are occasionally wanting in their most distinctive symptomatic phenomena; and, on the other hand, cases of bronchitis are sometimes equally deficient in its peculiar features. The differential diagnosis, under these circumstances, must rest mainly on physical signs. But in cases of a less doubtful description than those' just supposed, the physical signs enable the physician to dis- criminate with greater promptness, ease, and confidence, as well as with much less actual liability to error, than if he relied exclusively on the symptoms. So far as the results of exploration are con- cerned, the discrimination of idiopathic bronchitis from pneumonitis 358 DISEASES OF THE RESPIRATORY ORGANS. and pleurisy involves, first, undiminished resonance on percussion on both sides. In pneumonitis and pleuritis, as will be seen hereafter, dulness or flatness occurs on one side soon after the invasion. In bronchitis, the air-vesicles remaining filled with air, and sometimes even abnormally distended, the percussion-sound retains its normal clearness, while in pneumonitis the presence of solid matter within the vesicles, and in pleuritis the presence of liquid in the pleural cavity, diminish or abolish the resonance. Second: the bronchial rales, generally 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 pleurisy, but the two latter affections being con- fined to one side in the vast majority of instances, the bronchial rales are manifested chiefly on the affected side. On the other hand, idio- pathic or primary bronchitis is a symmetrical disease, and the bronchial 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 distinctive physical 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 pneumonitis, the evi- dence, other than that furnished by percussion, of solidification of lung, together with the characteristic rale (the crepitant), are generally available. Hence, absence of the physical phenomena which charac- terize these two affections warrants their exclusion. Lobar pneumonitis, the ordinary form of the disease in the adult, is referred to in the foregoing remarks. The form occurring in young children, viz., lobular pneumonitis, in which the inflammation attacks isolated pulmonary lobules on both sides, is habitually asso- ciated with bronchitis, and hence called broncho-pneumonia. The diagnostic marks by which broncho-pneumonia is distinguished from simple bronchitis are much less distinctly defined than those which contrast it with lobar pneumonitis. The discrimination is in fact not always easy. Evidence derived from physical exploration is incom- plete, owing to the positive signs of pneumonitis being generally want- ing or imperfectly developed in this form of the disease. Symptoms are more to be relied upon than signs. And the symptoms indicating lobular pneumonitis in connection with bronchial inflammation, are those which show the respiratory function to be compromised to a greater extent than is usual in cases of uncomplicated bronchitis, viz., ACUTE BRONCHITIS. 359 frequency of the respirations; dilatation of the alae nasi; lividity of prolabia, etc. If in connection with the local symptoms of ordinary bronchitis, the respiration be but little accelerated, the alae not dilated, the blood properly oxygenated, and the physical signs of pneumo- nitis not discoverable, the affection may be considered to be simply bronchial inflammation; but if, in connection with the same local symptoms, the respirations are hurried, the alae dilating, the blood imperfectly oxygenated, even with the absence of the characteristic signs of pneumonitis, the disease nevertheless may be broncho-pneu- monia. The absence of the signs which are characteristic of lobar pneumonitis, viz., the crepitant rale, relative dulness of percussion- sound on one side, bronchial respiration, bronchophony, and exag- gerated fremitus, do not authorize the exclusion of lobular pneumonitis, because all these signs may be wanting in cases of the latter form of the disease. But this subject will be considered more fully in con- nection with the diagnosis of broncho-pneumonia. In the suppositions just made, an important qualification is introduced. 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 broncho-pneumonia; and hence, great frequency of the respirations, dilatation of the alae, and lividity, may indicate the former, instead of the latter affection. The differential diagnosis of these affections, however, will present itself for consideration more appropriately hereafter. The liability of confounding tuberculosis of the lungs with bron- chitis, relates rather to the chronic than the acute form of the latter affection. In some cases of acute phthisis, the abrupt invasion 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 bron- chitis being preceded, in a large proportion of instances, by inflam- mation or irritation of the air-passages above the trachea, has some bearing on this discrimination. In tuberculosis, the symptoms from the first are oftener 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 catarrh, or coryza, gradually advancing downward to the pul- monary organs, the presumption is in favor of its being simple bron- chitis. Other points of difference are entitled to vastly more weight 360 DISEASES OF THE RESPIRATORY ORGANS. 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 characterized by sharp, lancinating pains situated at the summit of the chest on one side, frequently beneath the scapula. The pulse in acute phthisis, accompanied by tubercu- lous fever, is accelerated out of proportion to the local pulmonary symptoms, either indicating or simulating bronchial inflammation. The reverse is true of acute bronchitis. The respirations are more frequent in acute phthisis than in ordinary bronchitis; the loss of strength is notably greater, and the emaciation more rapid. But the physical signs establish conclusively the differential diagnosis. In the great majority of cases of tuberculosis, percussion reveals marked disparity between the two sides, the dulness being almost uniformly at the upper portion of the chest. This will be associated with more or less of the auscultatory signs of solidification. The bronchial rales denoting coexisting bronchitis are especially marked on one side, and at the summit, in front, while in uncomplicated bronchitis they are especially heard over the base of the lungs, on the posterior surface of the chest. The question, in cases of acute phthisis, whether the disease be simply bronchitis, can only arise during a short period after the invasion, for in the progress of the affection unmistakable evidence of its character is soon developed, exclusive even of 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, pneumonia or pleurisy, the distinctive symptoms which characterize these affections being ab- sent. The history and physical signs enable the physician readily to determine the associated morbid condition 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 consideration of 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 ACUTE BRONCHITIS. 361 fevers. It forms an important constituent, in a pretty large propor- tion of cases of rubeola ; and being 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 circum- stances, to consider the disease simply and exclusively bronchitis. In rubeola, the bronchial symptoms preceding for several days the appearance of the eruption, this error does not necessarily imply want of care or skill on the part of the diagnostician. The chief dis- tinguishing points are the degree and persistency of the coryza, the irritation or inflammation extending along the lacrymal passages to the conjunctiva, and the disproportion between the local evidences of bronchitis and the general symptoms, such as febrile movement, pain in head and loins, loss of appetite, etc. These points, however, are not infrequently unavailable; and, in fact, in a certain propor- tion of cases, it is difficult, if not quite impossible, to predict with posi- tiveness 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 some occasional in- stances, continued fever is not ushered in by marked symptoms of a bronchial affection ; these symptoms become developed after the fever is confirmed. The disease has a prodromic period, in which usually other phenomena are more prominent than those pertaining to the pul- monary organs. Limiting the attention to typhoid fever, the form of continued fever generally observed in this country, and the form in which the bronchial element is oftener 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, eruption, etc., the pulmonary affection compared with the febrile movement, the prostration, anorexia, etc., is dispro- portionately 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 discrimination is made, in the vast majority of cases, renders it superfluous to dwell longer on the details of the differential diagnosis. 362 DISEASES OF THE RESPIRATORY ORGANS. SUMMARY OF THE PHYSICAL SIGNS BELONGING TO ACUTE ORDINARY BRONCHITIS. Percussion-resonance clear on both sides of the chest. In the early stage, before liquid secretion takes place, the dry rales, espe- cially the sonorous, irregularly 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 exaggerated and harsh in the early stage. Subsequently liable to be diminished or suppressed over a part or the whole of the chest. Sometimes reproduced suddenly after an act of coughing. In some mild cases preserving its normal intensity and characters. A rhonchal fremitus occasion- ally 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 neces- sarily implicated. Extending to the latter, and limited to more or less of the pulmonary lobules, the affection called broncho-pneumonia is superadded. Capillary bronchitis was formerly described by medical writers under the titles, peripneumonia notha, and suffocative catarrh. Its true character and seat have been but recently understood. It is with great propriety considered to be a distinct form of bronchitis, differing from the ordinary form in important particulars, pertaining to symptoms, laws, and signs, as well as to anatomical characters. The anatomical conditions, on which the physical signs are immedi- ately dependent, are, irregular contraction of the calibre of the minute tubes, the presence of liquid within these tubes, and obstruction to the passage of air to and from the vesicles. The latter condition, 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 bron- chitis, the air within the pulmonary vesicles remaining undiminished, and, indeed, increased in quantity (excepting the reduction due to CAPILLARY BRONCHITIS. 363 the collapse of lobules, which takes place, to a greater or less extent, in a certain proportion of cases, the percussion-resonance is unim- paired, and acquires an exaggerated clearness, especially at the supe- rior and anterior portion of the chest. A clear sound on percussion, and equal on the two sides, although negative, is a fundamental point in the diagnosis. Dulness denotes either that the affection is compli- cated 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 musical, 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 murmur, 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, which usually coexists, and the amount of the consequent mucous secretion. But a moist rale characteristic of an affection of the minute tubes is the sub- crepitant. This rale in its sensible characters, as well as in its source, holds an intermediate place between the mucous, on the one hand, and the crepitant (intra-vesicular), 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 small, and somewhat unequal in size. The sound is finer than that of the finest mucous rales. It may accompany either inspiration or expiration, or both 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 in fact does not belong in the category of the bubbling rales; the crepita- tions 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 charac- ters alone.1 The law of symmetry here, as in the ordinary form of 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. 364 DISEASES OF THE RESPIRATORY ORGANS. bronchitis, has an important bearing on the diagnosis. In confor- mity 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. It is true that, capillary bronchitis occurring generally in children, the dis- crimination is to be made between it and the lobular form of pneu- monitis in which the inflammation affects both sides. But, as will be seen hereafter, in lobular pneumonitis the crepitant rale is rarely appreciable. The sub-crepitant rale in capillary bronchitis is heard especially over the lower third of the chest posteriorly. Present in this situation, diffused over a considerable space, on both sides, and the percussion- resonance unimpaired, this combination of signs in connection with the symptoms of the disease, renders the diagnosis positive. The sub-crepitant rale, under these circumstances, becomes pathogno- monic. Aside from its connection with capillary bronchitis, this rale occurs in oedema of the lungs, in haemoptysis, in some 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 affections and idiopathic capillary bronchitis. (Edema is a secondary affection, frequently limited to one side, and gives rise to dulness on percussion. In haemoptysis, the bloody expectora- tion 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 tuberculosis. In pneumonitis it occurs at a late stage of the disease, after the diagnosis has been determined, but the connection is easily established by the concomitant physical signs, viz., bronchial respiration, bronchophony, dulness on percussion, etc., these signs being, in the vast majority of cases, limited to one side of the chest. If the practitioner were to be guided exclusively by the symptoms, he might be at a loss in some instances to decide between the exis- tence of capillary bronchitis, and acute pneumonitis, or pleuritis, occurring in the adult, albeit the distinguishing features of the for- mer, as contrasted with the two latter affections, are of a striking character. Acute pneumonitis and pleuritis are generally charac- CAPILLARY BRONCHITIS. 365 terized by sharp, lancinating pains, which do not enter into the symp- tomatic history of capillary bronchitis. The latter, in the great majority of instances, supervenes either on ordinary bronchitis or pul- momonary catarrh. The former are preceded by an inflammatory or catarrhal 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 with orthopnoea, the cyanotic hue of the lips and surface, the great frequency of the pulse, the rapid progress frequently to a fatal issue, distinguish severe cases of capillary bronchitis; these symptoms not being present to the same extent, save in rare excep- tional cases, of pneumonitis and pleuritis. But with the aid of physi- cal 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 warrants 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 uni- versally over the chest. The fact, however, is not to be lost sight of, that capillary bronchitis may become complicated with lobar pneu- monitis in the adult; and it is to be borne in mind that in these re- marks the form of pneumonia peculiar to children (broncho-pneu- monia) is not referred to. An instance has fallen under my observation of acute 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 physical 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 symptoms. Other diseases for which there is a liability of capillary bronchitis being mistaken, and vice versa, are, first, certain affections of the larynx, inducing the phenomena of asphyxia; and, second, certain pulmonary affections in addition to those already mentioned, viz., asthma, ordinary bronchitis in connection with emphysema, lobular pneumonitis, or broncho-pneumonia, and the variety of bronchitis to be next noticed, called plastic or pseudo-membranous. 366 DISEASES OF THE RESPIRATORY ORGANS. The laryngeal affections referred to, are oedema glottidis, spasm of the glottis (laryngismus stridulus), acute laryngitis in the adult, and in children croup. In oedema glottidis, the seat of the obstruction is indicated by the sudden arrest of the inspiration, the expiration re- maining free : the reverse obtains in capillary bronchitis. Either ordinary bronchitis or pulmonary catarrh precede and accompany it as a coincidence, not as a law. Auscultation, if there be no pul- monary 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 exis- tence 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 fre- quently 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 respiration incident to the latter, although increased at times, is persisting. The positive signs of inflammation of the minute bronchial tubes are wanting. Laryngitis in the adult, and croup in children, present distinctive characters referable to the voice, in addition to other points of dif- ference. The voice is hoarse, husky, or extinguished, while its quality remains unaffected in capillary bronchitis. Moreover, in croup the sonorous tubular breathing and cough are diagnostic. The absence of the auscultatory signs of capillary bronchitis in both these affec- tions, as in the foregoing instances, renders the diagnosis positive. A paroxysm of asthma is characterized by symptoms not unlike those presented in capillary bronchitis. The orthopnoea and evidences of defective haematosis are similar in the two affections. The situa- tion of the obstruction is the same, viz., in the minute bronchial branches; and the physical signs, exclusive of the mucous and sub- crepitant rales, are identical in character. The sonorous and sibi- lant rales are equally, or even more, marked in asthma. But in this affection the pathological element is spasm. The affection is pa- roxysmal, although the paroxysms may have considerable duration. The liability of the patient to attacks of asthma is known, since in the great majority of instances they occur in persons who are habi- tuated to them. Generally, the previous history and physical signs denote the pre-existence of emphysema. The pulse furnishes a grand point of difference. In asthma, the pulse may remain unaffected in CAPILLARY BRONCHITIS. 367 frequency, and never is accelerated to the degree observed in capil- lary bronchitis. Acute bronchial inflammation extending beyond the larger, but not to the minute branches, occurring in a person affected with emphy- sema, induces a train of symptoms resembling closely those of the capillary form of bronchitis. The suffering and labor with respi- ration, and the impaired oxygenation of the blood, may be equally marked, but the prognosis is far less grave. The existence of emphy- sema 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 sub- crepitant. The coexistence of the emphysema renders the symptoms pertaining to the respiration and haematosis 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 symp- toms 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 obstruc- tion. Moreover, as such subjects are generally liable to asthma, spasm of the muscular fibres of the bronchial tubes is a more prominent element than in cases in which the capillary bronchitis is uncomplicated, 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 inter- ference, rather than to the diagnosis. The affection with which capillary bronchitis is most likely to be confounded, and from which it is with most difficulty distinguished, is lobular pneumonitis or broncho-pneumonia. Both affections are peculiar to young subjects, and hence, occasions are oftener presented to the practitioner for discriminating between these, than between capillary bronchitis and the other form of disease, to which in some of its features it bears resemblance. Moreover, capillary "bronchitis and broncho-pneumonia may actually be combined; and, in fact, the latter probably always involves inflammation of the minute bronchial branches in direct communication with the inflamed lobules. In capillary bronchitis, the inflammation extends from the larger to the minute bronchial tubes generally throughout the pulmonary organs, either with or without the air-cells of more or less of the lobules be- 368 DISEASES OF THE RESPIRATORY ORGANS. coming implicated. In broncho-pneumonia, the inflammation extends from the larger tubes to a certain number of the air-cells of the lobules on each side, affecting, of course, the intermediate minute branches leading to the lobules which have become inflamed, but limited to these, and in this respect differing very materially from general capillary bronchitis. In both affections, ordinary bronchitis exists, with the symptoms and signs incident thereto. In both, the respirations are hurried, with more or less dyspnoea, and perhaps with evidences of defective haematosis. In the lobular form of pneumonitis, as has been already stated, and as will appear more fully hereafter, the characteristic physical signs, as well as certain symptoms pertaining to lobar inflammation of the pulmonary parenchyma, are frequently wanting. The crepi- tant rale, the bronchial respiration and bronchophony, are often not discoverable. The matter of expectoration in young children is swallowed. In view of these facts, how is the differential diagnosis to be made ? The following are the chief points of distinction. Gene- ral capillary bronchitis, as a rule, is a graver affection than lobular pneumonitis; the respirations are more frequent; the asphyxiating effects are greater, and the symptoms representing these effects, viz., dyspnoea, restlessness, lividity, in a corresponding degree more marked. In fatal cases, the career of the disease is more rapid. With refe- rence to physical signs, one source of difficulty is the incompleteness of the explorations with which the physician must be content in ex- amining young children. With care and perseverance the character- istic phenomena of pneumonitis may, in some cases, be discovered. In addition to the auscultatory phenomena just mentioned, if the number of lobules consolidated by inflammation be considerably more numerous on one side than on the other, relative dulness on percus- sion may be apparent. But the same result will follow collapse of a greater number of lobules on one side from bronchial obstruction. The sub-crepitant rale belongs to both affections, but in lobular pneu- monitis it is limited in its seat to the minute tubes in immediate re- lation to the inflamed lobules, while in general capillary bronchitis the physical conditions for the production of the sound exist every- where throughout the lungs. In the latter affection, therefore, the sub-crepitant rale is diffused over the whole surface of the chest; and in the former it is limited to certain portions. This is the most dis- tinctive evidence to be obtained by physical exploration, provided the positive signs of pneumonitis are not to be discovered. In the in- PSEUDO-MEMBRANOUS BRONCHITIS. 369 stances in which the signs are appreciable, the diagnosis is, of course, established. With due attention to the foregoing points of distinction, cases will occur in which the discrimination is difficult, if not impossible. And it may be remarked that the uncertainty which must attach to the differential diagnosis in certain instances, accords with the present unsettled pathological views respecting the connection between bron- chitis and morbid conditions heretofore considered to be dependent on inflammation of the pulmonary lobules. Recent researches tend to show that in a large proportion of the cases of the so-called broncho- pneumonia, the disease is exclusively bronchial inflammation, leading to collapse of the lobules to a greater or less extent. Finally, capillary bronchitis presents symptoms and signs belonging alike to the form of bronchial inflammation called plastic or pseudo- membranous, which will presently be noticed under a distinct 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 exaggerated ; 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 the inferior posterior portion of the chest; coarse 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 fibrin on the mucous surface of the smaller bronchial tubes, forming 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 bronchitis commences in the minute branches, and extends upward towards the trachea. A fibrinous exudation in some of the tubes is occasionally observed as a contingent anatomical element of capillary bronchitis; but it is the 24 370 DISEASES OF THE RESPIRATORY ORGANS. basis of a distinct form of bronchial inflammation, when it constitutes the most distinctive and important feature of the disease. Patho- logically, it denotes a peculiar modification, without necessarily great intensity of the inflammatory process. The expectoration of croupal matter is preceded by cough more or less violent, generally accompanied by dyspnoea. These character- istic sputa are expectorated at intervals varying greatly in different cases; days, weeks, months, and sometimes even years intervening. Aside from this peculiar feature, the symptoms may be those of an acute or sub-acute bronchial inflammation. Dyspnoea and the evi- dences of defective haematosis may be absent, or present in a degree proportionate to the amount of obstruction, and the number of the bronchial ramifications affected. The danger and the rapid career of the disease depend on the circumstances just mentioned. The ex- pectoration of false membrane may be followed by relief more or less complete. Collapse of pulmonary lobules, or solidification from an extension of the inflammation to the air-cells, will add to the gravity of the symptoms, and the danger. Cases in which the exudation takes place extensively throughout the lungs, present all the distress- ing 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 comparatively mild, and not indica- tive of immediate danger. Under the latter circumstances, the affection may continue indefinitely, or recur from time to time, or, after the expectoration of the membranous products, 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 idiopathic. If the exudation take place extensively, or if it occur in connection PSEUDO-MEMBRANOUS BRONCHITIS. 371 with other pulmonary affections, a fatal result may be expected. Of the cases, however, in which false membrane, in more or less abun- dance is expectorated, a large proportion end in recovery.1 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, solidi- fication from inflammation, and great accumulation of liquid products within the air-tubes, percussion elicits a resonance clear and equal on the two sides. The sonorous and sibilant rales will be likely to be heard, on auscultation, more or less diffused over both sides of the chest. The moist or bubbling rales are developed in the progress of the disease, as in the other forms of bronchitis. Suppression of the rales and of all respiratory sound over portions of the chest, is liable to occur from obstruction of the tubes by the exudation, in which case it may be temporary, and variable in situation and extent; or from collapse and solidification, in the latter case being more persisting both in seat and duration. The sub-crepitant rale may be discovered, but limited to certain portions of the chest. A diagnostic point per- tains to the fact last stated. The presence of the sub-crepitant rale distinguishes this from ordinary bronchitis. The limited extent of surface over which the rale is heard, distinguishes the affection from capillary bronchitis. In the latter variety, the sub-crepitant rale is diffused over the chest. It is proper to add, however, that the point of distinction just stated is determined inferentially, rather than by induction from a sufficient number of clinical observations. M. Barth and M. Cazeaux, separately, have reported each a single case in which a peculiar valvular or flapping sound (petit bruit de soupape), was heard on auscultation, attributed to the vibration of partially de^ tached 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- 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. 372 DISEASES OF THE RESPIRATORY ORGANS. teristic expectoration. Prior to false membrane being expelled, the symptoms and signs are not sufficiently distinctive for the practitioner to decide that this particular form of bronchitis exists. If membran- ous formations are discovered in the matter of expectoration, their appearance may at once denote their source, and, consequently, 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 in- volved. But if the false membrane expectorated consist simply of fragmentary pieces or shreds, the fact of the exudation being bron- chial is settled by the quality of the voice remaining unaffected, and the absence of other evidences of laryngeal disease. The circum- stances just mentioned suffice for the differential diagnosis between croup, and plastic or pseudo-membranous bronchitis. The period of life at which this affection is most apt to occur, has some importance in a diagnostic point of view. In this respect it differs from capillary bronchitis, as well as croup. The latter are eminently infantile diseases, while the affection under consideration is oftenest observed in persons between the ages of twenty and fifty. The age of the patient is entitled to a certain amount of influence, in forming a probable opinion of the character of the disease before it is settled by the characteristic expectoration. 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 croupal exudation depends, to be completed. The discrimination of this form of bronchitis from affections other than bronchitis, which compromise respiration and the function of haematosis, and therefore have certain symptoms in common, involves the same diagnostic points already noticed in treating of ordinary and capillary bronchitis, and it would be superfluous to reproduce them in this connection. SUMMARY OF THE PHYSICAL SIGNS BELONGING TO PLASTIC OR PSEUDO- MEMBRANOUS BRONCHITIS. In addition to the physical phenomena, positive and negative, inci- dent to other varieties of bronchitis, a peculiar valvular or flapping sound (bruit de soupape) has been observed. The sub-crepitant rale, if present, less diffused than in most cases of capillary bronchitis. CHRONIC BRONCHITIS. 373 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 yields a clear vesicular resonance on percussion. The only excep- tion to this rule is, occasionally the occurrence of slight or mode- rate dulness from excessive accumulation of the liquid products of the inflammation within the bronchial tubes. Exclusive of this ex- ception, marked disparity between the two sides as respects reso- nance, assuming the chest to be well formed and symmetrical, de- notes that the bronchitis is complicated with some affection which either increases the density of the lung, such as collapse, pneumonitis, tuberculosis; or, on the other hand, abnormal rarefaction from em- physema. Complications exist in chronic, oftener than in acute bronchitis; and hence, clearness and equality of the percussion-re- sonance are found in connection with the symptoms of the former, less commonly than in the latter affection. The bronchial rales, moist arid dry, are heard in different cases with every diversity as respects character, intensity, combination, and relative predominance of the different varieties. The bubbling rales will be 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 distribution. The sound will be loud and coarse when produced in the larger tubes; finer and less intense in the smaller branches. These rales will predominate in cases characte- rized by copious expectoration. The vibrating rales will be especially prominent 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 for- mation of small solid mucous pellets (dry catarrh), a clicking, valvular sound, was described by Laennec as occasionally present, and attributed 374 DISEASES of the respiratory organs. by him to their movement within the tubes to and fro by the current of air. As the inflammation is generally limited to the larger tubes, the sonorous are oftener heard than the sibilant rales; 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 simul- taneously at different points on the chest. The numerous diversities 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 are 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 speedily effected. Sometimes in cases of this descrip- tion rales may be discovered, if pains are taken to auscultate early in the morning, before the matter which may have accumulated during sleep is removed; when afterward, during the day, the tubes being kept clear by repeated acts of coughing, the chest is free from adven- titious sounds. The presence or absence of the rales, and in a great measure their diversities, thus depend on contingent 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 exis- tence 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 bronchial subdivisions, and suddenly reproduced after an act of coughing, 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 diminished, and in some instances scarcely, if at all, appreciable. Occasionally a respiratory sound is heard resembling an exaggerated vesicular mur- mur, 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. Aa remarked by Walshe, it is probably not of vesicular but of bronchial origin. It is, in fact, an approximation to a rale. Laennec probably had reference to this modification, in stating that in some cases of chronic bronchitis the vesicular murmur becomes puerile,—a statement CHRONIC BRONCHITIS. 375 not confirmed by subsequent observations. And it is probably this modification which Dr. Bowditch terms a mucous respiration.1 A rational explanation is, that the swelling of the mucous membrane, or the presence of a little mucus, occasions an audible bronchial sound, but does not furnish the physical conditions for a fully deve- loped dry or moist rale. The vocal resonance and fremitus in chronic bronchitis, as the rule, remain unaffected. The exceptions to this rule are certainly extremely 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. Diagnosis.—The diagnosis of chronic bronchitis, so far as concerns the determination of the fact of its existence, is attended practically with little or no difficulty. The points which call for attentive and skilful investigation, relate to the presence or absence of compli- cations and resulting lesions. Is the bronchitis uncomplicated? or is it associated with dilated bronchiae, 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 condi- tions than those pertaining to the mucous membrane is to be deter- mined by the presence or absence of the signs and symptoms which belong to them respectively. The signs and symptoms distinctive of other affections will, of course, be embraced in the consideration 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 tuber- culosis 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 combina- tion with the former. Is this simply a case of chronic bronchitis, or is there superadded a deposit of tubercle ? is a question not unfre- quently arising in medical practice, which is of momentous import to the patient, and which, for many reasons, it is extremely desirable for the practitioner to be able to answer definitively. Prior to the introduction of physical exploration, this question often presented 1 The Young Stethoscopist, page 38, second edition. 376 DISEASES OF THE RESPIRATORY ORGANS. insuperable difficulty. Cases of chronic bronchitis 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 more appropriately 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 pertaining 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, are entitled to considerable weight in the diagnosis. To these considerations attention will be at present limited. Chronic bronchitis occurring at the period of life when the tubercu- lous 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 ob- tains rarely in chronic bronchitis, and if it occur is generally in paroxysms. The pulse is often notably accelerated in phthisis, rarely in chronic bronchitis. Febrile paroxysms, occurring generally in the progress of tuberculosis, do not belong to the history of chronic bron- chitis. Haemoptysis is an event of very frequent occurrence 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 bronchitis. 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 generally considerable and progressive. It is less marked in chronic bronchitis. SECONDARY BRONCHITIS. 377 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. In the former affection 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 tubercu- lous disease. 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 invariably present, heard especially over the base of the lungs on both sides. A harsh respiratory sound occasionally present. The vesicular mur- mur 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 accompany 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, not preserving its symmetrical character. In the instances last cited, it is secondary to local affections. In this category may be included the frequent instances in which it occurs in connection with pertussis. In diseases of the heart it is often developed as a secondary affection. Questions 378 DISEASES OF THE RESPIRATORY ORGANS. 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 varie- ties of secondary, as distinguished from idiopathic bronchitis, pre- sent peculiarities which are important. Some of these have been already incidentally noticed. Others will be conveniently referred to in treating of the diseases which remain to be considered. It does not, therefore, seem advisable to bestow upon the diagnosis of bron- chitis occurring secondarily special consideration, under a separate head. Bronchial or Pulmonary Catarrh. The term catarrh, originally applied to affections characterized by copious liquid secretion or flux, subsequently came to be used in an extended sense to embrace most of the inflammatory affections seated in the air-passages. Inflammation of the bronchial mucous membrane is more appropriately designated by the title bronchitis, but the term catarrh, may be conveniently retained to denote either a morbid state falling short of inflammation, or an extremely mild grade of inflam- matory action. In this sense pulmonary or bronchial catarrh is illustrated by the disorder popularly known as a common cold. The pathological appearances, determined mainly by inference from those presented in analogous structures, accessible to view dur- ing life, are due simply to hyperaemia, consisting of redness and swelling. The mucous secretion is more or less increased and modi- fied. Serous exhalation occurs, constituting, when abundant, a variety of bronchorrhea. As thus defined, pulmonary or bronchial catarrh is a frequent sporadic and also an epidemic affection. In a certain proportion of the cases of influenza the local morbid condition of the air-passages is of this description, a condition allied to, and often eventuating in inflammation. The affection of the bronchial mucous membrane induced secondarily in the course of fevers, the typhus and typhoid fevers especially, in many, if not most instances, falls more properly under the denomination of catarrh than bron- chitis. Cases of pulmonary or bronchial catarrh may present auscultatory phenomena identical with those observed in ordinary bronchitis ; the contracted calibre of the tubes at certain points, and the presence of serum or mucus, constituting the physical conditions requisite for the BRONCHIAL OR PULMONARY CATARRH. 379 dry and bubbling rales. The discrimination between bronchitis and catarrh, is to be based on the local and general symptoms which de- note in the one case the existence, 'and in the other case the non-ex- istence of inflammation; and inasmuch as the latter merges into the former so insensibly that it is not easy to define the exact line of demarcation dividing them, it is not always practicable to make the distinction clinically. The point, however, is not one of great prac- tical consequence. Limiting the attention to the diagnosis, exclusive of questions re- lating to etiology, pathological relations, &c, these few words com- prise all that need be said under the head of pulmonary or bronchial catarrh. CHAPTER II. 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 pri- mary and prominent local symptoms of which pertain to the pulmo- nary air-passages. Asthma is characterized by phenomena which appear to be dependent on spasm of the bronchial muscles. Dilatation of the Bronchial Tubes.1 Dilatation of the bronchiae was scarcely known to pathologists prior to the researches of Laennec. The inference naturally drawn from this fact relative to the rare occurrence of the lesion is not alto- gether correct. The inattention paid to the condition of the bronchial tubes in autopsical examinations led to the existence of dilata- tion being often overlooked, and sometimes confounded with tuber- culous 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 ser- vice 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 affection in its produc- tion. The mode in whieh it is produced is an interesting point of pathological inquiry, admitting of extended discussion. But it would be a digression from the range of practical topics to which this work 1 Called Bronchiectasis. This name is too formidable for common use, and I do not therefore adopt it. DILATATION OF THE BRONCHIAL TUBES. 381 is limited, to indulge in more than a brief passing allusion to it. Laennec attributed the dilatation chiefly to mechanical distension of the bronchial parietes from the accumulation of mucus. This expla- nation is now generally deemed inadequate, and the accumulation is regarded 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 dilating forces, is, probably, as first pointed out by Dr. Stokes, a pre-requisite, the result usually of prolonged inflammation. Hence, the lesion is one of the sequels of chronic bronchitis. With regard to the causes more immediately en- gaged, they are doubtless not in all cases the same. Extraordinary efforts of the respiratory organs, as in the violent paroxysms of cough- ing 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 obstruction to lead to per- manent enlargement. But in the great majority of cases, there is reason to believe the dilatation depends on a prior morbid condition of the pul- monary parenchyma. Dr. Corrigan1 has described a special affection involving this lesion, consisting in a morbid deposit around the tubes, which assumes the characters 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 combined 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 deposit becoming attached to the longitudinal fibres of the tubes, so that dilatation in this way results from the shrink- ing 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 an apparent resemblance to the affection of the liver known by that title. 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 cells from pneumonitis, and the compression to which they are subject in cases 1 Dublin Medical Journal, May, 1838. 382 DISEASES OF THE RESPIRATORY ORGANS. 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, and the liquid effusion in pleuritis, the bronchial tubes, previously weakened by the process of inflammation, yield to the pressure of the inspired air. Under these circumstances what will be presently noticed as the uniform or cylindrical 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 the lung from obstruction of the lesser bronchial twigs in some cases of bronchitis, when the collapsed 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.1 With reference to the practice of 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 varie- ties of dilatation. One variety consists in a spherical, sacculated, or pouch-like dilatation, occurring usually in the third or fourth subdi- visions, 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 interme- diate portions retaining the normal size. The tube presents an appearance compared by Elliotson to a string of beads. In the third variety, a cylindrical and nearly uniform enlargement of a tube, with more or less of its branches, takes place. The last spe- cies of dilatation sometimes extends over a whole series of bronchial subdivisions, the enlargement gradually increasing toward their ex- tremities, 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. Bronchial dilatation associated with obliteration of the cells, and contraction of the pulmonary parenchyma, is attended with a corre- 1 The reader desirous of a fuller exposition of the mechanism of the production of this lesion may consult with advantage the works on Pathological Anatomy by Hasse, Am. Ed. page 280, et seq.; Jones and Sievekings, Am. Ed. page 389; and Rokitansky, Syd. Ed. vol. iv, page 5. DILATATION OF THE BRONCHIAL TUBES. 383 sponding amount of diminution of the size of the chest, sometimes 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 condensed. 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 exudation of a 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 ex- isted near the apex of the lung, communicating by intervening bron- chiae, so as to resemble closely a united group of excavations similar to those not unfrequently met with in subjects dead with tuberculous disease. Under these circumstances the lesion, on a superficial ex- amination, might readily be considered to have proceeded from phthisis. In the other forms, bronchial dilatation was formerly, as already remarked,1 confounded with phthisical cavities. On the other hand, in the opinion of a distinguished pathologist, many of the in- stances of the so-called cirrhosis of the lung are, in fact, cases of tuberculous cavities.2 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, partially or entire, and the consequent contraction of the thoracic walls. Physical Signs.—Dulness on percussion generally attends dilata- tion of the bronchial tubes. The dulness is due mainly to the con- densation and contraction of the parenchyma which accompany the dilatation, and it is marked and diffused in proportion to the degree and extent of the abnormal density which the lung acquires. The dulness may be somewhat increased at times by an accumulation 1 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. I take the liberty of making this statement on the strength of a verbal expression of the opinion to the writer. See also, Treatise on the Pathology and Treatment of Pulmonary Tuberculosis. Edinburgh edition, pages 48 and 49. 384 DISEASES OF THE RESPIRATORY ORGANS. of mucus within the enlarged tubes. To the foregoing rule there are exceptions. Increased clearness of percussion-resonance is occasion- ally observed, notwithstanding the pulmonary parenchyma surrounding the enlarged tubes is more or less condensed and contracted. This arises from the air within the tubes being sufficient to overbalance the abnormal density of the lung. The resonance under these circumstances becomes either purely tympanitic (tubular), or vesiculotympanitic. The vesicular quality, in other words, is impaired or lost, and the pitch raised. The resonance may even assume an amphoric character. Increased clearness is of course only present when the bronchial tubes are free from morbid products; and as their condition in this respect varies at different times, percussion will elicit only at certain periods, a clear sound 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 more eminently favorable for the pro- duction of tubular or bronchial respiration, when the tubes are unob- structed, provided the dilatation be of the cylindrical variety. The enlarged calibre of the bronchiae and the pulmonary condensation combine to render the respiratory sound non-vesicular and blowing. The bronchial characters are strongly marked and the sound intense, ceteris paribus, in proportion to the enlargement and increased density. The diffusion of the tubular 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 bron- chitis. 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 is often 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 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. DILATATION OF THE BRONCHIAL TUBES. 385 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., the cavernous respiration, gurgling, and in some instances pectoriloquy. Even metallic tinkling was observed in a case reported by Dr. Barlow, of London.1 Diagnosis.—The diagnosis of dilatation of the bronchial tubes is fre- quently attended with extreme, and in some instances insurmountable difficulty, owing to the physical signs being similar and indeed identical with those incident to other forms of disease. 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 consoli- dation of lung incident to pneumonitis, and tuberculosis. With acute pneumonitis, dilatation of the tubes can hardly be confounded, except the attention be directed exclusively to the physical signs. The one is an acute, and the other eminently a chronic affection. As respects acute symptoms, a resemblance exists only when acute bron- chitis supervenes on bronchial dilatation. Under these circumstances the pulmonary symptoms will be those belonging to bronchitis, ex- clusive of the distinctive features of pneumonitis, viz., lancinating pains and the rusty or bloody expectoration. The characteristic auscultatory 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 (which with due care should not be made), 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 resolution of the inflammation. From chronic pneumonitis the discrimination must be less easy. But chronic pneumonitis is an affection so rare that, prac- tically, the fact of its occasional occurrence mayT almost be disre- garded. When it occurs, it is generally preceded by the acute form of ' Guy's Hospital Reports, 1847. 25 386 DISEASES OF THE RESPIRATORY ORGANS. the disease. If in a doubtful case the pre-existence of acute pneu- monitis be clearly determined, this constitutes an important diagnostic point. Moreover, chronic pneumonitis is accompanied by general symptoms indicative of a graver malady than simply bronchial dila- tation. 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 instances is seated in the upper lobe. The difficulty of diagnosis relates chiefly 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 re- spiration, bronchophony, increased vocal fremitus, which attend cylindrical dilatation, denote, under certain circumstances, the pre- sence of crude tubercle. Cavernous respiration and gurgling are the signs of an excavation in forty-nine of fifty 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 the two varieties, they claim separate consideration. Dilatation of the cylindrical variety may present, as just stated, a group of physical signs which, in connection with cough and expec- toration, may appear to indicate a tuberculous deposit. What are the circumstances favoring the conclusion that these signs and symp- toms are due, not to tuberculous disease, but to dilatation of the tubes ? The situation of the physical signs, viz., the bronchial respiration and bronchophony, 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 clavicular, supra-clavicular, and infra-clavicular regions. The phenomena due to bronchial dilatation, on the other hand, are oftener manifested over the middle portion of the chest, than at the summit. Taken in con- nection with other circumstances, this is a strong diagnostic point; but it is to be borne in mind, that the rule with respect to the situa- DILATATION OF THE BRONCHIAL TUBES. 387 tion of the tuberculous 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 part, to the greater density of the pulmonary tissue, but more to the en- larged calibre of the tubes. In tuberculous disease, these phenomena proceed exclusively from the consolidation ; and, other things being equal, they are intense in proportion to the increased density of lung. Hence, in tuberculous disease, bronchial respiration 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 contrary, the enlargement of the calibre of the bronchial tubes may be considerable, and the conden- sation moderate or slight. Under these circumstances, the bronchial respiration and bronchophony may be strongly marked, while the percussion-resonance is but little impaired. A striking disproportion, then, between these auscultatory phenomena, and the evidence fur- nished by percussion of pulmonary solidification, authorizes, to say the least, a presumption 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 gene- rally 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, haemoptysis, lancinating pains in the chest, diarrhoea, marked accele- ration of the pulse, hectic paroxysms, night perspiration, chronic laryngitis. If all these are absent, the fact favors the supposition of dilatation being the pathological change giving rise to physical phe- nomena which, associated with more or less of the symptomatic phe- nomena just enumerated, would denote unequivocally the existence of tuberculous disease. Occasionally, however, it happens in cases of phthisis, that nearly all these rational indications are wanting. Hence, under these circumstances 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 certain phy- 388 DISEASES OF TnE RESPIRATORY ORGANS. sical signs are due to cylindrical dilatation of the bronchial tubes, and not to tuberculous solidification. In fact, the discrimination 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. Fortunately 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 prac- titioner to disregard the fact that cases of dilatation 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 conside- rable solidification from the presence of crude 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 bronchiae. The presence of cavernous signs, there- fore, with slight dulness surrounding the site of the cavity, favors the hypothesis of dilatation. The signs of cavities from dilatation may be unattended by any appreciable dulness on percussion. This was true of a case of bronchial dilatation, simulating phthisis, reported by Louis.1 In the case referred to, an error of diagnosis is admitted by that conscientious and accomplished observer. 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-reso- nance above the site of a cavity, in other words in the supra and infra- clavicular region on the same side, be found to be clear 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 circumstances to render the supposition of dilatation probable. Another point pertaining to the physical signs is applicable to 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 1 Recherches sur la Phthisic DILATATION OF THE BRONCHIAL TUBES. 389 in the great majority of cases, shortly afterward in the other lung. In cases of phthisis, therefore, advanced to the stage of excavation, there may be expected to be present on both sides of the chest phy- sical signs of tuberculous disease. Now, if with the evidences of a cavity on one side, the other side yield no signs of disease, the fact favors the exclusion of tuberculosis. If a case has been under observation for a considerable period, the existence of tuberculosis is evidenced by the physical signs of excava- tion becoming developed where previously the signs had denoted solidification. This succession of physical phenomena does not belong, 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 alteration 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, is possible, and occasionally occurs, but only as a rare exception to the general rule. A notable degree of flattening of the chest at the summit is strong evidence against dilatation, the depression thus limited in this affec- 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 dilatation or phthisis advanced to excavation, for a longer duration of the tu- berculous 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 much confidence. In this statement it is of course understood that cavities from abscess, or circumscribed gangrene, are excluded. In connection with the subject of the differential diagnosis of dila- tation and tuberculosis, the fact is not to be lost sight of, that both may exist conjointly. As remarked by Walshe : " This compound 390 DISEASES OF THE RESPIRATORY ORGANS. state is, probably, beyond the reach of diagnosis." Dr. Bowditch1 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 pectori- loquy, 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 bronchiae enormously dilated were found to fill up the major part of the lung over which had been heard the physical signs above men- tioned. The protective influence of dilatation against tubercle is 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 haemorrhages 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 pul- monary symptoms, but by an affection of a testicle. He was not emaciated; did not present the aspect of a tuberculous patient, and had recently gained in weight. Over the left chest the percussion- resonance was moderately dull, with a somewhat tympanitic quality. Over the upper and middle thirds, in front, of the left side, bronchial respiration was intense, the expiration notably prolonged, high in pitch, and metallic. 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 per- cussion-resonance. The 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. 1 Young Stethoscopist, second edition, page 101. CONTRACTION OF THE BRONCHIAL TUBES. 391 SUMMARY OF THE MORE IMPORTANT OF THE DIAGNOSTIC CHARACTERS. The physical signs accompanying cylindrical dilatation, viz., bron- chial respiration, exaggerated vocal resonance, or bronchophony, and increased vocal fremitus, found to be persistent, and, unless acute bronchitis coexist, unattended by any of the signs and symptoms of acute pneumonitis. If acute bronchitis coexist, certain of the signs and symptoms distinctive of acute pneumonitis absent, viz., lancina- ting pains, bloody or rusty expectoration, and the crepitant rale. The bronchial respiration and bronchophony not diminished, and perhaps increased after the symptoms of acute bronchitis have dis- appeared. The previous history not showing the existence of prior acute pneumonitis, which is generally true of cases of chronic pneu- monitis. The bronchial respiration and bronchophony oftener found over the upper than over the lower lobe. Frequently a disproportion between the auscultatory phenomena, and the evidence of solidifica- tion afforded by percussion. The general symptoms 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. Frequently, the dulness on percussion relatively to these auscultatory phenomena, proportionately less than in most cases of tuberculosis; and in some instances no dulness existing, or the percussion-resonance clear at the summit. The physical signs when strongly marked and diffused over a considerable space, inclusive of the phenomena due to cavities, fre- quently limited to one side of the chest. The cavernous signs not preceded, but sometimes followed, by notable dulness on percussion. The physical phenomena persisting for a long period without any material alteration. Absence of the rational evidence of phthisis derived from the symptoms and effects of the latter affection, such as great emaciation, feebleness, anaemia, haemoptysis, 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 occurs in various pathological con- nections. It varies in extent, being sometimes limited to a small 392 DISEASES OF THE RESPIRATORY ORGANS. space, and in other instances extending to considerable distance. Its situation may be near, or more or less remote from the primary bron- chus. In degree it is variable. It may end in complete obliteration. Obliteration of the bronchial tubes, strictly considered, is a lesion dis- tinct from contraction. For practical purposes, however, it suffices to notice both under the head of contraction. As occurring in connec- tion with the different varieties of bronchitis, contraction and even obliteration of bronchiae 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 probably impossible. To the diagnostician they are interesting, chiefly in the light of disturbing elements, as it were, in physical exploration, giving rise to phe- nomena which may simulate other affections or modify their charac- ters, occasioning embarrassment if not 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 1835.1 Reynaud was led by his observations to the opinion that bronchial obliterations were not very uncommon. Hasse, however, suggests that he may not have distinguished in all instances between the simple obstruction produced by the presence of exudation of lymph in plastic bronchitis, and acute obliteration arising from organization of the exudation, 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, which is compared by Prof. Gross, to continuous stricture of the urethra, or the tubes may be narrowed or closed at one or more points, as if a ligature had been applied.3 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, extending more or less along the tube leading to that point, is apt to follow. 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 the effect just mentioned, sur- Mam. de l'Acadsmie Roy. de Me"d. vol. iv. 1835. 2 These two varieties are described and figured in Gross's Pathological Anatomy, to which the reader is referred. CONTRACTION OF THE BRONCHIAL TUBES. 393 rounding lobules are likely to take on an abnormal increase of bulk, becoming, in other words, emphysematous. This compound state defies diagnosis. It is obvious, that the extent of the consecutive pulmonary changes, together with the symptoms and signs, will depend on the size of the bronchial tube, or tubes, which are contracted or obliterated, as well as on the amount of obstruction, provided complete occlusion does not exist. Continuous obliteration affects usually the smaller divi- sions of the bronchiae. Contraction or obliteration limited to a small portion of the tube, is observed principally in bronchiae of the second or third order.1 Obstruction more or less complete, however, has been met with at different situations between the bronchi and the minute ramifications. Seated in a primary division of the bronchi, 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 diminished or cut off. The atrophy and collapse of the lobe which ensue are proportionate to the obstruct'on. These results will be less extensive, 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 bronchiae. Within the tubes, they consist of plastic 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, viz., calcareous format ons, melanotic cysts, or acephalocysts gaining en- trance 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 pleuritic effusions. Several cases were reported some years ago by Mr. T. W. King, of London2, in which pr.-ssure of the left auricle, in connec- tion with enlargement of the heart, was found to have occasioned » Gross's Path. Anat. page 419. 3 Guy's Hospital Reports, April, 1838. For summary, see Gross's Path. Anat., page 420. 394 DISEASES OF THE RESPIRATORY ORGANS. considerable flattening of the left bronchus, reducing its calibre suffi- ciently to produce partial obstruction. From the foregoing enume- ration, it is evident that, as already stated, the pathological 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 bronchial tube of large size, more especially when the obstruction is rapidly induced, and if it occur in connection with some other affection which compromises the pulmonary functions. Nothing, however, pertaining to the embarrassment of respiration would indicate specially these lesions. The signs, theoretically determined, are dulness on percus- sion 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 condensation. In the latter case the clearness may be preserved, with perhaps a vesiculo- tympanitic quality. Both conditions, i. e. the collapse of certain lobules, and the over-distension of others, combine to render the respiratory murmur feeble or inaudible. The phenomena incident to bronchial dilatation may coexist, and supersede 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, depression of the thoracic walls will follow. This, as well as the other 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 upper 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 majority of instances. The coexistence of feebleness or absence of respiratory sound, with dulness and perhaps depression, under circumstances when this combination of signs is not otherwise explicable, 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 obliteration are limited. The same combination of signs, situated elsewhere than at the sum- mit of the chest, warrants a suspicion of the existence of these lesions. This suspicion may be indulged the more if the patient have suffered PERTUSSIS — HOOPING-COUGH. 395 from chronic bronchitis; and still more if plastic exudation, in the form of bronchial moulds, or if calculi, have been expectorated. Situ- ated at the summit of the chest, these signs would be considered to denote a tuberculous deposit; and, it is not improbable, as intimated 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 bronchiae. Fortunately for diagnosis, the lesions are extremely rare. Pertussis—Hooping-Cough. The seat of hooping-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 affections, and like the 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. I have observed abdominal tympanitis irrespective of any other apparent intestinal complication, a symptom mentioned by M. Blache, as incident to this affection. Bronchial dilatation and pulmonary emphysema are occasional sequels of hooping-cough, the latter, according to Rilliet and Barthez, much less frequently than is generally supposed. External em- physema 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 hooping-cough. During the catarrhal period, the bronchial rales incident to catarrh and mild bronchitis may be heard, and also, more or less, during the continuance of the disease. These, of course, only show the coexisting irritation or 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 hooping inspiration, the expansion of the cells is unaccompanied by an audible vesicular murmur. The latter 396 DISEASES of the respiratory organs. is probably owing to reduction in the column of air caused by the contraction at the glottis. The diagnosis of hooping-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 catarrhal period, the disproportionate violence of the cough in comparison with the other pulmonary symptoms, its abruptness and paroxysmal charac- ter, with more or less of the peculiarities which are afterward so promi- nent, 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 spasmodic stage. At this period, in children, there is little room for hesitancy, except what sometimes happens, the symptoms are so extremely mild, that the special cha- racteristics are not prominent. Cases of this kind are, however, ex- tremely rare. In adults, the affection is less readily recognized from the fact that the hooping inspiration is less uniformly 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 liab'e to become developed in the course of the disease. The presence of the dry and bubbling rales during the intermissions between the paroxysms of coughing, shows the coexis- tence of bronchitis, and by their character, extent, and situation, the practitioner is enabled to judge of the number and size of the tubes affected, as in cas?s of primary bronchial inflammation. Negatively the absence of physical signs, or the presence only of those belonging to bronchitis, are important, in determining the non-existence of other and more serious complications, viz., pneumonitis, tuberculosis, pleuritis, and emphysema. The existence of any one or more of the complications just named, is to be determined by means of the phy- sical evidence of their presence, taken in connection with vital phe- nomena. 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 hooping-cough are essen- tially 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. 397 Asthma. The term asthma, formerly applied to dyspnoea, occurring as a symp- tom of different diseases of the organs of respiration and the circulation, is now restricted to a paroxysmal affection, the primary local mani- festations of which consist in spasmodic contraction of the circular muscular fibres of the smaller bronchial tubes. Like the affection last considered (hooping-cough), it belongs, nosologically, among the neuroses, and is consequently wanting in appreciable 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 associated 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 clearness of resonance. From the very frequent coexistence of emphysema, the percussion- resonance, in the majority of cases, is clearer than in health, with, perhaps, more or less tympanitic modification. If emphysema be not present, the volume of the lungs may be reduced by the expiratory efforts so as to diminish appreciably the clearness on percussion.1 Owing to the obstruction to the entrance of air into the cells, the lungs may not expand readily to fill the vacuum caused by the en- largement of the chest by inspiration. Hence, the pressure of the atmosphere occasions obvious retraction of the epigastrium, 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 expiration; the sonorous oftener predominating during this act. The rales with 1 Walshe, op. cit. 398 DISEASES OF THE RESPIRATORY ORGANS. inspiration frequently merge into those attending expiration, so that they appear to be continuous. They are diffused extensively over the chest on both sides, and the sounds are generally loud and diversified, whistling, chirping, cooing, snoring, etc., in alternation, or heard simultaneously in different portions of the chest. The moist or bub- bling rales are rarely present during the severity of the paroxysm; but may be observed toward its close, at the time when expectoration is apt to occur. After the paroxysm, bronchial rales generally con- tinue 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 difficult respiration, presenting the physical phenomena 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 suspicions of croup. But a little examination suffices to show that the obstruction is not seated at the larynx. The absence of the striking characters pertaining to the voice and cough, when the aperture of the glottis is diminished, whether it be from exudation or spasm, warrants the ex- clusion of croup, and also laryngismus. From the infrequency of cases of asthma in childhood, the disease is not expected, and hence, when it does occur, other affections more common in early life are suspected 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 mentioned, which are equally ap- plicable, the patient's sensations indicate correctly the seat of the obstruction. Difficulty of breathing, occurring in paroxysms, is incident, in cer- tain cases, to disease of heart, giving rise to what has been known by the name of cardiac asthma. The existence of heart disease may be positively ascertained by means of physical signs. It is true that dilatation of the heart occurs as a complication of asthma ; but under these circumstances the asthma is known to have existed for a long time, and is generally, if not always, associated with emphysema. The dyspnoea occasioned by embarrassment of the pulmonary circu- lation differs in several obvious particulars from that caused by ob- ASTHMA. 399 struction 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 praecordia, and a feeling of impending dis- solution. 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 paroxysmal dyspnoea, generally produces more or less habitual difficulty of breathing, or at least dyspnoea is frequently excited by slight causes, such as exercise, etc. Angina pectoris, which may involve intense dyspnoea, is attended by other symptoms so distinctive that it is not readily confounded with asthma. 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 paroxysmal 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 stationary period of the inflammatory condition of the membrane, and disappearing gradually in proportion as resolution of the bronchitis takes place. It is accompanied with more cough and expectoration than belong usually to pure asthma, and the matter 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 the emphysema is ascertained by means of its characteristic signs, which are hereafter to be consi- dered. 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, expectoration of mucus more or less modified, and substernal soreness. The respira- tions are more frequent. Great acceleration of the pulse is a dis- 400 DISEASES OF THE RESPIRATORY ORGANS. tinctive feature. The mucous and the sub-crepitant rales are dis- covered on auscultation. The dyspnoea and associated symptoms are persistent, increasing until the inflammation reaches its acme, and slowly diminishing as the inflammatory condition subsides, presenting thus, in its course, a striking contrast to an asthmatic paroxysm. In capillary bronchitis, as in ordinary bronchial inflammation combined with emphysema, the dyspnoea may present exacerbations which are due to spasm; but the spasm is only an incidental element of the affection, not, as in pure asthma, the primary, and in relation to the bronchial obstruction, the sole pathological condition. 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 momentary doubt, and, in such cases, the distinctive symptomatic characters, taken in connection with the absence of the physical evidence of other affec- tions giving rise to embarrassment of respiration, suffice for a prompt and positive discrimination. As already remarked, instances of simple, uncomplicated asthma are exceedingly rare. Disconnected from even catarrh (dry asthma), and consisting of pure spasm, the affection is to be classed among the curiosities of clinical experience. 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 affections is to be determined by the presence or absence of their diagnostic symptoms and signs. SUMMARY OF PHYSICAL SIGNS BELONGING TO ASTHMA. Clear percussion-resonance. Retraction of the base of the chest in front and the epigastrium in the act of inspiration. Vesicular murmur enfeebled or abolished. Sibilant and sonorous rales, with both respiratory acts, loud and diversified, extensively diffused over the chest. Moist rales, in some cases, at the close of the paroxysm. CHAPTER III. PNEUMONITIS—IMPERFECT 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 under three forms, viz., 1. Lobar pneumo- nitis, the ordinary form of the acute disease in the adult; 2. Lobular pneumonitis, a form peculiar to children; and 3. Chronic pneumo- nitis. This division is of practical importance, and each form claims separate consideration. Varieties based on other circumstances, such as the situation and extent of the inflammation, its occurrence as a primary, secondary, or intercurrent affection, etc., will be noticed in- cidentally so far as is consistent with the scope of this work. Under the head of Lobular Pneumonitis, I shall notice certain morbid con- ditions which have been hitherto generally considered to belong to that variety of the disease, and which, at present, are most conveni- ently arranged in the same nosological category, viz., imperfect ex- pansion of more or less of the pulmonary lobules after birth (atelecta- sis), and collapse. Acute Lobar Pneumonitis. The ordinary form of acute pneumonitis in the adult is called lobar, in contradistinction to lobular pneumonitis, the form peculiar to children. The appellation imports that the inflammation is diffused over an entire lobe of the lungs. This is true, at least in the vast majority of cases, provided the pneumonitis be primary. Secondary or intercurrent pneumonitis may be more circumscribed. Primary lobar pneumonitis is of frequent occurrence. Secondarily the disease is often associated with periodical, continued, eruptive, puerperal 26 402 diseases of the respiratory organs. and rheumatic fevers, and with purulent infection of the blood. It is developed also as a complication of croup, hooping-cough, acute affections of the heart, encephalon, etc. In these various pathological connections, the vital phenomena, or symptoms, are presented with additions and modifications which serve to enhance the importance of the physical signs in the diagnosis of the disease. Authors make several varieties of primary lobar pneumonitis, based mainly on semeiological distinctions. So far as relates to diag- nosis, it will suffice merely to enumerate the varieties generally re- cognized. If the phenomena of the disease indicate purely an acute inflamma- tion unattended by any unusual features, it is frequently styled frank pneumonitis. A better title is simple acute pneumonitis. Accompanied by a marked degree of prostration, and more espe- cially with passive or low delirium, it is called typhoid pneumonitis. Primitive pneumonitis may present these characters, but it is proba- ble that typhoid and typhous fevers, complicated with inflammation of the lungs, are sometimes confounded with pneumonitis presenting what are ordinarily known as typhoid symptoms. Occurring in combination with general bronchitis or catarrh, which is apt to be the case, more especially when the latter affections pre- vail epidemically, constituting influenza, the disease has been dis- tinguished as catarrhal pneumonitis. 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 application to cases complicated with icterus it has an obvious significance, which is less apparent when it is extended to cases in which the only evidence of disordered function of the liver are sallowness 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 peri- odical 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 remarkably latent; but under these circumstances it is rarely the case that the ACUTE LOBAR PNEUMONITIS. 403 existence of the disease may not be ascertained by means of the evidence derived from 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 in- flammation 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 inflammation extends over the whole of one lung. This might properly enough be con- sidered a variety of the disease, but it has no distinctive appellation. The foregoing varieties of pneumonitis, it will be observed, relate to the disease occurring as a primitive affection. It is developed, as already stated, in the course of numerous diseases. Occurring thus secondarily, it is often wanting in diagnostic symptoms, or they are masked by the phenomena of the disease of which it is a complication, so that without the aid of physical signs it would frequently escape detection. Following Laennec, pathologists agree in describing a series of anatomical changes in acute pneumonitis belonging to three different periods. The career of the disease is divided into stages correspond- ing to these periods, and each stage or period, during life is charac- terized by phenomena, vital and physical, which are more or less distinctive. The first period constitutes the stage of inflammatory engorgement; the second, the stage of solidification, or red hepatiza- tion ; the third, the suppurative period, stage of purulent infiltration, or gray hepatization. For a detailed description of the anatomical characters belonging to these different stages, the reader is referred to works which treat of the morbid anatomy of the affection. The essential anatomical characters which are particularly in- volved 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 vesicles, which are, as yet, not closed to the entrance of air; co-existing pleuritis. Second stage. Solidification in consequence 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 fibrin on the pleura, with more or less liquid effusion within the pleural sac. Third stage. Puriform fluid escaping from the cells into the bronchial tubes in greater or less abundance; persisting solidification ; 404 DISEASES OF THE RESPIRATORY ORGANS. in some cases formation of collections of puriform matter resulting in cavities. Physical Signs.—The several methods of exploration, with the single exception of succussion, may all furnish morbid phenomena in cases of lobar pneumonitis. The physical signs pertaining to the disease are therefore numerous; but it will be seen that as regards particular phenomena and their combinations, uniformity in the dif- ferent 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 much difficulty in the way of diagnosis, although it renders an acquaintance with the variations which are liable to occur, in a prac- tical point of view, highly important. The percussion-resonance, in the first stage, or stage of engorge- ment, may be diminished ; in other words, the sound over the affected lobe, compared with that elicited in corresponding points on the un- affected 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 ever 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 demonstrate the incorrectness of this opinion, are seldom offered. An instance has fallen under my observation, in which, owing to the disease 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, which has been already referred to,1 the limits of the affected lobe (the lower lobe of the right lung) were easily defined by dulness on percussion, toge- ther with the presence of the crepitant rale. In general, however, it is probably true that if the resonance be diminished, in a marked degree, it is to be predicated that the exudation of solid matter has occurred, a result which it is to be borne in mind may follow even 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 mea- sure of the amount of solidification. The vesicular resonance may, in fact, be abolished; but it is rarely the case that absolute flatness 1 Vide note, page 104. ACUTE LOBAR PNEUMONITIS. 405 exists. If a certain proportion of the air-vesicles of the affected lobe do not still contain air, the bronchial tubes are never completely filled with morbid products. The quantity of air which the latter contain is sufficient to prevent total extinction of sonorousness. In this respect the loss of resonance in cases of solidification differs from that which frequently attends large pleural effusions. In the latter the abolition of sonorousness, in other words absolute flatness, is much oftener observed. 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 corresponding situations on the healthy side of the chest. This sign exists in a marked degree in the second stage of pneumo- nitis, 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 deposit, and the completeness of the final restoration of the affected portion of the pulmonary organs. The acoustic phenomena elicited by percussion which have just been mentioned, 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 deposit, whatever sonorousness remains must, of course, be non-vesicular, 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 yet sufficiently appa- rent. In the second stage of pneumonitis, then, if there be not total extinction of sonorousness, in connection with a greater or less amount of dulness on percussion, a tympanitic resonance will be observed. In some instances the vesicular resonance is replaced by a strongly marked tympanitic sound. In intensity and clearness, the sonorous- ness over the solidified lung may even exceed the resonance on the 406 DISEASES OF THE RESPIRATORY ORGANS. unaffected side. Its non-vesicular character and highness of pitch are the more striking, contrasted with the normal resonance, in pro- portion to its intensity. The sense of resistance on percussion, or pressure, in addition to other circumstances, serves to distinguish the tympanitic resonance occurring over solidified lung, from that inci- dent to some cases of emphysema, and from all cases of pneumo-hydro- thorax, the thoracic parietes retaining their elasticity in the latter forms of disease. In cases of pneumonitis affecting the left lung, a tympanitic resonance may be due to distension of the stomach with gas. This source is often sufficiently evidenced by the gastric character of the sound, viz., notable 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 superior part the tympanitic reso- nance is lower in pitch and without any metallic tone; and a tympa- nitic 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 ; but it is observed over the superior and middle thirds 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 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 dull, but distinctly tympa- nitic and high in pitch. Over the middle third the pitch was con- siderably lower, but the tympanitic resonance 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, receiving by degrees the vesicular quality of sound, becoming vesiculotympa- nitic, and finally assuming the normal character. But in other in- stances marked variations are observed at the examinations repeated « ACUTE LOBAR PNEUMONITIS. 407 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 the change from a marked degree of tympanitic sonorousness to great dulness, to occur within the space of an hour. Without designing to discuss the subject of the rationale of the phenomenon under consideration, I will simply remark that these fluctuations, except when the sound is of gastric or intestinal origin, point to the bronchial tubes as the source of the tympanitic resonance in cases of solidification. The varying condition of the tubes as respects the accumulation of mucus or other morbid products, will perhaps account 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 same explanation. In cases of pneumonitis affecting the lower lobe, the percussion- resonance over the unaffected lobe on the same side is frequently, if not generally, modified. The sonorousness is greater than in corre- sponding situations on the opposite side ; it is higher in pitch, and is vesiculo-tympanitic in quality. These characters are more marked on the anterior surface of the chest, but they may also be apparent posteriorly in the upper scapular region. On the side free from dis- ease the resonance is usually strongly marked, and highly vesicular. By means of percussion the limits of the inflammation may gene- rally be defined without difficulty. The change from the vesicular or a vesiculo-tympanitic resonance, to dulness or a non-vesicular sono- rousness, is generally abrupt, and the line of demarcation between the healthy and solidified lung is easily traced on the chest. In view of the fact that lobar pneumonitis extends 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, as a rule, 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, ex- tends obliquely upward and outward, from between the fifth and sixth ribs, in a direction toward the vertebral extremity of the spinous ridge of the scapula,—this being the situation 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 cartilage. This is a point not 408 DISEASES OF THE RESPIRATORY ORGANS. only of interest, but one which may be in some instances of impor- tance in diagnosis. In the absence of the auscultatory phenomena distinctive of solidification of lung, which, although generally present, may yet 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 circumstances, 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. With the resolution of the inflammation, 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 lessen materially in twenty-four hours. It is, however, a long time before complete equality in the resonance of the two sides is restored; a marked disparity may exist for months after the patient has appa- rently recovered perfect health ; and it is probable that in some in- stances the symmetry of the two sides as respects percussion-reso- nance is never fully regained. Auscultation, in most cases of pneumonitis, furnishes numerous and important signs. As the inflammation does not invade simultaneously the whole of a lobe, but, commencing at one or more points, ad- vances 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 cen- trally situated. The healthy parenchyma surrounding the portion inflamed, presents the phenomena originating in the latter from reaching the ear. Under these circumstances, according to Fournet, the existence of pneumonitis, taking into account the symptoms, may sometimes be predicated 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 abnormally 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 oftener to diminish its activity, giving rise to an abnor- mally weak respiration. Both these statements, although they may ACUTE LOBAR PNEUMONITIS. 409 at first appear to be contradictory, are correct; in other words, the respiratory sound in the immediate vicinity of an inflamed portion may be either exaggerated or weakened. The opportunity of ob- serving 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, which shortly make their appearance, showing that the inflammation has extended from its central situation to the surface. The oppor- tunity 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 cases, both exaggerated and weakened respiration; and in the same case I have observed on two successive days, in the same situation, first exaggerated, and next weakened respiration. In some instances, while the area of the in- flamed lung is limited, especially if it be situated near the surface, a broncho-vesicular respiration precedes the appearance of other signs. The earliest and most characteristic of the positive signs of pneu- monitis in most instances, is the crepitant rale. This sign is incident to physical conditions belonging to the primary local effects of in- flammation, and is heard when the inflamed portion is sufficiently large, and near enough to the surface for the sound to be transmitted. Contrary to the opinion of Skoda, it is present in a very large ma- jority 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 was made, and in all at a period more or less remote from the commencement of the disease. It is probable that examinations re- peated, and 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 absence in sixty-four. The collec- tion of cases analyzed did not embrace cases of lobar pneumonitis occurring in infancy. My observations lead me to concur with others in the opinion that the crepitant rale is much less constantly present in children than in adults. It is perhaps oftener absent than present in infant life. The constancy of the rale in acute primitive pneu- monia, affecting the adult, is shown by the much more extensive re- searches of Grisolle. This author, in his treatise on pneumonia, based 410 DISEASES OF THE RESPIRATORY ORGANS. 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 dif- ferences as respects its abundance, loudness, proximity or remoteness, 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 instances it exists in a marked degree, occupying the whole or the greater part of the inspiratory act, in other instances being com- paratively faint, and heard only at the end of inspiration. In some instances, even during this stage, it is not discovered in ordinary re- spirations, but is developed by forced breathing, and especially by the deep inspirations which precede and follow an act of coughing. In a small proportion of cases the methods just named fail to produce it, and the diagnosis must be based on other signs. It may be de- tected in the majority of cases, for a greater or less period, after the disease has advanced to the second stage. It is then, generally, con- fined to the end of the inspiratory act, and much more frequently re- quires for its production that the force of the act be voluntarily 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 apparently origi- nates 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 period of resolution. This must be ranked among the instances (singu- larly 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 very often meet with disappointment. The crepitant rale, as just stated, may continue through the whole course of the disease. It may dis- appear and reappear at irregular intervals. I have known it to be- ACUTE LOBAR PNEUMONITIS. 411 come more marked after the lapse of several days than at an early period in the disease. I have even 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 harbin- ger of recovery, cannot with propriety be said to constitute a portion of 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 limited to the inspiratory act,—may occur at any period of the disease. Present on both sides of the chest, in the early stage, and diffused especially over the posterior base, it denotes the coexistence of capillary bronchitis. The two rales may be combined and distinguished from each other, the crepitant appearing at the end of the inspiration, and the sub-crepitant in both acts. This I have observed in a case to which reference was made in treating of the crepitant rale in Part I. Ex- clusive of the very rare instances in which pneumonitis and capillary bronchitis are associated, the sub-crepitant rale is much more likely to occur at a late period in the disease, during the progress of reso- lution. Developed under these circumstances it is, in fact, the re- turning crepitant rale of Laennec. But its appearance is by no means constant. Indeed it is wanting in a large proportion of cases. The other bronchial rales, both moist and dry, are all liable to occur in cases of pneumonitis. Since, however, as a general remark, they imply the coexistence of bronchitis, which, save in a limited ex- tent, is only an occasional complication, the occurrence of the sibi- lant, sonorous, and mucous rales, as prominent physical phenomena, being limited to a small proportion of cases only, is in accordance with the pathological laws of the disease. Clinical observations show that these rales are far from being common in cases of pneumonitis. In the majority of cases, examinations, repeated at different periods, do not show their existence, except occasionally, as transient phe- nomena. 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, irrespec- tive of the sub-crepitant, in ordinary cases of pneumonitis, is shown 412 DISEASES OF THE RESPIRATORY ORGANS. 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 extremely 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 phenomena. The modifications constituting the bronchial and the broncho-vesicular respiration, very rarely fail in being deve- loped during the course of the disease. The bronchial respiration is absent in but an exceedingly 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 remaining 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 patient died on the second day in the stage of engorgement, the disease being complicated with dilata- tion of the heart. In the large collection of cases analyzed by Grisolle (373), the bronchial respiration 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 which the inflammation was limited to a single lobe, it was wanting in nine.1 The bronchial respiration is a sign of soli- dification. In connection with percussion it affords evidence of the progress of the disease to the second stage. It denotes the continu- ance of the solidified state of the lung, indicating by its gradual dis- appearance the removal of the solid exudation. Other things being equal, its intensity is probably in proportion to the completeness of the solidification. As regards 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 twenty-four 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 have an 1 Op. cit. ACUTE LOBAR PNEUMONITIS. 413 opportunity of watching its development, we may observe that the transition from the vesicular murmur is not abrupt, but takes place gradually, the broncho-vesicular modification 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 tubu- lar or blowing. In some instances the presence of the crepitant rale prevents us from appreciating a wrell-marked alteration affecting 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 maxi- mum, as respects intensity and completeness; continues without much diminution or alteration for a certain period, and gradually becomes less intense and complete, at length merging into the bron- cho-vesicular respiration. The bronchial respiration in acute lobar pneumonitis, is 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, however, occa- sional 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 expected to be present, rarely occurs in ordinary cases of pneumonitis. During the progress of the disease in 40 cases, the bronchial respiration 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 certain of its cha- racters, 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 (occasionally metallic) inspiration, followed, after an interval, by an expiration, prolonged, more intense, and higher in pitch (oftener metallic) than the sound of inspiration. Of 27 cases, in the records of which the bronchial respiration is described as re- spects 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 414 DISEASES OF THE RESPIRATORY ORGANS. 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 examina- tions a tubular inspiratory sound, without a sound of expiration, existed in 11, and an expiratory, without an inspiratory sound, in 10. In six of the latter 10 instances, however, 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 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 rarely, however, if ever, the case, that in connection with 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 vesiculo-bronchial respiration, the change is frequently, if not generally, 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 normal murmur. The transition from an intense bronchial to a broncho-vesicular respiration, like that of the percussion-sound from marked to mode- rate 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, often continues broncho-vesicular. When the characters of ACUTE LOBAR PNEUMONITIS. 415 the bronchial and the broncho-vesicular respiration have nearly or quite disappeared, the respiratory sound over the affected lung is often abnormally feeble, being sometimes scarcely appreciable except the breathing be forced. Fournet states that the bronchial respiration is apt to be succeeded in the affected portion of lung by an exag- gerated vesicular murmur. Judging from the cases that I have ob- served, I should say that the rule is directly the reverse. With re- spect to this point, the following are the observations of Grisolle :— Of 103 convalescents discharged from hospital, between the twentieth and fifty-fifth days of the disease, 37 had no morbid signs; in 36 the respiration was weak ; in 14 the respiration was slightly blowing; and in 16 there existed sub-crepitant or other bronchial rales.1 In the majority of cases of pneumonitis the disease being limited to the lower lobe of one lung, the abnormal modifications of the respi- ratory sounds, as well as other physical phenomena, are to be sought for especially on the posterior surface of the chest below the spinous rido-e of the scapula. They are also manifested on the lateral surface below a diagonal line corresponding to the interlobar fissure. Ante- riorly the bronchial respiration, and also the crepitant rale, may be discovered at the base of the chest, but it not infrequently 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 by passing 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 indicating the situation of the inter- lobar fissure have been already traced by the change in the percus- sion-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 affected, the different lobes being attacked in succession, the bronchial respiration will present differences as respects intensity, and other characters, in different situations. On the right side in front, I have observed a striking disparity in 1 Walshe, op. cit. 416 DISEASES OF THE RESPIRATORY ORGANS. 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 accordance 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 middle thirds in front. It will be found frequently, if not generally, to continue longer in the lower scapular, than in the infra-scapular region; but this is probably owing to the proximity in the former region to the larger bronchial tubes. 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, accord- ing 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 ex- tremely feeble, almost null, so that conjoined with a tympanitic per- cussion-resonance, the physical evidences of emphysema are present.1 I have, however, observed an exaggerated 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 phenomena 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 ob- served in 25, and not discovered in two. By bronchophony, it will be borne in mind, I do not mean simply exaggerated vocal resonance, but a greater or less apparent approach of the voice to the ear of the auscultator. In the great majority of instances this increased proximity of the voice is accompanied by an abnormal resonance or reverberation, but not invariably. It is not very infrequently the case that the approach of the voice and the reverberation do not corre- spond, as respects relative intensity. The voice sometimes seems very near the ear when the resonance is but little exaggerated; and, 1 In Part I, 1 have suggested the inquiry whether an emphysematous condition may not serve to account for the vesiculo-tympanitic resonance which so frequently exists over the upper lobe when the lower is solidified. ACUTE LOBAR PNEUMONITIS. 417 on the other hand, the resonance may be intense while the voice re- mains as distant as in the normal condition. An increased vibration or thrill is frequently felt by the ear applied either directly to the chest, or to the stethoscope. The latter may or may not accompany the bronchophony and vocal resonance, and it is sometimes present when the other vocal phenomena are wanting. In intensity there is not a uniform correspondence between it and the vocal transmission and resonance, more than exists between the tAvo latter. The vibration or thrill, indeed, may be greater on the unaffected side of the chest in pneumonitis, when bronchophony and increased reverberation are marked over the solidified lung. 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 approximation appreciable only by a careful comparison of the two sides of the chest, every grade of intensity may be observed in different cases, and sometimes in a series of successive examinations in the same case. When the bronchophony has a marked intensity, or, in other words, is strong, the vocal sound in some instances appears to strike the ear with a certain 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. It acquires sometimes a metallic tone. Other things being equal, the maximum of the degree of intensity to which either bronchophony or exaggerated vocal resonance attains, in the progress of pneumonitis, denotes the greatest amount of solidi- fication. It coexists, therefore, with the greatest loss of vesicular resonance on percussion, and with the maximum of intensity of the bronchial respiration. As the disease pursues its course, these vocal phenomena reach their maximum by degrees, and gradually become weaker as the solidification decreases in the progress of resolution. In this retrograde course, when bronchophony and exaggerated reso- nance are associated, the former disappears first, the latter continu- ing to be more or less marked for a period varying considerably in different cases. With respect to the vocal, as well as the respiratory phenomena indicative of solidification, often a marked diminution is observed to occur within a short space of time, and occasionally they disappear rather abruptly. The duration of the vocal signs in different cases of pneumonitis is variable. Of 88 examinations, made on different days in 27 cases, 21 418 DISEASES OF THE RESPIRATORY ORGANS. 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 existed, but disappeared. When, however, it is once developed, it is a persistent sign until it disappears as the consequence of the progress in resolution; that is, it is generally found at each successive examination. This statement is in opposi- tion to the opinion of Skoda, who maintains that the bronchophonic voice is constantly fluctuating, sometimes even appearing and disap- pearing 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 instances was the sign absent when its existence was noted at the examination pre- ceding, and also 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 at different points over the affected lobe or lobes. Its highest 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. Posteriorly, when the lower lobe is affected, it is generally more marked over the lower scapular, than in the infra-scapular region. Well-marked bronchophony may exist over the larger bronchial tubes, while at a little distance the vocal resonance is simply exaggerated. It is not uncommon to find bron- chophony over the scapula, and exaggerated resonance below the scapula. By means of an abrupt change in the vocal phenomena, limiting by the use of the stethoscope the space from which the sounds are 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 percussion and the respiratory sounds, in the manner already described; and when this has been done by means of the two latter phenomena, the auscultation of the voice furnishes another method of verification. The transmission of the articulated voice or speech, in other words pectoriloquy, is a physical sign occasionally observed in cases of solidification from pneumonic inflammation. In 2 of 27 cases words (numerals) spoken aloud were transmitted. In 2 other cases whis- pering pectoriloquy was complete, and in several instances whispered words were imperfectly transmitted. Contrary to the opinion of Walshe, who regards whispering pectoriloquy as eminently distinctive of a cavity, I have found it oftener present in connection with solidifi- cation than the transmission of words spoken aloud. ACUTE LOBAR PNEUMONITIS. 419 When whispered words are not transmitted, a souffle, or puff is generally produced over solidified lung, which claims the attention of the auscultator. Under certain circumstances in pneumonitis, and other affections involving solidification, e. g. tubercle, it constitutes a valuable physical sign, its significance being the same as broncho- phony and the bronchial respiration. It is valuable, not only as con- firmatory of the fact of solidification, associated with the signs just named, but still more because it may be developed in some instances in which they are wanting. The souffle or puff, accompanying the act of whispering, and heard over solidified lung, is more intense than that over healthy lung in corresponding situations on the opposite side of the chest, and acute or higher in pitch. The contrast is as striking as between a vesicular and a well-marked bronchial respira- tory sound. In some cases it is distinctly marked over a portion of lung solidified, and no sound is developed over a corresponding situa- tion on the healthy side. Owing to the small number of instances in which the bronchial respiration and bronchophony are absent in ordi- nary pneumonitis, this vocal sign is of less diagnostic importance than in other affections in which other phenomena denoting abnormal density of lung are less commonly present. In some cases of pneumonitis, it is stated, the voice in passing through the chest acquires the aegophonic characters, viz., tremulous- ness and acuteness of pitch. Some observers, indeed, profess to have discovered strongly marked aegophony in pneumonitis; and it is claimed that this vocal sign may occur in cases in which there is no pleuritic effusion. The latter point it is difficult to establish, since, if in fatal cases, no liquid is found, it may have existed during life and been absorbed. I have never met with a well-marked bleating into- nation of the voice in pneumonitis; but the elevation of pitch has in several instances attracted my attention. 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 well marked. It is more marked if the breathing be labored, or voluntarily forced. 420 DISEASES OF THE RESPIRATORY ORGANS. Under these circumstances the three types of breathing may be con- spicuous 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 health. The disparity under these circumstances is increased by 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 autho- rity1 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 conse- quence of the removal of the solidifying deposit, and the contraction of the plastic exudation on the surface. With regard to mensuration, my recorded observations do not fur- nish sufficient data to serve as the basis of any conclusions. Walshe states that in ajninority of cases he has found positive, though slight, increase of size at the base of the chest on the affected 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. On this question an opinion has just been expressed. Finally, palpation furnishes physical phenomena in different cases of pneumonitis, somewhat contradictory. As a rule, the vocal fre- mitus 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 1 Woillez, Grisolle. ACUTE LOBAR PNEUMONITIS. 421 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 naturally it is frequently 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 pneumonitis was seated on the right lung. This shows that an effect of solidification, under certain circumstances, is a diminution of the natural fremitus. Instances of this description are, however, it is probable, extremely rare. 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 is 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 infe- rior 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 prac- titioner. Of these phenomena the characteristic expectoration and the physical sign may be said to be pathognomonic. A viscid expec- toration, containing a variable quantity of blood in intimate combina- tion, is a symptom belonging exclusively to inflammation of the pul- monary parenchyma. If this statement be not correct in the most rigorous sense, it may at all events be practically so regarded.1 So with regard to the crepitant rale, if we are sure of its presence, that 1 According to the observations of Dr. Remak, of Berlin, if the sputa from a patient affected 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. Remak 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. 422 DISEASES OF THE RESPIRATORY ORGANS. is, if the characters which distinguish it from other rales are clearly made out, and it occurs in the situation and in connection 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. 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 discoverable. 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 pneumonic inflammation, 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 is somewhat changed, presenting the characters of the broncho-vesicular modification, these physical phenomena, although not intrinsically significant of pneumonitis, taken in connection with the associated circumstances, render it probable that inflammation exists, but as yet confined to a portion of the lobe. On repeating the examinations, a crepitant rale is at length satisfactorily made out, and the fact of pneumonic inflammation is then established. The characteristic expectoration, however, is by no means uniformly present in cases of pneumonitis, and if not altogether absent, 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 incident to the second stage of the disease become developed. This delay is much oftener requisite in cases of lobar pneumonitis affecting children. In children the expectoration is generally swallowed, and hence its diagnostic cha- racters are unavailable. The crepitant rale is also frequently want- ing. Adding to these circumstances the difficulty frequently expe- rienced 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 insufficient until the signs of solidification are apparent. ACUTE LOBAR PNEUMONITIS. 423 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 continue, but frequently be- come less marked. The added symptoms and signs pertain chiefly to the solidified condition of the lung. The function of haematosis being compromised in a greater degree, the respirations are accele- rated, cceteris paribus, in proportion to the completeness of the solidi- fication and the extent of the pulmonary organs involved. The alae nasi dilate, and there may be lividity of the prolabia and face. The cheeks often present a circumscribed flush. The acceleration of the breathing is out of proportion to the frequency of the pulse. The physical evidences of solidification are easily ascertained. On per- cussion, 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 relations of the inferior lobe to the anterior and posterior surfaces of the chest. So small a portion extends in front, that in many, if not most instances, physical exami- nation anteriorly is comparatively 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 sur- face of the chest obliquely, and its situation is generally determinable by the abrupt change in the percussion-sound. The fact of a line indicating the limits of dulness on the lateral surface of the chest, corresponding in direction with the interlobar fissure and not varying with the position of the patient, is a diagnostic feature in itself almost conclusive. Assuming the inferior lobe to be the seat of solidifica- tion, in the lower scapular and infra-scapular regions, 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. Bronchophony or exaggerated vocal resonance is present also, with few exceptions; also the bronchial souffle or high-pitched puff with whispered words. In the larger proportion of instances, at least in adults, the evidence afforded by auscultation of the respira- tion and voice is corroborated by an increased vocal fremitus. If the upper lobe be primarily the seat of the inflammation, the physical phe- nomena will, of course, be manifested within its limits, viz., in front above the fourth rib, behind in the upper scapular region, and later- ally above the interlobar fissure. The occurrence of highly marked 424 DISEASES OF THE RESPIRATORY ORGANS. tympanitic or tubular percussion-resonance over solidified lung, espe- cially anteriorly when the superior lobe is affected, is a point not to be forgotten. It is superfluous to add that if the inflammation ex- tend beyond the lobe primarily attacked, an event occurring at a period more or less remote from the date of the attack, the local phenomena will be reproduced over the lobe or lobes which are suc- cessively affected. Of the signs which enter into the physical diagnosis of pneumonitis 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 acute vocal souffle, 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 observed, together with the antecedent and concomitant symptoms, suffice for the discrimination of the solidification which arises from lobar pneu- monitis. 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 considered. It remains to devote a few remarks to the diagnostic characters which belong to the third or purulent stage. The transition to this stage, in the rare instances in which it occurs, is not, like that of the first to the second stage, signalized by the development 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 may be inferred after a protracted duration of the dis- ease, when the evidences of resolution of the disease fail to occur, and the symptoms denote an unfavorable termination, not directly in con- sequence of the extent to which haematosis is compromised (for death thus produced takes place in the second stage), but as the result of asthenia and apnoea combined. A symptom which has a positive bearing on this question, is an abundant puriform expectoration, sometimes taking place rapidly like the discharge from a ruptured abscess, and occasionally emitting a fetid odor. A physical sign possessing considerable significance is the occurrence of abundant moist bronchial rales, at a late period, not preceded by general bron- chitis coexisting with the pneumonitis, the dulness on percussion re- maining undiminished, the bronchial respiration and voice becoming ACUTE LOBAR PNEUMONITIS. 425 less marked, these circumstances being taken in connection with symptoms denoting a fatal tendency, viz., prostration, 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.1 Do excavations thus formed give 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. Judging from the physical conditions in- cident to the formation of cavities under these circumstances, and from the testimony of experienced observers, the physical signs occa- sionally indicating excavations otherwise formed, and which will be noticed more especially in connection with tuberculous disease, are to be deemed possible, but by no means of probable occurrence. 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, recog- nized the presence of abscess by the aid of auscultation or percussion. In every case, the abscess, though communicating with the bronchial tubes, was filled with pus or sanies."2 The progress of the resolution of pneumonitis is indicated by dimi- nution of the dulness together with the sense of resistance felt on percussion; decrease of the intensity of the bronchial respiration, which, becoming first broncho-vesicular, gradually assumes the normal characters ; cessation of bronchophony, and the return to the normal vocal resonance; disappearance of an undue vocal fremitus,—these changes in the physical phenomena associated, of course, and gene- rally succeeding rather than anticipating a marked improvement in the cough, respiration, etc. Facts relating to this point have entered into the consideration of the physical signs furnished by the different methods of exploration in this disease. Pneumonitis, so far as symptoms are concerned, is sometimes re- markably latent. Expectoration, cough, pain, may all be wanting, and the respiration be but little increased in frequency. The dis- ease fails to present its usual symptomatic phenomena when it is con- secutive, much oftener than when primary; as when it is developed 1 Of 750 cases treated in the great Hospital of Vienna, from 1847 to 1850, pulmonary abscess was observed in but a single instance. 2 Op. cit. Am. edition, page 311. 426 DISEASES OF THE RESPIRATORY ORGANS. in the course of fevers, purulent infection of the blood, etc. Under these circumstances the diagnosis is to be based almost exclusively on the physical signs. But as regards the latter, the disease may 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 respiration, bronchophony and exaggerated vocal resonance, and fremitus. The solidification which occurs in the latter stage of fevers and other affections, and characterized by the absence of the usual 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 wanting, 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. Inasmuch, however, as lobar solidification may take place irrespective of inflammation (from oedema), the existence of pneumonitis notwithstanding this evidence might be questionable. Fortunately a clinical problem so intricate as that just supposed, although within the limits of possibility, is re- moved far beyond the boundaries of the probable. The different affections from which pneumonitis is practically to be discriminated, are acute ordinary bronchitis, capillary bronchitis, acute pleuritis, dilatation of the bronchiae, acute phthisis, and pulmo- nary 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 ordinary bron- chitis ; but guided exclusively by symptoms, the discrimination is not always easy, and in some cases it is impracticable. Moreover, the two affections may be conjoined, and under these circumstances 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 contrast in several promi- nent symptoms. The pain in pneumonitis is sharp, lancinating, and generally referred to the vicinity of the nipple. In bronchitis, if pain be present, it is dull, contusive, and situated beneath the ster- num. The expectoration in bronchitis rarely contains blood, and, when present, it is in the form of bloody points or streaks. In pneu- monitis bloody expectoration is common, and the blood is intimately ACUTE LOBAR PNEUMONITIS. 427 mixed with viscid mucus, giving rise to the characteristic rusty sputa. The febrile movement in cases of acute pneumonitis is generally in- tense, while in ordinary bronchitis, however acute, it is only moderate. More or less acceleration of the breathing generally characterizes cases of pneumonitis, and occurs only occasionally in ordinary bron- chitis. 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 gene- ral bronchitis. When observed in cases of pneumonitis not associated with general bronchitis, they are limited to one side of the chest, save in the very rare instances of double pneumonitis; but in bronchitis they are found on both sides. The chest in cases of bronchitis every- where preserves its normal sonorousness on percussion, which, in- deed, may be abnormally increased. In pneumonitis, on the other hand, soon after the access of the disease, marked dulness, with in- creased sense of resistance, is found to exist over a space correspond- ing in size and situation to one of the pulmonary lobes. Broncho- phony, exaggerated vocal resonance and fremitus, and the acute bronchial souffle, with whispered words, 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 suffi- cient for the differential diagnosis. Capillary bronchitis is accom- panied by greater embarrassment of respiration and suffering from defective haematosis, than obtain in pneumonitis. The acceleration of the pulse is greater. The rusty sputa are wanting; blood, if present, existing in streaks. Reliance, however, must be placed chiefly on the physical signs. The percussion-resonance in capillary bronchitis generally remains unaffected, and may be abnormally in- creased. If dulness occur, it arises from collapsed lobules, and is not found to extend over a space corresponding to an entire lobe. Auscultation discloses a sub-crepitant rale, succeeding or coexisting with the sibilant rale, and existing on both sides of the chest over the posterior surface. 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, 428 DISEASES OF THE RESPIRATORY ORGANS. which have been fully pointed out, suffice for their discrimination from each other. Finally, in capillary, as in ordinary acute bron- chitis, bronchial respiration, bronchophony, increased vocal resonance, and the acute bronchial souffle with whispered words, are wanting. The diagnostic features of acute pleurisy 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 a con- siderable quantity of liquid effusion within the pleural sac. The physical signs denoting the presence of fluid in the chest, together with the absence of the crepitant rale and the phenomena denoting a marked degree of pulmonary solidification, establish the differential diagnosis. Moreover, in pleurisy the febrile movement is less intense than in acute pneumonitis; cough and expectoration are frequently slight or altogether absent; the rusty sputa are wanting, and the matter of the expectoration, unless bronchitis be associated, is unal- tered mucus. It is not very uncommon for practitioners possessing an imperfect knowledge of the principles and practice of physical exploration, to mistake pneumonitis for pleurisy, and vice versa. Due acquaintance with the circumstances involved in distinguishing pulmonary solidification from liquid effusion, will obviate the liability to this error. The points of distinction between these two morbid conditions have been already considered, and will be recapitulated in connection with the subject of pleurisy. Dilatation of the bronchia, in connection with an attack of acute bronchitis, gives rise to certain of the physical signs present in pneu- monitis, viz., bronchial respiration and bronchophony or exaggerated vocal resonance, together with dulness on percussion. The symp- toms 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 history and present phenomena, in such a case, will show that chronic cough and expectoration 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 interlobar 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 physical phenomena Btill persisting, owing to the permanency of the lesion. Dilatation of ACUTE LOBAR PNEUMONITIS. 429 the bronchiae is an affection of such rare occurrence, 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 respi- ration, bronchophony or exaggerated vocal resonance, 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 suggest at once the idea of tuberculosis. Careful and con- tinued investigation, however, will lead to the discovery of certain of the positive features of phthisis, and at the same time authorize the exclusion 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 in- vaded, and its boundary line determined by means of percussion and auscultation to be in the situation of the interlobar fissure. Hemor- rhage will be likely to occur in connection with tuberculous disease, and not in pneumonitis, except in so far as it enters into the produc- tion of the rusty sputa. The lancinating pains in phthisis are gene- rally referred to the summit of the chest, or 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 symptomatic of an acute local inflammation. In the former the pulse is often very frequent, vibra- tory or thrilling, denoting irritability rather than increased force in the ventricular contraction. In the latter it 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, notwithstanding the greater frequency of the pulse, and with an equal, if not greater disturbance of the respiration than ordi- narily attends pneumonitis, does not yield to the disease and take to 430 DISEASES OF THE RESPIRATORY ORGANS. the bed, as when attacked with 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 laws of the disease, takes place first at the base of the lung, and gradually extends upward. This anomalous form of tuberculous development, according to the obser- vations of Dr. H. I. Bowditch, occurs in a ratio of 1 to from 150 or 200 cases.1 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 pnumonitis exists, and the presence of certain of the traits significant of phthisis, point to the nature of the disease. With the physical signs just mentioned, patients preserve strength sufficient 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 some- times observed. Acute symptoms are by no means uniformly present in this variety of tuberculous disease. The crepitant rale is persis- tent, 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 correc- tion of an error in diagnosis, liable to arise from inadvertency or a premature conclusion. CEdema 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, broncho- phony or exaggerated vocal resonance, and fremitus. These auscul- tatory phenomena, however, are rarely marked, and often absent. A well-marked crepitant rale is sometimes observed, but the sub-crepi- tant is much oftener present. (Edema occurring always as a secon- 1 Cases of anomalous development of tubercles, etc., by Henry I. Bowditch. Ameri- can Medical Monthly, N. Y. 1855. ACUTE LOBAR PNEUMONITIS. 431 dary affection, 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 the symptoms of acute pneumonitis. Moreover, the causes producing the oedema acting equally on both lungs, the local evidences of the solidification in a certain proportion of cases, although not generally, are found on each side of the chest. An oedematous 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 BELONGING 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 affected lobe; the vesicular resonance often replaced by a tympanitic sonorousness, more or less marked ; the crepitant rale generally dis- covered by auscultation, accompanied or followed by the broncho- vesicular and the bronchial respiration; bronchophony and exagge- rated vocal resonance generally present; increased vocal fremitus over the solidified lung existing in a large proportion of cases, occa- sionally pectoriloquy ; an acute souffle, frequently intense, accompa- nying whispered words ; sub-crepitant 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 infiltration, 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 ; dimi- nished 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. 432 DISEASES OF THE RESPIRATORY ORGANS. Lobular Pneumonitis. Lobular Pneumonitis ; Broncho-Pneumonia; Imperfect Ex- pansion (atelectasis) and Collapse of Pulmonary Lobules.— The term lobular when properly applied to cases of pneumonitis, implies that the inflammation, instead of extending over an entire lobe, is more circumscribed, being confined to lobules, either isolated or in clusters, situated at different points, more or less numerous, and disseminated usually over the pulmonary organs, on both sides of the chest. It is only within a few years that the attention of patho- logists has been directed to the study of such a form of the disease. It was first fully described as a distinct variety of pneumonitis, occurring in children under six years of age, in this country by Dr. Gerhard,1 and in France by Dr. Rufz,2 Rilliet and Barthez,3 Valleix,4 and others. As described by the writers just mentioned, lobular pneumonitis embraces all cases in which, after death, the lungs are found to present solidified portions (exclusive of solidifications from tubercle or other heteromorphous deposits), 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 affection is often called broncho-pneumonia, a term first applied, in 1837, by a German author, Seifert. Researches still more recent have shed new light on the morbid anatomy and the pathology of affections heretofore, and still to a greater or less extent, included under the appellation of lobular pneumonitis and broncho-pneumonia. In 1832, Prof. Jorg, of Leip- sic, published an account of a morbid condition found in the bodies of newly born children, analogous to that regarded 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 title of atelectasis. This condition had been previously described by a French writer, M. Duge's, in 1821, in a thesis which failed to attract attention to the subject. The anato- 1 Am. Jour, of Med. Sciences, 1834. 2 Journ. des Conn. Me"dico-chirurg. 1835. s Traite des Maladies des Enfans. 4 Traite des Maladies des Enfans nouv. nes, 1833. LOBULAR PNEUMONITIS. 433 mical characters regarded as distinctive of a persisting foetal condition, are as follows:—the solidified lobules giving rise to depressions on the surface of the lung; the pleural covering retaining its glistening polished aspect; the size of the lobules affected, and the lobe in which they are found not augmented, but diminished; the cut sur- faces, when the solidified lobules are incised, wanting a granular appearance, 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 condition called by him atelectasis, was, that by insufflation the condensed lobules were found to be capable of being brought to a normal condition.1 Still more recently, the researches of MM. 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 removed 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 distinguished 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 insuffla- tion. The authors just named first suggested this simple test of the 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 Jbrg in cases of supposed atelectasis.2 The distinctive appearances of the parts in the one case preserving, 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 morbid 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 peculiar to early life. The investigations of Jorg, and Legendre and Bailly, tend to the conclusion that the cases of so-called lobular pneu- monitis, in which the lobules are in the foetal state, or carnified, 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 atelec- tasis. 2 Archives Gene'rales de M^decine, 1S48. 28 434 DISEASES OF THE RESPIRATORY ORGANS. do not involve the existence of inflammation of the air-cells or paren- chyma, and that they are not properly cases of pneumonitis. This subject at the present moment is one of the most interesting, and perhaps one of the most important of those with which patholo- gical inquirers are occupied. Dr. Fuchs of Leipsic, and Dr. W. T. Gairdner of Edinburgh, have published facts tending to show that condensation of more or less of the pulmonary 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 pro- ducts ; and in proportion as so-called lobular pneumonitis consists of cases of solidification thus produced, the lesion is, in fact, incident to bronchitis, and is not rightly called either lobular pneumonitis, or broncho-pneumonia. As a complication of bronchial inflammation, lobular collapse has been already referred to in connection with the consideration of bronchitis. The researches of Dr. Gairdner render it probable that collapse of portions of the lung is by no means an event exclusively pertaining to early life, and that bronchial obstruc- tion sustains an important pathological connection with an affection to be next considered (emphysema). It is, however, entirely foreign to the plan of this work to engage in inquiries or discussions relative to questions which concern the aetiology of the diseases affecting the respiratory organs, 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 recent scientific developments pertaining to lobular pneumonitis, has seemed to be requisite for a proper understanding of the affections which are to be included under this caption. In the existing state of pathological views, I do not deem it advisable to treat, in this work, of atelectasis, collapse of the lung, and true lobular pneumonitis, under separate heads. I shall notice them, severally, as falling within the division of pneumonitis, entitled lobular, wishing it, however, to be fully understood, that this course is adopted for the sake of convenience, and, it may be added, expe- diency, in view of the importance of further investigations as the basis of settled nosological distinctions.1 1 The reader desirous of becoming acquainted with recent views and researches relating to the different morbid conditions heretofore included under the appellation lobular pneumonitis, may consult with advantage, in addition to the publications already cited, Hasse's Path. Anat.; West on the Diseases of Children ; Review of Dr. Gairdner in the Brit, and For. Med. Chir. Review, April, 1853, and a publication by the same author, entitled " On the Pathological Anatomy of Bronchitis, and the Diseases of the Lung connected with Bronchial Obstruction," Edinburgh, 1850. LOBULAR PNEUMONITIS. 435 Collapse and true lobular pneumonitis, although peculiarly infan- tile affections, are by no means exclusively confined to early life. Collapse, it is probable, may take place at any age, and according to the observations of MM. Hourmann and Dechambre,1 it occurs not infrequently in the aged. On the other hand, the pneumonitis occurring secondarily in cases of purulent infection of the blood, may be said to be lobular. 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 expansion. A judgment, however, may be formed, to some extent, of an abnor- mal 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 auscultation. The force of the respiratory movements is probably inadequate, in most in- stances, to develope the bronchial or even a well-marked broncho- vesicular respiration, the existence of which in view of the solidifica- tion, might be rationally anticipated. Over the non-solidified portions of lung, the vesicular murmur, instead of being supplementarily ex- aggerated, 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 respi- ration. Inspection shows the visible movements 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, from the outward pressure of the atmosphere, upon the condensed lung. With these signs, taken in connection with the symptoms which have been mentioned, the diagnosis of imperfect expansion or atelec- tasis may be made with much positiveness. 1 Archives G6n6rales de M6decine, 1835 and 1S3C. 436 DISEASES OF THE RESPIRATORY ORGANS. In cases of lobular condensation from collapse, if it be sufficient in extent to give rise to considerable embarrassment of respiration, per- cussion may be expected generally to furnish evidence of the solidifi- cation. 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 in rendering the dulness obvious by contrasting the percussion-sounds 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 determinable. The proportion of such instances in cases of collapse remains to be ascertained by numerical investigations ; but it is probably not great, since 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. The fact that cases of collapse have hitherto been confounded with true lobar pneumonitis may serve to account in a measure (but by no means entirely, as will be presently seen), for the opinion that this rale is rarely heard in the latter affection. Auscultation discovers more or less of the dry and mucous rales in certain cases, but not uniformly. Collapse is not always, although probably in the large proportion of cases, associated with bron- chitis ; and, moreover, the bronchial rales are far from being con- stant in cases of bronchial inflammation. More or less of the characters of the bronchial or the broncho-vesicular respiration will be present in a certain proportion of cases; but the numerical fre- quency of their occurrence, in common with other points pertaining to the semeiological history of that affection, as distinguished from true lobular pneumonitis, is to be settled by future researches. The same remarks are alike applicable to increased vocal resonance and fremitus, auscultatory signs less available in young children, owing to the absence of their voluntary co-operation. The voice as mani- fested in crying must be the imperfect substitute for the method practised after speech is acquired, and the patient is of an age to employ it voluntarily for the benefit of the auscultator. 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 sonoreity, is a point possessing diagnostic importance. LOBULAR PNEUMONITIS. 437 Its significance however, as distinguishing the condensation of collapse from that of pneumonitis, is less than it would be, if observations did not show solidification from inflammation in some instances to take place with great rapidity, a marked change in the percussion-reso- nance occasionally taking place within the space of twenty-four hours. As regards physical signs it must be admitted that, with our pre- sent knowledge, there are few very striking points which enable us to discriminate between the condensation from collapse, and solidification involving pneumonitis. The symptoms and attendant circumstances, taken in connection with the physical signs, have an important bear- ing on the diagnosis. Among the symptoms the absence of febrile movement is highly significant. The abrupt occurrence of difficult breathing and the evidences of defective haematosis, is another point possessing a certain amount of significance. The state of the muscular power, at the time the vital and physical evidences of condensation became apparent, is to be considered. Occurring during great exhaus- tion, 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. And if, under these circum- stances, the symptoms of bronchial inflammation are absent, the chances are in favor of collapse, in view of the small proportion of instances in which, in children, true lobular pneumonitis occurs as a pri- mitive affection, that is, independently of bronchitis. The differential diagnosis is not simply a matter of scientific interest. The practical bearing is obvious, since the two conditions may call for precisely opposite measures of therapeutics. Future clinical investigations may render the discrimination less a matter of inferential reasoning than it is at the present moment. In lobular pneumonitis the characteristic rale, viz., the crepitant, which, in the lobar form of the disease, affecting adults, is an early and almost constant sign, fails to be observed in a certain proportion of cases. Eliminating the cases of collapse which have been hitherto considered to be cases of lobular pneumonitis, and the ratio of in- stances in which this rale is discoverable is much increased, but it is by no means uniformly or frequently present even in well-marked primitive lobar pneumonitis, occurring in the child. The probabilities of its existence are to be settled by future clinical observations. When present, it has the same significance as in cases of pneumonitis affecting the adult. It is nearly pathognomonic. It is therefore to 438 DISEASES OF THE RESPIRATORY ORGANS. be sought for with care, and by patience it may sometimes be heard at the end of an unusually deep inspiration, such as occurs in con- nection with a fit of coughing, when in ordinary breathing it is not appreciable. It may be developed during a short interval separating successive examinations, owing to inflammation having in the mean- time extended to new portions situated nearer the surface of the lung. It may be observed or drowned by the bronchial rales incident to ante- cedent and coexisting bronchitis. Dulness on percussion may not be apparent while the inflamed por- tions are but few in number, small and centrally situated. When, however, the solidification has extended over a certain space, the per- cussion-resonance is obviously impaired. The advantage of contrast- ing the two sides is oftener available in cases of solidification from inflammation, than from collapse, because in the former instance it is more likely to be limited to one lung. An increased sense of resist- ance on percussion, will serve to confirm the fact of relative dulness on one side. The broncho-vesicular and a well-marked bronchial respiration oftener accompany lobular pneumonitis than condensation from col- lapse, owing to the greater force of the respiratory movements in the former affection. The same remark is equally applicable to exag- gerated vocal resonance and fremitus, manifested in connection with the cry of the patient. For a similar reason the existence of supplementary respiration in healthy portions of lung, will be likely to distinguish this form of disease from collapse. A greater activity of the respiratory move- ments will also be apparent on inspection. The points pertaining to physical signs just mentioned, in addition to those belonging to the history and symptoms, will assist in the discrimination of lobular pneumonitis from collapse. Lobular pneumonitis is to be clinically discriminated from other affections. In cases of ordinary acute bronchitis, the question will sometimes arise, whether the affection be bronchitis simply, or bron- cho-pneumonia. The former, as has been seen, often merges into the latter. The circumstances indicating an extension of the inflam- mation to the parenchyma are, acceleration of the breathing, with dilatation of the alae nasi; circumscribed flush of the cheeks; increased febrile movement. To these symptoms may be added, the crepitant rale in some instances, this, of course, rendering the diagnosis as complete as possible. Exclusive of this sign, if dulness on percussion LOBULAR PNEUMONITIS. 439 be well-marked, the diagnosis lies between pneumonitis and collapse; and the associated signs and symptoms, taken in connection with the history, will frequently, if not generally, enable the practitioner to arrive at a decision. The discrimination is also to be made between lobular pneumonitis and capillary bronchitis. The latter is a much graver form of dis- ease. The respirations are more hurried; the dyspnoea more in- tense ; the evidences of imperfect haematosis greater; the circulation more disturbed. Percussion, if the affection have not induced col- lapse of more or less of the pulmonary lobules, elicits everywhere over the chest a clear resonance; and, at all events, solidification, if it exist, is insufficient in extent to account for the extreme disorder of the respiration and the circulation. The crepitant rale is want- ing ; but the sub-crepitant is extensively diffused over both sides of the chest. Due attention to these points will render the differential diagnosis, in general, not difficult. Some cases of acute phthisis in young children, may present cha- racters derived both from symptoms and signs, causing it to simulate lobular pneumonitis. It is well known that in children the tubercu- lous deposit takes place frequently with great rapidity, and, as regards situation, does not obey the law, in accordance with which, in adults, the superior portion of the upper lobe is first affected in the vast majority of cases. So also the law which determines the seat of pneumonitis in the inferior lobe with rare exceptions, does not apply to the same extent to the child. These deviations impair the facility of diagnosis. The physical signs attendant on solidifica- tion from tubercle are essentially the same as in consolidation from inflammation. Bronchitis and febrile movement may accompany both affections. Moreover, the two affections may be combined, con- stituting what pathologists have called tuberculous pneumonia. The circumstances attending the development of the disease, and its pro- gress, which belong to the history of phthisis, and the prior condi- tion of the patient as regards a constitutional tendency to that dis- ease, together with the positive indications of a tuberculous diathesis, in cases of doubt, must be relied upon in making the discrimination. These points cannot be here considered without anticipating subjects belonging to another chapter. Lobular pneumonitis is not unfrequently overlooked, the patient being supposed to labor under some other affection. Thus the occur- rence of convulsions, and drowsiness, sometimes lead the practitioner 440 DISEASES OF THE RESPIRATORY ORGANS. to refer the chief malady to the head. Vomiting and diarrhoea, events of occasional occurrence, may cause the attention to be con- centrated on the alimentary canal. The disease may be mistaken for infantile fever. These errors of diagnosis are chargeable on a want either of proper knowledge or attention. The discrimination does not involve sufficient real difficulty to require that the differen- tial diagnosis should be formally considered. 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 certain cases of tuber- culosis characterized by solidification of the pulmonary parenchyma between the tuberculous deposits. Under these circumstances the morbid condition, admitting it to be chronic pneumonitis, is inci- dental 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 M. Requin, and detailed by Grisolle,1 in which the lower lobe of the right lung was found after death firmly condensed, non-granular, without tubercles or miliary granu- lations, may be suspected to have been of that description. The same remark will apply to cases of carnification supposed to result from chronic inflammation of the pulmonary parenchyma. An instance of this kind is quoted by Grisolle, from MM. 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 smaller groups of air-cells, and he applies to this form of disease the 1 Traite Pratique de la Pneumonie, p. 351. This case is referred to by Dr. Walshe, under the head of Chronic Pneumonia. CHRONIC PNEUMONITIS. 441 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 sub- stance, which compresses and obliterates the air-cells, leading to con- traction 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 bronchiae. 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.1 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 symptoms disappear, but more or less febrile movement continues, occurring in paroxysms, or with marked exacerbations. Cough and expectoration persist, the latter not preserving the characters significant of the acute disease ; the respiration is accelerated, with dyspnoea; the appetite does not return, or if it returns 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 M. 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 very limited number of cases of the latter which have been reported. It is evident from the foregoing brief account of chronic pneumo- nitis that except so far as it is involved in a lesion already considered, viz., dilatation of the bronchiae, it is an affection possessing compara- tively small interest and importance in a practical point of view. 1 Valleix, op. cit. 442 DISEASES OF THE RESPIRATORY ORGANS. Although the physician is very rarely called upon to make the diag- nosis, 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 exacerbations, loss of strength and weight, cough and expectoration, etc., the question may arise whether the patient be affected with chronic pneumonitis or tubercu- losis. If the physical signs denote solidification of the upper lobe, and especially if they denote that the solidification is confined to the upper portion of the lobe, the chances against the existence of tuber- cle 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 deposit 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 different 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 the pulmonary affec- tion, to the extravasation of air into areolar structure, the latter being the morbid condition designated by emphysema when it is used with- out special reference to the pulmonary organs. Dilatation of the air-cells, and rarefaction of the lung, are titles more expressive of the morbid condition, and are to be preferred. Vesicular emphy- sema and true pulmonary emphysema, are expressions employed by Laennec and subsequent writers to distinguish the affection now referred 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-pleural 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 researches, 444 DISEASES of the respiratory organs. a distinguished morbid anatomist of the present day,1 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 pathological relations of dilatation of the air-cells, and the mode in Avhich the lesion is pro- duced, are subjects of great interest and importance, which at the present moment are under discussion, and concerning which conflict- ing 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.2 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 sonorous- ness. The resonance is deficient in vesicular quality. The pitch is raised. The sound, in other words, without becoming purely tympa- nitic, acquires more or less of the tympanitic character ; it is vesiculo- tympanitic. This abnormal modification is more marked, of course, when the emphysema is limited to one side, being contrasted with the normal resonance on the unaffected side. The emphysema, how- ever, when it exists on both sides, being usually greater on one side than on the other, a disparity between the two sides is apparent. Under these circumstances, the vesiculo-tympanitic character of the sound is generally obvious on both sides, but this character is more strongly marked on the side which, at the same time, presents other signs significant of a greater amount of dilatation of the air-cells. Occasional exceptions to the rule of exaggerated resonance are ob- served. In a single instance, the emphysema existing on both sides, but greater on the right side, I have noted that the sonorousness on the left side exceeded that on the right, the resonance being less vesicular and higher in pitch on the right side. It is to be borne in mind, that a natural disparity as respects the points just named exists in many persons. 1 Rokitansky. 2 The author cannot forbear referring the reader to the late 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 inte- resting 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. Review, April, 1853; or a treatise entitled " On the Pathological Anatomy of Bronchitis, and the Diseases of the Lung connected with Bronchial Obstruction." Edinburgh, 1850. VESICULAR EMPHYSEMA. 4*45 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 per- cussion, is present in a marked degree. An unnatural clearness of resonance is found in the praecordia, espe- cially if the left lung be affected. The heart may be removed from contact with the walls of the chest, and carried downward, so that be- tween the sternum and nipple, the chest becomes highly resonant. If the emphysema be general, or affect the lower lobes, the pulmonary resonance extends below its normal limits, toward 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 resonance is tubular. In cases in which the em- physema is confined to one side, if the volume of the lung be conside- rably augmented, the exaggerated vesiculo-tympanitic resonance ex- tends beyond the median line on the opposite side, in consequence of the lung exceeding laterally its normal limits and encroaching on the space belonging to its fellow. The auscultatory phenomena due to the emphysema are to be dis- tinguished from those attributable to bronchial inflammation or catarrh which so frequently coexist. Exclusive of those to which these com- plications give rise, the signs pertaining to the respiration are, in themselves, highly characteristic of the affection, and in combina- tion with the evidence derived from percussion, their diagnostic signi- ficance 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 immediate auscultation, and is scarcely heard with Cammann's instrument. Other things being equal, the feebleness is proportioned to the degree of the emphysematous condition. When both lungs are affected, but one lung more than the other, a disparity will be found to exist be- tween the two sides in this particular ; and the greater feebleness of respiratory sound, is on the side presenting the greater clearness and 446 DISEASES OF THE RESPIRATORY ORGANS. 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, but more or less below the normal amount. On the other hand, if the emphysema be limited to one lung, the respira- tory sound emanating from the other lung will be likely to exceed the normal intensity, in other words, be supplementarily exaggerated. An exaggerated respiration may also exist on the affected side or sides, over the portions of lung to which the emphysema does not ex- tend. When the emphysema is confined to the upper lobe, the respi- ratory 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 altered in other respects than intensity. It is changed in rhythm. The inspiration is shortened. The inspi- ratory sound is deferred; that is, more or less of the inspiratory act takes place before the sound is appreciable. Sometimes a very brief sound only is heard at the close of the act. The expiratory sound, on the other hand, is often prolonged, frequently exceeding conside- rably 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 vesicular quality than belongs to the normal murmur, and is raised in pitch. So far it presents the characters of that abnormal modification gene- rally distinguished as roughness. It differs, however, materially from the broncho-vesicular respiration incident to a morbid condition, the opposite of rarefaction, viz., increased density of the pulmonary structure. The prolonged expiration, if it be a pure respiratory sound without an admixture of a sibilant rale, is lower in pitch than the sound of inspiration, while in a broncho-vesicular respiration due to condensa- tion, 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 condensation it is unfinished. In the majority of instances, at the time the affection comes under the observation of the physician, it is associated with bronchitis, or catarrh, and frequently with bronchial spasm constituting an attack VESICULAR EMPHYSEMA. 447 of asthma. Under these circumstances physical signs are present, due to the coexisting affections, but more or less modified by the em- physema. The moist bronchial rales are observed in a certain pro- portion of cases, consisting of the fine mucous or the sub-crepitant varieties, if the inflammation extend to the smaller tubes. Much oftener the dry rales are present—the sonorous or sibilant. The latter is heard more frequently than the former, but both are not un- frequently combined. In asthmatic paroxysms these rales are loud and diffused, accompanied by wheezing, which may be heard at a con- siderable distance from the patient. Exclusive of asthma, they denote either bronchial inflammation or irritation superadded to the emphy- sema. The rales often take the place of the respiratory sound, i. e. nothing else is heard. They are generally more marked in expira- tion than in inspiration ; and the sibilant are 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 resonance 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 when 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, ex- isting irrespective of the emphysema. Auscultation in the praecordial region, with reference to the pulmo- nary and cardiac sounds, affords a means, in addition to percussion and palpation, of determining whether the heart is abnormally over- lapped by lung, or displaced from its normal situation. The presence of a layer of lung between the organ and the thoracic walls may be shown by a feeble respiratory murmur, or the bronchial rales diffused over the whole of the praecordia. The heart-sounds, under these cir- cumstances, are faint and distant. They may be inappreciable in the praecordia, but if the displacement be downward toward the epigas- trium, they may be heard with distinctness in the latter situation. Inspection furnishes striking corroborative evidence of the exist- ence of emphysema. The frequency of respiration is often abnormal. 448 DISEASES OF THE RESPIRATORY ORGANS. 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 circulation is accelerated, or from other causes, irrespective of bronchial obstruc- tion ; and especially if the emphysema involve atrophy, as a predo- minant anatomical element, frequency of the respiration may be a prominent feature. In a case of atrophous emphysema, I have ob- served 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 prolonged 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 obstructed, which occurs if the emphysema be complicated with inflammation, irrita- tion, or spasm affecting the smaller bronchiae, the expiratory move- ment is still more prolonged, owing to the obstruction offered to the passage of air from the cells. Under these circumstances, and, in- deed, from the impaired contractility of the lung alone, the labor and slowness with which expiration is performed, increase from the beginning to the close of the act; while in cases of obstruction to the air-passages exterior to the lungs, the difficulty is manifested equally during the whole of the act of respiration. Certain characteristic signs pertain to the appearance of the chest while in rest and in motion. If both lungs are affected, and their volume be considerably augmented, the form of the chest is altered. The superior and middle thirds present an unnaturally rounded, glo- bular, barrel-shaped appearance. Instances, however, in which the augmented volume of the lungs is sufficient to produce so striking an alteration are extremely rare. Partial enlargement between the VESICULAR EMPHYSEMA. 449 clavicle and a point at or a little below the nipple, the degree of en- largement approaching to that of full inspiration is not uncommon. This abnormal fulness will, of course, be confined to one side, if the emphysema be thus limited. In cases in which both the lungs are affected, the abnormal prominence will generally be greater on one side than on the other, owing to the fact that the two lungs are rarely equally affected; and as observations appear to show that 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 dis- parity having been overlooked, a greater relative fulness of the summit of the left side may in some instances have been incorrectly attri- buted to a larger amount of emphysema on that side. A test of the prominence here or elsewhere, 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 depres- sion existing above the clavicle, causing'a bulging in this situation. 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 in consequence of the enlarge- ment 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. A close examination of the expanded portion of the chest shows the same relations of its different parts which obtain in health after a full inspiration, viz., the obliquity of the ribs is diminished; the ribs and costal cartilages are nearly on one 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 29 450 DISEASES OF THE RESPIRATORY ORGANS. 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 de- pression 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 diminished, 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, that the emphy- sema is generally limited to or is much greater at the upper portion of the lungs. Another reason is, that traction of the diaphragm renders the depressions deeply marked during inspiration, not- withstanding the increase of the volume of the lung. In a case of emphysema limited to one side, not- attended by dyspnoea, or labored respiration, I have observed the antero-lateral intercostal depressions at the lower part of that side abolished, presenting, in this particular, an appearance very similar to that caused by the distension of the chest by liquid in the pleural sac, and, in fact, prior to the case com- ing under my observation, the patient was supposed to be affected with chronic pleurisy. 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 respi- ration 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 haema- 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 straight- ened by the permanent expansion, the elevation of the ribs carries the sternum upward, so that the whole chest, including in some in- stances the clavicles, rises and falls with successive respiratory acts, as if it were a solid bony case. VESICULAR EMPHYSEMA. 451 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 abdomen 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 received into the bronchial tubes, and consequently the weight of the atmo- sphere 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 effort; 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 reference, for the most part, to the appearances manifested on both sides of the chest in cases in which both lungs are affected to a considerable extent. If the disease be limited to one lung, the dyspnoea is not sufficient to give rise to the general effects just described. On com- parison of the two sides, under these circumstances, a marked dis- parity will be observed as regards permanent expansion, reduced range of motion with the successive acts of respiration, etc. Cases in which the emphysema is limited to one side are rare; 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 movements, 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 452 DISEASES OF THE RESPIRATORY ORGANS. 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 touch as well as and in some respects better than by the eye. The sense of resis- tance, of which a judgment is formed incidentally while practising percussion, may be made a separate object of examination, 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 instances increased, oftener diminished, and in other instances remaining 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 praecordia, 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 situa- tion. Diagnosis.—The physical phenomena incident to vesicular emphy- sema, as already remarked, are highly distinctive of the affection. With an adequate knowledge of these phenomena the diagnosis 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 pleurisy, pneumo-hydro- thorax, capillary bronchitis, pneumonitis, and acute phthisis. It will suffice to mention the more important points involved in the diffe- rential diagnosis from the several affections 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 his- tory, in general, affords evidence of disturbance of the respiration for a long period prior to palpitations, or other symptoms of cardiac disturbance. With or without the conjunction of the symptoms 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. VESICULAR EMPHYSEMA. 453 Aneurism of the aorta may cause a partial enlargement of the chest from the pressure of the tumor. But over the enlargement the percussion sound will be dull or flat, in place of the increased sonor- ousness 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, synchronous with the heart's action. I have known the affection to be mistaken for chronic pleurisy. In this instance (to which reference has been already made) the dilatation was limited to the left side. This side on mensuration was found to be larger than the right, which was apparent on inspec- tion, and the intercostal depressions were effaced. Judged by these appearances, without the information furnished by percussion and auscultation, the existence of chronic pleurisy would be inferred, in view of the great infrequency of emphysema, to that extent, limited to one side. A vesiculo-tympanitic percussion-sound, extending to the base of the chest, in connection with feebleness of the respiratory murmur, and abnormal fulness above and below the clavicle on the left side, were the positive signs of emphysema; the absence of flat- ness, or at least absence of vesicular resonance, excluding pleurisy with an amount of liquid effusion sufficient to produce obvious dilata- tion. So far as physical signs are concerned, the affection to which em- physema bears the nearest resemblance is pneumo-hydrothorax. In pneumo-hydrothorax the presence of air in the pleural sac causes di- latation of the chest, abnormal sonorousness on percussion, and sup- pression of the vesicular murmur of respiration. But as regards the physical phenomena, circumstances distinguishing the two affections are sufficiently marked. In pneumo-hydrothorax the percussion-re- sonance is purely tympanitic, while in emphysema the vesicular quality of sound is diminished but not lost. The latter affection never ac- quires the extreme drum-like sonorousness which characterizes dilata- tion of the chest from air within the pleural sac. In pneumo-hydro- thorax the sonorousness extends to a certain 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 emphy- sema, when the affection is limited to the superior portion of the lung, the percussion-resonance is clear at the lower part of the chest. Pneumo-hydrothorax is always confined to one side of the chest; this is very rarely true of emphysema. Moreover, pneumO-hydro- 454 DISEASES OF THE RESPIRATORY ORGANS. thorax has its characteristic physical signs, which never occur in con- nection with emphysema, viz., amphoric respiration, metallic tinkling, splashing on succussion. In 49 of 50 cases, pneumo-hydrothorax occurs from perforation 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 affection is attended with great danger, the other, however distressing the symptoms, is rarely dan- gerous. The symptoms and signs, taken in connection with the previ- ous 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 fre- quency. In capillary bronchitis the sub-crepitant rale is diffused over the chest on both sides, especially over the posterior surface; in emphysema it is an occasional sign, and never so much diffused. Capillary bronchitis occurs especially in childhood. Emphysema, sufficient to give rise to great disturbance of the respiration in con- nection with ordinary bronchitis, is rarely observed in early life. In cases of emphysema, in which the symptoms are rendered severe by an intercurrent ordinary bronchitis, the previous history, in the vast majority of cases, shows clearly the existence for a long period of dila- tation of the cells, and in a large proportion of instances the patient is subject to attacks of asthma. These circumstances have an impor- tant bearing on the differential diagnosis, not only from capillary bronchitis, but other affections with which it may possibly be con- founded. From pneumonitis and acute phthisis (to which may be added dila- tation of the bronchia), 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 respiration, increased vocal resonance or bron- chophony, and exaggerated 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 INTERLOBULAR EMPHYSEMA. 455 this knowledge it is recognized without difficulty in cases in which the dilatation of the cells is sufficient to give rise to the characteristic phenomena of the affection. SUMMARY OF THE PHYSICAL SIGNS BELONGING TO VESICULAR EMPHYSEMA. Exaggerated sonorousness on percussion, with a few exceptions. The resonance vesiculo-tympanitic. Sense of resistance increased. Feebleness, and in some instances suppression of the respiratory murniur. Inspiratory sound shortened (deferred); expiration pro- longed, but the pitch of expiration not higher than that of inspira- tion. The bronchial rales denoting bronchitis, pulmonary catarrh, 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 chest generally or partially enlarged, more or less, within the limits of a full inspira- tion. The space above and below the clavicle occasionally bulging. The intercostal depressions sometimes effaced. Curvature of the dorsal portion of spine forward, if the disease be general and of long stand- ing. 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, with but slight expansion. The movements of the dia- phragm restrained. The beating of the heart not felt in the praecordia, 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 emphysema 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 traumatic, arising from rupture of the air-vesicles in consequence of violent re- spiratory efforts. It is an exceedingly rare affection. The anatomi- cal characters consist of enlargement of the interlobular septa, the increased size being greater toward the surface of the lung, causing 456 DISEASES OF THE RESPIRATORY ORGANS. 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 some- times attain to a considerable magnitude. I have seen a globular tumor, thus formed, as large as an English walnut, and they have been ob- served 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 are 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 fact that they are seated in the interlobular areolar structure. In some cases the surface of the lung is studded with numerous small elevations of the pleura, presenting an appearance compared by Rokitansky to that of froth. Close examination of sections of lung affected with inter- lobular 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 lobe. The symptoms will be those incident to defective haematosis, 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. Cases have been reported 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 collapse of the lung. Owing to the great infrequency of the affection, the histories of well-attested cases have not as yet accumulated sufficiently to furnish data for 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 bulks); and the other a friction sound (bruit de frottement). The INTERLOBULAR emphysema. 457 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 sonorousness 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 effects of this variety of emphysema on the configuration and size of the chest, as well as on the respiratory movements, remain to be studied. The combination of the physical signs furnished by percussion and auscultation 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 imprac- ticable. 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 are deve- loped suddenly, or with more or less rapidity, evidently proceeding 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 occur 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 V. PULMONARY TUBERCULOSIS—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 hetero- morphous product, tubercle. The nature of this product, the precise situation at which it is first deposited, its varying characters, the metamorphoses which it undergoes, and the structural changes inci- dent 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 conditions which stand in immediate relation to the phenomena furnished by physical exploration. The presence of tubercle causes, in proportion to its quantity, an increased density of the affected lung. Existing in the form of small isolated deposits, more or less numerous, the intervening pulmonary parenchyma being healthy, it constitutes a form of miliary and disseminated tubercles. The increased density due to the pre- sence of tubercles, either discrete or distributed in small clusters, may be but slight, but will, of course, correspond to their abundance and approximation to each other. Obstruction 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 reduction in volume by collapse, more or less, of the cells not filled with tuberculous matter, and thus the density is still farther increased 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 de- posits 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 emphati- PULMONARY TUBERCULOSIS. 459 cally tuberculous solidification, and a corresponding difference per- tains to the representative physical signs. So, also, if the tubercles be disseminated, and the intervening parenchyma become consolidated by inflammatory exudation, or infiltration of tuberculous matter (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, preceding inflamma- tory exudation and solidification, 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 different from those which pertain 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 different stages of the progress of tuberculous disease, viz., solidifi- cation and excavation, are likely to be conjoined. The size of exca- vations, their situation, their number, and even the firmness of their walls, as well as the varying contingent conditions relating to their contents, are found to affect the physical phenomena to which they give rise. The bronchial tubes in proximity to tuberculous deposits and exca- vations, are the source of physical signs. Circumscribed bronchitis, 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 bronchiae, 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 tuber- culosis. 460 DISEASES OF THE RESPIRATORY ORGANS. Abnormal dilatation of air-cells, or emphysema, affecting more or less of the lobules in the vicinity of tuberculous deposits, is another morbid condition incidental to the disease in a certain proportion of cases, modifying the physical phenomena, and is not therefore to be lost sight of in clinical investigations. Systematic writers generally divide tuberculous disease of the lung into three stages, viz.: 1. Stage of crude tubercle; 2. Stage of softening ; 3. Stage of excavation. With reference to the study of physical signs and their application to diagnosis, a more convenient division, as it seems to me, is the following : (a.) Small, disseminated tuberculous deposits ; (b.) Abundant deposition, involving considera- ble solidification ; (c.) Tuberculous disease advanced to the formation of cavities.1 I shall consider the physical signs and the diagnosis with reference to these three forms and periods of the disease. The following laws of pulmonary tuberculosis will frequently be re- ferred to. The deposit in the vast majority of cases takes place first at or near the apex of the lung. Exceptions to this law are occasionally observed. The deposit takes place at the summit of the lung on one side before the other lung is attacked ; but the opposite lung is subse- quently affected in the vast majority of instances. Hence, in the bodies of persons who have died with tuberculosis, the two lungs almost inva- riably are found to be diseased, but the deposit is most abundant or the ravages are more extensive on one side. These laws are of funda- mental importance in diagnosis. The claims of pulmonary tuberculosis on the attention of the medi- cal student and practitioner are sufficiently obvious in view of its great prevalence and mortality in all countries. But the study of its diagnosis is rendered immensely important by the fact that the prospect of exerting a control over the disease, and diminishing'its tendency to a fatal issue, is in proportion to its early recognition. Pulmonary tuberculosis, as the rule, is essentially a chronic affec- tion. The chronic form is understood by the simple expression pul- monary tuberculosis. Occasionally, however, the rapidity of its career and the intensity of its symptoms denote an acute affection. Acute phthisis, I shall notice briefly under a distinct head. This chapter will also embrace a few remarks on the retrospective diag- 1 To consider a stage of softening, as distinct from the stage of excavation, may be cor- rect as regards the morbid anatomy of the disease, but clinically it seems to me to be a needless division. The physical signs supposed to indicate such a stage are of doubtful significance. Hence, it will be observed that I do not undertake to point out means by which it may be recognized. PULMONARY TUBERCULOSIS. 461 nosis of pulmonary tuberculosis, and on the diagnosis of bronchial phthisis. Physical Signs.—The clinical history of pulmonary tuberculosis embraces signs furnished by all the different methods of physical exploration. The phenomena developed by percussion are highly important. They are by no means altogether uniform at different periods of the disease, nor in different cases at the same period, varying with the various anatomical conditions just enumerated, and also affected by circumstances not included in that enumeration. Diminution of the normal vesicular resonance is a constant result of a tuberculous deposit, sufficient in amount to give rise to other signs, or to marked pulmonary symptoms. The varieties of percus- sion-signs consist of abnormal modifications of sound superadded to deficiency of vesicular resonance. Simple dulness, slight or moderate in degree and more or less extensive, at the summit on one side, compared with the resonance on the other side, is the evidence com- monly afforded, by percussion, of the existence of small disseminated collections of tubercle. To determine the fact of slight or moderate relative dulness, percussion is to be practised alternately at correspond- ing points on the two sides, observing all the precautions which have been pointed out in the chapter on percussion in the first part of this work. These precautions are essential if we would avoid errors. The symmetrical conformation of the two sides of the chest is to be ascer- tained. Slight or moderate dulness, on one side, ceases to be a morbid sign if, from spinal curvature, antecedent pleurisy, or other causes, this symmetry be disturbed. The natural disparity between the two sides at the summit which is habitual in many persons, must also be taken into account. It is to be borne in mind that, as a rule, in the majority of healthy persons with well-formed chests, the percussion- sound in the left infra-clavicular region has more sonorousness, more of the vesicular quality, and is lower in pitch, than in the corresponding region on the right side. Hence, distinct dulness, however slight, on the left side, is highly significant, while on the right side, if slight or moderate, it is to be taken as a morbid sign with considerable reserve. Distinct dulness at the left summit, be it ever so slight, in connection with the diagnostic symptoms of tuberculosis, may almost suffice to establish the fact of the existence of the disease, when, if situated on the right side, other corroborative evidence is requisite. 462 DISEASES OF THE RESPIRATORY ORGANS. Delicacy of hearing, and a nicety of discrimination acquired by practice, undoubtedly enable one person to detect, promptly, a dis- parity in sounds elicited by percussion, when, to a person whose auditory sense is more obtuse and uncultivated, it is not apparent. A person with a musical ear recognizes a variation in the pitch of sound more readily than a difference in the amount of sonorousness, or of vesicular quality; hence, it is useful to bear in mind that, as a rule, when the sound is dull it is at the same time raised in pitch. In making a close comparison, however, the attention should be di- rected to the several elements combined in diminished vesicular re- sonance, viz., usually lessened sonorousness, deficiency of the vesicular quality, shortened duration of sound and elevation of pitch. But it is rarely the case that the quantity of tuberculous deposit, when it exists, is so small as to require extraordinary skill, either in eliciting or.appreciating the results of percussion. Disparity in the percussion-resonance, from a source extrinsic to the thorax, I am satisfied, exists oftener than is to be inferred from the results of the analysis of the recorded examinations given under the head of Percussion in Health, in Part I. I refer to transmitted gastric tympanitic resonance. It is not very uncommon to find the sound at the summit of the left side obviously modified by this disturbing ele- ment. In practising percussion at the summit of the chest with reference to the existence of small tuberculous deposits, the clavicular, post- clavicular, and infra-clavicular regions in front, and the upper and lower scapular regions behind, are to be examined. Owing to the difficulty of making equal percussion in the post-clavicular region, a disparity limited to this situation is to be distrusted, unless it be ex- tremely marked. I have, however, noted very distinct dulness here, in undoubted cases of tuberculosis, when it was not appreciable in the clavicular and infra-clavicular regions. Over the scapula the evidence afforded by percussion is often extremely valuable, corroborating that obtained in front, the disparity sometimes being marked in this situa- tion, when it is slight and even wanting in the anterior regions. Per- cussion here is the more valuable because a natural disparity between the two sides exists less frequently than in front; when present, how- ever, the rule being the same, viz., less resonance and elevation of pitch on the right side. Of the relative proportion of instances in which dulness is found in the several regions, respectively, at the summit of the chest, in cases PULMONARY TUBERCULOSIS. 463 of small tuberculous deposit, some idea may be formed by the follow- ing analytical results. Out of 100 examinations in different cases of tuberculosis, in 22, from the aggregate of physical signs, the quantity of tubercle was presumed to be small. In each of these 22 examina- tions, dulness at the summit was distinct, being either slight or moderate in degree. In 14 cases the fact of dulness at the summit is simply recorded ; in 9 cases the particular situations of the dulness are specified. Of the latter 9 cases, the dulness existed in the post- clavicular region in 7, in the clavicular region in 6, in the infra- clavicular region in 6, and over the scapula in 9. Of the 22 cases, in 10 the evidences of the deposit were manifested on the left, and in 12 on the right side. These 100 cases, which will be repeatedly referred to, are taken in order from my clinical records, beginning with the last case recorded. The number, which might have been much larger, it is presumed is sufficient for the present objects of analysis. If the tuberculous deposit be abundant, the evidence of its presence afforded by percussion, in general, consists in a corresponding amount of dulness. The disparity at the summit of the chest is sufficiently obvious, requiring no unusual delicacy of manipulation or of the sense of hearing to elicit and discover it. The degree of diminution of the vesicular resonance is a measure of the completeness with which the lung is consolidated, and the area over which this resonance is found to be impaired or lost, is proportionate to the diffusion of the solidifi- cation. Dulness under these circumstances is not invariable. In complete and considerable solidification at the summit of the chest, the percussion-sound may be abnormally clear, the sonorousness even exceeding that of the opposite side. So far as my observations go, this anomaly occurs only on the left side, and in the few instances in which I have noted its occurrence, from the coexistence of marked gastric resonance at the inferior portion of the chest on that side, it is fair to conclude that in great part, at least, the sonorousness was transmitted from the stomach. However this may be, the sound is not a vesicular resonance; it is tympanitic, i. e. devoid of the vesicu- lar quality, and elevated in pitch. With due attention to the quality and pitch of the sound, it need never be mistaken for a normal reso- nance, and the lesser sonorousness of the opposite side in consequence be attributed to disease. Other signs, moreover, will concur to pre- vent such an error. Without exceeding in sonorousness the resonance on the opposite side, the percussion-sound over tuberculous solidification may be more 464 DISEASES OF THE RESPIRATORY ORGANS. or less clear and tympanitic. The sonorousness is diminished, but the diminution of the vesicular quality of resonance is greater than the loss of clearness. To quote the happy expression employed by Dr. Stokes, there exists, under these circumstances, "tympanitic dul- ness." The source of the tympanitic resonance, which thus, in a certain number of cases, replaces the vesicular, in connection with tuberculous solidification, when not transmitted from the stomach or intestines, as stated in Part I, must be the air contained in the bron- chial tubes, or emphysematous dilatation of the air-cells, surrounding the solidified portion of lung; or both may be combined. The occa- sional coexistence of emphysema affecting lobules in the vicinity of tuberculous deposits, is a fact belonging to the morbid anatomy of pulmonary tuberculosis, which was enumerated among the conditions modifying the physical signs. If the tuberculous deposit be abun- dant, but the solidification of lung not complete, then the vesicular resonance will not be wholly lost, but more or less diminished. And under these circumstances, the conditions giving rise to tympanitic resonance will cause a combination of diminished vesicular and of tympanitic resonance in various and varying proportions; the sound, in other words, elicited by percussion will be vesiculo-tympanitic, the vesicular or the tympanitic quality predominating in different cases. Judging from my observations, I should say that in cases of abun- dant tuberculous deposit (of course not advanced to excavation), the diminution of the vesicular resonance is accompanied, as a rule, by more or less of tympanitic sonorousness, but the former, i. e. the dulness, is the more obvious element, and the latter, i. e. the tympa- nitic quality of sound, is overlooked if it be not unusually prominent, unless the attention be directed particularly to it. On the other hand, in a small proportion of cases, the percussion-sound over tuber- culous solidification is dull almost to flatness. The tympanitic resonance due to transmitted gastric sonorousness on the left side, at the summit, may prevent dulness at the summit of the right side, dependent on an abundant deposit of tubercle, from being readily appreciated. I have noted an instance of this descrip- tion, the auscultatory phenomena showing the existence of a consi- derable quantity of tuberculous matter at the summit of the right lung. An abnormal sense of resistance is a valuable collateral means of determining the fact of tuberculous solidification, in the practice of percussion. Especially is this point important when there is found PULMONARY TUBERCULOSIS. 465 to be only a moderate relative dulness on the right side, which we may not be altogether certain is not due to a natural disparity. An increased sense of resistance in concurrence with the dulness, confirms its morbid character. Irrespective of the quality of the resonance which remains, marked dulness on percussion, as already stated, over the site of an abundant tuberculous deposit, is the rule. Out of 100 examinations of diffe- rent cases of pulmonary tuberculosis, of which I have transcribed the recorded physical signs for the sake of reference in writing these remarks, excluding the cases in which the quantity of tuberculous deposit was small, and also the cases in which the evidences of exca- vation were ascertained, 65 cases remain of more or less complete and extensive solidification depending upon abundant tubercle. In 35 of these cases the dulness is noted to have been marked, and in several instances the fact of dulness is alone stated without expressing its degree. In five instances the percussion-sound v^as almost flat. In three cases only was there greater sonorousness, tympanitic in quality, over the solidified lung, and in each of these instances the left side was the seat of the solidification, and gastric resonance was marked over the whole of the left side. With a single exception, whenever the different regions of the summit were specified, the diminished vesicular resonance was observed over, above, and below the clavicle in front, but frequently more marked oyer the scapula behind. In the single exceptional instance just referred to, a disparity was marked over the scapula and not in front. It was often sufficiently obvious that the resonance was diminished at the summit on both sides. The existence of marked relative dulness in front on one side, and an equally marked relative dulness over the scapula on the other side, is also noted. When tuberculosis has advanced to the formation of cavities, the phenomena furnished by percussion vary, not only in different cases, but often in the same case at different examinations made during the same day, the latter variations depending on the state of the excava- tions as respects their liquid contents. More or less tuberculous solidification continues after cavities are formed; and if, in addition, the cavities are filled with liquid, the physical conditions favorable to marked dulness or even flatness on percussion are eminently present. But if they are empty, and of considerable size, they may give rise to an abnormally clear and tympanitic percussion-sound, which occasionally presents other and more characteristic modifications of 30 466 DISEASES OF THE RESPIRATORY ORGANS. quality, viz., the amphoric and the cracked-metal varieties of tone. So far as percussion is concerned, the evidence of the existence of excavations consists in the signs just mentioned, viz., tympanitic reso- nance and the amphoric and cracked-metal modifications. How far are these phenomena available in determining the existence of exca- vations ? A tympanitic sonorousness, as we have seen, may replace the vesicular resonance over tuberculous solidification, and the tym- panitic sound, under these circumstances, may be quite intense at the summit of the left side. When incident to solidification, the tympanitic quality is considerably diffused. On the other hand, if it be due to the presence of air in a cavity, it is circumscribed in proportion to the limited size of the excavation. This is a differential point. Another point relates to the percussion-sound over the por- tions of the chest adjoining the space to which the tympanitic sonor- ousness is limited. Tuberculous excavations being usually surrounded by solidified lung, the limits of the circumscribed tympanitic sonor- ousness may be somewhat abruptly defined by a dulness which con- trasts strongly with the sound elicited over the cavity. It is possible in some instances, by careful percussion, to delineate on the chest, by means of this abrupt change from a clear to a dull sound, the site of an excavation. The alternate presence and absence of tympanitic sonorousness in the same situation at different examinations is a diagnostic point. By taking the necessary pains to practise percus- sion very early in the morning, before the contents of an excavation are expelled, and subsequently after an abundant expectoration, the change from marked dulness to clearness of resonance in a particular part of the chest may be ascertained, and thus shown to depend on the removal of morbid products, which, in view of other signs and symptoms, we cannot doubt came from a cavity. The modifications of tympanitic resonance called amphoric and cracked-metal, in them- selves are highly significant of a tuberculous cavity. Both may occur independently of excavation, as has been pointed out in Part I, but the instances are exceptional and rare. Inasmuch, however, as these modifications are only occasionally observed when cavities undoubt- edly exist, their absence is not evidence of the non-existence of exca- vation. They have a positive significance when present, but in a negative point of view are unimportant. In a considerable proportion of cases of tuberculosis advanced to excavation, percussion fails to develope any distinct evidence of the existence of cavities. This remark will be found presently to be PULMONARY TUBERCULOSIS. 467 also applicable to the other methods of exploration. The reason is, that in addition to the existence of excavations, various contingent circumstances must be combined, in order that the distinctive signs shall be produced. The circumstances favorable for the character- istic percussion-signs, and at the same time most of the distinctive phe- nomena derived from other methods of exploration, have been already mentioned (Part I), but they may be repeated in this connection. The size of the cavity is important. It must have attained to a cer- tain magnitude, and, on the other hand, should not be too capacious. It must be empty, or at least only partially filled with liquid. Its situation relative to the superficies of the lung is important. The thinner and the more condensed the stratum of the lung separating the cavity from the thoracic wall, the greater the tympanitic sonor- ousness ; and it is a still more favorable circumstance if over the excavation the pleural surfaces have become firmly adherent. The incompleteness with which these circumstances are conjoined in many cases, and the occasional absence of the indispensable condition per- taining to the contents of the cavity, sufficiently account for the in- frequency with which the existence of excavations is positively ascer- tained, especially at a single examination. Of the 100 examinations already referred to, in 13 the physical signs were considered to denote the existence of excavations. It is, however, more than probable that among the 65 cases of abundant tuberculous deposit, were many cases in which the disease had ad- vanced to the formation of cavities, the physical signs at the time of the recorded examination indicating only solidification. Of the 13 cases, in 6 circumscribed tympanitic sonorousness existed, which was attributed to empty excavations. In some of these cases the exis- tence of cavities was subsequently verified by autopsical examinations. In 4 cases the amphoric modification, and in 2 the cracked-metal intonation was noted. In leaving the subject of the percussion-signs belonging to tubercu- losis, two or three rules, with respect to the practice of percussion may be mentioned, which are to be borne in mind, particularly in cases in which the tuberculous deposit, if it exist, be small. ^ The importance of observing the general precautions pointed out in the chapter on percussion in Part I, has been already adverted to. In cases of doubt, it is useful to compare the chest as regards the results of superficial and deep percussion alternately. Slightly increased density near the surface of the lung on one side may give rise to dulness on light percussion, when with forcible strokes the disparity 468 DISEASES OF THE RESPIRATORY ORGANS. may not be appreciable. On the other hand, deep-seated tuberculous deposits require a certain force to develope a relative dulness, which may not be perceptible if the percussion strokes are feeble. In cases in which great delicacy of comparison of the two sides is desirable, it should be made, successively, after a full inspiration and after a forced expiration. A difference may be perceived when the air con- tained in the lungs is reduced by an expiratory effort, which becomes less marked when the chest is fully expanded. It is, however, to be recollected, that a disparity in this way sometimes becomes developed in health. Percussion at the summit behind should never be ne- glected. This rule is to be impressed the more, because it has been said by a late author on diseases of the chest, that percussion is of no value over the scapula. This, if I mistake not, is a common im- pression. A comparison of the two sides as respects degree, quality, and pitch of resonance, may be made here, as well as in other situa- tions. My observations have taught me that a relative dulness on one side from tuberculous deposition is more uniformly appreciable in this situation than in front. Moreover, as stated by Fournet and Louis, the tuberculous deposit is in some instances confined to the upper and posterior portion of the lung, and under these circumstances, the physical signs are limited to the scapular region. During the existence of haemoptysis, or in cases in which this symptom has very recently occurred, percussion should be employed very cautiously. Deep percussion should be refrained from. I have known profuse hemorrhage to follow so closely on an examination of the chest, that it was fair to conclude the force of the strokes to have been the exciting cause. Finally, a variation in a percussion-resonance between the two sides, which exists irrespective of deviations from symmetrical confor- mation or a natural disparity, may proceed from morbid conditions ' other than tubercle, so that this sign, exclusively of other signs and of symptoms, by no means invariably denotes tuberculosis. A slightly emphysematous condition, for example, on one side, gives rise to an obvious disparity. The converse of the above statement, viz., that equality in resonance may continue notwithstanding the presence of a considerable number of disseminated clusters of tubercles, I believe to be rarely the case. It is stated by Fournet and other writers, that even when the tuberculous solidification is not small, either in degree or extent, owing to the emphysematous dilatation of adjoining lobules which is apt to take place, the dulness is, as it were, compen- PULMONARY TUBERCULOSIS. 469 sated for, and a disparity in the percussion-sound is not obvious. This may be true occasionally, as regards mere sonorousness, or the degree of resonance ; but under the circumstances just mentioned, the quality and pitch of sound can hardly fail to undergo an appreciable alteration : the resonance, although not less clear than on the opposite side, becomes vesiculo-tympanitic and raised in pitch. The impor- tance of analytically resolving the sound elicited by percussion over the chest into its different elements, and studying the abnormal modifications which these elements may respectively undergo, is illustrated in the instance just cited. The auscultatory phenomena belonging to the clinical history of pulmonary tuberculosis, embrace the greater part, if not, indeed, the whole of the catalogue of the physical signs furnished by this method of exploration. In their relation to the disease the follow- ing distinction may be made: the adventitious sounds, viz., the rales and friction-sounds, are contingent or accidental phenomena, occa- sionally present, and although possessing, when present, diagnostic significance, their absence does not constitute any ground for inferring the non-existence of the disease. On the other hand, the signs which are included in the class of modified respiratory sounds, are more intimately and constantly connected with the morbid conditions inci- dent to the disease. They are therefore more important as diag- nostic criteria, and they are important in a negative point of view. If the respiratory sounds are free from any abnormal modification, a tuberculous deposit can hardly exist. The fact enables us to ex- clude the disease. In cases of small, disseminated tuberculous deposits, so far as the phenomena consist of modified respiratory sounds, they will mostly come under the head of broncho-vesicular respiration. In the sense in which I have used this term, it embraces all the elements of the bronchial respiration, except that the inspiratory sound is not wholly tubular, but presents the tubular and vesicular qualities combined. It is the rude respiration of writers on the subject of physical explo- ration, sometimes also styled harsh and dry respiration. If all the characters of the broncho-vesicular respiration are present, we shall have an inspiratory sound neither purely tubular nor vesicular in qua- lity, but a mixture of both (broncho-vesicular), the duration somewhat shortened (unfinished), the pitch raised; a brief interval, followed by an expiratory sound,' prolonged, frequently longer and more intense than the inspiration, and higher in pitch. Sometimes in connection 470 DISEASES OF THE RESPIRATORY ORGANS. with a small amount of tuberculous disease all these characters are observed, but oftener more or less of them are wanting. The pre- sence of certain of the broncho-vesicular elements, and the absence of others, give rise to considerable diversity in different cases. These diversities it will be useful to study with a little detail. It is need- less to remark that in determining the existence and the characters of abnormal modifications of the respiration, auscultation is to be practised at the summit of the chest on both sides, and the pheno- mena carefully compared. On the side affected, the intensity of the respiratory sound may be either increased or diminished." It is much oftener diminished,1 but when it is not too feeble to be distinctly heard, if the lessened intensity be due to increased density of lung, pro- duced by tuberculous disease, it is always altered in other particulars; in other words, more or less of the broncho-vesicular characters are added, these characters being independent of the intensity of the sound. The fact just stated will serve to distinguish the feeble respi- ration due to tuberculous disease from that incident to simple emphy- sema. Occasionally the inspiratory sound is inappreciable, unless Cammann's stethoscope be employed. On the other hand, the inspi- ratory sound may be alone heard, i. e. without any sound of expira- tion. The abnormal modifications will then consist of shortened duration, diminished vesicular or acquired tubularity of quality, and elevation of pitch, pertaining, of course, exclusively to the inspira- tion. These three characters go together. The variation in pitch is frequently the character most readily recognized. Rudeness, harshness, and dryness of the sound, pertain to this character to- gether with the tubularity. These three characters"are shown by contrast with the longer duration, the more marked vesicular quality, and the comparative lowness of pitch, which belong to the inspiratory sound on the opposite side, or over the middle and lower third of the chest on the same side. If an expiratory sound be present, it is often, if not generally, more intense than the sound of inspiration. Its intensity, however, varies. More or less prolonged, its duration differs in different cases. It is uniformly higher in pitch than the inspiratory sound, the disparity being in some cases much more marked than in others. A point of contrast between the two sides of the chest in some instances is the presence of an expiratory sound 1 Fournet states that increased intensity of the respiratory sound is the first change induced by the deposit of tubercle (op. cit.). My observations lead me to ari opposite conclusion, as stated above. PULMONARY TUBERCULOSIS. 471 on one side and not on the other ; and if diffused over both sides, its characters are the reverse of those which render it a sign of increased density of lung from tuberculous disease; they are relative shortness of duration, with less intensity and pitch lower than belong to the sound of inspiration. As the expiratory sound is sometimes wanting, so in some instances it is alone present, no sound of inspiration being discoverable. It is not uncommon in cases of tuberculosis to find the following results on comparing the two sides of the chest: on one side a vesicular inspiration, more or less intense, with no expira- tory sound, and on the opposite side a prolonged, more or less intense and acute expiration, with a very feeble or scarcely appreciable sound of inspiration. The diversities which different cases present as respects the pre- ' sence or absence of more or less of the elementary characters of the broncho-vesicular respiration, are not of importance from their pos- sessing respectively any special significance. The simple point practically is to determine the existence of any of the elements of the broncho-vesicular respiration. The broncho-vesicular respiration, in conjunction with other signs and with symptoms, is diagnostic of a tuberculous deposit not producing complete solidification, extending over a considerable space, at or near the apex of the lung. Its availability in diagnosis of course depends on its constancy, and the facility with which it may be recognized. Guided by the impressions derived from my own experience, I should say that cases belonging in the class of small, disseminated tuberculous deposits, are extremely rare in which certain of its elements are not sufficiently marked to be appreciated by one acquainted with the subject, and possessing a fair amount of skill as a practical auscultator. In comparing the respiratory sounds at the summit of the chest, in front and behind, on the two sides, it is essential, if we would avoid errors, to make due allowance for the points of normal disparity exist- ing in many persons in this part of the chest. These have been con- sidered in the chapter on auscultation, in the first part of this work, to which, in the present connection, the reader is referred. It is to be borne in mind, that on the right side, at the summit, especially in front, the inspiratory sound is frequently less intense, less vesicular, and higher in pitch, than on the left side, and that a prolonged expi- ration on the right side, occasionally more intense and higher in pitch than the inspiratory sound, and sometimes existing alone, is observed in healthy persons. Hence, the character of the broncho- 472 DISEASES OF THE RESPIRATORY ORGANS. vesicular respiration should be strongly marked at the summit of the right side, for it to be considered, in itself, as evidence of disease; but, on the other hand, if situated at the summit of the left side, it is much more significant of a morbid condition. Until the deposit of tuberculous matter becomes abundant, the broncho-vesicular modification of the respiration, in the greater pro- portion of instances, is limited to one side of the chest. This fact obtains in cases in which there is every reason to suppose that both lungs contain tubercles. In view of the fact that after a tuberculous deposit has taken place in one lung, in a short time the other lung becomes affected, I have often been surprised at finding the respira- tion over the lung least affected nearly or quite normal. It is true that under these circumstances we have not a healthy lung to serve as a standard of comparison, but without such a comparison, it is practicable to judge of the pitch and vesicular quality of the inspira- tion, and the relative intensity, duration, and pitch of the expiration, if the latter be present, and thus to determine whether the respira- tion be broncho-vesicular or not. I can only account for the fact now referred to, by supposing that when the increased density at the summit of one lung is sufficient to occasion a distinct modification of the respiratory sound, the activity of the other lung is sufficiently increased for the normal characters to be maintained, notwithstand- ing the presence of a certain number of tubercles, without giving rise necessarily to a well-marked exaggerated respiration. A well- marked exaggerated respiration, as will be presently noticed, does occur in the opposite lung in some instances, in which the amount of tuberculous deposit is considerable on one side. Interrupted, wavy, or jerking respiration, is a modification occur- ring in a certain proportion of cases of small tuberculous deposit, but also observed occasionally when other signs and the symptoms do not denote tuberculous disease. Its value as a diagnostic sign, therefore, depends on its being associated with other evidence of tuberculosis. In the 22 examinations in cases of small, disseminated tubercles, among the 100 analyzed, this sign was observed in two. Of adventitious sounds or rales, the crepitant, dry crackling, crump- ling, the sub-crepitant, and the other bronchial rales, moist and dry, particularly the latter, are all occasionally observed in cases of tuber- culosis. They do not indicate the disease directly, but, on the con- trary, if we except dry crackling and crumpling, they are the signs generally of other morbid conditions. Indirectly, they become signi- PULMONARY TUBERCULOSIS. 473 ficant of a tuberculous affection when they occur under circumstances which warrant the inference that the particular morbid conditions which they immediately represent involve the 'coexistence of tuber- cles. Their relation to the disease, as already remarked, is therefore contingent or accidental. A veritable, well-defined crepitant rale denotes pneumonitis in the vast majority of cases. Pneumonitis, occurring between the extremes of life, if it be circumscribed, i. e. extending over a portion only of a lobe, and situated at or near the apex of the lung, is highly signifi- cant of tuberculosis, because, in the first place, under these circum- stances it is not primary, since primary pneumonitis extends over a whole lobe, and affects by preference the inferior lobe; and, in the second place, observations show that circumscribed pneumonitis is occasionally developed in the vicinity of tuberculous deposits, viz., at or near the apex of the lung. A crepitant, rale is thus inferentially a diagnostic sign of tuberculosis when it is found at the summit of the chest, extending over a limited area. As respects the frequency of the occurrence of circumscribed pneumonitis, in connection with tuberculous disease, and the consequent frequency with which a cre- pitant rale well-marked (in distinction from dry crackling) becomes a sign of the latter affection, my experience accords with that of Dr. Walshe, viz., the coincidence is rare. It is not, however, less signi- ficant on this account when it does take place. Dry crackling, as distinguished from a well-marked crepitant rale, consists of a few crepitations, apparently reaching the ear from a distance, generally confined to the end of the inspiratory act. What- ever opinion may be entertained of the mechanism of its production, observations show that it frequently occurs in the early stage of tuberculosis, and is rarely observed, at the summit of the chest, except there exist a tuberculous affection. Hence it possesses a cer- tain degree of significance, especially when associated with other signs and with symptoms having a similar diagnostic bearing. Of the 22 examinations in cases presumed to be of small disseminated tubercles, it was noted in 9. In several instances it existed at the summit of the chest on both sides, but was more marked on the side which the associated signs indicated as the seat of the deposit. The same remarks are applicable to a crumpling sound, except that the latter is much less frequently observed in cases of tubercu- losis. For all practical purposes it suffices to consider this as a variety of crackling. 474 DISEASES OF THE RESPIRATORY ORGANS. A sub-crepitant rale is occasionally developed in proximity to tubercles, proceeding either from the presence of liquid matter es- caping from the cells into the smaller bronchial tubes, or produced within the tubes as the result of circumscribed capillary bronchitis. In either case its situation at the summit of the chest, and the limited space in which it is heard, are the conditions under which it is signi- ficant of tuberculosis. The occasional development of bronchitis, not only in the smaller but the larger tubes in the vicinity of tubercles, is an event belong- ing to the natural history of pulmonary tuberculosis. Hence, the production of sibilant, sonorous, and mucous rales. These rales re- present morbid conditions pertaining to bronchitis; but bronchitis limited to the upper portion of the lungs, and especially confined to one side, is not a primary affection. These restrictions conflict with the laws of primary bronchitis, which is one of the symmetrical dis- eases, and extends over the bronchial tubes distributed to the lower as well as the upper lobes. The physical signs of primary bronchitis, as has been seen, are especially manifested, not in front at the sum- mit, but over the middle and lower portions of the chest behind. Hence, when confined to the summit, and especially to one side, the bron- chitis is secondary, and in this situation the probabilities are greatly in favor of its being induced by tuberculous disease.1 Moist crackling or mucous rales may, however, be produced by the escape of softened tuberculous matter into the tubes without necessarily involving the coexistence of circumscribed bronchitis. The development of moist or bubbling sounds is generally regarded as a circumstance distinctive of the fact that softening has taken place. Undue significance, as it seems to me, has been attached to this circumstance. It is impossible to determine from the characters of the sounds whether they proceed from the presence of softened tuberculous matter, or from mucous secretions, or (as must be the case frequently) from both combined. And inasmuch as circum- scribed bronchitis may undoubtedly exist before softening of the tuberculous matter ensues, mucous rales are heard before the disease has advanced to this stage. Not indicating necessarily softening, moist rales limited to the summit of the chest are highly diagnostic of ' A clicking sound has been supposed to be specially significant of the existence of tubercles. It is so, however, solely for the reasons which invest other bronchial rales with this significance. There are no grounds for regarding the character of the sound as distinctive. A clicking sound is heard in primary as well as secondary bronchitis. PULMONARY TUBERCULOSIS. 475 tuberculosis, and in cases of doubt it is useful to auscultate repeatedly, and especially in the morning before expectoration has taken place, in order to discover them, if they exist. It thus appears that with respect to all the adventitious sounds or rales just noticed, their diagnostic value in cases of tuberculosis depends on their being limited to a circumscribed space at the summit of the chest. Their value is enhanced by association with other phenomena, physical and vital, pointing to tuberculous disease. They are occasionally, not constantly, present in cases of tuberculosis. They cannot, therefore, be relied upon in the diagnosis ; and, as already remarked, although of importance when present, we cannot argue against the existence of tuberculous disease from their absence. As criteria of the disease, they are much less important than the phenomena included under the title of the broncho-vesicular respira- tion. An abnormal transmission of the heart-sounds, oftener observed and more marked in cases of abundant tuberculous deposits, may be a sign of some value when the affection consists of small disseminated tubercles. If the sounds of the heart are heard with equal, if not greater distinctness, at the summit of the right as of the left side, it is a point the more worthy of attention from the difficulty of deter- mining, in some instances, whether the characters of the broncho- vesicular respiration on the right side are due to a morbid source, or merely to a natural disparity. This difficulty, which is an obstacle in the way of the diagnosis when the tuberculous affection is seated in the right lung, renders the collateral evidence of the disease in this situation of greater practical value than when the left lung is affected. It is chiefly with reference to the detection of tuberculosis on the right side that this sign is useful; and, obviously, it is a sign more available on the right, than on the left side. Passing next to the auscultatory phenomena produced by the voice, an exaggerated vocal resonance is an important physical sign of tuberculosis when it exists at the summit of the chest on the left side. On the other hand, a relatively greater degree of resonance on the right side, in itself, has little or no diagnostic importance. This difference is owing to the normal disparity found in most persons, especially in front. The greater intensity of vocal resonance on the right side natural to many persons, is such that it is not safe to pro- nounce positively any amount, within the limits which small dissemi- nated tubercles are competent to produce, to be morbid when it is 476 DISEASES OF THE RESPIRATORY ORGANS. observed on this side. If, however, a greatly exaggerated resonance on the right side is found in conjunction with other signs existing on this side which point to tuberculosis, it derives some weight from the association. The fact of the disparity between the two sides so often existing in health, renders an exaggerated resonance on the left side doubly significant. It is entitled to great weight in the diagnosis. It is frequently the case, however, that notwithstanding a tubercu- lous deposit in the left lung, the vocal resonance continues greater on the right side. The fact, therefore, that the resonance is not exaggerated on the left side does not militate against the existence of tuberculous disease on that side. A bronchial souffle or puff accompanying whispered words is to be included among the vocal phenomena indicating increased density of lung from tuberculous deposit. A bellow's-sound, more or less intense and high in pitch, existing within a limited space of the summit of the chest on one side, and especially on the left side, is a valuable sign in the diagnosis of tuberculosis. Analogous in its character and mechanism to the high-pitched intense expiratory sound in the bronchial and the broncho-vesicular respiration, it may be developed in cases in which the signs just mentioned are obscure or even absent. This sign is presented in a more marked degree in connection with an abundant tuberculous deposit, but in cases of small disseminated tubercles a souffle may be discovered on the affected side when it is absent on the opposite side, or, if present on both sides, the greater intensity and the elevation of pitch on one side constitute the morbid characters. It is a more significant sign if it exist on the left side, because it is found in some persons more developed and acute on the right side as a normal disparity. Directing attention now to the phenomena furnished by auscultation when the tuberculous deposit is abundant, and the lung near its apex to a greater or less extent solidified, the respiratory sound may pre- sent still the broncho-vesicular modification, more marked than before, or more or less of the elements of the bronchial respiration may be strongly marked, or the respiratory sound may be sup- pressed. Suppression of the respiratory sound over tuberculous solidification, is rarely observed at the summit of the chest in front. It occurs oftener, but by no means frequently, over the scapula. It is noted in but 5 of 62 examinations. Diminished intensity of the respiratory sound, however, is a frequent modification. It occurs much oftener PULMONARY TUBERCULOSIS. 477 than an increase of the intensity. Of 38 examinations in different cases in which the facts pertaining to this point were noted, the number of instances in which there was diminution on the side most affected is 26, while the intensity was greater than on the opposite side in 12. The diminution in different cases varies much in degree. In several instances among the cases just referred to, the sound was so feeble as to be scarcely appreciable, and it was difficult to study its characters aside from the intensity. The characters, under these circumstances, are those which belong either to the broncho-vesicular or to the bronchial respiration. Occasionally tuberculous solidifica- tion gives rise to a bronchial respiration, with all its characters as intense as in the cases of pneumonitis in which it is most strongly marked,—the inspiration loud, tubular, high in pitch, followed, after a brief interval, by an expiratory sound, prolonged, higher in pitch, and more intense than the sound of expiration. Thus complete, it occurs in but a certain proportion of cases. Usually a portion only of the elements of the bronchial respiration are present. An inspi- ratory sound may alone be heard, which, if bronchial, is purely tubular, i. e. devoid of any vesicular quality. Less frequently an expiratory sound is alone heard, which is more or less prolonged, high in pitch, sometimes loud and near the ear; in other instances faint and distant. These diversities, when the quantity of tubercu- lous deposit is abundant, as well as when it is small, do not denote any special pathological distinctions. The practical point is simply to determine the fact of the existence of more or less of the elements of the bronchial respiration. With an equal amount of disease, owing to differences in the disposition of the tuberculous matter, the bronchial respiration in one case may be intense and complete, and in another case comparatively feeble and imperfect. The most strongly marked bronchial respiration may only show that the solidi- fication, in its relations to the larger bronchial tubes and the surface of the lung, is disposed in a manner most favorable for the develop- ment and transmission of the sound. In cases of considerable tuberculous solidification at the summit of one lung, a deposit more or less in amount exists at the same time in the other lung. Auscultation on the side opposite to that most affected, may discover the characters of the broncho-vesicular or the bronchial respiration more or less marked. An obvious disparity between the two sides is usually apparent; but it is occasionally somewhat difficult, by the combined results of percussion and auscul- 478 DISEASES OF THE RESPIRATORY ORGANS. tation, to determine on which side the disease is most advanced. This difficulty, however, very rarely exists if the disease has not advanced to excavation, and, under the latter circumstances, is not often experienced. On the other hand, while the physical evidence of extensive tuberculous solidification on one side exists in some instances, on the opposite side the vesicular murmur apparently retains its normal characters. In such cases the respiration on the side least affected is supplementarily exaggerated ; and this abnormal development of the vesicular murmur prevents those modifications from being manifested which would be observed with the same amount of disease, if the other lung were not affected. Adventitious sounds, or rales, are frequently heard in auscultating patients with abundant tuberculous deposit. Including friction-sounds, they are noted in 25 of 62 recorded examinations, made in different cases. The rales noted in these examinations are either the crepitant or sub-crepitant (the record, sometimes only stating crepitation) in 6; dry crackling, in 3 ; sonorous, in 5; sibilant, in 6; a clicking sound in 3; a mucous or bubbling sound in 2. Interrupted respira- tion is also observed in a certain proportion of cases in which the quantity of tubercle is abundant. It is noted in 5 of 62 examina- tions. But in three of these five instances it was observed on the side opposite to that most affected,—a fact going to illustrate the rela- tion of this sign to a small, rather than an abundant, deposition of tubercle. The rales have the same significance as at a prior date, when the • quantity of tubercle is small. The modified respiratory sounds, being more constant, are in a diagnostic point of view of much more importance. The latter becoming generally more marked as tuberculous solidification is induced, the rales are of less value than at an earlier period in the disease, when the deviations from the character of the normal respiration are not so apparent, and the diagnosis accordingly more difficult. A friction-sound may accompany a tuberculous deposit small in amount. Instances are referred to in the first part of this work in which this sign was due to the pulmonary pleural surface becoming roughened by the projection of numerous isolated miliary tubercles, deposited immediately beneath it. This is an accidental circumstance of very rare occurrence. When the sign occurs it is significant, gene- rally, of circumscribed dry pleuritis over the tuberculous' deposits. While the quantity of tuberculous matter is small, it is extremely rare for a friction-sound to be developed; nor is it by any means a PULMONARY TUBERCULOSIS. 479 frequent sign of abundant tubercle. Although circumscribed pleuritis is so constant an event in the history of tuberculosis, the superior costal movements probably do not involve sufficient attrition of the roughened surfaces to give rise to an appreciable sound; and, more- over, adhesion doubtless speedily follows the fibrinous exudation. This sign was noted in 2 of 62 cases of abundant tuberculous deposit. In both these cases the patients were females, and it is probably true that a friction-sound at the summit of the chest is oftener met with in females, owing to the predominance in them of the superior costal type of respiration.1 In cases of tuberculous solidification on the right side, the sounds of the heart are found to be unduly audible in a large proportion of the cases in which the attention is directed to this point. Like the other contingent phenomena, however, this sign is of less importance than at an earlier period, when the physical evidence of the disease derived from percussion and the modified respiration is less clear and positive. An arterial bellow's-murmur, in the infra or post-clavicular region, is a physical sign occasionally observed, probably due to pressure of a mass of tubercle on the subclavian artery. This sign has not infre- quently attracted my attention. When present on one side, and not on the other, and especially on the side presenting other phenomena indicating tuberculous disease, it is to be included in the list of con- tingent signs which concur to confirm the diagnosis. If it exist on both sides it may be an anaemic murmur, or attributable to pressure of the stethoscope. As an isolated sign it is entitled to but little consideration. The vocal phenomena furnished by auscultation are more uniformly present and much more marked when considerable tuberculous solidi- fication exists, than in cases of small disseminated tubercles. If the • right side be the seat of the more abundant deposit (which, so far as my , observations go, is true of the larger proportion of cases), the vocal re- sonance is generally so disproportionately intense, compared with the left side, that there can be no question as to its not being due to the natural disparity existing between the two sides. On the left side the intrinsic evidence of its morbid character is, of course, still more con- clusive. But the rule as to an increased vocal resonance is by no means 1 A friction-sound at the summit of the chest, developed in the course of pulmonary tuberculosis, is always of the grazing variety; never rough or rasping, as at the lower part of the chest in some cases of general pleurisy. 480 DISEASES OF THE RESPIRATORY ORGANS. invariable. Exceptions are observed. There may be no appreciable resonance on either side; and with an abundant deposit on one side it may be equal on the two sides. This will be more likely to be observed in cases in which the abundant deposit is seated in the left side; and under these circumstances, the equality of resonance may be evidence of an abnormal increase on the left side, assuming that there existed a natural disparity in favor of the right side. I have observed the vocal resonance to be more marked at the summit of the right side, when other physical signs showed an abundant deposit in the left lung, the resonance on the affected side either not being ex- aggerated, or not sufficiently so to equal that which naturally existed on the opposite side. Bronchophony, as distinguished from exaggerated vocal resonance, is observed in a less proportion of cases. Not unfrequently, however, it is strongly marked. I have observed, in connection with a more abundant deposition in the left, than in the right lung, both sides being affected, that the vocal resonance was greater on the left side, while weak bronchophony existed on the right, and not on the left side. I may repeat here, what has been said already in the chapter on pneumonitis, and in the first part of this work, that when broncho- phony exists, it is generally a persistant sign, not disappearing and reappearing at successive examinations, as is assumed by Skoda. It does not sustain any fixed relation to the bronchial respiration. I have in several instances observed strong bronchophony in cases in which a respiratory sound was so feeble as to be scarcely appreciable, ' and conversely, there may be an intense bronchial respiration without marked bronchophony. This is a discrepancy not easy to reconcile, if both phenomena are explained by consonance, according to the • theory of Skoda. A bellows-sound accompanies whispered words more uniformly, and is more intense and acute, cceteris paribus, in proportion to the abundance of the tuberculous deposit. This sign may be present in a notable degree, when the bronchial respiration, bronchophony, or exaggerated vocal resonance are not strongly marked. In cases of tuberculous disease advanced to the formation of cavi- ties, more or less solidification of lung remains; and hence, the aus- cultatory phenomena just described, do not altogether disappear, although they may be diminished, combined with, and to some extent replaced, by other signs. The characteristics which distin- PULMONARY TUBERCULOSIS. 481 guish this period in the clinical history of tuberculosis, consist in the addition of cavernous signs to the phenomena denoting solidification. It suffices, then, to inquire, what are the cavernous signs furnished by auscultation, and to what extent are they available in diagnosis ? As regards cavernous respiration, observations directed more espe- cially to the variations in pitch of respiratory sounds, have led me to the conclusion, in opposition to high authority, that the ingress and egress of air, to and from an excavation of an adequate size, under favorable circumstances ; may be readily distinguished; that the cavernous and the bronchial respiration are not, so far as audible characters are con- cerned, identical; and that the normal laryngo-tracheal respiration is the type of the bronchial, but not of the cavernous respiration. The distinctive features of the cavernous respiration have been con- sidered at some length in Part I. It is sufficient to reproduce a simple enumeration of them here. They consist of an inspiratory sound, non-vesicular or blowing, but compared with the bronchial in- spiration low in pitch, hollow, more slowly evolved; and of an expi- ratory sound, if present, lower in pitch than the sound of inspiration. A fair number of observations in which these features of the respira- tion were localized during life, and found to correspond in their situ- ation with cavities ascertained to exist after death, have led me to entertain the belief, that the existence and seat of excavations may be predicated on the auscultatory characters just mentioned, when- ever they are distinctly manifested. But owing to the number of circumstances which must be combined, in order that a cavernous respiration may be developed, it will often happen that when cavities have formed, examinations fail to discover the evidence of their existence. Indeed, it is often only after repeated explorations, made at different times, and conducted with much care and patience, that they are detected. For an account of the method of prosecuting a search for cavities, and of the circumstances upon which the develop- ment of the cavernous respiration depends, the reader is referred to that portion of the chapter on Auscultation, in Part I, which is devoted to this subject. The cavernous respiration, like the bronchial, is by no means always presented, clinically, with the sum of its characters complete. The inspiratory sound may be alone present. Possibly this is true also of the expiration, but I cannot affirm that I have met with an instance. The lowness of pitch, together with the absence of the vesicular quality, are the points of distinction, when, an inspiratory 31 482 DISEASES OF THE RESPIRATORY ORGANS. sound being alone heard, the contrast in pitch between this sound and that of the expiration is not available. Owing to the solidifica- tion generally surrounding tubercular excavations, the bronchial respiration is frequently present in the immediate vicinity of the cavernous, and by means of this comparison, the characters of the latter are rendered more conspicuous. If the distinctive features of the cavernous respiration are mani- fested within a circumscribed space, and the characters of the bron- chial respiration surround this space, the localization of an excava- tion may be made with confidence. The evidence is rendered still more complete, if at different periods of the day the cavernous respi- ration is found to be sometimes present, ~and at other times absent, and more especially if, when found to be absent, it is observed to be reproduced after an abundant expectoration. And if over this space a circumscribed tympanitic resonance on percussion is found to co- exist with the cavernous respiration, and to disappear when it ceases, the resonance perhaps presenting a metallic or cracked-vessel intona- tion, nothing more could be desired to strengthen the proof of the seat of a cavity. In some cases a cavernous respiration is not thus circumscribed, but is more or less diffused over the summit of the chest. The con- ditions which may be supposed to exist in these cases are either a very large excavation, or numerous cavities, which if they do not communicate, are situated in close proximity to each other, the aggregate amount of excavation being sufficient to cause a predomi- nance of the cavernous over the bronchial characters of the respira- tory sound. On the other hand, if cavities exist, which are small, in size, and not numerous, the intervening solidification causes a pre- dominance of the bronchial over the cavernous characters, so that, under these circumstances, auscultation fails in discovering the exis- tence of excavations. In auscultating patients with tuberculosis more or less advanced, the cavernous and the bronchial respiration seem to me not infrequently to be combined; in other words, the respira- tion appears to present the characters of these two modifications mixed, the cavernous predominating in some cases and the bronchial in others. The existence of cavities may be predicated on such a combination, although their size and situation are not determined. This combination might with propriety be styled a broncho-cavernous respiration. An amphoric intonation is probably conclusive, in itself, of the PULMONARY TUBERCULOSIS. 483 existence of a cavity. This variety of the cavernous respiration is, however, rarely present in tuberculous excavations. Gurgling, also, when well marked, is sufficient proof that the dis- ease has advanced to excavation; but as the sound is more or less diffused, it does not serve to fix the precise location of the cavity so well as the cavernous characters of the respiration. A cavernous vocal sign is transmission of speech, i. e. articulate words, to the ear applied over the seat of an excavation. Pectorilo- quy, however, as this sign is called, is not exclusively a cavernous sign. It occurs, perhaps more frequently, over solidified lung, and, hence, it is occasionally observed over a mass of crude tubercle before the disease has advanced to the formation of cavities. For this reason, and from the fact that it is very rarely discovered where cavities exist, on account of a combination of various contingencies being indispensable to its production, it possesses very little value, clini- cally, as evidence of an -excavation. Circumstances which render it distinctive, as a cavernous sign, are its being limited to a circum- scribed space; its occurrence without being associated with marked exaggerated vocal resonance, or strong bronchophony; its inter- mittency, and its coexistence with cavernous respiration and a tympa- nitic percussion-resonance (with or without the amphoric or cracked- metal intonation) confined within the same limits. An amphoric resonance, produced by the voice, is a rare vocal phenomenon, which, when present, is, in itself, more distinctive of a cavity than pecto- riloquy. The act of coughing may develope auscultatory phenomena which are highly significant of tubercular excavation. When a cavity of considerable size and superficially situated is empty, the violent expi- rations incident to coughing occasion, within a circumscribed area, a hollow, blowing sound, sometimes accompanied by a forcible shock against the ear applied to the chest. If the cavity be partially filled with liquid, a loud gurgling or splashing noise is frequently produced. The latter is eminently a cavernous sign. Finally, the physical sign which is at once a respiratory, vocal, and tussive sign, viz., metallic tinkling, is occasionally produced in connection with a large pulmonary excavation. The conditions for its production are only present when the cavity is extremely large, and when it contains liquid and air in certain relative proportions. It is so rarely incidental to a tuberculous cavity, that it is only inte- resting in this connection as a clinical curiosity, and as furnishing an 484 DISEASES OF THE RESPIRATORY ORGANS. exception to the rule, that it denotes perforation of the lung and pneumo-hydrothorax. In employing auscultation in cases of suspected tuberculosis, the attention is, of course, as in practising percussion, to be directed especially to the summit of the chest, in view of the fact that in the vast majority of cases a tuberculous deposit takes place first and chiefly at or near the apices of the lungs: the occasional exceptions to this law will be hereafter noticed. In auscultating as in percuss- ing the chest for the evidences of tubercle, it is equally important to examine behind, over the scapulae, as in front. The post-clavicular space is not to be overlooked, provided the physical evidence of the disease be not sufficiently distinct in other situations. The pheno- mena discovered by auscultation, as well as those developed by per- cussion, are to be compared on the two sides of the chest, corre- sponding points being successively explored. The respiratory sounds being examined first on one side and next on the other side, and contrasted with each other, the observer is to decide whether these sounds are equal on both sides. A disparity between the two sides (making due allowance for certain natural differences) indicates dis- ease. The sounds on both sides may be abnormal, but a law of tuber- culosis determines almost invariably the evidences of a greater amount of disease on one side than on the other. Having discovered that a morbid disparity exists, the next step is to analyze the sounds on each side, and ascertain the characters which are morbidly pre- sented. These elementary characters relate to the intensity, quality, pitch, duration, and rhythmical succession of the inspiration and the expiration. After such an analysis we refer morbid alterations to their appropriate place in the catalogue of physical signs: in other words, we determine whether there be present a broncho-vesicular, a bronchial, or a cavernous respiration. The coexistence or the absence of adventitious sounds, or rales, are at the same time ascer- tained. It is frequently useful to compare the phenomena found not only in corresponding points on opposite sides, but in different portions of the same side. For example, the respiratory sounds over the scapula, above and below the spinous ridge, may present striking points of contrast; as, also, the post-clavicular and the infra-clavi- cular regions in front, and different parts of the latter region. The upper third of the chest may be compared with the middle and lower thirds, in order to judge by contrast with respect to morbid changes. The chest-sounds may be brought into comparison with the laryngo- PULMONARY TUBERCULOSIS. 485 tracheal, when it is desired to compare the former with the type of the bronchial respiration. Similar comparisons are to be instituted with respect to vocal phenomena. The different methods of auscultation have been sufficiently con- sidered in the first part of this work; but I avail myself of this opportunity to bear testimony to the value of the stethoscope recently introduced by Dr. Cammann. Since the chapter on Auscultation, in Part I, was written, several months have elapsed, and in the mean time I have been in the habit of using this instrument more or less, almost daily. In cases of suspected tuberculosis, in*which tuberculous deposits are either wanting, or are small and disseminated, by means of this stethoscope a closer comparison of the respiratory sounds can be made than with the ordinary cylinder or the naked ear. A dis- parity, therefore, on the one hand, is in some instances rendered appreciable which otherwise would not be discovered; and, on the other hand, the absence of a disparity, and the completeness of the normal characters, are more satisfactorily determined than is always practicable without this improved means of auscultatory exploration. It enables the auscultator to study the characters of the respiration in some cases in which it is so feeble as to be with difficulty appre- ciated by the ordinary cylinder or by immediate auscultation. Its usefulness in cases in which it is desirable to make nice comparisons with respect to vocal phenomena, is not less than in examinations with reference to respiratory sounds. These advantages render the instrument particularly serviceable, both in a positive and negative point of view, in the diagnosis of pulmonary tuberculosis. Inspection furnishes signs of tubercular disease, consisting of morbid appearances which pertain to the size and form of the summit of the chest, and to the respiratory movements in this situation. Some depression on the affected side, tand diminished expansion with inspiration, are apparent in a small proportion of cases, at an early period, when the quantity of tuberculous matter, so far as it can be estimated by means of other signs, is small. A disparity in size and motion, although less frequently observed at this period than subse- quently, is of more importance than when the quantity becomes abundant, because the diagnosis, in general, is only difficult so long as the disease has not made much progress. After the deposit has attained to a certain amount, involving considerable solidification, the evidence of its existence derived from the combination of different signs is sufficiently clear and decisive. The obstruction to full ex- 486 DISEASES OF THE RESPIRATORY ORGANS. pansion of the upper portion of the lung, and the collapse of air-cells produced by a few small disseminated tubercles, may occasion an undue depression either above or below the clavicle, or in both situa- tions, ascertained by comparison of the two sides. Moreover, circum- scribed pleuritis, leading to the formation of false membrane, and thereby tending to contract the apex and restrain its expansion, belongs frequently to the early history of tuberculosis, as is evidenced by the symptoms. In comparing the superior costal movements of the two sides, observing the precautions pointed out in Part I, in the chapter on Inspection, the effect of forced as well as tranquil breathing is to be observed. Owing to the limited amount of expan- sion at the summit of the chest in ordinary breathing, a disparity in males is rarely developed except when the intensity of respiration is increased; and in females, in consequence of the habitual predomi- nance of the superior costal type, a disparity is manifested earlier, more frequently, and in a more marked degree. Mensuration, by means of the graduated inelastic tape, but more especially with the chest-measurer of Dr. Sibson, or the stethometer of Dr. Quain, will Bhow a disparity in expansive motion with greater precision. For clinical purposes, however, inspection suffices. Callipers also enable the explorer to determine, with proper care, the exact amount of variation between the two sides in their antero-posterior diameters. But this exactness, for ordinary practical purposes, has no advantage over the information obtained by the readier and more simple method of comparing with the eye. It is not to be forgotten that a want of symmetry between the two sides, due to curvature of the spine, former pleurisy, or other causes, occasions more or less dis- parity in size and expansibility, irrespective of present disease ; and even when no want of symmetry in the general conformation of the chest is discoverable, a slight difference in the curves of the clavicle may cause the regions above and below this bone to appear on one side relatively somewhat depressed. In making observations on the healthy chest, I have observed that occasionally, even when it appears to be perfectly well formed, there exists a slight disparity in motion at the summit. Isolated from other signs, therefore, variations in size and expansibility, if slight, possess very little diagnostic value. Their importance depends mainly on their connection with other signs, and with symptoms which render probable, if not certain, the conclusion, that they are due to a morbid cause. At a later period in the progress of the disease, when the tuber- PULMONARY TUBERCULOSIS. 487 cular solidification is considerable, and when, as already remarked, the signs furnished by inspection or by mensuration are of less importance in the diagnosis, the depression at the summit and the defective expansion, are generally conspicuous. The cases are few in number in which these signs are wanting. Of .35 recorded examina- tions, in different cases, in which the appearances on inspection were noted, in all but 4 there was either abnormal flattening, or diminished superior costal motion, or both were combined. The latter was oftener observed than the former, but in the majority of instances depression and deficient expansion coexisted. Depression is gene- rally made apparent by the greater projection of the clavicle, but it is sometimes the case, as remarked by Walshe, that this bone follows the retreating ribs, and then the greater concavity above and the appa- rent flattening below may be on the side least affected. I have met with instances of this description. In such cases callipers are requisite to demonstrate the side on which exists the real reduction in size. As would be rationally inferred, a disparity between the two sides, at the summit, in size and expansibility, continues after tuberculosis has advanced to the formation of cavities. It is stated by Walshe that in some cases in which a very large cavity is formed, the depres- sion is less marked than at a prior period, and the expansion move- ment may be increased. An increase of size under these circum- stances would hardly be expected d priori, and its occurrence might fairly be distrusted, except it had been positively ascertained by careful comparative measurements at different periods. The in- creased expansibility is more intelligible. A bulging in the inter- costal spaces over a circumscribed space, with the act of coughing, I have in some instances observed, an appearance indicating the site of a large cavity, with its walls situated near the superficies of the lung, and the pleural surfaces adherent. Palpation may furnish information of some utility in its bearing on the diagnosis of pulmonary tuberculosis. The increased sense of resistance to pressure over tubercular solidification, is ascertained by this method more satisfactorily, than incidentally in the practice of percussion. By placing the hand on the summit, the extent of ex- pansive movement can be estimated, and the two sides compared in this respect. But it is especially with respect to the vocal fremitus that this method of exploration is applicable. Its utility in this point of view is comparatively slight. An exaggerated fremitus is an occasional, not a constant, effect of increased density of lung. 4SS DISEASES OF THE RESPIRATORY ORGANS. Even when solidification is complete and extensive, as it is in some cases of pneumonitis, an appreciable exaggeration of the fremitus is by no means uniform. In the partial and imperfect solidification from tubercle, the sign is often wanting : especially in the early period of tuberculosis, when it is most valuable, it is rarely present. Another reason for the frequent unavailability of this sign is the disparity between the two sides as regards the normal amount of fremitus. It is habitually greater on the right side. Equality in this particular constitutes the exception rather than the rule. This fact renders the sign almost nugatory in cases in which a greater fremitus is found on the right side. Observations show that the fre- mitus may continue greater on the right side, when other signs indi- cate unequivocally an abundant tubercular deposit on the left side. But this normal difference between the two sides renders the sign, in some instances in which it exists on the left side, more significant than it would be, were the two sides equal in health. A vocal fre- mitus existing on the left and not on the right side, or more marked in the former situation, is, in fact, highly significant, but the coex- isting signs, under these circumstances, leave no room for doubt as to the fact of solidification of the lung. In accumulating, however, data from every quarter, in order either to render the proof of tuberculous disease perfectly conclusive, or, on the other hand, to exclude the disease, comparison of the two sides as respects vocal fremitus should not be overlooked, although the information, positive and negative, derived from other methods, is vastly more important. Finally, a succussion-sound, or splashing, has been observed when a large tubercular cavity is partially filled with liquid. It is suffi- cient simply to mention this fact. The sign belongs in the list of phenomena denoting a cavity, but it is so rarely available that the importance of resorting to this method of exploration hardly need be recommended. Diagnosis.—Pulmonary tuberculosis, although embracing in its career most of the phenomena furnished by the different methods of exploration, has no special pathognomonic physical signs. The phe- nomena' which it embraces belong also to other affections. They represent morbid conditions not peculiar to tuberculosis, but existing in other forms of disease. Isolated from other signs, and dissevered from symptoms, pathological laws, and associated circumstances, none of the physical phenomena which have just been considered would PULMONARY TUBERCULOSIS. 489 possess marked diagnostic importance. Nevertheless, from their combinations, their conjunction with vital phenomena and with facts pertaining to the natural history of the disease, they acquire a posi- tive value, and are hardly less significant than if they belonged to it exclusively. These general remarks are alike applicable to the symptoms. The semeiology of pulmonary tuberculosis embraces a series of events which are common to this and other affections, and which, in a diag- nostic point of view, derive their importance chiefly from association with each other, from coexisting physical signs, accompanying cir- cumstances, and the laws of the disease. The diagnosis of pulmonary tuberculosis is based on the positive evidence of its existence. If this evidence is present, we do not call to our aid, save to a very limited extent, the mode of investigation called " reasoning by way of exclusion." The differential diagnosis from other affections hinges mainly on the presence or absence of the signs and symptoms which denote a tuberculous deposit. We do not, in other words, undertake to exclude other affections, but, on the other hand, we direct our investigation to ascertain whether there is sufficient proof of the existence of tuberculosis. Hence it follows, that in order to make the discrimination clinically, and to decide correctly whether a patient be affected with this disease or not, the physician must be acquainted with its symptoms and signs, and understand the conditions under which they constitute positive evidence of its existence. The physical signs have been considered. It remains now to enumerate the symptoms prominently involved in the diagnosis. The latter I shall notice very briefly, limiting the attention exclusively to diagnostic points. And inasmuch as the diagnosis very rarely presents difficulty, except at an early period, before the disease has made much progress, those points which have relation to its development and incipient stage, are chiefly important. The circumstances, then, which invest the various symptoms attend- ing the development and progress of pulmonary tuberculosis with diagnostic significance are the following. A cough, not originating from a distinct attack of acute bronchitis, and not preceded by coryza, but frequently commencing so imperceptibly that the date of its first appearance cannot be definitely ascertained; in degree slight, moderate, or violent, but persisting for some time with little or no expectoration. Dryness of the cough, continuing for a greater or less period, according to my experience, obtains in a larger ratio of 490 DISEASES OF THE RESPIRATORY ORGANS. cases than is estimated by Walshe, viz., one-tenth. I should say that careful inquiry of patients will show it to be the rule. An expecto- ration at first small, transparent, and frothy; becoming gradually more abundant, solid, opaque, yellow, and non-aerated, subsequently consisting of sputa streaked with yellow lines, particolored, and frequently presenting irregular ragged edges ; occasionally including small particles resembling boiled rice, and a grumous-looking sub- stance contained in a thinner fluid, like the deposit in barley water. According to Walshe, from whom is borrowed the description of the appearance last named, such a deposit occurs only in cases of phthisis. At a more advanced period purulent matter, in greater or less abun- dance, running together and forming an ash-colored mass, with a nauseous and occasionally fetid odor. Small fibres, supposed to be exfoliated elastic tissue, discovered by microscopical examination; also detached fragments of other of the anatomical elements of the pulmonary structure, and possibly, in some instances, the tubercular corpuscle. Acute stitch-pains at the summit of the chest, sometimes in front, oftener beneath the scapula ; recurring from time to time ; at times severe, and lasting for several days; in other instances slight and of brief duration ; experienced more frequently on one side than on the other, but often occurring successively, or in alternation, on both sides. These pains generally denote repeated attacks of cir- cumscribed pleuritis. Chills, or shiverings, sometimes observing an approach to periodicity, and liable to be attributed to an irregular or imperfectly developed intermittent. Haemoptysis,1 frequently the first symptom to create alarm in the mind of the patient; sometimes preceding other symptoms, and all appreciable physical signs.2 In- creased frequency of the respirations, other things being equal, the increase proportionate to the abundance and rapidity of the tubercu- lous deposit; want of breath on slight exertion, and in some cases dyspnoea; acceleration of the pulse, not invariably but generally present, and frequently a marked symptom ; a vibratory or thrilling character, together with frequency of the pulse, the latter occurring when the tuberculous affection is actively progressing. Nocturnal perspiration, occurring frequently at an early period, as well as 1 The subject of hemoptysis in its relation to tuberculosis, has been elaborately inves- tigated b^Dr. Walshe; vide British and Foreign Medico-Chir. Review, January, 1849. 2 In 91 of the 100 cases which I have analyzed, as respects physical signs, the histo- ries contain information concerning haemoptysis. It had occurred in 53 cases prior to the time of my examinations. Of 22 cases of small tubercular deposits, it had occurred m 13. Of 11 cases in which the existence of cavities was ascertained, it had occurred in 6. Of 58 cases of abundant deposit, it had occurred in 34. PULMONARY TUBERCULOSIS. 491 when the disease is advanced, in the latter case preceded by febrile movement, and forming an element of hectic paroxysms. Diarrhoea frequently recurring or persisting, denoting intestinal tuberculosis ; this complication in some instances developed at an early period, but generally after the pulmonary affection is considerably advanced. Chronic peritonitis, which is very rarely developed, except as the result of tuberculous deposit, consequent to pulmonary tuberculosis, and, therefore, inferentially evidence of the existence of the latter. Chronic laryngitis, which does not precede the pulmonary disease, as was formerly supposed, but indicates a tuberculous affection of the larynx, succeeding the deposit in the lungs, and therefore indicative of the latter. Progressive loss of weight, diminution of the muscular strength, and a marked anaemic aspect, almost invariably accompa- nying and frequently taking precedence of prominent pulmonary symptoms. Finally, mental buoyancy and freedom from apprehen- sion on the score of disease. This list might be extended, by the addition of symptomatic characters incident to a period of the disease when the diagnosis is rendered sufficiently easy by obvious symptoms as well as by physical signs. In a case in which are combined the greater part of the diagnostic points just enumerated, there would be very little room for doubt that the patient was affected with pulmonary tuberculosis. Physical exploration, however, would at once supply additional points, giving to the evidence of the existence of the disease nearly the force of demonstration. The physical phenomena would consist of those denoting increased density or solidification of lung, on the summit of the chest, on one or both sides, with perhaps the addition of the signs of cavities. If, in a case such as is now supposed, presenting a collec- tion of symptoms indicating, with a high degree of probability, tuber- culosis, this disease really exists, the physical evidence of its existence is almost invariably positive and easily discovered. But cases fre- quently present themselves in medical practice in which the diagnostic symptoms are less marked. For example, in conjunction with cough, which is perhaps slight, or, in itself, insignificant, together with a morbid aspect, there may be simply a moderate loss of weight and' strength, neither being very apparent to the patient, and yet physi- cal exploration may reveal an abundant tuberculous deposit. , With- out the aid of physical signs in such a case, there is only room for the suspicion of tuberculosis; with their aid, the existence of the disease is determined promptly and in the most positive manner. To cite another example: a patient may be attacked with haemop- 492 DISEASES OF THE RESPIRATORY ORGANS. tysis, having previously supposed himself to be in good health. An examination of the chest may fail in detecting any signs of disease. This is the result in a certain proportion of cases. Or, on the other hand, the evidence of a tuberculous deposit may be clear and unequi- vocal. In either case the information obtained by physical explora- tion is of immense importance. As regards the comparative reliability of the diagnostic characters derived from symptoms and from signs, it is to be remarked that many of the former are only occasionally available. This is true of those dependent on tuberculous complications, viz., intestinal, peri- toneal, and laryngeal. Haemoptysis occurs in only a certain propor- tion of cases, albeit this proportion is large. The loss of weight and strength is not always marked, and may be due to a variety of mor- bid conditions other than tuberculosis. Chills and pleuritic pains are not constant events, and their significance depends on their being associated with other symptoms. The pulse is not invariably accele- rated, and the respirations may not be increased in frequency. The distinctive characters pertaining to the cough and expectoration may be absent, or not readily ascertained. In short, cases of tuberculous disease by no means always offer, even after it has existed for some time, in the symptomatic characters embraced in the previous history and present phenomena, data sufficient for a probable, still less a positive, opinion as to the diagnosis. On the other hand, a tubercu- lous deposit is rarely so small in amount as not to induce physical changes in the lung, adequate to the production of signs indicating their existence. The fact just stated, is highly important in its bearing on the value of physical exploration in this disease. A tuberculous deposit sufficient to give rise to the symptoms which lead a patient to seek for medical advice, is almost invariably detected without difficulty by careful physical exploration. On this subject, the student or young practitioner is liable to derive an incorrect notion, from the stress which is very properly laid on the symptoms and signs concurring to establish the diagnosis of small disseminated tubercles. That instances do occur in which the evidence derived from symptoms and signs, conjointly, are slight, and the diagnosis is consequently attended with difficulty, must be admitted ; but instances of this^ kind are exceptions to the general rule. Of the cases of sus- pected tuberculosis which the physician meets with in practice, if the disease really exist, the physical signs, in conjunction with the symptoms, are positive and easily determined in the vast majority. PULMONARY TUBERCULOSIS. 493 This opinion is based on a pretty extensive experience for the last ten years. Let the student, or the practitioner who is not accustomed to physical exploration, then, not be repelled by the erroneous idea that the diagnosis of tuberculous disease very often hinges on points so delicate and difficult to be appreciated, as to compel him to rely in most cases on the symptoms alone. This idea, which I know to be common, does injustice to the subject of physical diagnosis. An important practical question is, how few physical signs, taken in connection with symptoms pointing to tuberculous disease, are sufficient to establish the diagnosis ? The physical phenomena in- cident to a deposit of tubercle by no means always correspond in amount with the diagnostic characters pertaining to the symptoms. A case may present symptomatic circumstances strongly indicating the disease, arid the signs be found not to be proportionately marked. On the other hand, it much oftener happens that while the symptoms alone would leave the diagnosis extremely doubtful, the physical evidence is abundantly conclusive. Assuming the existence of cer- tain symptoms which give rise merely to a suspicion of tuberculosis, for instance, a persisting cough, with loss of weight and a pallid com- plexion, provided the chest be symmetrical, if on examination a dis- tinct dulness, however slight, is discovered at the summit of the left side, in front, or behind, and especially in both situations, together with an obvious modification of the respiratory murmur, consisting in diminished vesicular quality, with elevation of pitch of the inspira- tion, or in a prolongation with elevation of pitch of the expiratory sound, in short, more or less of the elementary characters of the broncho-vesicular respiration, the diagnosis is rendered nearly if not quite conclusive. The addition of a highly significant symptom, viz., haemoptysis, and of an equally significant sign in this situation, viz., increased vocal resonance, scarcely leaves any room for doubt. If these same physical phenomena (which it is assumed are slight), are found at the summit of the right side, the evidence is less con- clusive. Contingent or accidental signs are then of much more im- portance, as showing that the disparity is due to a morbid condition, and not to a natural difference between the two sides. A persisting or frequently recurring sibilant rale, a fine mucous or sub-crepi- tant rale, or dry crackling, limited to the summit, render i,t alto- gether probable that the disparity is morbid, and hence, these signs become highly valuable as diagnostic indications. Their value is much less, under the circumstances supposed, on the left side, be- cause they are comparatively superfluous. 494 DISEASES OF THE RESPIRATORY ORGANS. Will an amount of physical evidence still less than has just been assumed suffice for the diagnosis? Pertinent to this inquiry it may be stated, as a rule, that the amount of physical evidence required for the diagnosis is small in proportion as the rational evidence is abun- dant ; in other words, if the diagnostic circumstances relating to the history and symptoms tend very strongly to the opinion that tuber- culosis exists, fewer and less marked signs are needed, provided, such as they may be, they are distinct and unequivocal in their character. In point of fact, under these circumstances, the physical signs are generally sufficiently numerous and striking. Assuming, however, that in conjunction with certain significant symptomatic characters, the only physical phenomena discovered are of the class which I have distinguished as contingent or accidental, viz., bronchial rales, crepi- tation, and dry crackling, within a limited area near the apex of the lung, these signs would authorize a highly probable although not a positive diagnosis. But judging from my own experience, I should never expect to find these phenomena persisting or present in a marked degree without, at the same time, discovering disparity in the percussion-resonance and in the respiratory murmur. Among the circumstances which, in a rational point of view (as distinguished from physical phenomena), are entitled to weight in the diagnosis of pulmonary tuberculosis, hereditary influence may fairly be included. The statistical researches of Walshe appear to lead to the conclusion that this influence may have been overrated. But while we witness, as we do not infrequently, a family of children springing from a tuberculous parentage swept off in succession by this disease, we cannot doubt that it involves in such instances a con- genital predisposition.1 Age is also entitled to consideration, since it is sufficiently established that the development of the disease is much more likely to take place between 20 and 40, than prior or subsequent to these periods of life.2 Another important practical question is the following: Does the absence of any apparent disparity between the two sides, no adven- titious sounds being discovered, the percussion-resonance remaining clear and vesicular, and the respiratory murmur apparently normal, 1 A remarkable instance of this kind recently came under my notice. In the space of five years 7 children died of phthisis, all between 18 and 23 years of age. They constituted all the children in the family. The mother died of phthisis shortly before the death of the first child, aged 45 years. The disease was developed shortly after confinement, and the child died in infancy. The father is living and in robust health. 2 Vide statistical researches of M. Lombard. Valleix, op. cit. PULMONARY TUBERCULOSIS. 495 warrant a positive opinion that tuberculosis does not exist ? This ques- tion is equivalent to the inquiry, whether a tuberculous deposit may exist in the lungs in a latent form so far as concerns physical signs. In its clinical bearing this question has, in fact, been already virtually answered. I have said, that whenever there are present symptoms warranting a strong suspicion of a tuberculous affection, which in reality does exist, it may be confidently expected that the physical evidence of its existence will be discovered; and, moreover, this evi- dence will often be found when the symptoms do not strongly indi- cate the disease. ' That tuberculous deposit may be so small in quan- tity and so distributed as not to give rise to appreciable physical signs, I do not doubt. Autopsical examinations of persons'"dead with different diseases, appear to show that small depositions not infre- quently take place, which remain dormant, become obsolete, or pass through their changes on a minute scale, the ulterior morbid con- dition on which the deposit depends being from some cause arrested. In these cases it is probable that the disease is frequently latent as respects diagnostic symptoms not less than physical signs. At all events, judging from clinical experience, if on careful and repeated explorations, the resonance on percussion and the respiratory mur- mur are found to be normal and equal on the two sides, no adven- titious sounds being present, it is quite safe to consider the patient non-tuberculous. A practitioner will, of course, feel greater posi- tiveness in the negative result of his examinations, in proportion to his confidence in his tact in exploration, and his ability to appreciate and compare physical phenomena. Moreover, he is not bound to commit himself and the art to an unqualified opinion, whatever may be the strength of his private conviction. It is enough that he state the absence of appreciable evidence of the existence of the disease. Discretion is, however, to be exercised in giving more positive assu- rances, in cases in which the remedial influence of their moral effect is desirable. It seems gratuitous to add that the prudential course just alluded to is the more politic the less the experience of the phy- sician in physical exploration ; but it often happens that patients are pronounced free from tuberculosis, when subsequent events show that the hopes and wishes of both patient and physician had much to do in determining this conclusion. The absence of apprehension which characterizes the mental condi- tion of persons affected with tuberculosis, often makes them tardy in seeking medical advice. This is one reason why, in the majority of 496 DISEASES OF TH-B RESPIRATORY ORGANS. cases, when patients first feel the need of resorting to a physician, the diagnosis is sufficiently easy. On the other hand, in various affec- tions in which the mind is differently affected, the apprehension of consumption is a source of great anxiety, and it is the dread of this disease which leads patients to desire a physical exploration of the chest. The timidity and agitation which are sometimes manifested during an examination, and the solicitude shown respecting the result, constitute some ground for a presumption that tuberculosis does not exist. Of the different non-tuberculous patients whose fears of the disease bring them under the cognizance of the physician, a portion suffer from neuralgic pains in the chest, in conjunction with more or less of the numerous ailments sometimes grouped under the title of spinal irritation. This class embraces females in much the larger proportion. They are usually anaemic and affected with uterine disorder of some sort, together with, not infrequently, hysterical symptoms more or less marked. Judging from the rare instances in which, so far as my observations go, tuberculosis is found under these circumstances, I should say that the morbid condition referred to, to say the least, does not involve any predisposition to the disease. It is not common to find well-marked spinal tenderness in tuberculous patients. Another class consists of dyspeptics. The hypochondriasis which forms so constant and prominent a feature of the affection known as dyspepsia, induces suspicion and sometimes a fixed conviction that phthisis exists, even when there are no pulmonary symptoms whatever. Tuberculosis has been supposed by some distinguished authors to be often preceded and accompanied at its commencement by notable disorder of the digestive function.1 Such has not been the fact in my experience. I have not observed that dyspeptics are prone to become affected with tuberculous disease ; and, conversely, tubercu- losis has seemed to me oftener than otherwise to originate without being attended by any marked evidence of gastric disorder. So far, then, from dyspepsia constituting any ground for anticipating that the evidence of tubercles will be discovered, I have come to re- gard it in an opposite light. Another class, and for the last few years perhaps the most numerous, is composed of persons affected with chronic pharyngitis. Chronic pharyngitis is a common affection not only among clergymen, but with persons of different callings. The attention which has of late been directed to it has given it a popular as well as professional prominence ; 1 Wilson Phillip, Sir James Clarke, and Professor J. Hughes Bennett. PULMONARY TUBERCULOSIS. 497 and the idea is generally held that it is a precursor of pulmonary tuber- culosis. Moreover, it is often accompanied by more or less cough and expectoration. Having had opportunities of observing numerous cases in which chronic pharyngitis has persisted for years, I am satis- fied that so far from the affection tending to tuberculosis, it is rather rare for the latter disease to become developed in this class of patients; and, in fact, I have been led by experience to regard the former as militating against the presumption of the existence of the latter. Tuberculosis is apt to be suspected during the protracted convales- cence from chronic pleurisy, since it is inculcated by most writers that under these circumstances tuberculous disease is very apt to be secon- darily developed. Statistical researches show that chronic pleurisy is not, as is commonly supposed, prone to eventuate in phthisis.1 Tuberculosis, however, does occasionally become developed as a com- plication, and as a sequel. The diagnosis is attended with difficulty, owing to the fact that the presence of liquid effusion and its perma- nent effects prevent a comparison of the two sides of the chest. Moreover, chronic pleurisy is apt to be overlooked, and I have known the physical phenomena at the summit of the chest on one side due to the compression by a certain quantity of liquid, attributed to a tuberculous deposit, the presence of the liquid escaping observation from the exploration being limited to the summit. The permanent con- traction of the chest, if not great, is also liable to be overlooked, with- out careful attention, the patient perhaps not being aware that he has ever had chronic pleurisy, or not deeming it important to mention the fact if inquiries are not directed to that point, in endeavoring to deter- mine whether tuberculosis exists, or not; under these circumstances, allowance is to be made for an amount of disparity between the two sides fairly attributable to the past or present pleurisy. The cha- racters of the respiratory sound on the affected side are to be carefully studied. The nearer they approach those found on the opposite- side, the less ground is there to suspect a tubercular deposit. This supposes, of course, that the deposit, if it exist, is in the side affected with pleu- risy. The remark just made with respect to the respiration will also apply to vocal resonance. The result of an examination of the side not affected with pleurisy is important. Assuming the side first affected to be that in which the pleurisy is or was seated, according to a law of tuberculosis, a deposit will be likely to take place shortly afterward in the other lung ; hence, we examine for the physical 1 Vide Blakiston on Diseases of the Chest, and Essay on Chronic Pleurisy by Author. 32 498 DISEASES OF THE RESPIRATORY ORGANS. • signs denoting disease of the latter. The contingent phenomena, viz., sibilant, mucous, sub-crepitant rales, and dry crackling, if limited to the summit of the chest on either side, and more especially on the side opposite to that affected with the pleurisy, are highly significant when taken in connection with symptoms pointing to tuberculous dis- ease, such as purulent expectoration, haemoptysis, and progressive emaciation. The latter are entitled to great weight in the diag- nosis. I have known, however, frequent attacks of copious hemor- rhage to occur during recovery from chronic pleurisy, and subse- quently to recovery, when the other symptoms, the signs, and the issue rendered it probable that tuberculosis did not exist. The diagnosis of pulmonary tuberculosis being based, as has been stated, on the positive evidence of its existence derived from physical signs and symptoms presented in combination, under circumstances which render them distinctive of the disease, it is unnecessary to dwell on the discrimination from other affections with which it has some features in common. The differential diagnosis, in general, hinges mainly on the answer to this inquiry : Is there adequate positive proof of tuberculosis? If an investigation of the phenomena, vital and physical, develope this proof, the existence of the disease Is deter- mined. If the result of the investigation is negative, the diagnosis fails, and, observing proper care and caution, the disease may be ex- cluded. Affections from which it is to be distinguished clinically, in addition to those already referred to in this chapter, are chronic bronchitis, chronic pneumonitis, dilatation of the bronchia, and pul- monary apoplexy. The points involved in the discrimination from these affections, severally, will claim but a few words. With the ex- ception of the affection last named (pulmonary apoplexy), these points have been mentioned in previous chapters. Chronic bronchitis does not commence with a slight and dry cough, accompanied by an expectoration at first small, transparent, and frothy, and becoming more abundant, solid, and opaque. On the contrary, it generally succeeds the acute form of the disease. Haemoptysis, pleuritic stitch-pains, chills, progressive marked emaciation, accele- ration of the respiration, frequency of the pulse, night perspirations, are events which do not belong to its clinical history. The signs of solidification of the lung and of pulmonary excavations are wanting. The bronchial rales, when present, are observed at the inferior poste- rior part of the chest, not limited to a situation near the apex, and frequently confined to one side. PULMONARY TUBERCULOSIS. 499 • Chronic pneumonitis is exceedingly rare. When it occurs, it suc- ceeds acute inflammation. Acute pneumonitis, on the other hand, is rarely followed by a tuberculous deposit. The inferior lobe is the seat of pneumonitis in the great majority of cases, while a tubercu- lous deposit, commencing in the lower lobe, occurs only as an ex- tremely infrequent exception to a law of the disease. The liability of mistaking tuberculosis for chronic pneumonitis is greater than of taking the latter for the former. This error I have known to be committed. A case may present itself in which the error, for a time, would be very likely to be committed. An hospital patient, somewhat advanced in years, is admitted, with acute pneumonitis affecting the upper lobe. Taking the age into consideration, the situation of the inflammation is not remarkable. The appearance of the patient, and the previous history, which is not obtained at first with minuteness, owing to the inconvenience to the patient to reply to many questions, does not lead to a suspicion of tuberculosis existing prior to the pneumonitis. He passes through the acute disease in a favorable manner, and ap- pears to be rapidly convalescing. Cough and puruloid expectoration continue, and on physical examination, marked dulness, bronchial respi- ration, and bronchophony, are found to persist, with very little diminu- tion, at the summit of the chest, even after the patient has recovered from the pneumonitis sufficiently to be up and dressed. For a little time these physical signs are supposed to indicate a slow resolution of the inflammatory solidification. Their continuance, however, leads to a more minute investigation of the case, when it is ascer- tained that cough and expectoration have existed for several years, the patient retaining sufficient strength to labor, and not considering himself much of an invalid. On inquiry, it appears that haemoptysis has formerly occurred. A careful examination reveals the physical sign of disease at the summit on both sides. Tuberculosis is suffi- ciently established, and the progress of the case confirms the diag- nosis. This is a transcript of the leading circumstances of a case which actually occurred. Dilatation of the bronchiae, as has been seen in treating of this lesion, may present the physical signs characteristic both of tuber- culous solidification and excavation. The diagnostic points have been fully considered. A simple enumeration of the more important of them will here suffice. The significant symptoms of tuberculosis are wanting, viz., haemoptysis, notable and progressive emaciation, night perspirations. The situation of the physical signs is less uniformly 500 DISEASES OF THE RESPIRATORY ORGANS. at the summit of the chest. The percussion-dulness is not propor- tionate to the intensity of the bronchial respiration ; and if cavernous signs exist, they may be accompanied with little or no evidence of solidification surrounding the excavation. These are negative points, which may warrant the exclusion of tuberculous disease. Instances, however, are occasionally met with in which the differential diagnosis is difficult, and, indeed, cannot be made with positiveness. But the infrequency of cases involving doubt is such, that occasions for em- barrassment belong among the extraordinary incidents of clinical experience. The period of life when dilatation of the bronchiae is found to exist sufficiently to simulate phthisis, is usually more ad- vanced than that at which tuberculous disease is most apt to be deve- loped. The age is therefore entitled to some weight in the diagnosis. It will seldom be a matter of question, whether an existing affec- tion be tuberculosis or pulmonary apoplexy. Yet I speak from per- sonal experience when I say, that to the young auscultator the inquiry may arise under the following circumstances. A person believing himself to be in good health is attacked with copious haemoptysis. The hemorrhage is not preceded by cough or any apparent pulmonary symptoms. For some months afterward the cough and expectora- tion are slight. There are no chills, pleuritic pains, nor any of the symptoms significant of phthisis. The average weight is retained. The respirations, when the patient is tranquil, number only 16. The aspect is not morbid ; the appetite and digestion good. On physical exploration, marked dulness is found over the upper and middle thirds on the right side; the respiratory sound scarcely appreciable, with no sound of expiration, and vocal resonance moderately greater than on the opposite side. On the left side the percussion-resonance is clear and vesicular; the respiratory murmur appearing normal, except the intensity is increased. The parents are both living and well. Moreover, the patient, who is a young physician, expresses the belief that the dulness on the right side is less than heretofore. These are the prominent points noted in the history of a case, in which, I confess, I was disposed to think sanguineous infiltration had occurred. On examination a few months afterward, the evidence of tuberculous disease was ample, and the patient died with undoubted phthisis. The diagnosis of pulmonary apoplexy is confessedly obscure; but of this it will be more appropriate to speak in connection with that affection", which will be noticed in the next chapter. I will only re- mark here, that it probably is a result in the majority of cases, of PULMONARY TUBERCULOSIS. 501 obstruction incident to heart-disease. This furnishes an important diagnostic point, which is the more significant, because pulmonary tuberculosis is rarely associated with cardiac lesions involving obstruc- tion. Tuberculosis and pulmonary apoplexy may coexist. I have known the latter to supervene upon the former, and destroy life so speedily, that a coroner's inquest was held to determine the cause of death. In the foregoing remarks under the head of diagnosis, it has been assumed all along that tuberculous disease commences always at or near the apex of the lung on one side, the other side subsequently becoming affected, as a rule; and that the deposit more or less gra- dually extends from the superior portion downward. Exceptions to the laws of pulmonary tuberculosis just stated occasionally occur. The deposit in a very small proportion of instances commences at or near the base of the lung, and extends upward, thus completely reversing the usual course of the disease. Dr. H. I. Bowditch of Boston, has lately reported eight cases of this kind, in a paper to which reference has been already made in the chapter on Pneumonitis. Dr. Bowditch estimates that these exceptional instances are liable to occur in a ratio of 1 to 150 or 200 cases.1 The instances observed by him were characterized by a well-marked crepitant rale, behind, over the lower lobe, persisting for weeks or months, followed by the physical signs of solidification, the disease finally extending to the upper lobe, affecting both sides, and advancing to the formation of cavities, as in the ordinary form of tuberculosis. The sympto- matic phenomena in these cases did not present any material varia- tion from those usually observed in phthisis. The diagnosis involves discrimination from pneumonitis. The physical signs are common to the two affections, but with this essential difference: in the tubercu- lous affection the crepitant rale persisted for weeks and months, soli- dification being slowly induced. Limiting the attention to the phy- sical phenomena, this course bears but a remote analogy to pneumo- nitis. Moreover, the history and symptoms embrace points which mark the distinction. Symptomatic fever was absent in the majority of the cases after they came under medical cognizance, and the local indications of inflammation. The patients did not lose their strength except gradually in the progress of the disease, as in ordinary phthi- sis. They were able for a certain period to be up and out of doors. Certain of the symptoms highly significant of tuberculosis were noted, 1 Louis found tuberculous disease confined to the lower lobe in 2 of 123 cases. 502 DISEASES OF THE RESPIRATORY ORGANS. viz., ragged opaque sputa, and in two cases haemoptysis. The occa- sional deposition of tubercle primarily at the base of the lung, en- forces the importance of not limiting exploration for the physical evidence of the disease to the summit of the chest. When the laws regulating the seat and progress of the deposit are thus reversed, the diagnosis may require some delay and repeated examinations. The physical taken in connection with the symptomatic phenomena will at length furnish sufficient data for a correct opinio*!. SUMMARY OF THE PHYSICAL SIGNS BELONGING TO PULMONARY TUBERCULOSIS. Diminished vesicular resonance on percussion at the summit of the chest, varying in degree from slight dulness to a near approach to flatness; present on one or on both sides, but in the latter case more marked on one side; the dulness, in general, proportionate to the abundance of the tuberculous deposit; increased sonorousness occa- sionally observed at the summit of the left side, due to transmitted gastric resonance, the sound tympanitic in quality and high in pitch; the vesicular, frequently replaced by a tympanitic sound on either side, when the sonorousness is not increased, constituting tympanitic dulness. An increased sense of resistance in proportion to the amount of crude tubercle. A tympanitic resonance over a circumscribed space at the summit, present and absent at different examinations, in some cases presenting an amphoric and the cracked-metal intonation, constituting the evi- dence afforded by percussion of the existence and situation of tubercu- lous excavations. On auscultation, the broncho-vesicular and the bronchial respira- tion, the latter denoting tuberculous solidification. Frequently, with these modifications, diminished intensity of the respiratory sounds ; occasionally suppression of all respiratory sound ; interrupted or jerking respiration. Exaggerated vesicular murmur on the side, either healthy or least affected; the crepitant, sub-crepitant, sibilant, or sonorous, mucous, and crackling, or crumpling rales, occurring as contingent signs, their significance dependent on their being found within a circumscribed area at the summit of the chest; abnormal transmission of the heart-sounds, especially at the right summit; increased vocal resonance when situated on the left side at the ACUTE PHTHISIS. 503 summit; an acute and more or less intense souffle, or bellows' sound, accompanying whispered words, especially if present on the left side; bronchophony, and occasionally transmission of speech, complete or incomplete, over tuberculous solidification; a friction-sound, limited to the summit of the chest. The cavernous respiration, occasionally observed, alternating with suppression, or gurgling, occasionally amphoric, and, very infre- quently, pectoriloquy, constituting the evidence, afforded by auscul- tating the respiration, of the existence and situation of excavations; the characters of the cavernous and bronchial modifications of the respiration, sometimes combined (broncho-cavernous respiration); splashing, an impulse, seen and felt, existing within a circumscribed space at the summit—signs of cavities furnished by the act of cough- ing ; occasionally, when the cavity is very large, metallic tinkling. By inspection, flattening, or depression at the summit, either con- fined to one side, or more marked on one side than on the other; the clavicle generally more prominent, but occasionally receding with the ribs; diminished expansibility with the act of inspiration ; the range of motion found to be lessened, as well as size of the chest at the summit, by mensuration. Disparity at the summit of the chest in vocal fremitus, provided it be found to be greater on the left side. A splashing succussion-sound in some cases of very large excava- tion. Acute Phthisis. Pulmonary tuberculosis in the vast majority of instances is emi- nently a chronic disease. It rarely terminates under several months, and is frequently protracted for a series of years. Occasionally, however, the disease runs a rapid career. In a case observed by Louis, it passed through its different stages, and ended fatally in a month after the occurrence of the first symptoms.1 A case has fallen under my observation, in which death took place in seventeen days, dating from an haemoptysis which was immediately followed by grave pulmonary symptoms, the patient at the time of the hemorrhage being apparently in excellent health. A latent tuberculous deposit, however, probably existed previously. A slight haemoptysis had occurred several months before, and, meanwhile, there existed a little hacking ' Valleix, op. cit. 504 DISEASES of the respiratory organs. cough, without expectoration, so trifling as not to excite the least apprehension. The pre-existence of a latent tuberculous deposit is perhaps not unusual in cases in which the duration of the disease, as determined by prominent symptoms, is remarkably short. In the exceptional instances in which the disease apparently ends in a few weeks, it is distinguished by the title of acute phthisis. In certain of the cases embraced by this denomination, the affection may not differ in its anatomical characters from ordinary tuberculosis. The only difference is, that the deposit is remarkably abundant and exten- sive, and passes through its changes with unusual rapidity, softening and excavation taking place within a very short space of time. But the term acute phthisis, is more particularly applied to an accumula- tion in great numbers of gray semi-transparent granulations, either remaining isolated, or coalescing, and giving rise to a species of infil- tration. Restricted to the conditions just mentioned, acute, miliary, or granular phthisis (phthisie granuleuse), in the opinion of some pathologists, is essentially a different form of disease from ordinary tuberculosis.1 The granular deposit affects both lungs, and may be present in both sides, in about an equal proportion, death taking place without softening and excavation. . The diagnosis of the form of disease just referred to (which may be denominated acute in distinction from rapid as well as chronic phthisis), is not unattended by difficulty. The physical signs are less distinctive than in ordinary tuberculosis. Owing to both lungs being simultaneously and in some cases about equally affected, a marked disparity in the percussion-resonance is not always apparent. If the granulations remain isolated, although very numerous, notable dulness is not produced. Auscultation may not furnish morbid phe- nomena other than are afforded in acute bronchitis, viz., the vibrating and bubbling sounds, inclusive of the sub-crepitant rale. The vocal signs of tuberculous solidification, viz., exaggerated resonance, bron- chophony, and fremitus, are wanting. The prominent symptoms attending the progress of the disease, are chills, followed by febrile movement, the pulse becoming rapid, with heat and dryness of the surface; great muscular prostration; notable increase in the frequency of the respirations, with or without a corresponding degree of suffering from want of breath or dyspnoea; lividity of the prolabia; toward the close of the disease quiet delirium; subsultus tendinum and incontinence of urine sometimes occurring before death; pains in the 1 M. Robin, Dictionnaire de Medecine, Paris, 1855, art. Phthisie et granulation. ACUTE phthisis. 505 chest, which are rarely severe; cough more or less violent, dry, or accompanied by small expectoration which is sometimes slightly bloody; occasionally diarrhoea. Owing to the rapid march of the disease, emaciation is a symptom much less marked than in ordinary tuberculosis. The differential diagnosis from other affections offers an exception to the rule stated, with reference to chronic tuberculosis, viz., that it turns mainly on the presence or absence of the positive characters of the tubercular disease. The positive characters of acute phthisis being less distinctive, in discriminating, clinically, between this and other affections, the latter are to be excluded by the absence of their diagnostic traits. The frequency of the respirations, dyspnoea, lividity, and rapidity of the circulation, might lead to a suspicion of disease of heart. The latter is to be excluded by the absence of the positive physical signs which denote its existence when present. Pneumonitis is excluded by the absence of signs denoting solidifi- cation extending over an entire lobe (in the adult), which is oftener the lower lobe; by the physical phenomena showing the development of disease simultaneously on both sides ; the affection not travelling successively from lobe to lobe, and the upper portion of the lung being generally found to be especially affected. The .existence of simple acute bronchitis, either of the ordinary or capillary form, is disproved by a disparity, in a certain proportion of cases, existing between the two sides in the resonance on percussion ; by the bronchial rales being less marked, and most manifested at the summit of the chest, instead of over the inferior posterior surface ; by a less abundant muco-purulent expectoration; by the dyspnoea and increased frequency of respiration being, on the one hand, much greater than in ordinary acute bronchitis, and, on the other hand, less marked, the immediate danger less imminent, and the career of the disease longer than in acute general capillary bronchitis. The affection with which acute phthisis is most liable to be con- founded is typhoid fever. The latter affection is to be excluded by the absence of its characteristic abdominal symptoms, viz., tympanites, iliac tenderness, gurgling, and diarrhoea. Diarrhoea, however, it is to be borne in mind, is occasionally a prominent symptom during the latter period of acute phthisis, dependent on a tuberculous complication of the intestines. The presence of the typhoid eruption, if well marked, settles the diagnosis; but the absence of the eruption is not proof 506 DISEASES OF THE RESPIRATORY ORGANS. that the disease is not typhoid fever. The accelerated breathing and dyspnoea of acute phthisis do not belong to the natural history of typhoid fever, except when it becomes complicated with pneumonitis, and this complication is ascertained by means of physical signs. Even with a pneumonic complication, it is extremely rare for the respiration to become embarrassed to the extent which obtains in cases of acute phthisis. Typhoid fever is farther distinguished by being preceded by a pro- dromic period, by the earlier occurrence of the peculiar mental con- dition, as well as its greater prominence, and by the pulmonary symptoms, when present, being developed secondarily, at a period more or less remote from the date of the attack. It is chiefly when cases first come under observation at a late period in the disease, and it is impossible to obtain an account of the previous history from the patient, or others, that the differential diagnosis is attended with real difficulty. Retrospective Diagnosis of Tuberculosis. The frequency with which small cretaceous formations, indurations, and puckerings, are found after death in the bodies of persons who have not died from pulmonary disease, renders it probable that a small tuberculous deposit often takes place and is arrested, in conse- quence either of a limitation inherent in the disease, or from certain influences brought to bear upon it, without advancing through its usual changes, and not producing any serious injury of the pulmonary organs.1 Clinical observations confirm the correctness of the suppo- sition that an arrest of tuberculosis may take place, the deposit ceas- ing, the symptomatic evidences of the disease, if present, disappearing, and the patient recovering perfect health. In making examinations of the healthy chest, I have met with instances in which a slight disparity was found in the percussion and respiratory sound at the summit, not attributable to any want of symmetrical conformation, and not in accordance with the laws regulating the normal variations between the two sides. On inquiry, it appeared to be a rational con- clusion, that at a former period, these persons had been affected with a small tuberculous deposit. The circumstances which rendered this 1 Dr. W. T. Gairdner suggests that the indurations frequently found in the lungs and attributed to tuberculous deposit, are frequently due to collapse of lobules from bron- chial obstruction. See Art. in Brit, and For. Med. Chir. Rev., already referred to. RETROSPECTIVE DIAGNOSIS OF TUBERCULOSIS. 507 supposition probable, were certain significant symptoms, such as per- sisting cough, loss of weight, and in one instance haemoptysis, which had existed years before, continued for a time, and in the intermediate period the persons had been free from any obvious indications of a pulmonary affection. The physical phenomena in these cases consisted in dulness at the left summit, with feebleness and diminished vesicu- larity of the respiratory sound. These signs, if slight, in view of the normal disparity frequently existing between the two sides, possess much greater significance as evidence of past, as well as present tuberculous disease, when they are found at the summit of the left side. I have also preserved notes of examinations in several cases in which the symptoms and physical signs were considered as indicating unequivocally the existence of tuberculosis, and the patients afterward recovered excellent health, the pulmonary symptoms gradually dis- appearing. A captious reader might suggest that in some of these instances an error of diagnosis was committed. I am far from pro- fessing not to have committed such errors, but in the cases to which I refer, the evidence was quite positive, and of a character not easily mistaken. In some of these cases I have examined the chest after recovery, and found a persisting disparity between the two sides, con- sisting of comparative dulness on percussion, with relative feebleness, and an approach to the characters of the broncho-vesicular respira- tion. Arrested tuberculosis, therefore, is to be included among the con- ditions giving rise to a permanent disturbance of the symmetry of the chest as respects the phenomena furnished by physical exploration, and not indicating present disease. In view of this fact, it is im- portant, in examinations of the chest which disclose a slight disparity at the summit, more especially if the abnormal modifications are situated on the left side, to inquire into the previous history of the patient, in order to ascertain whether at some former period there did not exist symptoms rendering it probable that there was at that time a tuberculous deposit. But it is sufficiently established that recovery from tuberculosis may take place after an abundant deposit, and when the disease has advanced to the formation of cavities of considerable size. Gradual contraction and cicatrization of excavations may take place, or they may remain in a stationary and innocuous condition ; the tuberculous matter may be quiescent, and probably its complete absorption is not, 508 DISEASES OF THE RESPIRATORY ORGANS. as has been supposed, impossible.1 Instances exemplifying recovery from tuberculosis, even when considerably advanced, it may reasona- bly be hoped, will be of more frequent occurrence than heretofore, in consequence of improved views of the pathology and treatment of the disease. I am acquainted with two persons who have been af- fected with tuberculosis, as shown by the previous history, one for 21, and the other for 28 years. Both have had repeated hemor- rhages, with cough and expectoration, during the periods named, which still continue. But yet both enjoy a tolerable amount of health. It is a curious fact with respect to these cases, that the patients are husband and wife. The husband was tuberculous at the time of his marriage ; the affection in the case of the wife became developed subsequently. It is worthy of being added, that in both cases the disease has been allowed to pursue its course with very little medical interference, and both have steadily continued to perform the active duties of life, the husband as a merchant, and the wife as an active superintendent of household affairs. An illustration of recovery from an abundant tuberculous deposit, and of the subsequent physical signs, is afforded by a case in which I examined the chest, noting the results, five years ago, and an oppor- tunity presented of repeating the examination a few months since. At the first examination, December, 1850, the patient, a female, aged 19, had been affected with the disease for two years, dating from the occur- rence of haemoptysis, which was shortly followed by cough and ex- pectoration. There existed marked dulness at the left summit in front and behind, with diminished expansibility, a feeble bronchial respiration, and weak bronchophony. At the summit of the right side the respiration was broncho-vesicular. The patient after this exami- nation passed from under my observation, and I did not again see her till I was requested to decide on the propriety of her being ad- mitted as a novice into the order of the Sisters of Charity. Her aspect was not morbid. She had a fine complexion, and considered herself well and abundantly able to perform the duties of the religi- ous vocation to which she aspired. She had, however, a slight cough 1 To consider the processes by which recovery is effected, is not, of course, appro- priate in this work. For this the reader is referred to late treatises on tuberculosis, and on the subject of morbid anatomy. I would particularly recommend the late essay on tuberculosis by Prof. J. Hughes Bennett of Edinburgh, for evidence and illustrations of recovery from phthisis. And I avail myself of this opportunity to express my obliga- tions to Prof. B. for the privilege, while in Edinburgh, in 1854, of examining the speci- mens which are figured in his work. BRONCHIAL PHTHISIS. 509 and expectoration chiefly occurring in the morning. The upper third of the left side was notably depressed, the clavicle having also some- what receded. Dulness on percussion was marked in this situation. The respiration was feeble on the left side, without obvious disparity in pitch or quality. The difference in intensity was marked. A pro- longed expiration existed on the left side, the pitch being obscured by a sibilant rale; on the right side an expiratory sound scarcely ap- preciable. The vocal resonance was notably greater on the left side. The subject of arrested tuberculosis and recovery from the disease is one of very great interest and importance, in its relations to patho- logical inquiries and the management of the disease. It is foreign to the objects of this work to consider it in these aspects. The main purpose of these few remarks, as implied in the heading, has been to illustrate the application of physical exploration in supplying data for a retrospective diagnosis of the disease. Tuberculosis of the Bronchial Glands—Bronchial Phthisis. In a large proportion of the cases of pulmonary tuberculosis, the tuberculous affection extends to the bronchial glands. Enlargement of these glands belongs among the varied anatomical conditions repre- sented by the physical phenomena pertaining to the disease, not, how- ever, giving rise to any special signs by which the existence of this com- plication can be determined during life. But the tuberculosis may.be limited to these glands. They may be the seat of a tuberculous deposit involving a considerable increase in size ; and by means of processes similar to those which take place in connection with tubercles deposited in the pulmonary structure, cavities may be produced, communicating with the bronchia, occasionally opening into the oesophagus, and some- times into the pleural cavity. The glands primarily affected are those situated near the bronchi; thence the disease extends to the glands imbedded in the lungs, in the direction of the bronchial subdivisions, and also to those in the neighborhood of the pericardium, the oeso- phagus, and the large vessels in the anterior mediastinum.1 In all these situations the bronchial glands are frequently affected as a complication of ordinary pulmonary tuberculosis, especially in children. It is only when they are the seat of a tuberculous deposit exclusive of pulmonary tubercles, that the disease is properly distin- 1 Hasse. 510 DISEASES of the respiratory organs. guished as bronchial phthisis. Tuberculosis limited to the bronchial glands is a disease peculiar to childhood. With this restriction to early life, it is a rare form of disease, for, if not preceded, it is apt to be followed, by pulmonary tubercles. In a certain proportion of the cases of true bronchial phthisis recovery takes place. This pro- portion would be larger than it is, except for the liability during the course of the disease to the occurrence of ordinary pulmonary tuber- culosis. The diagnosis of bronchial phthisis is desirable, especially in view of the fact that the chances of recovery are more than in ordinary tuberculosis ; and, on the other hand, it is important to distinguish it from simple bronchitis or'pertussis, with which it may be confounded, these affections being attended comparatively with much less danger. In either case the discrimination is attended with difficulty, in part from the obstacles in the way of a satisfactory exploration of the chest in children, and partly because physical signs distinctive of the disease are often wanting. The difficulty of discrimination relates more particularly to the differential diagnosis from ordinary tubercu- losis, with which it is so frequently associated. The disease coexists with either persisting or recurring attacks of bronchitis ; the symptoms and signs of the latter affection are there- fore likely to be present. The cough is apt to assume a paroxysmal character, resembling that of hooping-cough. (Edema of the face and swelling of the veins of the neck are events occasionally occurring, arising from pressure of the bronchial glands on the vena cava. The respiration is more or less hurried. The loss of flesh is marked, but in this respect, and as regards other symptoms, during the course of the disease remarkable fluctuations are observed.1 The lymphatic glands of the neck are frequently affected. As regards physical signs, feebleness or suppression of the respira- tory sound on one side is an occasional incidental effect due to pres- sure of an enlarged gland on one of the bronchi or its larger subdivi- sions. Dulness on percussion may be apparent in the interscapular regions. The bronchial respiration at or near the situations where it is normally sought for, viz., in the interscapular space behind, and in the neighborhood of the sterno-clavicular junction in front, may be abnormally exaggerated. Mucous rales are more abundant, and pos- sibly gurgling may be observed in the same vicinity. These signs, provided pulmonary tuberculosis be excluded by the absence of 1 Vide West on Diseases of Children, Am. Ed. 1854, p. 287. / BRONCHIAL PHTHISIS. 511 the physical evidence of solidification over the chest elsewhere than at the parts just named, taken in connection with the ra- tional evidence of phthisis, viz., persisting cough and emaciation and sometimes perspirations, constitute the data for the diagnosis. Assuming all these data to be available, the diagnosis may be made with much confidence. Even if the positive signs are wanting, if the history and symptoms show that the disease involves something more than bronchitis, and render the existence of phthisis alto- gether probable, provided the physical signs of pulmonary tubercu- losis are also absent, reasoning by exclusion there is good ground for the opinion that the patient is affected with bronchial phthisis. CEdema of the face and swelling of the veins of the neck constitute, in connection with other evidence, a significant indication. Enlarge- ment of the lymphatic glands of the neck is also entitled to weight in the diagnosis. CHAPTER VI. PULMONARY CEDEMA—GANGRENE OF THE LUNGS—PULMONARY APOPLEXY—CANCER OP THE LUNGS—CANCER IN THE MEDI- ASTINUM. The affections named in the heading of this chapter will complete the list of those which in their anatomical seat have relation to the air-cells or the pulmonary parenchyma. The order in which they are enumerated corresponds to the relative frequency of their occurrence. Collectively they claim a much less extended consideration than has been bestowed on each of the affections belonging in the same group which have constituted the subjects of the three preceding chapters. Pulmonary (Edema. The anatomical characters of oedema of the lungs are due to serous effusion taking place, according to Rokitansky, primarily and chiefly within the air-cells, the infiltration, however, extending to the inter- vesicular areolar tissue. The volume of the affected lung is slightly augmented; it does not collapse or crepitate on pressure. The yel- lowish limpid fluid which oozes in abundance on section, is usually slightly frothy, showing the access of a small quantity of air to the cells; the texture is solid, resisting, non-elastic, pitting on pressure as in subcutaneous oedema. Pulmonary oedema, more or less circumscribed, is found very fre- quently as an anatomical condition incidental to nearly all affec- tions of the lungs which prove fatal. It occurs as a consequence of the hypostatic congestion taking place in the latter part of fevers and various diseases. It may even be a post-mortem event. De- veloped in conjunction with other pulmonary affections, the phe- nomena to which it gives rise are so interwoven with those incident to the coexisting morbid conditions, that their recognition is imprac- PULMONARY (EDEMA. 513 ticable. It is only as an independent affection, i. e. disconnected from other pulmonary diseases, that it is of clinical importance in a diagnostic point of view. As a separate pulmonary disease it is always dependent on some anterior morbid condition. It arises secondarily in the course of organic diseases of the heart accompanied by mitral regurgitation or obstruction, and more rarely, from hyper- trophy affecting the right ventricle. It may also proceed from the condition of the blood which, at the same time, gives rise to dropsical effusions in other situations. Hence it is liable to occur in Bright's dis- ease. These pathological relations are important to be borne in mind with reference to the diagnosis. When the serous infiltration takes place rapidly and extensively, as has been sometimes observed, induc- ing death suddenly, it has been termed serous apoplexy of the lungs. Developed in the course of heart-disease or general dropsy, it is not always either limited to or most marked in the inferior and posterior portions of the lungs on both sides, which is the case when it depends on hypostatic congestion. It may exist on one side only, and be con- fined to the superior lobe. In a case which recently came under my observation, the oedema occurring in connection with hydro-peri- cardium, and softening of the heart, moderate serous effusion existing also in the pleura and peritoneum, the upper lobe of the left lung was alone affected. Physical Signs.—Oedema sufficient in amount and in the extent of lung affected to constitute an important pathological condition, is accompanied by marked dulness on percussion. According to Skoda, the tympanitic quality of sound may be elicited over lung made dense by serous infiltration, as in cases of solidification from inflam- matory exudation or tubercle. The resistance of the thoracic wall over the oedematous lung is notably increased. Owing to the presence of serous liquid in the air-cells and minute bronchial tubes, a sub-crepitant rale is discovered on auscultation. Occasionally, the rale presents all the characters distinctive of the true crepitant, viz., finer than the sub-crepitant, dry, equal, and limited to the inspiratory act: Such instances must be extremely rare exceptions to the rule, that fine bubbling, or the sub-crepitant rale, belongs to this form of disease. The respiratory sound, when not obscured by the presence of rales, is found to present more or less of the characters of the broncho- vesicular, or the bronchial modifications. The bronchial respiration, however is never so strongly marked in oedema as in cases of inflam- 33 514 DISEASES OF THE RESPIRATORY ORGANS. matory or tuberculous solidification, and the high-pitched metallic quality frequently observed in connection with the latter morbid con- ditions, does not belong to this affection. Great feebleness, and sup- pression of the respiratory sound, are oftener incident to oedema than to pneumonitis and tuberculosis. The vocal resonance may or may not be increased. The same re- mark is applicable to the vocal fremitus. As regards the souffle with whispered words, I am unable to offer the results of any observations. Inspection furnishes negative results. Diagnosis.—The symptoms belonging to pulmonary oedema offer nothing diagnostic. With more or less cough, and the expectoration of a serous or muco-serous fluid, the respiratory function is compro- mised in proportion to the degree and extent of the oedema. These are the only symptoms referable to the morbid condition of the lungs ; and since the affection occurs as a complication of other diseases, symptoms due to the latter are intermingled. Thus, in the larger proportion of cases, the symptomatic phenomena arising from disease of heart are present, and, in other cases, hydrothorax, together with effusions into other serous cavities, anasarca, &c, dependent on disease of the kidneys. The positive signs, as has been seen, are dulness on percussion, and a sub-crepitant rale. These signs being present over a portion of the chest, on one or both sides, with or without the characters of the broncho-vesicular or the bronchial respiration, exaggerated vocal resonance and fremitus, and accompanied by more or less acceleration and labor of the respiration, the diagnosis involves, first, their asso- ciation with diseases in connection with which oedema is known to occur; and, second, the exclusion of other affections in which solidifi- cation of lung takes place, more especially pneumonitis, and the hy- postatic congestion, or pseudo-pneumonitis, which is incident to the course of fevers, and some other diseases, particularly toward the close of life. If the above-mentioned physical signs become de- veloped in the course of an organic affection of the heart, especially if attended with obstruction to the pulmonary circulation, such as is incident to diseases affecting the mitral orifice, or in conjunction with general dropsy, the occurrence of oedema is established with con- siderable certainty, provided we are satisfied of the non-existence of the affections to be excluded. The existence of ordinary pneumonitis is rendered improbable by the absence of pain, of the characteristic GANGRENE OF THE LUNGS. 515 sputa, of febrile movement, and the physical signs denoting solidifi- cation of lung from the deposit of inflammatory exudation, viz., a well-marked and intense bronchial respiration, bronchophony, and the true crepitant rale. The latter sign, however, it is to be borne in mind, may be observed in cases of oedema. Hypostatic congestion, as already stated, involves oedema as an anatomical element. To make the distinction clinically under the circumstances which attend the development of hypostatic congestion, is unimportant. CEdema is most apt to affect the inferior and posterior portions of both lungs simultaneously, but this rule is invariable with respect to hypostatic congestion. The latter condition is, therefore, of course excluded whenever the phenomena denoting oedema are manifested at the supe- rior and anterior portion of the chest. With hydrothorax, oedema need not be confounded. The change of level of the liquid with the different positions of the patient, suffice to indicate the former. But the two affections may coexist. To de- termine the fact of this coexistence may not be easy. The presence of the sub-crepitant rale, and the modifications of the respiratory sound due to solidification, viz., the broncho-vesicular or bronchial respiration, superadded to t,he physical evidence of liquid in the pleura, taken in connection with the existence of general dropsy, may enable the diagnostician to make out this combination. Practically, however, success is not very important. SUMMARY OF PHYSICAL SIGNS BELONGING TO PULMONARY 03DEMA. Absence of vesicular resonance on percussion, with increased parietal resistance; sub-crepitant, and, occasionally, the crepitant rale; broncho-vesicular or the bronchial respiration, never intense or metallic; absence of respiratory sound; increased vocal resonance and fremitus uncertain, and rarely, if ever, present in a marked degree. Gangrene of the Lungs. Since the time of Laennec, writers have considered gangrene of the lungs as divisible into two forms, viz., diffuse and circumscribed. In diffuse gangrene, a considerable extent of lung is affected, gene- rally, the whole or the greater part of a lobe, and the boundaries of the gangrenous portion are not sharply defined. Both varieties 516 diseases of the respiratory organs. are exceedingly rare, but of the cases that occur, those of the diffuse form are vastly less frequent. Circumscribed gangrene is more limited in extent, and a well-de- fined line of demarcation separates the affected part from the adjacent pulmonary structure. The gangrenous portion varies in size from that of a bean to a hen's egg. A single portion only may be affected, or the disease may attack several distinct parts. The gangrene leads to sloughing, as in other situations. The decomposed lung-substance, reduced to a dark, greenish, fetid, diffluent mass, is evacuated generally through the bronchial tubes, but occasionally into the pleural cavity. Two instances of the latter have fallen under my observation. It has been known to find its way into the oesophagus, and into the peri- toneal cavity. After the evacuation has taken place, an excavation remains, proportionate in size to the extent of the gangrene. In a- certain ratio of cases, cicatrization takes place, and a complete cure is effected; or, if the disease do not end fatally, a cavity may remain for an indefinite period. Dr. Gerhard has reported a case in which an excavation was found post-mortem, nine years after the date of the disease. The anatomical conditions which are represented by physical signs are, in the first place, solidification of the pulmonary structure, until the sloughing of the affected portion of lung is accomplished. The extent of the solidification will at least be equal to the size of the gangrenous portion or portions. But it is often more extensive, for, in a certain proportion of cases, the gangrene occurs in the course of pneumonitis, and when not preceded by pneumonitis, inflammatory exudation, and oedema, taking place secondarily, extend to a greater or less distance around the eschar. A cavity, left by the removal of the decomposed portion of lung, constitutes a second anatomical con- dition. The occurrence of bronchitis, affecting the tubes in proximity to the gangrene, and the presence of liquid in these tubes, also give rise to physical signs. Circumscribed gangrene is most apt to occur in the inferior lobes oftener situated near the surface, but occasionally deeply seated; on the other hand, diffuse gangrene attacks by preference the upper lobes. Physical Signs.—The physical signs belonging to gangrene of the lungs are divisible into 1st, those which represent the condition of solidification prior to the separation and removal of the decomposed GANGRENE of the lungs. 517 pulmonary substance; 2d, those due to the circumscribed bronchitis incidental to the disease, and to the presence of liquid in the bron- chial tubes; and 3d, those distinctive of an excavation. Inasmuch as the diagnosis of the affection, as will be seen presently, is rarely made prior to the appearance of the gangrenous matter in the expec- toration, and, from the insidious manner in which the affection is deve- loped, examinations of the chest often being omitted until the event just mentioned occurs, the phenomena characteristic of this period are determined inferentially, and from isolated cases which have been reported. Deductions based on an analysis of recorded cases are wanting, and this desideratum is the less readily supplied, owing to the great infrequency of the disease. Diminished vesicular reso- nance on percussion, or dulness more or less marked, will be propor- tioned to the size of the gangrenous portion of lung, its proximity to the surface, and the extent of superadded solidification from ante- cedent or consecutive inflammatory exudation, and oedema. When the gangrene occurs as a result of pneumonitis, the dulness will be likely to extend over the space occupied by an entire lobe. But if the gangrene be circumscribed, seated in the interior of a lobe, and the surrounding inflammatory exudation be limited, the percussion- dulness will be confined to a comparatively small area, and may not be discovered even by the most careful exploration. If the affection supervene on an attack of pneumonitis, percussion furnishes no infor- mation which could warrant a suspicion that gangrene had taken place ; and if the affection be developed without being preceded by the evidence of inflammation of the lungs, the existence of dulness, if discoverable, will be often overlooked, or if discovered may not be attributed to gangrene. Auscultation in the part of the crTest where dulness is found to exist, may furnish the respiratory and vocal signs of solidification, viz., more or less of the elements of the bronchial respiration, and increased vocal resonance, or bronchophony. Rationally considered it would be anticipated that during the decomposing processes lead- ing to softening and diffluence of the gangrenous mass, marked feeble- ness or extinction of respiratory sound would be a result often ob- served ; and, also, absence of reverberation and transmission of the voice. Bubbling rales, the mucous or sub-crepitant, are heard in the vicinity of the affected part, but they have been observed to extend over a larger space than that corresponding to the gangrenous por- tion of lung. These rales are due to incidental bronchitis, and at a 518 DISEASES OF THE RESPIRATORY ORGAN'S. later period to liquid in the bronchial tubes derived from the excava- tion. It is possible that a true crepitant rale may be produced by the secondary inflammation of the pulmonary parenchyma surround- ing the circumscribed gangrenous portion. When an excavation has been produced and a bronchial communi- cation established, cavernous signs succeed those due to solidification. The cavernous respiration I have observed well marked in a gangre- nous excavation. Gurgling will be heard at variable periods, and sometimes pectoriloquy. Diagnosis.—The symptoms of gangrene of the lungs, before the matter of expectoration contains portions of the decomposed pulmo- nary substance, are not distinctive of the affection. In a certain proportion of cases pneumonitis precedes, and the symptoms, of course, are those of the latter affection. Exclusive of these cases, the symptomatic phenomena referable to the lungs are often vague. Cough, with expectoration, denoting bronchitis, may be present, and obscure pains in the chest, accompanied by febrile movement, marked prostration, and general malaise. The disease may be developed with- out any symptoms which direct attention to the chest. Gangrene of the lungs, in fact, is rarely a purely primary affection. It occurs in the course of fevers, in connection with epilepsy, cerebral affections involving insanity, the effects of intemperance, etc. Illustrations of the several pathological connections just mentioned have come under my observation. The disease is rarely suspected until it is declared by characters of the expectoration which are highly distinctive. A remarkable fetor of the expectoration is the most characteristic trait. The odor is of the peculiar kind called gangrenous, and is similar to that of other moist fissues undergoing decomposition, while in contact with living parts.1 It is intense, rendering the atmosphere of the apartment frequently almost insupportable. It is generally perceptible in the patient's breath, but is much greater during acts of coughing, even when unaccompanied by expectoration, and, in some instances, is confined to the breath expired in coughing. The matter expectorated is at first of a dirty grayish or greenish color, resembling the diffluent decomposed substance of lung, found in the gangrenous parts after death, in cases in which its removal had not been accom- plished during life. Subsequently the expectoration becomes puru- * The odor is said by Louis and Grisolle to be stercoraceous. It has not appeared to me to have that character in the cases that have come under my observation. GANGRENE OF THE LUNGS. 519 lent, and the fetor diminishes or may disappear. Even before the eschar has been removed, the fetor is sometimes observed to be inter- mittent, owing probably to the occurrence of transient obstructions of the bronchial tubes leading to the gangrenous mass. If perforation of the lung ensue, the fetor may diminish or cease. The diagnosis hinges on the distinctive characters pertaining to the breath and expectoration. Without these it would be impossible to determine the existence of gangrene. But a gangrenous fetor is not alone sufficient to establish the diagnosis. This is an occasional symptom in bronchitis, in abscess following pneumonitis, in the caver- nous stage of tuberculosis, and in pneumo-hydrothorax. There are, however, certain circumstances connected with this symptom which render it almost pathognomonic of gangrene, and, on the other hand, with due attention to the points involved in the differential diagnosis from the several affections just named, the discrimination is rarely attended with much difficulty. If the expectoration suddenly assume a gangrenous fetor, at the same time becoming copious and present- ing the appearances characteristic of decomposed pulmonary sub- stance, the existence of gangrene is quite certain. The diagnosis is rendered still more positive if, prior to the irruption of this peculiar matter, the expectoration, as is sometimes the case, had been slight or altogether wanting. And it is established beyond question if, prior to the characteristic expectoration, the physical evidence of circum- scribed solidification had been ascertained, and subsequently the cavernous signs are discovered in the same locality. In the absence of the circumstances just mentioned, precision of diagnosis is to be based on the exclusion of the other affections in which fetor of the breath and the expectoration is an event of rare occurrence. Occurring in the course of bronchitis, and due, probably, to slough- ing of minute portions of the bronchial mucous membrane, it rarely, if ever, attains to the intensity common in pulmonary gangrene. It is always preceded and accompanied by the symptoms of bronchitis. It is developed less suddenly. The gangrenous matter is not apparent in the expectoration, or, at all events, is less abundant. The physical signs of solidification succeeded by those denoting an excavation are wanting. An abscess following pneumonitis offers the same physical signs as when gangrene results from that disease. The purulent matter expectorated in the former case is sometimes fetid, but it never has 520 DISEASES OF THE RESPIRATORY ORGANS. that intense fetor which occurs in the latter case. The contents of a pneumonic abscess do not present the dark, sanious appearance which characterizes liquefied gangrenous lung-substance. On these characters, associated with intense fetor, succeeding an attack of pneumonitis, may be confidently predicated the opinion that gangrene has taken place. The sloughing of small portions of lung-substance within a tuber- culous cavity occasionally communicate a gangrenous odor to the expectoration, very rarely, however, to the extent which obtains in gangrene. But the antecedent history, the present symptoms, and the physical signs at this stage of tuberculosis, sufficiently establish the disease if present; and on the other hand, failure to discover the evidence derived from these sources disproves the existence of the disease if it be not present. Pneumo-hydrothorax, which, as has been stated, may result from perforation of the pleura in connection with gangrene, is sufficiently evidenced by physical signs, or it is easily excluded by the absence of these signs. In some very rare instances a superficial gangrenous slough, limited in extent, may escape into the pleural cavity without any communi- cation with the bronchial tubes. This occurred in a case coming under my observation.1 Under these circumstances the diagnostic symptom, fetor of the breath and expectoration, may be wanting. Acute pleuritis eventuating in pneumo-hydrothorax will be the result, and the prior existence of gangrene may be suspected; but to esta- blish the fact is impossible. Gangrene of the lungs is to be looked for oftenest in children, next in adults, and last in aged persons.9 In four of five cases occurring in children which were observed by Boudet, a gangrenous affection was seated in other organs as well as in the lung, and in two cases both lungs were gangrenous. The coexistence of gangrene in other situations is a point of some importance with reference to the diag- nosis. SUMMARY OF PHYSICAL SIGNS BELONGING TO GANGRENE OF THE LUNGS. Dulness on percussion, varying in degree and extent, unless the gangrenous portion be quite limited, and deeply seated. Bronchial respiration, or suppression of respiratory sound within the area of 1 The case is detailed in Essay on Chronic Pleurisy by the author, page 46. 2 Dr. Ernest Boudet, in Archives Generates de Medecine, 4 Serie, 1843. PULMONARY APOPLEXY. 521 dulness on percussion; increased vocal resonance or bronchophony and fremitus, occasionally present; mucous or sub-crepitant rales in the vicinity of the gangrenous portion ; possibly, a true crepitant rale; subsequent to the occurrence of fetid expectoration, cavernous respiration, gurgling, and in some instances pectoriloquy. Pulmonary Apoplexy. Pulmonary apoplexy is a term used to designate extravasation of blood into the parenchyma of the lungs. The term is an unfortunate one, and for the sake of conformity to the nomenclature now in vogue, it is desirable to substitute the word pneumorrliagia. Extra- vasation may take place primarily, either into the air-cells, or into the interlobular and intervesicular areolar tissue, the blood in both cases, unless considerable laceration of the pulmonary structure be produced, coagulating and forming a consolidated mass, resembling, so far as density is concerned, a hepatized portion of lung. The space thus solidified varies in size, frequently being less than a cubic inch, and rarely exceeding four cubic inches. The extravasation may be confined to one spot, or it may occur at several isolated points. In some very rare instances it extends over a whole lobe, and even over the greater part of an entire lung. The limits of solidification are sometimes extended by oedema of the pulmonary substance surrounding the extravasation. Absorption of the effused blood is possible ; suppuration may ensue, and an excavation occupy the site of the apoplectic mass; occasionally gangrene results. In some cases the extravasation occasions immediate and considerable laceration of the pulmonary structure, and a cavity is at once formed, containing fluid and coagulated blood, which has been known to be evacuated into the pleural sac. Apoplectic extravasations are most apt to occur in situations deeply seated in the pulmonary parenchyma, near the roots of the lungs, or in the posterior portion of the lower lobes. The escape of blood into the bronchial tubes giving rise to haemop- tysis, occurs only when the extravasation takes place, or the blood gains access, into the air-cells. This constitutes the hcemoptoic in- farctus of Laennec. In the larger proportion of cases of pulmonary apoplexy, hemorrhage manifested externally, in other words, haemop- tysis, does not take place. 522 DISEASES OF THE RESPIRATORY ORGANS. Physical Signs.—Dulness on percussion will be marked if the portion of lung solidified be of considerable size and situated near the pulmonary superficies. But if it be small, or if the extravasation occur at several points quite limited in extent, and disseminated, and imbedded beneath the surface of the lung, dulness will be slight or not discoverable. The development of auscultatory phenomena involves the same conditions. If dulness be appreciable, or marked, the respiration over the site of the extravasation may be found to be suppressed, or to present more or less of the characters belonging to the broncho- vesicular or the bronchial respiration. But if the size and situation of the consolidation are such that no alteration of the percussion- resonance is apparent, it is not probable that any distinct modification of the respiration will be discovered. Exaggerated vocal resonance and fremitus have been observed over an amount of consolidation of blood sufficient to give rise to dulness on percussion. Mucous and sub-crepitant rales are often heard in the vicinity of the extravasation. Occasionally the true crepitant rale is discovered over or near the situation of the solidified mass. If an excavation be produced, the cavernous signs may be developed. Diagnosis.—Very little was known respecting pulmonary extrava- sations prior to the researches of the illustrious discoverer of auscul- tation. Laennec supposed that they were always accompanied by haemoptysis. Subsequent observations have shown that this symptom is present in only a certain proportion of cases, and, also, that of the instances in which haemoptysis occurs, extravasation into the pulmo- nary parenchyma coexists in an exceedingly small ratio. It follows that the expectoration of blood cannot be counted on as a diagnostic indication when pulmonary apoplexy actually exists, and that still less is the existence of pulmonary apoplexy to be predicated on the expectoration of blood. Laennec also entertained the belief that the physical signs of an apoplectic extravasation were quite distinctive. According to him, absence of respiratory sound over a limited area, and the presence of the crepitant rale around the borders of this space, constitute a com- bination which is diagnostic, provided haemoptysis be present. Obser- vations, however, have failed to establish the constancy of these associated phenomena. With reference to the crepitant rale in this connection, it is to be borne in mind that the distinction between, it and the sub-crepitant, has been made since the time of Laennec. PULMONARY APOPLEXY. 523 The diagnosis of pulmonary apoplexy, in fact, can rarely be made with precision, and in many cases is wholly impracticable. The most experienced auscultators concur in the remark made by Bouil- laud, that the occurrence of extravasation is rather guessed at than diagnosticated. Aside from haemoptysis, cough, expectoration, and embarrassment of the respiration, are incident to the affection, but they are not in themselves distinctive, inasmuch as they are incident to other forms of disease. The suddenness with which embarrassed respiration, in connection with hemorrhage and other pulmonary symptoms, is developed, is a circumstance which should give rise to a suspicion of extravasation. A patient attacked at once with these symptoms, having been previously free from all evidence of pulmonary disease, has some affection of rapid development, and this feature is accounted for on the supposition of an apoplectic effusion. Pulmo- nary apoplexy is very rarely, if ever, a primary affection. It occurs secondarily, in the vast proportion of cases, as a result of disease of heart, consisting in either hypertrophy of the right ventricle, or mitral valvular affection involving obstruction at that orifice. The latter is the lesion with which it is most frequently associated. The symptoms due to the extravasation will therefore be commingled with those proceeding from the heart affection. Its connection with disease of heart, however, is a point to be taken into account in the diag- nosis. The presence of signs and symptoms pointing to pulmonary apoplexy derive considerable force from the coexistence of cardiac lesions, especially contraction or patescency of the mitral orifice. Dulness on percussion over a limited space, situated not at the summit of the chest, and more especially if found on the lateral or posterior surface, together with the auscultatory evidence of solidifi- cation, or suppression of respiratory sound, and accompanied by diffi- culty of respiration suddenly developed, warrants a strong suspicion of extravasation. The sudden development of embarrassed respira- tion is a point of some significance ; but so far as the physical signs are concerned there is nothing in them to distinguish it from the solidification produced by gangrene, oedema, or carcinoma. If hemoptysis be added, or if the expectoration consist in part of a dark, grumous, bloody liquid, there is ground for a presumption of the existence of pulmonary apoplexy. The non-occurrence of fetid expectoration strengthens this presumption by excluding gangrene. A bloody expectoration may occur equally in carcinoma, but other symptoms and signs denoting carcinoma may be absent so as to render it highly probable that this affection does not exist. 524 DISEASES OF THE RESPIRATORY ORGANS. If the physical signs which I have supposed to be present are found at the summit of the chest in front or behind, a tuberculous deposit is vastly more probable than an apoplectic extravasation; and under these circumstances the occurrence of haemoptysis renders the fact of tuberculosis still more probable. The liability to attri- bute tuberculous solidification accompanied by haemoptysis, in certain cases, to pulmonary apoplexy, has been referred to in the chapter on pulmonary tuberculosis. In attempting to make the differential diagnosis from a tuberculous deposit, situation is an important point, observations showing that extravasation is not likely to occur at or near the apices of the lungs, where tubercle is first deposited in the vast majority of cases. The coexistence of heart disease is another point possessing diagnostic significance in this discrimination, since it is rarely found associated with pulmonary tuberculosis. It is thus seen that considerable uncertainty attends the diagnosis, in cases in which the extravasation is sufficient in amount to give rise to well-marked physical signs. And it is to be borne in mind that in a certain proportion, perhaps the majority of cases, the result of physical exploration is negative. In the absence of physical signs it is in vain to attempt to reach even a probable opinion as to the existence of the affection. The difficulties in the way of the diagnosis of pulmonary apoplexy render its infrequency a subject for congratulation, irrespective of the danger to life which belongs to it. The diagnosis involves a grave prognosis. In a case which came under my observation, in which it occurred as a complication of tuberculous disease of the lungs, death took place so suddenly as to call for a coroner's inquest. SUMMARY OF PHYSICAL SIGNS BELONGING TO PULMONARY APOPLEXY. The evidence of circumscribed solidification, furnished by percussion and auscultation, present in a certain proportion of cases only ; moist bronchial rales occasionally observed ; cavernous signs succeeding those denoting solidification in some instances. Cancer of the Lungs. Notwithstanding the extreme infrequency of cancer of the lungs, the disease possesses practical interest in consequence of the recent investigations of Stokes, Walshe, and others, with reference to its diagnostic characters, which are better established and more reliable than in the instance of the affection last considered. The form CANCER OF THE LUNGS. 525 of cancer distinguished as encephaloid is that generally present when the lungs are the seat of a malignant disease. Examples of the affection called colloid are exceedingly rare. The morbid de- posit is found either in circumscribed masses or nodules, varying from the size of a hazel-nut to that of an orange, more or less numerous, sometimes limited to one lung, but oftener existing in both sides; or, it is infiltrated more or less extensively into the air-cells,1 giving rise to a condition analogous to hepatization. It is stated that when the disease is primary, the cancerous deposit is infiltrated, and that the nodulated variety occurs when the disease is developed in the pulmo- nary organs secondarily, i. e. subsequent to a deposit in other organs. According to Rokitansky, the latter is met with oftener than the former variety. In proportion to the cancerous growth the pulmonary structure is destroyed, and the surrounding parenchyma undergoes compression. Solidification, then, is a morbid condition incident to the disease, re- presented by physical signs. In some cases, softening and elimina- tion through the bronchial tubes of the morbid material ensue, giving rise to the presence of liquid in the tubes, and the formation of cavities. Here are other conditions originating physical signs. In infiltrated cancer the affected lung suffers reduction in volume, and consequent contraction of the chest follows. This variety of the disease is usually limited to one side. The bronchial glands are generally involved. Liquid effusion within the pleural sac not infre- quently coexists. Cancer is very rarely found associated with a tuberculous deposit. Physical Signs.—If the deposit consist of a few small, dissemi- nated nodules, the intervening parenchyma being healthy, physical exploration may fail in furnishing positive results. If sufficiently large, numerous, or aggregated, and especially if situated near the surface, or if the surrounding lung-substance be oedematous, the phe- nomena denoting solidification will be more or less marked, viz., per- cussion—dulness, suppressed or enfeebled respiratory sound, with the characters of the broncho-vesicular or the bronchial respiration, and in some instances increased vocal resonance. In infiltrated cancer, physical signs are more constant and more marked. The percussion-sound is extremely dull or flat, the vesicular resonance over the middle third being sometimes replaced by tym- 1 Rokitansky's Path. Anat. Am. Ed. 1855, vol. 4, p. 100. 526 DISEASES OF THE RESPIRATORY ORGANS. panitic sonorousness. The dulness may extend beyond the median line on the healthy side. The sense of resistance is notably in- creased. The respiration is bronchial, and may be either intense or feeble. The respiratory sound is sometimes suppressed. This will occur when the calibre of the bronchus or its larger divisions is diminished by pressure of the cancerous deposit. Increased vocal resonance and bronchophony are observed in a certain proportion of cases. The heart-sounds are unduly transmitted. In short, the physical signs denote complete solidification, which is greater or less in extent. On inspection, flattening or contraction of the affected side is apparent, but not the depression of the shoulder, and spinal curvature, which result from chronic pleurisy. The intercostal de- pressions are somewhat deepened. The respiratory movements are diminished. On palpation, the vocal fremitus may at first be found to be increased, and afterward lessened. If softening and elimination take place, the physical phenomena correspond to the changes in the physical conditions of the affected lung. Percussion elicits more sonorousness, which, however, must be non-vesicular in quality. The sense of resistance is diminished. Mucous rales are now more or less prominent, and the cavernous signs may become developed. On the healthy side, in cases of infiltrated cancer, or of the nodulated variety, if the latter be extensive, and limited to one lung, the respiratory murmur will be abnormally intense or exaggerated. Diagnosis.—With reference to the symptoms and signs inyolved in the diagnosis, it is important to distinguish cancer of the lungs from cancerous tumors situated exterior to the pulmonary organs, generally developed in the mediastinum, which extend into the chest, displacing the lung and other organs. I shall notice the diagnosis of mediastinal tumors under a distinct head. Intra-thoracic cancer, however, may exist simultaneously, both Avithin and exterior to the lungs, and then the phenomena of both will, of course, be combined. Limiting, at present, the attention to cancer seated within the lungs, in the vast majority of cases, the march of the disease is ac- companied by symptoms denoting a grave pulmonary malady, and some of which possess diagnostic significance. A uniform symptom is cough, which is at first dry, but at length is attended by an ex- pectoration more or less abundant, and presenting variable characters. The expectoration consists, for a time, and always in part, of matter CANCER OF THE LUNGS. 527 furnished by the bronchial mucous membrane. It assumes frequently a purulent appearance, and is sometimes fetid. In a certain pro- portion of cases, it resembles, according to Stokes, black, and accord- ing to Hughes, red currant jelly. This appearance, due to an inti- mate admixture of blood with the morbid products, is regarded by the observers just named as highly characteristic of the disease. Pure haemoptysis occurs in a large proportion of cases during the course of the disease; according to Walshe, the ratio being seventy- two per cent.1 It is possible that the microscopical characters of cancer may be discovered in the sputa. Pain, more or less severe, in the affected side, is a pretty constant and persisting symptom. The pain differs in character in different cases, being acute or lancinating, dull and burning. This symptom is valuable with respect to the diagnosis. The respirations are increased in frequency in proportion to the extent of solidification or destruction, and sometimes, although rarely, dyspnoea becomes a prominent symptom. Dysphagia is a symptom noticed in some cases of pulmonic as well as mediastinal cancer. The pulse, for a considerable period during the progress of the disease, is not notably increased in frequency. Marked febrile movement is rarely present. This is a negative fact of im- portance in a diagnostic point of view. Emaciation is generally less marked than in most cases of tuberculosis. The complexion, in a certain proportion of cases, denotes anaemia, and may present the waxen or straw-colored hue, which has been considered heretofore as highly significant of malignant disease. In a small proportion of cases, cancer of the lungs is a latent dis- ease as regards symptoms. And when it is limited to small, cir- cumscribed, disseminated deposits, and especially if these are about equally distributed in both lungs, physical exploration, as already stated, may not furnish positive results. But if the extent of the affected lung be sufficient to give rise to the signs of solidification, which is true of the great majority of the cases of infiltrated cancer, the symptoms and history, taken in connection with the results of exploration, are generally adequate to establish a diagnosis. Under these circumstances, the nature of the disease is ascertained not so much from any positive diagnostic characters, as by excluding other chronic affections also involving solidification of lung, and certain of the symptoms as well as signs which belong to cancer. 1 The analysis by Walshe embraced cases of cancer of the mediastina as well as of the lungs. 528 DISEASES OF THE RESPIRATORY ORGANS. As remarked by Walshe, infiltrated cancer can only be confounded with diseases lessening the bulk of the lung. These affections, ex- clusive of cancer, are tuberculosis, chronic pneumonitis, chronic pleu- risy, and the affection called by Corrigan cirrhosis of the lung. It will suffice to notice the points involved in the differential diagnosis from these affections respectively. In pulmonary tuberculosis, the physical signs of solidification, with contraction of the summit of the chest, are equally present; and in- asmuch as this affection is as frequent as cancer is rare, the practi- tioner is very likely to mistake the latter affection for phthisis. More- over, certain of the symptoms highly characteristic of tuberculosis belong to the history of cancer, viz., haemoptysis, emaciation, and anaemia. The distinctive circumstances pertaining to both signs and symptoms, are, however, striking. In cancer, the solidification fre- quently remains for a considerable or even a long period, i. e. several months, without material change; in other words, without softening and excavation, as evidenced by the development of mucous rales, gurgling, and the cavernous modification of respiration. On the other hand, with an equal amount of tuberculous deposit, the signs just mentioned would be expected to supervene more uniformly, and after the lapse of a shorter period. And as the softening and elimination of tubercle go on, in general, more extensively as well as more rapidly, these signs become more strongly marked than in the course of cancer. In the latter affection, the phenomena due to the solidification, viz., dulness or flatness, with suppression of respiratory sound, or the bronchial respiration, and perhaps bronchophony, con- tinue without the addition of the contingent adventitious sounds, or rales, for a longer time than in phthisis. In infiltrated cancer, the deposit, being extensive, and, in the majority of cases, limited to one lung, the affection differs from phthisis in presenting the signs of solidification exclusively on one side, the other side affording no evi- dence of disease. With a similar amount of tubercle in one lung, more or less of the evidences of a tuberculous deposit in the other lung would be expected. The two circumstances just mentioned are the strong points in the differential diagnosis, so far as concerns the physical signs. As regards symptoms, the expectoration of matter resembling currant jelly, which occurs in a certain proportion of the cases of cancer, is foreign to the semeiological history of tuberculosis. Febrile movement, or marked acceleration of the pulse, which, in the majority of cases, characterize the march of phthisis, do not occur CANCER OF THE LUNGS. 529 till late in the progress of cancer. Pain in the chest, exclusive of that attending the occasional attacks of dry, circumscribed pleurisy, does not belong to the history of phthisis. The pleuritic stitch-pain just referred to, is readily recognized, and constitutes, as has been seen, one of the characteristic symptoms of tuberculous disease. Cancer, on the other hand, generally gives rise to persisting pain, which becomes thus a prominent feature of the disease. The dis- turbance of the circulation is disproportionately less, compared with the pulmonary symptoms, than in cases of tuberculous disease, the pulse frequently, for a considerable period, remaining nearly or quite natural. Emaciation is not so prominent a feature early in the career of the disease as in the majority of the cases of phthisis. In a cer- tain proportion of cases, cancer of the lungs coexists with a cancerous deposit in some part where its characters are open to inspection or manual examination. The existence of cancer elsewhere than in the lungs, with pulmonary solidification, renders it altogether probable that the latter is cancerous; and if, after the extirpation of a can- cerous part, the occurrence of pulmonary symptoms and signs denotes some grave affection of the lungs, the development of cancer in these organs is highly probable, since observations show that, under these circumstances, they are apt to be invaded. Attention to the foregoing points of distinction will, probably, in a large proportion of cases, enable the practitioner to discriminate clinically between the two affections. Chronic pneumonitis is nearly if not quite as rare an affection as cancer of the lungs. It is attended by contraction of the chest, but in a less degree than infiltrated cancer. A cancerous deposit differs from tubercle, as has just been seen, in undergoing less uniformly and more slowly the processes of softening and elimination. On the other hand, it differs from chronic pneumonitis in the greater fre- quency with which it eventuates in excavation. In extensive cancer- ous solidification, the percussion-dulness sometimes shows the exten- sion of the disease laterally beyond the median line. This does not- occur in chronic pneumonitis.. Chronic pneumonitis generally succeeds the acute form of the disease. Acute pneumonitis is an antecedent of cancer only as a coincidence. The lower lobe of the lung is most prone to be attacked with inflammation. A cancerous deposit is most apt to take place in the superior lobe. Pure haemoptysis, which oc- curs in a large proportion of cases of cancer, very rarely, to say the least, is a symptom of pneumonitis; nor is the jelly-like expectora- 34 530 DISEASES OF THE RESPIRATORY ORGANS. tion distinctive of cancer observed in cases of the latter affection. The concurrence of cancerous deposits elsewhere than in the lungs, has the same diagnostic significance as in the differential diagnosis from tuberculosis. In chronic pleurisy, marked contraction of the chest follows the ab- sorption of a considerable portion of the liquid effusion. Assuming that a case comes under observation at this period of the disease, there is a possibility of mistaking it for cancer. But, in general, if a case have not been observed, either from the beginning, or an early period in the disease, the previous history will supply facts sufficient, in conjunction with present signs and symptoms, to render the character of the disease abundantly clear. The distinctive circumstances, how- ever, are not less available than in the other affections which are to be excluded in arriving at the diagnosis of cancer. The contraction of the chest is greater and more general on the affected side in chronic pleurisy : the shoulder is depressed, the spine frequently curved in a lateral direction, the intercostal spaces, except at the summit, nar- rowed, and the respiratory movements more diminished. Unless the liquid effusion be completely absorbed, flatness and absence of respi- ratory sound extend from the base of the chest upward to a certain height. But it is to be borne in mind that pleurisy, with liquid effu- sion, may occur as a complication of cancerous disease. The pulmo- nary and general symptoms are not sufficiently grave for an amount of cancerous disease sufficient to account for the physical signs. Cough and expectoration are frequently slight or wanting in chronic pleurisy. The strength and weight are better preserved. Haemop- tysis occurs but rarely, unless the pleurisy be complicated with tubercle. The jelly-like expectoration peculiar to cancer is never observed. Cirrhosis of the lung with dilatation of the bronchiae presents, in connection with thoracic contraction, this distinctive feature of cancer, viz., persistency of the signs of solidification. In the differ- ential diagnosis the existence of the latter affection is determined or disproved by the absence or presence of bloody expectoration and pure haemoptysis; by pain being either wanting or prominent; by the evidence of a grave affection, which belongs to the history of can- cer, derived from loss of weight and strength, and the physiognomy indicating a malignant disease; or, on the other hand, the deficiency of this evidence, which, comparatively speaking, distinguishes cirrho- sis, and by the existence or non-existence of cancerous deposit in situations accessible to direct examination. CANCER IN THE MEDIASTINUM. 531 SUMMARY OF THE PHYSICAL SIGNS BELONGING TO CANCER OF THE LUNGS. Absence of positive signs, if the cancerous deposit be in the form of small, disseminated nodules, distributed in both lungs. Dulness on percussion with the auscultatory signs of solidification, when the nodules are sufficient in number and size, agglomerated, accompanied by oedema, and especially if limited to or more abundant on one side. In cancerous infiltration, contraction of the chest over the affected lung, and lessened respiratory movement. Marked diminution or absence of vesicular resonance on percussion, with or without the substitution of tympanitic sonorousness, and marked resistance of thoracic wall. Bronchial respiration, or suppression of respiratory sound, with or without increased vocal resonance, or bronchophony, and vocal fremitus. Undue transmission of the heart-sounds. After a time, mucous rales, gurgling and cavernous; the percussion-reso- nance greater than previously, but tympanitic. Supplementary respiration on the unaffected side. Cancer in the Mediastinum. Intrathoracic cancer exterior to the lungs may originate in the pleura or mediastinum, forming one or more tumors, of greater or less size, displacing and compressing the pulmonary organs, the trachea and bronchi, the heart and its large vessels, the oesophagus, thoracic duct, and nerves, and giving rise to symptoms and signs which distinguish it from a cancerous affection, properly speaking, of the pulmonary organs. Although perhaps strictly more appropriate to include cancerous growths exterior to the lungs, in the group of diseases affecting the pleura, which will constitute the subjects of the succeeding chapter, it will be more convenient and useful to notice them in the present connection, in order to present their diag- nostic traits in contrast with those which belong to the same disease seated within the pulmonary organs. And it will answer every pur- pose to notice cancer in the mediastinum exclusively, since, with cer- tain qualifications, which will readily suggest themselves, the points involved in the diagnosis are the same as when the affection is deve- loped at any other point within the chest exterior to the lungs. More- over, the principles of diagnosis which relate to cancer in the medi- astinum will apply, with very few modifications, to other tumors 532 DISEASES OF THE RESPIRATORY ORGANS. having the same seat; and, therefore, it will suffice to consider the symptoms and signs belonging to the former, as representing the latter, irrespective of certain circumstances distinctive of a cancerous affection, which will be briefly alluded to. A fact already stated is to be borne in mind, viz., that cancer ex- ists exterior to, and at the same time within the lungs, in a certain proportion of cases. A cancerous growth originating in the mediastinum, will extend into one or both sides of the chest, in proportion to its magnitude and the direction laterally which it takes. It has been oftener observed to extend into the right than into the left side. In some cases it attains to such size as to fill nearly the entire thoracic space on one side, and also a considerable portion of that on the opposite side. An instance of this kind is given by the late Prof. Swett,1 in which the tumor weighed eleven and a half pounds. The tumor may ex- tend in either lateral direction about equally, compressing both lungs alike, and giving rise to similar physical phenomena on both sides of the chest. Physical Signs.—Diminution or abolition of vesicular resonance on percussion extends from the median line on one or both sides over an area within which the tumor is either in contact with or in close proximity to the thoracic parietes. The vesicular resonance, especially at the summit of the chest in front and behind, near the median line, may be replaced by a tympanitic or tubular sonorousness transmitted from the trachea and bronchi. A tympanitic sonorousness may also be found over the middle and lower parts of the chest, and an amphoric modi- fication is sometimes observed. The source of the sonorousness in the latter instance is probably gastric or intestinal. A marked de- gree of tympanitic sonorousness in either situation is an exceptional phenomenon. As a rule, percussion over the tumor elicits dulness or flatness. And this dulness or flatness being dependent on the pre- sence of a solid mass which is at least attached at the point whence it springs, the area over which it extends remains unaltered, or nearly so, in different positions assumed by the patient. If the tumor extend, so as to come into contact with the heart or liver, the relative positions of the latter to the tumor may frequently be ascertained by an alteration in the percussion-sound. The sense of resistance felt by the finger employed in percussing or in pressure, made expressly with reference to this point, is notably increased. 1 Diseases of the Chest, page 335. CANCER IN THE MEDIASTINUM. 533 Auscultation may discover strongly marked the characters of the bronchial respiration at the summit of the chest in front and behind, extending more or less therefrom over the chest; or these characters may be feebly manifested; or, again, the respiratory sound may be abolished over a greater or less portion of the space in which percus- sion-dulness or flatness are observed. These variations depend on the relations of the tumor to the trachea and bronchi, and on the amount of compression which may be made on these portions of the air-pas- sages. The bronchial respiration, when present, may be heard either over the compressed lung at the summit, or over the tumor, or in both situations. Its limitations, therefore, as well as those of suppressed respiratory sound, do not always rigidly correspond to the space occu- pied by the tumor. Adventitious sounds, or rales, are present as contingent phenomena, due to coexisting bronchitis, or, if a cancerous deposit within the lungs have taken place, to its softening and elimi- nation. The sounds of the heart are unduly transmitted. The vocal signs are variable. There may be marked increase of the vocal resonance and bronchophony, or these phenomena may be wanting. Even pectoriloquy may be present. Pressure of the tumor on the aorta may occasion an arterial thrill and bellows murmur. Inspection and palpation furnish important signs. Dilatation of the chest distinguishes cancerous growths developed exterior to the lungs, after they have attained a certain size. The dilatation is partial or extends over the whole of one side, or affects both sides, according to the size and direction of the morbid growth. It may be confined to the sternum and costal cartilages ; but as the resistance is less in a lateral direction, the tumor generally extends into the chest, instead of producing a circumscribed enlargement in the situations just men- tioned. The intercostal spaces are widened, and in some cases are dilated or even bulging, and remain unaffected by the act of inspira- tion.1 The heart may be removed in various directions from its normal position. In the case already referred to, reported by Prof. Swett, it was found to the right of the sternum, where its pulsations had been observed during life. If the tumor extend to the base of the chest, the diaphragm and the subjacent viscera may be depressed. The superficial thoracic veins of the affected side maybe enlarged, accom- panied with a livid hue and oedematous infiltration. Fluctuation is very rarely observed, but this was present in the case reported by i Vide case reported by Prof. Swett (op. cit. p. 334), in which bulging was observed. 534 DISEASES OF THE RESPIRATORY ORGANS. Prof. Swett. The vocal fremitus over the tumor is abolished. In proportion as the chest is dilated, its contraction with the act of ex- piration is restrained, and the range of expansive movement correspond- ingly lessened. Mensuration shows an increase of the size of the chest; an abnor- mal disparity in this respect existing between the two sides, if the dilatation be confined to one side, or if the two sides are unequally dilated. This disparity is manifested by semicircular measurements, by a comparison of the antero-posterior diameters, and by a greater distance from the nipple to the median line. Diagnosis.—The compression and displacement of the pulmo- nary organs, air-tubes, vessels, oesophagus, etc., by a mediastinal tumor, give rise to a variety of symptoms, as well as signs, which are measurably distinctive when contrasted with cancer of the lungs. In proportion to the extent to which the lungs, air-passages, pulmo- nary artery, and veins are compressed, the dyspnoea becomes a pro- minent symptom. The suffering from want of breath, as the tumor increases in size, may be extreme, rendering the recumbent posture insupportable. Pressure on the venous trunks communicating with the veins of the head and upper extremity induces congestion of these parts, which occasions tumefaction, lividity, and oedema. When the pressure is chiefly on the vessels of one side, 'the distension of the veins, together with tumefaction and oedema, are limited to that side. Heaviness and somnolency are incident to cerebral engorgement. Pressure on the oesophagus may occasion an obstruction to the pas- sage of alimentary substances, and hence results dysphagia, which is more likely to be prominent as a symptom than in cancer seated in the lungs. Diminishing the calibre of the arteria innominata or the subclavian on one side, the radial pulse of the extremity corresponding to that side may be perceptibly less in size and force than that of the oppo- site extremity. If the important nerves, the par vagum, recurrent, or the phrenic, are included in the parts compressed, here is another source of dis- turbance of the respiration, affecting the diaphragmatic action, and the respiratory movements of the glottis. Hydrothorax or pleurisy leading to the formation of pus (empyema) are contingent affections, giving rise to the phenomena dependent on liquid within the pleural cavity. Pain in the chest is more or less persisting and severe; CANCER IN THE MEDIASTINUM. 535 cough, haemoptysis, and the jelly-like expectoration referred to in connection with cancer of the lungs, may occur in the course of this affection, and toward the close of life anasarca is usually present. Perforation of the thoracic wall, of the lung, oesophagus, or some of the large vessels, is liable to occur, giving rise to additional trains of symptoms, or proving the immediate cause of a fatal termination. Numerous, diversified, and grave as are the results just enume- rated, Dr. Walshe states that he has seen them united in one and the same individual. Differentially, the diagnosis of mediastinal tumors involves, in the first place, a discrimination from cancerous infiltration of the lungs, and the several affections with which the latter is liable to be confounded. The distinctive circumstances are those which have relation to dilata- tion of the chest, and the pressure of the tumor on the vessels, air- passages, nerves, oesophagus, heart, etc. The phenomena due to en- largement, displacement, and compression, are rarely present, and never to the same extent in cancer seated in the lungs, in chronic pneumonitis, in tuberculosis, or in pleuritis after partial absorption. These phenomena, constituting a large share of the list of symptoms and signs just given, are characteristic of intrathoracic tumor exterior to the lungs. Moreover, from pneumonia, and tuberculosis, and chronic pleuritis, a cancerous tumor in the mediastinum may often be distin- guished by the occurrence, in the course of the disease, of certain of the symptoms which are observed in a cancerous affection of the lungs, viz., haemoptysis, and the currant-jelly expectoration. And in this connection the fact may be again stated, that mediastinal cancer frequently coexists with a cancerous affection of the lungs. In the second place, mediastinal tumor is to be discriminated from enlargement of heart, pericarditis with large effusion, and aortic aneu- rism. Many of the phenomena incident to the dilating, compressing, and displacing effects of a mediastinal tumor, which have been enu- merated, are common to the affections just named. The differential diagnosis turns on the presence or absence of the symptoms and signs distinctive of these affections; in other words, in arriving at the con- clusion that the phenomena proceed from a mediastinal tumor, and not from either of these affections, the latter are to be excluded. To consider the negative points warranting their exclusion, would involve a consideration of their positive diagnostic criteria; for these, the reader must be referred to works which treat of the diseases of the heart and arteries. 536 DISEASES OF THE RESPIRATORY ORGANS. In the third place, the affections for which there is the most liability of mediastinal tumor being mistaken, are chronic pleurisy, prior to retrac- tion of the chest, and empyema. Here we have the phenomena due to dilatation, displacement, and in a certain amount to compression, combined. Moreover, the fact is not to be lost sight of, that liquid effusion within the pleural sac, either purulent or serous, may exist as a complication of mediastinal cancer, or of a cancerous affection of the lungs. This complication renders the diagnosis less intricate than might at first be supposed. The phenomena due to compres- sion, viz., dyspnoea, tumefaction of face, lividity, swelling of the veins, dysphagia, are not present to the same extent in chronic pleuritis, or empyema, even when the chest is largely dilated. In a case of mediastinal tumor involving a considerable amount of dilata- tion of the chest, the effects of pressure on large vessels, trachea, oeso- phagus, and nerves, may be expected to be in a marked degree greater than when an equal amount of dilatation is caused by pleuritic effusion alone. This is a capital point of distinction. Moreover, the distinc- tive characters of cancer pertaining to the expectoration, viz., haemop- tysis, and the peculiar jelly-like matter, do not occur in chronic pleurisy or empyema. Hence, if these symptoms are present, they are diagnostic of a cancerous affection; and the coexistence of cancer in some part where the fact can be ascertained by examina- tion, here, as in other instances, is highly significant. Physical ex- ploration furnishes certain distinctive points. The bronchial respira- tion, and bronchophony are marked in cases of chronic pleuritis with large effusion, or of empyema, only in rare, exceptional instances. Although not uniformly observed in connection with cancer in the mediastinum, they are much more frequently present, and not infre- quently strongly marked. The dilatation of the chest from the dis- tension of liquid is more uniform than from an intrathoracic tumor. The intercostal depressions are more constantly and in a more marked degree affected by distension from liquid. It is rare that bulging between the ribs occurs from the distension of a tumor, while it is the usual effect of great enlargement from the presence of liquid. A sense of fluctuation is an exceptional phenomenon in the former case, and occurs more frequently in the latter.1 Finally, it is extremely 1 Bulging and fluctuation are stated not to occur in dilatation from the presence of an intrathoracic tumor, but both were observed in a case of cancer in the mediastinum, already referred to, reported by Prof. Swett, in which a trifling quantity of liquid only existed within the pleural sac. CANCER OF THE MEDIASTINUM. 537 rare in cases of chronic pleurisy with large effusion, or in empyema, to find vesicular resonance on percussion, denoting the presence of pulmonary normal substance below the level of the liquid. In cases of mediastinal tumor, on the other hand, it will frequently, and per- haps generally, be found that the physical evidence of lung containing air in the air-cells is obtained in parts of the chest in which, if the morbid phenomena were due to liquid effusion, the gravitation of the fluid would be almost sure to abolish both the vesicular resonance and respiration. The data upon which a probable opinion that a mediastinal or other intrathoracic tumor is of a cancerous nature, are briefly the following: Haemoptysis, and the characteristic jelly-like expectora- tion, or, possibly, the presence of cancerous matter, determined microscopically in the sputa, these phenomena, probably in the majo- rity of cases, indicating a coexisting deposit of cancer within the lungs; and the existence of a cancerous affection in other parts of the body, in which the fact of its existence may be positively ascer- tained. It is proper to state, that in treating of cancer of the lungs and in the mediastinum, I have relied on the observations of others, with- out having been able, owing to the infrequency of the disease, to verify their correctness by my own clinical studies; and I would particularly express my indebtedness to the treatise by Dr. Walshe, to which, in the course of this work, frequent reference has been already made. CHAPTER VII. ACUTE PLEURITIS —CHRONIC PLEURITIS — EMPYEMA — HYDRO- THORAX — PNEUMOTHORAX — PNEUMO-HYDROTHORAX — PLETJ- RALGIA—DIAPHRAGMATIC HERNIA. The group of diseases to which this chapter is devoted, consists of affections which are either seated in the pleura, or, as in the case of the two last named, in their situation are related more closely to this than to any other of the structures entering into the anatomical composition of the pulmonary organs. They form an interesting and important class of the diseases of the respiratory system. As regards their diagnosis, it will be found that, without the aid derived from physical exploration, they are frequently detected with great difficulty, and, indeed, in many instances cannot be distinguished from each other, or from certain of the diseases treated of in the preceding chapters. On the other hand, by means of physical signs in conjunction with symptoms, the discrimination is in general made with facility and positiveness. I shall consider these affections, respectively, in the order in which they are. enumerated in the heading of this chapter. Acute Pleuritis. In point of frequency this affection ranks third in the list of acute pulmonary diseases, bronchitis and pneumonitis taking precedence in this regard. It occurs either as an independent or a concomitant pulmonary affection. When developed as a complication of some other disease of the lungs, as in tuberculosis and pneumonitis, the inflammation is usually limited to a portion of the pleural surface: in other words, the pleuritis is circumscribed. Its occurrence in connection with the diseases just named, has been noticed in the chapters devoted to their consideration. When not thus consecutive, the inflammation is usually general, i. e. it extends more or less over ACUTE PLEURITIS. 539 the entire pleural membrane on one side. To this rule, however, there are exceptions. The inflammation is sometimes limited, con- stituting partial pleurisies, which are called, according to the portions affected, costal, pulmonary, diaphragmatic, mediastinal, and inter- lobar. Again, the pleuritic inflammation may be confined to one side, or affect both sides. In the former case it is single, and in the latter double pleuritis. In treating of the physical signs and diag- nosis of the disease, reference will be had, in the first place, to acute general pleuritis. Partial pleurisies will be briefly noticed after treating of chronic pleuritis. Acute general pleuritis is divided by some writers into several stages. For clinical convenience, and with especial reference to variations in physical signs, it suffices to recognize three different periods in the progress of the disease. 1st. The period from the commencement of the inflammation to the accumulation of an appre- ciable quantity of liquid effusion within the pleural sac. This period will comprise the dry and plastic stages of some writers. 2d. The period during which the liquid is either accumulating or remains sta- tionary. This period may be called the stage of effusion or of liquid accumulation. 3d. The period when the liquid effusion is being re- moved by absorption. Perforations of the thoracic wall, and of the lung, by which the effused liquid is evacuated, in the one case directly and in the other case indirectly through the bronchial tubes, are acci- dental events of rare occurrence, and do not, therefore, belong to the natural history of the disease, as deduced from the phenomena occur- ring in the large majority of cases. The physical conditions pertaining to the morbid anatomy, which are represented by signs in these three periods, are the following. First. The presence of plastic lymph, either in patches, varying in size, and more or less numerous, or sometimes diffused over the whole of the inner surface of the pleural sac. It has been hypothetically assumed that, prior to this deposit, there exists for a time an abnor- mal dryness of the membrane, which may give rise to acoustic phe- nomena. Second. The presence of liquid, which speedily gravitates to the bottom of the sac, compressing the lung, and displacing it in a direction upward and backward, except it have become fixed at certain points by previous morbid adhesions. The accumulation of liquid in some cases in sufficient quantity to expel by compression the air from the lung, reducing it to a small condensed mass (carni- fication) ; at length enlarging the size of the chest, depressing the 510 DISEASES OF THE RESPIRATORY ORGANS. diaphragm and subjacent organs, displacing the heart, and producing various alterations in the relations of the parts composing the tho- racic parietes. Third. The diminution and ultimate disappearance of the effused liquid, accompanied by an expansion of the compressed lung, which regains, only after a time, and frequently never, its former volume. Contraction of the chest, and often persisting or permanent alterations in form, and in the relations of parts, the re- verse of those which have occurred at a former stage. The pleural surfaces, in proportion as the liquid effusion diminishes, again coming into contact, roughened by a fibrinous coating more or less solidified, and in progress of organization. Finally, adhesion of the pulmonary and costal pleurae by means of the complete organization of the in- termediate plastic lymph. The foregoing sketch of the physical conditions belonging to the different stages of the disease, will apply equally to acute and chronic pleuritis, and as regards the effects of an abundant accumulation of liquid on the walls of the chest and the intrathoracic organs, they are generally much more marked in the latter variety of the disease. Physical Signs.—As remarked by Valleix, the phenomena belong- ing to the natural history of pleuritis, notwithstanding the frequency of the disease, have not been studied, by means of the analysis of clinical records, to the same extent as those of some other pulmonary affections, more especially pneumonitis and tuberculosis.1 Neverthe- less, its diagnostic traits, derived both from signs and symptoms, are well ascertained. With respect to the results of physical explora- tion, some interesting facts have been recently contributed. Proceeding to present the phenomena of the different stages of this affection, as furnished by the several methods of exploration, in the order in which the latter were taken up in the first part of this work, the signs obtained by percussion are to be first noticed. Prior to the accumulation of liquid in sufficient quantity to gravitate to the bottom of the chest, and to occupy a certain amount of space to the exclusion of the lung, the sonorousness on percussion may not be in a marked degree altered. • Moderate or slight diminution of the vesicular resonance, replaced, according to Skoda, by a tympanitic sonorousness,2 is usually discovered, attributable to several causes, 1 This distinguished clinical observer and author, lately deceased, at the time of his death was engaged in preparing a paper on the results of percussion in pleurisy. (Archives Generates de Medecine.) 2 Although much stress is laid by Skoda on modifications of resonance which he dis- tinguishes as tympanitic, yet, as remarked by M. Aran (his French translator and com- ACUTE PLEURITIS. 541 viz., lessened expansion of the lung on account of the pain attending the inspiratory act; the exudation of plastic lymph on the pleural surfaces, and, possibly, as contended by Woillez andHirtz, the pre- sence, during this stage, of a thin stratum of liquid uniformly diffused over the lung. The latter, which is called laminar, in distinction from gravitating effusion, is questionable; and that the lessened ex- pansion of the lung is the chief cause of the diminished resonance, may be shown by the fact that a deep inspiration (if the patient will disregard the pain which instinctively leads him to repress the move- ments of the affected side), restores the normal sonorousness. Due to the causes just mentioned, individually or collectively, the diminu- tion of resonance extends over the whole of the greater part of the affected side. During this stage especially, and frequently during the subsequent stages, percussion, unless lightly performed, is painful, owing to the soreness of the chest. The effusion of a sufficient quantity of liquid to gravitate, and elevate the lung to a greater or less extent, generally takes place with such rapidity, that in a large proportion of cases the opportunity of examining the chest during the first period of the disease is not offered. It very rarely happens that hospital patients come under observation before the disease has advanced to the second period. The stage of liquid accumulation may supervene even in a few hours after the date of the attack, and it is seldom delayed beyond the third or fourth day. When the liquid accumulates at the bottom of the pleural sac, elevating the lung, the vesicular resonance is abolished from the base of the chest upward over a space corresponding to the amount of effusion. The percussion-sound is flat, except a gastric or intestinal mentator), he nowhere gives a clear and distinct statement of the sense in which he intends to apply this term. The word tympanitic, as has been seen in Part I, is used with different latitudes of signification by different writers. From the language used by Skoda, in the chapter on pleurisy, it may be inferred that he considers a sound as tympanitic whenever it is non-vesicular, without regard to its intensity. He says, " The greater the depth of the exudation (in pleurisy), the duller the percussion-sound becomes, so that at least we are not able to recognize the tympanitic character of the dull percussion-sound." (Markham's translation, Am. Ed. p. 346.) Accepting this sense of the term tympanitic, which is precisely that adopted in this work, the doc- trine, of Skoda, that whenever " the lung contains less than its normal quantity of air, it yields a sound which approaches to the tympanitic, or is distinctly tympanitic," is more readily admissible, and at the same time more intelligible. Whenever the absolute quantity of air is reduced in the lung, as a rule, the relative quantity contained in the bronchial tubes exceeds that in the cells. Hence, going no farther for an explanation, while the sound becomes more dull it acquires a tympanitic quality. 542 DISEASES OF THE RESPIRATORY ORGANS. tympanitic sonorousness be transmitted from below, and under these circumstances the latter rarely occurs in a marked degree. Aboli- tion of vesicular resonance is invariable, and flatness is the rule. At the same time the elasticity of the thoracic wall is notably diminished, and the sense of resistance increased below the line indicating the upper boundary of the flatness. If the quantity of effusion be quite small, although sufficient to elevate the lung to some extent, the evidence of its presence afforded by percussion, while the patient is in one position only, may be incomplete, owing to the normal line of flatness being variable in different persons, and on the left side in the same person at different periods. The results of percussion in different positions will often, if not generally, in such a case, establish the presence of liquid. Having ascertained and marked the point at which the vesicular resonance is lost on the posterior surface of the chest while the patient is in a sitting posture, let him then lie upon the face, waiting a moment for the liquid to gravitate to the anterior portion of the sac. Percussion may now elicit a vesicular resonance below the line indicating its lower boundary when the body was in a vertical posi- tion. But it is seldom that the quantity of liquid is so small as to leave room for doubt whether the situation of the line of flatness be abnormal. The effusion varies greatly in amount in different cases. Although usually less abundant in the acute than in the chronic variety of general pleuritis, it is usually so considerable in the former as to render it evident that the flatness found at the base of the chest is due to some morbid condition, which is in all probability intra- thoracic. Extending upward from the base*over a third, a half, or two-thirds of the chest on the affected side, the line of flatness, generally defined without difficulty by percussion, marks the level of the liquid. This line may be found not to pursue a horizontal direction when the body is in a vertical position, owing to a portion of the lung being fixed below the level of the liquid by previous morbid adhesions. For example, in a case recently under observation, in which the evi- dence of liquid in the left pleural cavity was unequivocal, the line of flatness extended horizontally through the nipple, laterally and pos- teriorly, to within two or three inches of the spinal column. From this point percussion elicited a vesicular resonance for several inches below a continuation of the horizontal line, showing that at its infe- rior posterior extremity the lung was held down by an attachment which was sufficient to resist the upward pressure of the liquid. ACUTE PLEURITIS. 543 Variation in the line of flatness with different positions of the patient, in a proportion of cases, larger, as I am led to suspect, than is to be inferred from the opinions expressed by most writers on this subject, is available as a test that the flatness is due to the presence of liquid, provided the chest be but partially filled with the effusion. It is not available when the pleural surfaces are adherent above the level of the fluid, nor when the lung is so much compressed that its elasticity is destroyed. In the case just referred to, in which the infe- rior posterior extremity of the lung was fixed at the base of the chest, the evidence of the presence of liquid was afforded by 'percussion over the submerged portion of the lower lobe. When the patient inclined far forward, or lay upon the face, the resonance became notably greater than when the position of the body was vertical; showing that the portion of lung was not united to the thoracic wall by a close, uniform adhesion, but by bridles or bands of false mem- brane. The direction which the line of flatness is found to pursue when the patient is sitting or standing, serves to distinguish a gravitating effusion from the solidification of the lower lobe in lobar pneumonitis. In the latter case, as stated in the chapter on pneumonitis, provided the inflammatory exudation be limited to the lower lobe, and extend over the whole lobe, the situation of the interlobar fissure, crossing the chest obliquely from the fourth or fifth cartilages to the spinal extremity of the spinous ridge of the scapula, may be delineated by an abrupt change in the percussion-sound; and this line is found not to vary with the different positions of the patient. It could only be by a coincidence hardly falling within the range of probability, that a collection of liquid should happen to be confined by pleuritic ad- hesions within a space bounded exactly by the interlobar fissure. The loss of elasticity and sense of resistance on percussion are greater in proportion as the effusion is abundant, being strongly marked when the quantity is sufficient to produce considerable enlarge- ment of the chest. The abolition of sonorousness is usually more complete below the level of a considerable quantity of liquid, than over lung solidified by inflammatory or other exudation. The sound in the former in- stance is flat; in the latter, more or less dull, the presence of air within the bronchial tubes and some of the cells preventing total ex- tinction of resonance, which, under these circumstances, is not vesi- cular, but tympanitic in quality. Perfect flatness, therefore, although not conclusive evidence of the presence of liquid, for it may be caused 544 DISEASES OF THE RESPIRATORY ORGANS. by an intrathoracic tumor, and occasionally even by consolidation of lung, warrants a strong presumption that effusion exists. And this presumption is rendered still stronger by the flatness being found to extend from the base of the chest upward, the line indicating its upper limits being well defined, and pursuing a direction, if the body be in a vertical position, extending horizontally, or nearly so, around the affected side.1 In cases in which the quantity of liquid is large, distending the chest, and compressing the lung into a solid mass, either flatness exists universally over the affected side, or, at all events, there is com- plete abolition of vesicular resonance, and the flatness may not be confined to the affected side. The accumulation of liquid, when large, produces a lateral displacement of the mediastinum, and the distended pleural sac may even encroach on the opposite side, giving rise to dulness on percussion, sometimes extending from half an inch to an inch beyond the sternum. But when the effusion is less abundant, the fluid rising to within a third, a half, or two-thirds of the distance from the base to the top of the chest, percussion over the compressed lung, above the level of the liquid, furnishes interesting results. The sonorousness is frequently increased, being greater than in a corre- sponding situation on the opposite side, and it becomes more or less tympanitic in quality. This fact had attracted, in occasional in- stances, the attention of several observers, but the frequency of its occurrence has only of late been ascertained. The existence of a tympanitic resonance above the level of the liquid, in cases of pleuritis, is probably the rule, and an exaggerated sonorousness in the same situation, according to the observations of Dr. Roger of Paris, pro- vided the quantity of liquid be neither very large nor quite small, exists for a greater or less period during the progress of the disease, in a large proportion of cases. The tympanitic resonance over the lung above the liquid may have a metallic character, resembling the high-pitched, peculiar sound, obtained frequently by percussing over the stomach. A French observer, M. Notta, has recently reported two cases in which this character of sonorousness was strongly marked. On the left side, it might be suspected that the sound was 1 It is stated (Traite" de Diagnostic, etc., par le Docteur V. A.Racle), that when a cer- tain quantity of liquid is contained within the pleural sac, and the pleural surfaces are free from adhesions, the body being in a vertical position, the level is not exactly hori- zontal, the fluid rising somewhat higher behind than in front. ACUTE PLEURITIS. 545 actually transmitted from the stomach ; but in the cases reported by M. Notta, the effusion was on the right side.1 Even the cracked-metal-modification of tympanitic sonorousness has been observed by Stokes, Walshe, Roger, and Bouillaud, at the summit of the chest in cases of large effusion within the pleural sac. During the progress of the removal of the liquid by absorption, the vesicular resonance gradually returns, extending from above down- ward in proportion as the level of the fluid is lowered. Diminution of vesicular resonance, however, as compared with the healthy side, with or without the substitution of a tympanitic sonorousness, per- sists for an indefinite period; and, owing to the slowness with which absorption usually goes on after the quantity of liquid has been con- siderably reduced, flatness continues for a long time at the base of the chest. The displacement of intra-thoracic parts arising, on the one hand, from the pressure of a large quantity of effusion, and, on the other hand, from the suction-force developed by the absorption of the liquid, will be mentioned presently, in connection with palpation. As I have referred, however, already to the lateral displacement of the mediastinum, it may be added that, after absorption, a reverse dis- placement is liable to take place, and the sonorousness due to the en- croachment of the lung of the healthy side may be apparent even beyond the sternum on the side in which the effusion has existed. Auscultation furnishes results which, in a positive and negative point of view, are of great importance in the diagnosis of pleuritis. Feebleness of respiration on the affected side belongs to the period anterior to the stage of liquid accumulation. In quality and pitch, the respiratory sound is not materially changed. The intensity is alone altered—a result chiefly of the restrained expansion of the side affected. The murmur is frequently interrupted or jerking, owing to a want of continuity in the respiratory movements, an effect of the acute pains incident to this stage. During the period of effusion, the effects of the accumulation of liquid, as regards the respiratory sound, are always marked, but varying in different parts of the affected side; and the phenomena are by no means uniform in all cases. With a very small amount of fluid gravitating to the bottom of the chest, producing a slight de- gree of compression of the lung, the respiration will be likely to con- tinue feeble, with some of the characters of the broncho-vesicular 1 Archives Gen6rales de Me"decine, 4 se>ie, t. xxii, Avril, 1850. 35 546 DISEASES OF THE RESPIRATORY ORGANS. modification—the inspiratory sound less vesicular than on the opposite side, and higher in pitch, and perhaps a prolonged expiration. If, however, the quantity of liquid be considerable or large, filling at least one-half or two-thirds of the chest, the results of auscultation practised above and below the level of the fluid, are usually in striking contrast with each other. Over the condensed lung, the abnormal characters are of the broncho-vesicular or the bronchial variety, according to the degree of condensation of the pulmonary structure. One or the other is generally more or less strongly marked. The intensity is variable in different cases. In some instances it is loud, in other instances feeble. It is oftener feeble, but as exceptions to the general rule, I have observed a pretty strongly marked exag- gerated vesicular murmur, emanating from the lung above a moderate effusion. Below the line of flatness on percussion, -indicating the level of the liquid, the respiratory sound is frequently suppressed.1 The loss of sound, if the stethoscope be employed, is often abrupt, denoting, like the sudden loss of sonorousness on percussion, the height to which the liquid ascends in the chest. This account pro- bably expresses the rule, as respects the respiratory phenomena, above and below the hquid effusion, in cases in which the latter is more or less abundant. But there are important exceptions to this rule. In some instances in which a loud bronchial respiration is heard over the condensed lung, it is propagated below the level of the liquid, and may extend over the entire side. This fact has been repeatedly noted by numerous observers, even in cases in which a very large amount of effusion existed, producing considerable enlargement of the affected side. A well-marked bronchial respiration, diffused over the entire side, characterizes a certain proportion of the cases of pleuritis with large effusion. The ratio of instances in which this occurs is yet to be settled by numerical analysis. The number of instances in the adult is not sufficient to render them other than exceptions to a general rule. In early life, the ratio is larger. Indeed, according to Swett, a bronchial respiration more or less extensive is the rule, not the exception, in pleuritis affecting young children. In general, when a bronchial respiration is diffused over the side, 1 The sounds of the heart are transmitted with an abnormal intensity through the mass of liquid. In cases in which the right side is filled with fluid, the heart-sounds are heard with great distinctness. Auscultation of the heart is one of the means of ascertaining the displacements of this organ which are noticed presently, in connection with palpation. ACUTE PLEURITIS. 547 in cases of abundant or large effusion, certain points of difference pertain to the sign, as heard above and below the level of the liquid. Over the condensed lung, it is more intense, and conveys the idea of proximity to the ear. Over the liquid, it is more feeble, and seems to be transmitted from a distance. When the effusion is very copious, filling and dilating the affected side, and compressing the lung into a small, solid mass, the respiratory sound, in the adult, at least, is usually suppressed over the greater portion of the chest. A bronchial respiration, either feeble or more or less developed, under these circumstances may frequently be de- tected at the summit of the chest, sometimes below the clavicles, but more frequently behind, above the spinous ridge of the scapula, and more especially in the upper portion of the interscapular region. It is rarely altogether wanting in one or more of these situations.1 From the summit it may extend, with diminished intensity, conveying the sense of distance, over a variable area. The bronchial respiration will be more intense and more diffused if, in addition to the condensa- tion from compression, the lung is solidified, either by inflammatory exudation or a tuberculous deposit. A loud and persisting bronchial respiration warrants a suspicion of pulmonary consolidation. In a recent publication by MM. Monneret and Barthez, of Paris,1 it is stated that the respiration over the condensed lung in pleuritis may assume the characters of the cavernous and even the amphoric modifications. As described by these writers in the cases reported by them, I am unable to perceive any evidence of other than intense bronchial respiration. The intensity, in fact, appears to have been considered by them as the proof of its cavernous character. But a cavernous respiration is by no means always as intense as a loud bronchial respiration. The intensity is but an incidental element of both. That the two are not infrequently confounded even by ex- 1 MM. Barth and Roger found the bronchial respiration absent in 17 of 26 cases of pleuritis, selected indiscriminately, as quoted in Part I of this work. The experience of others goes to show that it is discoverable at the summit of the chest in a larger proportion of cases than this; and the latter accords with my own impressions. Further numerical results with respect to this point are to be desired. Valleix suggests that the disparity between the results obtained by Barth and Roger, and other observers, may be explained by the former studying the effect of natural or tranquil respiration, and the latter causing the patients examined to breathe with quickness and force. The influence of forced breathing in developing and increasing the intensity of the bronchial as of the normal respiratory sound, is well known to practical auscultators. 2 Archives Generates de M^decine, Mars, 1853. Vide, also, Valleix, op. cit. vol. i, p. 570. 548 DISEASES OF THE RESPIRATORY ORGANS. perienced auscultators, I am fully persuaded. If the distinctive cha- racters of each (having reference especially to the relation of the pitch of the inspiratory and expiratory sound) are correct, as they have been pointed out in Part. I, and also in the chapter on Pulmonary Tuberculosis, it is impossible for a true cavernous respiratory sound to be developed in connection with solidification of lung. It is proper, however, to add, that the occurrence of cavernous respiration in some cases of pleuritis, without excavations, is admitted by Barth and Valleix. In the instances referred to in the preceding remarks, I am led to suppose that the bronchial respiration may have been mistaken for the cavernous. But a mistake may arise, if, in connection with a certain amount of liquid effusion, the respiration (as may occur) is neither bronchial nor broncho-vesicular, but intensely vesicular, or in other words, highly exaggerated. The latter effect on the side affected in single pleuritis, I suppose to be very rarely produced, but I have already referred to it as a possible occurrence. I have observed this effect to be marked in a case of double pleuritis, to which allusion has been already made in treating of cavernous respiration in Part I. A patient was admitted into hospital apparently in the last stage of pulmonary tuberculosis, and died a few days after his admission. A single exploration of the chest only was made, which, on the pre- sumption of the case being one of advanced tuberculosis, was limited to the summit of the chest; and from the great weakness of the patient was confined to the anterior surface. The superior costal type of breathing was observed to be remarkably predominant, the patient being of the male sex. A clear resonance on percussion with tympanitic quality existed at the summit. The respiratory sound was loudly developed, the inspiration low in pitch, and followed by an expiration shorter, less intense, and lower than the sound of inspira- tion. Moreover, at the commencement of the inspiratory act, the sound appeared to present a slight amphoric intonation. These were the characters on both sides, and upon them, without an elaborate examination, as already stated, was predicated the opinion that the respiration was cavernous. At the autopsy I expected to find large excavations at the apex of both lungs ; but instead of this, there was double pleuritis. The chest on both sides was about two-thirds filled with liquid, the pleural surfaces being firmly adherent above the level of the fluid. A vesicular murmur, thus, highly exaggerated from ACUTE PLEURITIS. 549 the fact that the upper portion of the lung on each side was alone available for respiration, and from the great development of the superior costal type of breathing, presenting certain of the characters of the cavernous respiration, was mistaken for the latter in a case in which the general aspect suggested only the idea of advanced tuber- culosis. The error of observation was of course due to carelessness in physical exploration, and the lesson to be enforced by it is too ob- vious to require comment. The case illustrated the law laid down by Louis, that double pleuritis generally involves the existence of tuberculosis; for although excavations were wanting, small tubercu- lous deposits, not exceeding the size of a small pea, which had not advanced to softening, were found in both lungs. So far as the amphoric modification is concerned, according to the authors above named (Barth and Valleix), the sound in the so- called cavernous respiration incident to pleuritis, does not become distinctly amphoric, but only approaches that character. A bron- chial respiration with a metallic intonation is an approximation to the amphoric respiration. During the period of absorption, the expansion of the lung taking place in proportion, as the compressing agent is removed, the bronchial respiration, if it have existed, disappears, giving place to the broncho- vesicular, which gradually assumes more and more of the vesicular quality. The respiration, as absorption goes on, becomes audible, or resumes its normal characters, progressively from the summit downward. Absorption, when the liquid is reduced to a small quan- tity, taking place frequently very slowly, absence of respiration with dulness or flatness on percussion, often continues for a long time at the base of the chest. Feebleness of the respiratory murmur over the whole side, characterizes the renewal of the function of the com- pressed lung. This continues for weeks or even months. The per- manent effects following recovery from pleuritis with large effusion, will be noticed under a distinct head in connection with the chronic variety of the disease. Finally, on the unaffected side during the three periods of the dis- ease, but especially during the stage of liquid accumulation, the in- tensity of the respiratory murmur is abnormally increased, constituting exaggerated or supplementary respiration. Of adventitious auscultatory sounds, the bronchial rales are occa- sionally heard in cases of pleuritis. Their occurrence is purely acci- dental. Bronchitis and pulmonary catarrh coexist with pleuritic 550 DISEASES OF THE RESPIRATORY ORGANS. inflammation only as coincidences. The inflammation does not extend to the parenchyma of the lungs, and, consequently, the crepitant rale does not belong to the clinical history of the disease. Adventi- tious sounds, however, may be developed within the pleural sac, which are highly significant. I refer to attrition or friction sounds. If patients come under observation in the first period, or before much liquid accumulation has taken place, a grazing or rubbing sound may sometimes be detected over the lower part of the anterior or lateral surface, and in rare instances, during this period, it is audible over the greater part of the affected side. The production of the sound at this stage must be due, in most cases, to the deposit of fibrin on the pleural surfaces. It is possible that the increased vascularity of the superficies of the lung, together with the absence of the usual exhalation lubricating the pleura, may be adequate to produce it. Walshe gives an instance in which a loud rubbing sound was heard over the whole side, and after death, which occurred sixteen days from the time when this sign was noted, the pleural surface was found to be entirely free from lymph, except over a spot of the size of half a crown. The sound is heard in a certain proportion only of the cases which are examined anterior to the stage of effusion. The restrained movements of the affected side from pain are sometimes insufficient for its production, and then it may be developed by inducing the patient to disregard the pain and expand the side more fully. It would perhaps be detected at this period oftener than it is, were the side to be more frequently examined than is usual, and the explora- tions made with care over every point; for the sign is frequently in- termittent, and may be confined to a small space. After the accumulation of liquid, and during the stage of effusion, a friction-sound is rarely discovered. In exceptional instances it is observed, in this period, over the compressed lung. According to Walshe, it may occasionally be developed on the back by making the patient lie on the face for a little while. It has been observed, also, over a considerable area, even when the quantity of liquid is quite large. In the latter case it is attributable to the lung having become attached, by means of bands or bridles of false membrane, to the thoracic wall, which resist the pressure of the fluid, and permit the pleural surface to come into contact over a certain space, notwith- standing the amount of effusion. It is during the third period, or the stage of absorption, that fric- tion-sounds are most apt to occur in pleuritis. The pleural surfaces, ACUTE PLEURITIS. 551 after having been separated by the presence of liquid, are again brought into contact, more or less coated with semi-organized lymph. It is only during this stage that the rougher sounds, called rasping or grating, are produced. They may have this character, or in the third stage, as in the first, only the rubbing and grazing varieties may be developed. They are sometimes loud and strong, occasion- ally heard at a distance, attracting the patient's notice, and accom- panied by a vibratory motion of the parietes perceptible to the touch. Their duration is variable. They may last for a very brief period, and, on the other hand, they have been known to continue for months. Friction-sounds by no means constantly attend the stage of absorp- tion. The adhesion of the pleural surfaces, which quickly ensues, prevent their development. They would probably be more frequently discovered than they are, if repeated examinations were made for that object; but at this period of the disease they are generally un- important as regards the diagnosis, which has been already made, and they are generally sought for merely as a matter of curiosity.1 As evidence, however, that the pleural surfaces are again in contact, the sign is not altogether unimportant at this stage of the disease. Its occurrence subsequent to liquid accumulation is, of course, a proof of progress having been made in absorption; but this point is gene- rally easily settled by other signs which are more uniformly avail- able. In conclusion, friction-sounds are chiefly important, in a diagnostic point of view, when they are discovered early in pleuritis, because it is only at this period that the discrimination of the disease, as a general remark, is attended with any difficulty. When they are heard at the middle or inferior portion of the chest, or are found to extend over the whole side, they are almost pathognomonic. Taken in con- nection with symptoms characteristic of pleuritic inflammation, their presence establishes the diagnosis. In a negative point of view, however, they are of not much importance: that is, their absence is not evidence that pleuritis does not exist, owing to the want of con- stancy in their association with the disease. For the characters which distinguish friction-sounds, and by which they are to be recognized clinically, as well as for other practical 1 Bouillaud professes to discover friction-sounds, almost invariably after absorption, in cases of pleuritis (Valleix, op. cit.). This may be explained on the supposition tha he is accustomed to take greater pains than others in seeking for them. 552 DISEASES OF THE RESPIRATORY ORGANS. considerations connected with their production, the reader is referred to the portion of the chapter, in Part I, on Auscultation in Disease, which is devoted to this subject.1 The liability of mistaking a fric- tion-sound for a crepitant rale is to be borne in mind, since, practi- cally, it might lead to the error of confounding pleuritis with pneu- monitis. The occasional occurrence of a pleural friction-sound produced by the heart, exclusive of any disease of the latter organ, is an item among the curiosities of clinical experience, which is to be recollected. The movements of the heart sometimes cause a rubbing of the adjacent pleural surfaces sufficient to give rise to a sound. Its disconnection from other evidences of pericarditis, and association with the other evidences of pleuritis, will prevent mistakes. The results of auscultation of the voice are to be taken into ac- count in the diagnosis of pleuritis. The results before the stage of effusion, if not altogether negative, are not sufficiently marked to possess diagnostic importance. They are variable after accumulation of liquid has taken place, but are frequently useful in confirming the evidence derived from other signs. Over the compressed lung the vocal resonance may be abnormally exaggerated; well-marked bron- chophony is sometimes observed, and the occasional occurrence of pectoriloquy, under these circumstances, is sufficiently established. These vocal phenomena may all be absent, and are present in dif- ferent cases with greater or less intensity or prominence. They are more marked if, in connection with pleuritic effusion, the lung be soli- dified, not by compression only, but by inflammatory consolidation or a tuberculous deposit. When strongly marked they afford pre- sumptive but not positive evidence of solidification, in addition to the condensation due to the pressure of liquid effusion. If not strongly marked, they are significant of condensation, or some abnormal con- dition, on the left more than on the right side, owing to the normally greater vocal resonance on the right side. This remark is applicable to exaggerated vocal resonance only, not to bronchophony and pecto- riloquy. These vocal signs are generally limited to the summit of the chest, and confined to an area circumscribed in proportion to the space occupied by the compressed lung. They are oftener discovered over the scapula and in the interscapular region behind, owing to the usual situation of the compressed lung in cases of large effusion. Over the space occupied by liquid, the vocal signs which have been ' Vide, page 242. ACUTE PLEURITIS. 553 named are usually wanting. A contrast as regards vocal resonance between the upper and lower portion of the affected side, when the percussion-sound is at the same time observed to be flat below, and more or less sonorous above, is pretty conclusive evidence of the pre- sence of liquid; for if the relative flatness at the inferior portion of the chest proceeded from greater solidification of lung, the vocal resonance would be expected to be more marked than at the superior portion of the chest, where a certain amount of resonance is elicited by percussion. In like manner, a contrast between the two sides inferiorly, con- sisting in the presence of vocal resonance on the healthy side, and its absence on the affected side, affords strong proof of effusion. Here the allowance for a normal disparity between the two sides, is the re- verse of that to be made when it is a matter of question as to solidifi- cation of lung at the summit. If the flatness on percussion be on the right side, and the greater vocal resonance on the left side, the proof of effusion in the right pleura is stronger than it would be were the left side the one affected. But auscultation furnishes a vocal sign deemed by Laennec pathog- nomonic of pleuritic effusion, and still considered by many as highly significant. I refer to the sign called JEgophony. A singular dis- crepancy of opinion exists among different observers as regards the frequency with which this sign is discoverable in pleuritis, the extent of its diffusion, and its diagnostic importance. This discrepancy may perhaps in part be accounted for on the supposition that the term aegophony is used by some in a more comprehensive sense than by others. It may be applied to slight modifications of the transmitted voice, or it may be restricted to instances in which the tremulousness and acuteness are sufficiently distinct to constitute at least some ap- proach to the bleating cry of the goat, or the other sounds to which it has been compared.1 Without dwelling on the subject here, I shall refer the reader to the remarks under this head contained in the chapter on Auscultation in Disease, in Part I." That aegophony is properly regarded as a physical sign distinct from bronchophony and pectoriloquy, is unquestionable. That it is highly significant of pleuritic effusion, when well marked, appears to be sufficiently established. I am free to confess, however, my inability to speak of ' The distinction between transmitted voice and transmitted speech is to be kept in mind. The former is bronchophony ; the latter pectoriloquy. 2 Vide page 267. 554 DISEASES OF THE RESPIRATORY ORGANS. its value from much practical acquaintance with it; but this is per- haps owing to the fact that I have not made it the subject of much clinical study, repeated disappointments in seeking for it having led me to distrust its availability. The reader will, of course, attach due weight to this confession in connection with the remarks in Part I, to which he is referred. Inspection and mensuration furnish striking and valuable signs in pleuritis. Under the influence of pain the movements of the affected side are so far restrained by the will, as to give rise to a perceptible diminution in expansion by the inspiratory act, and on measure- ment, the size, as also the range of motion, may be found slightly reduced during the first period. The voluntary restraint of motion is especially apparent in the act of coughing. These results give place to others more marked and distinctive in the second stage. The lower part of the affected side, in proportion to the amount of liquid accumulation, becomes dilated, and the inferior costal movements, with respiration, are lessened or arrested. The intercostal spaces exhibit less depression, and are generally not so deeply indented in the inspiratory act, as on the opposite side. Accumulating in still larger quantity, the liquid meets with more resistance from the condensed lung than from the thoracic parietes, and the latter accordingly yield to the dilating force. The affected side becomes conspicuously enlarged, and its range of motion in re- spiration proportionally limited. It is dilated frequently to the fullest extent of voluntary expansion, or even beyond this limit, and hence remains motionless, while the movements of the opposite side are supplementarily increased. The intercostal depressions are now abolished, and a slight convexity between the ribs may in some in- stances be apparent. Over the lower and middle portions of the side the ribs are abnormally separated, while at the summit they converge more than is natural. The obliquity in the direction of the ribs is diminished. Approaching to a horizontal line, their angular union with the costal cartilages is no longer obvious. Measurement of the semicircular circumference, of the vertical distance from the base to the summit, and, by means of calli- pers, of the antero-posterior diameters, shows an increase of size in all directions. The nipple is somewhat elevated, and is removed at a greater distance than on the opposite side from the median line. On a posterior view a marked contrast is observed between the two sides in the elevation of the scapula with the act of inspiration. ACUTE PLEURITIS. 555 These are the phenomena, determined by inspection and mensuration, which denote a very large accumulation of liquid within the pleural cavity. Occasionally presented in acute pleuritis, they are much oftener observed in the chronic form of the disease. In the progress of absorption of the effused fluid, a series of changes take place, the reverse of those which characterize progressive accu- mulation of fluid. The enlargement decreases; the bulging inter- costal spaces become flattened; the divergence of the lower ribs diminishes, and they assume a more oblique direction; the nipple falls, and its distance from the median line is lessened; some degree of expansive movement is perceptible, taking place more slowly than on the opposite side, and depression of the side at the summit is apparent. With these changes the affected side may be still nearly filled with liquid. Finally, when absorption of the whole or a greater part of the liquid is effected, the alterations in size, motions, and relations of the different parts are frequently still more marked. The side becomes contracted in every direction. It is obvious to the eye at the lower, as well as at the upper part, when the chest is examined either behind or in front. Mensuration with the inelastic tape, or with callipers, shows this to be the case. Lateral curvature of the spine is apt to occur, the concavity looking toward the affected side. The shoulder (with occasional exceptions) is depressed ; the interscapular space is narrowed; the lower angle of the scapula projects from the thoracic wall; the lower ribs approximate more than on the opposite side; the nipple falls below the level of its fellow, and is nearer the median line; the range of motion in the acts of respiration is greater than before, but still limited on comparison with the healthy side. These changes always succeeding chronic pleuritis with large effusion, but not so constant after the acute variety, in amount bear a certain proportion to the extent to which the side has been previously ex- panded ; in other words, to the quantity of liquid effusion which has existed. They are, however, also dependent on the condition of the compressed lung as regards its ability to become expanded as the pressure is removed; and since this condition is affected by other circumstances than simple condensation, viz., by the adhesion of the pleural surfaces, and the organization of lymph deposited upon it, the contraction of the side resulting from pleuritis will differ in different cases in which the quantity of effused liquid was about the same. Contraction of the affected side after pleurisy will be likely either to be wanting entirely, or to be less marked and less persisting in 556 DISEASES OF THE RESPIRATORY ORGANS. proportion as the effusion and its removal by absorption have been rapid. For this reason, assuming an equal amount of accumulation, the changes first mentioned characterize chronic rather than acute pleuritis. But they are more apt to follow chronic pleuritis for another reason, viz., the quantity of liquid effused is usually much greater in this variety of the disease. The rapidity with which ab- sorption goes on in acute, as well as in chronic pleuritis, varies much in different cases. It is not uncommon to observe a very great reduc- tion within a few days or even hours: but after the quantity is re- duced to a certain point, the removal is always effected more slowly. The side may be obviously depressed at the summit or middle third, when it is still enlarged at the lower part, as shown by mensuration. As regards permanent effects on the chest, there may not be any ob- vious disparity after the lapse of weeks or months succeeding an attack of the acute form, even when the quantity of liquid effusion was con- siderable, and a certain amount of contraction was evident immedi- ately after recovery. It is otherwise, however, with cases of chronic pleuritis; and I shall refer to this point under the head of the latter. Examinations of the chest by inspection and mensuration in cases of pleuritis, are not only useful in order to ascertain the exist- ence or non-existence of either dilatation or contraction, but that the progress of the disease may be watched from day to day, as regards, in the first place, the increase in the accumulation of liquid, and in the second place, its decrease by absorption. In cases in which the affected side is filled with fluid and the thoracic wall expanded, per- cussion and auscultation do not afford the means of determining from day to day variations in the quantity of effusion. Inspection and mensuration are available for this object, and the results may be im- portant in determining the practitioner either to continue or to change his therapeutical measures. Much interesting and important information is frequently derived from the employment of palpation in cases of pleurisy. In the first period it furnishes evidence of tenderness to the touch, and also that the soreness is not in the integument but in the intra-thoracic struc- tures. The pain produced by manual examination of the affected side is not superficial and occasioned by mere contact of the hand, as in some instances of hyperaesthesia of the surface, but is more deeply seated and proportionate to the degree of pressure made. But it is more especially during the second and third periods that this method of exploration furnishes useful facts. The effect of an ACUTE PLEURITIS. 557 accumulation of a considerable quantity of liquid is usually to abolish the normal vocal fremitus on the affected side over a space correspond- ing to that occupied by the effusion. And at the same time, in some instances, the fremitus is increased over the condensed lung above the level of the liquid. Marked diminution or suppression of the normal vocal fremitus may thus constitute a physical sign of liquid effusion, the more significant, because over consolidated lung the fre- mitus is frequently exaggerated. It is obvious that to become a sign of effusion, absence of fremitus must be associated with other signs; and it is to be borne in mind that in many persons the normal fre- mitus is greater on the right than on the left side. If flatness on percussion at the lower part of the chest coexists with absence of fremitus, while on the opposite side there exists vesicular sonorous- ness with a fremitus more or less marked, the evidence is strong that the flatness is due to effused fluid rather than solidified lung. And inas- much as in some persons a fremitus exists naturally on the right side and not on the left, the evidence is stronger when the effusion is into the right pleural sac ; in other words, flatness on percussion with absence of fremitus, indicates effusion more positively on the right than on the left side, making due allowance for the fact that this com- bination of signs may be produced by the encroachment of an en- larged liver on the thoracic space. Palpation furnishes still other facts. By this method better than by inspection are ascertained the most important of the displacements of intra-thoracic parts which take place in the second and third periods of pleuritis with large effusion. An accumulation of liquid in the left pleural sac removes the heart from its normal situation. This may occur, and to a great extent before the thoracic parietes become dilated. Occasionally the heart is pushed downward in a direction toward the epigastrium, but in the great majority of instances it is carried upward and outward in a diagonal line extending from the praecordia to the right shoulder. It is found, as the fluid accumu- lates, to be situated beneath the sternum, and at length its pulsa- tions may be felt and frequently seen on the right side, and some- times beyond the nipple.1 If, on the other hand, the effusion be within the right pleural sac, and the accumulation be large, the heart 1 Alteration of the heart-sounds, even with the 'greatest amount of displacement, is very rarely observed. A bellows' sound is occasionally developed, which disappears when the heart resumes its normal situation. The existence of a murmur, under these circumstances, therefore, is not proof of cardiac disease, even excluding anaemia. 558 DISEASES OF THE RESPIRATORY ORGANS. is displaced in a direction upward and outward toward the left axilla. If the impulse of the dislocated heart can neither be seen nor felt, which must be rarely the case except when it is beneath the sternum, the sounds of the organ, as determined by auscultation, must be the guide to its abnormal situation. Its return to the praecordia is evi- dence of the progress made in the absorption of the effused fluid. In some instances it has been observed to regain its normal situation in the course of a few days and even hours, showing very rapid diminution in the quantity of effusion. It does not, however, always return to its normal situation when the force which in the first in- stance pushed it out of place is no longer operative. It may be detained in its abnormal position by morbid attachments. And it is a curious fact that the suction-force developed by the absorption of the effused liquid may not only prevent the organ when displaced, from again resuming its position in the praecordia, but it may prove an active cause of displacement. In cases of copious effusion within the right pleura, after absorption, the heart has been found to be drawn into the right side ; and subsequent to the removal of an effusion in the left pleura sufficient to displace the heart to the right, it may at length occupy a position to the left of the praecordia. Displacement of the diaphragm is another of the mechanical effects of a large effusion. This, according to the observations of Stokes, may take place suddenly, so that the fluid finding additional space in this direction, the semicircular circumference of the affected side may possibly be diminished, and the line of percussion-flatness on the chest lowered, although the quantity of liquid is increasing. The depression of the diaphragm of course carries downward the subjacent organs. On the right side this is evidenced by the lower situation of the liver. Under these circumstances, owing to the convexity of its upper surface and the- convexity of the depressed diaphragm, a sulcus or furrow is sometimes apparent between the lower margin of the chest and the point at which the anterior surface of the liver projects against the abdominal wall. Again, after absorption, the diaphragm is drawn upward with the subjacent organs above the point at which it rises normally within the chest; and the liver on the right side, or the stomach and spleen on the left side, are found to ascend higher than in health. The latter changes, however, are ascertained by percussion rather than by palpation, and the same remark is appli- cable to lateral displacement of the mediastinum, to which reference has been already made under the head of Percussion. ACUTE PLEURITIS. 559 Owing to the abolition of the intercostal depressions during the stage of effusion, the affected side offers to the touch, as well as to the eye, an unnaturally regular and smooth surface, which is after- ward lost when contraction of the chest takes place, and finally, in some instances, the presence of liquid in the pleural sac may be made to give rise to a sense of fluctuation appreciable by palpa- tion. This may be discovered occasionally, by applying the left hand over the affected side at the base, and percussing the ribs with the pulpy portion of the fingers of the right hand. In thin persons, peripheric fluctuation, as it is called, is oftener available. If a finger be applied over an intercostal space, and a light, quick percussion- stroke be made at a short distance in the same space, the peculiar shock significant of the presence of fluid may be appreciable. Diagnosis.—Certain of the symptoms of acute pleuritis are some- what distinctive. Pain is usually a prominent symptom during the first period. It is sharp, lancinating in character, felt generally with the act of inspiration, and its severity increasing with the progress of the act, renders the latter interrupted, and shortens its duration. In these respects, however, it does not differ from the pain in pleu- ralgia. It is referred oftenest to the lower part of the affected side laterally, and in front; sometimes extending to the back or over the whole side, and occasionally felt exclusively on the opposite side or in the abdomen. It diminishes as effusion takes place, and at length ceases to be prominent or disappears. The respirations are multi- plied at first, by way of compensation for their incompleteness in con- sequence of pain, and afterward from the interruption of the function of the lung on the affected side due to its compression. Dyspnoea occurs in only a small proportion of cases, which are characterized by rapid and copious effusion. Cough is sometimes, but rarely, absent. It is usually dry, excited spasmodically, and partially suppressed to avoid the pain which it occasions. The significance formerly attached to position or decubitus, at different stages of the disease, appears to be in a great measure disproved. With an adequate knowledge of the physical signs which belong to acute pleuritis, the diagnosis, certainly in the great majority of cases, is sufficiently easy. It presents .difficulties only to those who do not qualify themselves to employ physical exploration. By those who rely exclusively on the diagnostic symptoms, it is not infrequently 560 DISEASES OF THE RESPIRATORY ORGANS. confounded with pleurodynia, intercostal neuralgia, and pneumonitis. Instances illustrating these errors of diagnosis have repeatedly fallen under my observation. It will suffice to point out the more impor- tant of the circumstances involved in the differential diagnosis from the affections just named, commending to the student the study of the physical signs of the disease until they become perfectly familiar. In pleurodynia and intercostal neuralgia, the physical phenomena which attend the march of acute pleuritis are wanting. The absence of these phenomena enables us either to exclude pleuritic inflamma- tion, or to establish its existence. In a purely neuralgic or rheumatic affection, however, diminished expansion of the affected side, with slight reduction in size, feebleness of the respiratory murmur and perhaps relative dulness may be present, these results being due ex- clusively to the restrained movements from pain. The affected side may also be more exquisitely tender on pressure than when pleuritic inflammation exists. Guided alone by the results of exploration, for a brief period after the attack, the discrimination might involve doubt. The existence of marked febrile movement is an important point at this period. Symptomatic fever constantly accompanies acute inflammation of the pleura, while it attends pleurodynia and intercostal neuralgia only as a coincidence. If a friction-sound be discovered which we are satisfied is pleural in its origin, it renders the diagnosis quite positive. But the constancy of this sign cannot be relied upon, and, indeed, it is rarely discovered in the early stage of pleuritis. Its absence, therefore, is not proof that a doubtful affection is either neuralgic or rheumatic. But the occasion for hesitancy usually exists for a brief period only. The occurrence of serous effusion, if the disease be acute pleuritis, gives rise to positive signs, which render certain the presence of something more than a neuralgic affection or an attack of rheuma- tism seated in the thoracic walls. And, on the other hand, the absence of the physical evidence of effusion authorizes an exclusion of acute pleuritis. A fact, however, observed by Louis and others, is impor- tant to be borne in mind, viz., an attack of acute pleuritis is occa- sionally preceded by a neuralgic affection of the side in which the inflammation becomes afterwards developed. Two instances illus- trating this fact have come under my observation, in which the patients experienced acute pains in the side, without febrile move- ment, or any of the physical signs of pleuritic inflammation, for several ACUTE PLEURITIS. 561 days before an attack of the latter which was signalized by a chill, increased pain, and febrile movement. In the differential diagnosis from acute pneumonitis, we have to distinguish between the physical signs belonging respectively to this affection and acute pleuritis. In pneumonitis there occurs, often within a short space of time, marked dulness on percussion over a certain portion of the affected side. If the upper lobe be first in- flamed, the dulness will be found at the summit and on the anterior surface, while the posterior surface below the scapula is resonant on percussion. The reverse obtains in acute pleuritis after effusion has taken place. But in the majority of instances, pneumonic inflamma- tion attacks the lower lobe, and in the lobar form invades speedily the entire lobe. The dulness will then be found to be bounded on the chest by a line pursuing the direction of the interlobar fissure, and not to vary with the change of position of the patient, the latter being observable in a certain proportion of the cases of pleuritis with effusion. The liquid in pleuritis generally accumulates rapidly, and the flatness on percussion is found to extend over a larger portion of the affected side than in cases of pneumonitis. In certain cases of pneumonitis, it is true, the entire lung may become solidified; but in these cases a single lobe is first attacked, and at a subsequent period the inflammation crosses the interlobar fissure, and invades the other lobe. If such cases are under observation from the beginning, the length of time occupied by the extension of dulness over the chest distinguishes the disease from acute pleurisy. Other differential points are not less distinctive. The presence of a considerable quantity of liquid in the pleural cavity gives rise to flatness on percussion. Solidification of lung produces only dulness, and, in a certain proportion of instances, the vesicular is replaced by tympanitic sonorousness, more or less marked. The dulness from solidified lung is accompanied, generally, by a well-marked bronchial respiration, frequently intense, metallic, and appearing to be de- veloped near the ear. The flatness from the accumulation of liquid is usually associated with suppression of respiratory sound; or, if a bronchial respiration be discovered, it is comparatively feeble and distant in the great majority of instances. Increased vocal resonance, bronchophony, and occasionally pectoriloquy, are signs belonging to solidification; their absence is the rule over liquid effusion, ^go- phony is occasionally heard over the latter, and rarely over the former. 36 562 DISEASES OF THE RESPIRATORY ORGANS. Vocal fremitus is often exaggerated by solidification, and it is abo- lished by the presence of liquid. An accumulation of a large quantity of liquid in the pleural cavity produces considerable or great enlargement of the affected side, and effaces the intercostal depressions. In pneumonitis, the enlarge- ment is slight, and the intercostal depressions remain. Displacements of the heart, diaphragm, and mediastinum, are marked effects of copious liquid effusion, and they occur but to a slight extent as re- sults of solidification. Moreover, a symptom and a sign almost pathognomonic of acute pneumonitis are wanting in acute pleuritis, viz., the rusty expectora- tion and the crepitant rale. Exceptional variations from general rules as regards the physical signs belonging to the two diseases just contrasted, can alone consti- tute sufficient ground for hesitation in making the differential diagnosis. For example, in some cases of pleuritis with large effusion, a bronchial respiration is found to pervade the whole of the affected side; and, on the other hand, in some cases of solidification from pneumonitis, absence of respiratory sound is equally extensive. Attention, how- ever, to other points of contrast, in all such instances, will develope ample data for the discrimination. SUMMARY OF PHYSICAL SIGNS BELONGING TO ACUTE PLEURITIS. First Period, viz., prior to Accumulation of Liquid.—Moderate or slight diminution of vesicular resonance, or dulness on percussion. Feeble and interrupted respiratory murmur. No alteration in vocal resonance or fremitus. Diminished expansibility of the affected side. Tenderness on pressure. Occasionally a grazing or rubbing friction- sound. Second Period, or Stage of Accumulation of Liquid.—Flatness on percussion from the base of the chest, extending upward, more or less, over the affected side; diminished elasticity of thoracic parietes, and sense of resistance notably increased. Tympanitic sonorousness varying in degree above the level of the liquid, frequently exceeding in intensity the sound on the opposite side. Amphoric or metallic modification of resonance at the summit, sometimes strongly marked, and occasionally the cracked-metal variety of sound discovered. The limits of flatness, in a certain proportion of cases, found to vary when the patient assumes different positions. The flatness sometimes found ACUTE PLEURITIS. 563 to extend, in front, on the opposite side, even beyond the sternum, in consequence of lateral displacement of the mediastinum. Respi- ration often suppressed below the level of the liquid effusion ; bron- cho-vesicular or bronchial over the compressed lung. A bronchial respiration sometimes diffused over the chest, but usually feeble and distant, except at the summit. In the latter situation generally dis- coverable either in front or behind, oftener the latter, varying in different cases as respects intensity and the area over which it is heard. Sounds of heart transmitted to distant parts through the mass of liquid. Friction-sounds occasionally heard in this stage. Increased vocal resonance, sometimes bronchophony, and, as a rare phenomenon, pectoriloquy, discovered at the summit of the chest on the affected side. All these vocal signs may be absent at the summit, and they are all absent, as a rule, over the portion of the side occu- pied by the liquid. iEgophony present in a certain proportion of cases at a particular and usually a transient period in this stage. Generally, when present, limited to the neighborhood of the inferior angle of the scapula behind, and to a zone extending from this point to the anterior part of the chest; but, exceptionally, in some instances diffused over the whole side. Dilatation of the affected side, com- mencing below and extending, in some cases, over the entire side; the intercostal depressions effaced, and various alterations in the re- lations of the external component parts of the thoracic parietes. Dislocation of the heart, and depression of the diaphragm, with sub- jacent organs, from the pressure of the fluid. Unnatural regularity and smoothness of the surface of the affected side. Fluctuation per- ceptible to the eye and to the touch in some instances. Comparative immobility of the affected side. Abolition of vocal fremitus below the level of the liquid. Increased respiratory movements and ex- aggerated vesicular murmur on the healthy side. Third Period, or Stage of Absorption.—Vesicular or vesiculo- tympanitic resonance on percussion, developed first at the summit and gradually extending downward, but, relatively to the opposite side, persisting dulness. Flatness continuing at the base. Respira- tion feeble and broncho-vesicular, progressively developed from above downward, gradually assuming the normal vesicular character. Sup- pression at the lower part of the affected side. Vocal resonance and fremitus absent at the lower part of the affected side, and either wanting or more or less marked above. iEgophony sometimes dis- 564 DISEASES OF THE RESPIRATORY ORGANS. covered in this stage. Depression at the summit of the chest, and afterward frequently, if the effusion have been large, marked con- traction of the whole side, with changes in the relations of the differ- ent external component parts of the thoracic parietes, the reverse of those which have previously existed indicating dilatation. Irregu- larity of the surface of the affected side. Limited expansive move- ments. Friction-sounds much oftener discovered in this stage than in the first or second, and in this stage frequently grating or rasping, accompanied sometimes by tactile fremitus. Displacement of the heart from the previous pressure of the liquid, or taking place as an effect of absorption. Abnormal elevation of the diaphragm and sub- jacent organs, after very large effusion, and lateral displacement of the mediastinum toward the affected side. Chronic Pleuritis. Chronic pleuritis with copious serous effusion is entitled, clinically, to be considered as an affection distinct from acute inflammation of the pleura, since, it rarely follows or is preceded by the latter. In the majority of cases, the inflammation is subacute from the first. The anatomical conditions, however, so far as concerns their relations to physical signs, are essentially the same as in acute pleuritis after an accumulation of liquid has taken place. The chief point of dif- ference relates to the quantity of effusion. In chronic pleuritis with copious effusion, the quantity commonly attains to an amount which is only occasionally observed, in the acute variety. The clinical his- tory of the former is therefore characterized by the phenomena to which a large accumulation gives rise. When cases of chronic pleu- ritis present themselves to the physician, they exhibit one of two phases of the affection; and it suffices for practical convenience to consider each phase as a distinct period or stage. The two periods or stages correspond to the second and third of acute pleuritis. The first period or stage of the latter is, in fact, wanting in chronic pleu- ritis. The first period, or stage, will, then, continue so long as the liquid in the pleural sac is accumulating, or remains stationary. This may be termed the stage of accumulation. The second period or stage extends from the time when the liquid begins to diminish, till its removal is effected ; and this may be called the stage of ab- sorption. The first period is frequently of brief duration, but it varies in this respect considerably in different cases. The second CHRONIC PLEURITIS. 565 period is usually much longer, being rarely limited to a few weeks, and often embracing many months. Although less frequent in its occurrence than the acute variety, chronic pleuritis is not a very rare affection. It was remarked by Dr. Hope that "there is no class of affections more habitually over- looked by the bulk of the profession than this;" and the previous histories in the cases that have fallen under my observation have afforded evidences of the correctness of the remark.1 This fact renders the diagnosis a subject of importance. The fact, however, is significant, not of intrinsic difficulties in the way of discriminating the disease, but of the extent to which physical exploration of the chest is neglected. As regards physical signs and the points involved in the diagnosis, they have, for the most part, been em- braced in the consideration of acute pleuritis. Inasmuch, however, as familiarity with the phenomena attained by exploration and their combinations is only to be acquired by repetition, a recapitulation of these signs and diagnostic points in the present connection will not be disadvantageous to the student. Physical Signs.—A patient with chronic pleuritis who comes under observation while the serous effusion is either accumulating or remains stationary at the highest point of accumulation, will be found, in the great majority of cases, to present the physical evidence of a sufficient quantity of liquid in the pleural sac to fill the affected side, compress- ing the lung into a small space, and frequently the phenomena inci- dent to enlargement and displacement of other intra-thoracic organs are superadded. The percussion-sound is flat from the base of the chest upward over the whole or greater part of the affected side. A tympanitic resonance may be discovered at the summit, with perhaps an ampho- ric intonation. The want of elasticity of the thoracic parietes and sense of resistance felt in percussing, are marked. In the majority of cases, at least in adults, all respiratory sound is suppressed over the greater part, and sometimes over the whole of the affected side. In a small proportion of instances, in adults, a bronchial respiration may be perceived more or less diffused. It is feeble, and conveys the impression of distance, except at the summit. In the infra-clavicular region, in a certain proportion of cases; in ' Vide Clinical Report on Chronic Pleurisy, based on an analysis of forty-seven cases, by the author, 1853. 566 DISEASES OF THE RESPIRATORY ORGANS. the upper scapular region, in a larger proportion; and in the inter- scapular region commonly, a bronchial respiration maybe discovered, more or less intense, and seemingly near the ear. It very rarely, in either of these situations, has that intensity, acuteness, and metallic tone which belong frequently to the bronchial respiration due to lung solidified by tuberculous, and still more by inflammatory deposit. On the healthy side the respiratory murmur is intensified but vesi- cular, distinguished as exaggerated, puerile, supplementary, or hyper- vesicular. Greater vocal resonance, and sometimes bronchophony, may be found on the affected side in the interscapular space, and less frequently in the upper scapular and infra-clavicular regions. Else- where than at the summit, these vocal signs are wanting. iEgophony is an event of rare occurrence. Inspection discovers comparative or positive immobility of the side affected; and on the opposite side the respiratory movements are manifestly increased. The affected side may remain quite motionless, even when the respirations are forced, or there may be a slight and tardy elevation of the ribs. In proportion as the side is but little affected by forced respiration, it is usually enlarged in size. It is distended to quite or even beyond the extreme limit of a voluntary expansion. The ribs are raised, and they approach to a horizontal direction. The lower ribs diverge and the upper converge. The intercostal depressions are effaced, and there may be bulging between the ribs. The nipple is raised, and removed at a greater distance from the median line than that on the opposite side. The side pre- sents an unnaturally regular and smooth appearance. Slight oede- matous infiltration beneath the integument of the affected side is sometimes observed. Semicircular measurements with the inelastic tape, applied just below the nipple and the lower angle of the sca- pula, show an increase of size, varying, of course, not only in differ- ent cases, but perhaps at different periods of this stage, the maxi- mum being about two inches. Diametrical mensuration with callipers will also show enlargement between different points. Palpation, in conjunction with percussion and inspection, shows dis- placement of movable parts within the chest, in addition to the com- pression and elevation of the pulmonary organs. The heart, if the left side be affected, is pushed to the right, carried beneath the ster- num, and frequently transferred to the right side, being found to pulsate sometimes even beyond the nipple. If the effusion be in the right side, it is elevated and carried in a diagonal direction to the CHRONIC PLEURITIS. 567 left. The mediastinum is displaced laterally, and flatness on percus- sion is sometimes discovered not only over the sternum, but for a little distance beyond on the opposite side. The dislocation of the heart will, of course, give rise to dulness over its new situation. Depres- sion of the diaphragm with the viscera in contact with its inferior sur- face, occasions on the left side extension downward of flatness from the presence of liquid; and on the right side hepatic flatness to an abnor- mal extent below the ribs, a tumor-like projection caused by the ante- rior surface of the liver, and a sulcus above due to the convexity of its upper surface. This sulcus, as remarked by Stokes, may after a time be lost, before absorption takes place,'in consequence of the convexity of the liver being diminished by pressure. Fluctuation in the intercostal spaces may sometimes be discovered. The vocal fremitus natural to the affected side is abolished. During the second period, the physical signs will present, at suc- cessive explorations, repeated at intervals of some duration, variations in degree rather than in kind, according to the rapidity with which the effused fluid is removed. The changes may consist in a gradual return to the normal condition as respects the size, mobility, and relations of the different anatomical parts, internal and external, of the affected side. But it is very rarely if ever the case that a normal condition is recovered, and the natural symmetry of the chest left unimpaired. As the quantity of liquid diminishes, the enlargement of the side decreases, and, at length, it falls within its natural dimen- sions. Depression of the upper third in front is first observed. This frequently takes place while the semicircular measurement still shows enlargement. Finally, contraction universally of the affected side is a uniform result when the liquid is completely absorbed or reduced to a small quantity. The various phenomena, ascertained by inspec- tion, which are incident to contraction of the chest after the removal of pleuritic effusion, in general terms, are the reverse of those which characterize dilatation. They have already been mentioned in con- nection with acute pleuritis, and will again be reproduced under the head of the Retrospective Diagnosis of Chronic Pleuritis: they need not, therefore, be here enumerated. But before marked contraction of the chest takes place, the dis- placed intra-thoracic organs, especially the heart, retrograde toward their normal situations. And as regards the final disposition of these organs, certain changes are liable to succeed chronic pleurisy, which have been already noticed, inasmuch as they occasionally follow the 568 DISEASES OF THE RESPIRATORY ORGANS. acute variety of the disease; and these also will be recapitulated pre- sently. Percussion-resonance, in proportion as the compressed lung under- goes expansion, becomes developed at the upper part of the chest, and extends downward. The affected side over the space occupied by the expanded lung, however, in most instances yields a dull sound compared with the resonance of the healthy side; and if sonorous- ness be marked, as is sometimes the case, it is vesiculo-tympanitic in quality. The respiratory sound becomes developed, extending lower and lower, but relatively feeble, and with more or less of a broncho- vesicular character. The vocal resonance may be greater or less than on the healthy side. The same is true of vocal fremitus. Friction-sounds are frequently discovered during this stage. They are to be sought for over the middle and lower thirds in front, late- rally, and behind. They are often rough and loud. I have known an instance, already referred to, in which they attracted the atten- tion of the patient, continuing when he was able to be up and out of doors. They may be accompanied by tactile fremitus. They persist in some instances for a long period. I have noted their ex- istence in a case ten months after the date of the commencement of the disease. iEgophony is sometimes discovered during the progress of absorp- tion. The period occupied by the successive and progressive changes indi- cating the diminution and removal of the liquid effusion in chronic pleuritis, as already stated, is variable, but in most cases it extends over several months. Diagnosis.—So far as the symptomatology of the disease is con- cerned, irrespective of the physical signs, chronic pleuritis is often remarkably latent. Excluding the small proportion of cases in which it is preceded by acute pleuritis, the development of the affection is very rarely attended by severe pain, and frequently this symptom is entirely wanting. In obtaining the previous history, the fact of pain having existed would often escape notice without careful inquiry, the attention of the patient being at the time scarcely attracted to it, and its occurrence forgotten. When cases come under observation after the disease has existed for several weeks, absence of pain is the rule. Cough and expectoration are sometimes wanting, and are rarely pro- minent. As a rule, these symptoms do not precede the development CHRONIC PLEURITIS. 569 of chronic pleuritis except they depend on antecedent pulmonary tuberculosis. When cough is present it is generally either dry or accompanied by a small expectoration, which consists of mucus more or less modified. The sudden occurrence of a copious sero-albumi- nous or puruloid expectoration, continuing for a greater or less period, indicates ulcerative perforation of the pleura commencing within the sac, and establishing a communication with the bronchial tubes. This accidental event gives rise to pneumo-hydrothorax. The respirations are usually increased in frequency, but to this rule there are excep- tions, even when the accumulation of liquid is sufficient to remove the heart to the right of the sternum. The increase in frequency is rarely great while patients are tranquil. Exercise or the use of the voice in conversation furnishes the evidence of want of breath. Under these circumstances dyspnoea, with lividity of the prolabia, may be produced, which is rarely observed while patients are at rest. The pulse in the majority of cases is more or less accelerated, ranging from 80 to 120 per minute; but I have observed it to be even below the normal average, viz., 64 per minute. Sweating frequently occurs at night, not uniformly preceded by a febrile paroxysm or exacer- bation. Chills or chilly sensations from time to time are apt to occur, even when the disease is simple, i. e. not complicated with tubercu- losis, and also when the liquid contained in the chest is not pu- rulent. The digestive functions may be more or less disordered, but in some instances the appetite is good, and the ingestion of food occasions no disturbance during the whole progress of the disease. Pallor of the countenance is marked in some cases, but in others the aspect is not notably morbid, although the chest be filled with liquid effusion. In a large proportion of cases, if the disease be uncompli- cated, the progress of the affection is not attended by great loss of weight or emaciation. The strength is sometimes preserved in an astonishing degree. I have known instances in which the disease was allowed to pursue its course without receiving any medical treatment, the patients prosecuting most of the time laborious occupations. The diagnosis in these cases was, of course, made retrospectively. It is not uncommon for cases to come under observation when the dis- ease has existed for several weeks or even months without any pre- vious application having been made for medical aid; little or no in- convenience having been experienced except from want of breath in active exercise. Employments involving violent exertions, such as chopping and sawing wood, stone-cutting, the duties of a house-maid 570 DISEASES OF THE RESPIRATORY ORGANS. of all work, and active participation in the rough out-door sports of youth, have been continued in cases that have fallen under my notice when the chest was filled with liquid, which, under these circumstances, has progressively diminished by absorption.1 The symptoms of chronic pleuritis embracing so little that is dis- tinctive, not only is it confounded with other pulmonary diseases, especially phthisis, by those who do not avail themselves of physical exploration, but frequently even the existence of a pulmonary affection is not suspected. Latent intermittent fever, bilious fever, dyspepsia, general debility, disease of heart, and the ideal affection called "liver complaint," are the maladies under which patients have been supposed to labor in cases that have fallen under my observation. To determine the existence of the disease with the aid of physical signs is generally one of the easiest problems in diagnosis. I have, however, known the phenomena to be attributed to hepatization of lung by those who had given some attention to the exploration of the chest. Circumstances pertaining to the physical signs suffice for the discrimination between the presence of an abundant effusion and the solidification from pneumonitis. The points involved in this discrimi- nation have already been presented in connection with acute pleuritis, and need not be recapitulated. But in view of the previous history, when flatness is found to extend more or less over the chest in cases of chronic pleuritis, pneumonitis is almost excluded by the law of probabilities alone. Antecedent acute inflammation of the pulmonary parenchyma would be evidenced in the vast majority of instances, by rational symptoms having occurred which do not accompany the de- velopment of chronic pleuritis, viz., pain, rusty expectoration, febrile movement, and confinement to the bed for a certain period. But, irrespective of this point, the existence of chronic pneumonitis, either as a sequel of the acute form of the disease or as a primary affection, is exceedingly improbable. The affections which may give rise to phenomena closely analogous to those belonging to chronic pleuritis, are infiltrated cancer of the lungs and mediastinal tumor. These affections are much less frequent in their occurrence than chronic pleuritis, and the liability, therefore, to error, is in attributing their phenomena to the latter affection; in other words, to suppose that chronic pleurisy exists, 1 The rate of mortality from uncomplicated chronic pleurisy in my experience is about 17 per cent. CHRONIC PLEURITIS. 571 when they are present. The liability to this error is somewhat in- creased by the fact that in both these affections pleuritic effusion is apt to occur. Infiltrated cancer of the lung produces contraction of the affected side of the chest. Mediastinal tumor, on the other hand, may lead to dilatation. In the first instance, the disease may be mistaken for pleuritis advanced to the second period, or the stage of absorption. In the second instance, pleuritis in the first period, or stage of liquid accumulation, may be supposed to exist. The points involved in the differential diagnosis from these affections have been already noticed in the preceding chapter, under the heads of Cancer of the Lungs, and Cancer in the Mediastinum. A brief reference to them will be all that is requisite in this place. A cancerous affection of the lungs or mediastinum (and it may co- exist in the two situations) is more uniformly accompanied by cough and expectoration than chronic pleuritis. The expectoration is more abundant, becoming purulent, and is frequently characteristic, re- sembling red or black currant jelly. Haemoptysis is an event of frequent occurrence. Pain is a more prominent and persisting symp- tom. The pulse, on the contrary, is less commonly accelerated until the affection is quite advanced. The contraction of the chest, pro- duced by the absorption of the liquid effusion in chronic pleuritis, is usually greater than in cases of infiltrated cancer. In the latter affection, the loss of strength, emaciation, and pallor, denote a graver malady than uncomplicated chronic pleuritis. Cancer in the mediastinum frequently extends more or less into both sides of the chest, giving rise, of course, to flatness on percus- sion and other physical phenomena, not limited to one side, as in cases of chronic pleuritis. Effacement of the intercostal depressions, and a sense of fluctuation, may be produced by the pressure of a tumor, but only in rare instances, while these effects are common when the side is dilated by the presence of liquid. The dilatation from a cancerous or other tumor is often partial or circumscribed, irregular, and extends from above downward; while in the stage of accumulation, in chronic pleuritis, it becomes general, extending from below upward, and the enlargement is more regular. Dyspnoea is a more constant and prominent symptom, in cases in which a tumor exists of sufficient size to occasion a considerable dilatation of the chest In both diseases, the heart and diaphragm, as well as .the lung, are subject to displacement. But when this occurs from the pressure of a tumor, certain symptoms are frequently superadded to 0(2 DISEASES OF THE RESPIRATORY ORGANS. those incident to an equal amount of displacement from the accumu- lation of liquid; viz., oedema of the face, lividity, swelling of the veins, dysphagia, as well as marked dyspnoea. These symptoms are due to pressure on the air-tubes, large vessels, nerves, and oesophagus; and liquid accumulation in the pleura, however large, never produces an amount of pressure on these parts, equal to that which results from a large mediastinal tumor. The symptoms, therefore, just mentioned, are distinctive of the latter. Reverting to physical signs, in cancer of the lungs or in the mediastinum, the bronchial respiration and increased vocal resonance, or bronchophony, are often found over the parts of the chest, where the percussion-sound is dull or flat. These are eminently the signs of pulmonary solidification. On the other hand, in chronic pleuritis, absence of respiratory murmur and abolition of vocal resonance, below the level of the liquid, is the rule; the reverse occurring in only exceptional instances. Absence of respiratory and vocal sound, with flatness on percussion, is a combination of signs eminently dis- tinctive of the presence of liquid. Vocal fremitus may be preserved or increased in cases of cancerous infiltration or tumor. It is uni- formly abolished below the level of the liquid, in chronic pleuritis. In the former affections, we may expect often to find vesicular reso- nance on percussion, at or near the base of the chest, below the limit of dulness or flatness. In chronic pleuritis, in all save some very rare instances, we find flatness from the base of the chest extending more or less upward. The distinctive circumstances involved in the differential diagnosis of chronic pleuritis from cancer in the mediastinum are applicable, in a great measure, to the discrimination in cases of intra-thoracic tumor, arising from any other part exterior to the lungs. RETROSPECTIVE DIAGNOSIS OF CHRONIC PLEURITIS. Cases not infrequently are presented in practice in which it is important to determine, from an examination of the chest, whether chronic pleuritis have existed at some former period. A sense of weak- ness in the chest, and some deficiency of breath on active exercise, are apt to remain for a long time after recovery—that is, after the liquid effusion is completely absorbed, and there are no other symptoms which denote any pulmonary affection. Instances of this description have come under my observation, in which patients had experienced CHRONIC PLEURITIS. 573 the disease several years before, its character, perhaps, at the time, not having been determined. In other cases there are present symp- toms which may be due to some existing affection of the lungs, and in endeavoring to ascertain its nature, the permanent changes which have resulted from the pleuritis, must be taken into account. Chronic pleuritis may lead to certain consecutive affections. Dilatation of the bronchial tubes has been observed to follow. Emphysema may be a result. It has been supposed to increase the liability to pul- monary tuberculosis. Statistics show this opinion to be incorrect ;l but phthisis, of course, supervenes in some instances, and it is not infrequently an important problem to solve, in individual cases, whether this be so or not; a problem which, as has been seen already, is rendered more difficult by the changes consequent on the absorp- tion of a large pleuritic effusion. The retrospective diagnosis of chronic pleuritis, therefore, is a subject which appears to me deserv- ing of separate consideration. The diagnosis is made retrospectively by means of the remote or permanent effects of the disease. These are essentially the proximate effects, which do not entirely disappear for an indefinite period, or even during the remainder of life, and they have already been ad- verted to. They consist in contraction of the chest, alterations in the relations of different anatomical parts on the exterior of the thoracic parietes, displacement, in some instances, of intra- thoracic organs, and variations in percussion, respiratory and vocal sounds—in short, disturbance of the natural symmetry of the two sides of the chest, as respects the results furnished by the different methods of physical examination. This disturbance of symmetry, presenting characters which, collectively, are highly significant of the pre-existence of chronic pleuritis, justify a retrospective diagnosis. For what length of time after recovery is this diagnosis practicable ? This will, of course, depend on the persistency of the characters just referred to. The period doubtless varies in different cases. The changes immediately succeeding the disease gradually diminish, and examinations repeated at long intervals show progressive advance- ment toward restoration of the natural symmetry. Much will depend on the extent of the proximate effects. The age of the patient will also affect the final condition. In proportion to youth, other things "Vide "Practical Observations on Certain Diseases of the Chest, etc By Peyton Blakiston, M.D." Am. Ed. 1848. Also, " Clinical Report on Chronic Pleurisy," by author. 574 DISEASES OF THE RESPIRATORY ORGANS. being equal, will be the ultimate approximation to the normal sym- metry. But it is probable that in many, if not most instances, cha- racters sufficient for a retrospective diagnosis remain during life. I have preserved notes of two examinations made ten years after re- covery, and in both the traces of the disease were strongly marked. The brief account which I shall give of the remote effects on which the retrospective diagnosis is to be based, will be derived from the recorded results of fifteen examinations of different patients, made at periods varying from ten months to ten years from the date of the attack. In all these cases recovery had taken place, and the patients (all of them adults), so far as could be judged from the symptoms and signs, were free from existing pulmonary disease.1 Of fourteen cases in which either the existence or non-existence of diminished width of the chest was noted, it had occurred in all save two, and in these two instances there was flattening of the summit. In one case, at the summit of the affected side, instead of depression, there was greater comparative fulness; and this, coexisting with a clear, vesiculo-tympanitic percussion-resonance, and feebleness of the respiratory murmur, rendered it probable that emphysema had be- come developed in that situation. In the two instances in which diminished width was not apparent, the examinations were made in one ten months, and in the other three years from the date of the disease. The relative measurements of the semi-circumference of the two sides were noted in six cases. In these cases the contraction varied from half an inch to one and a half inches, always allowing for the right side half an inch as a normal disparity. The compara- tive contraction of the affected side after pleuritis is partly absolute and in part relative, the opposite side augmenting in size from the hypertrophy of lung resulting from the supplementary increase of the respiratory movements. The disparity between the two sides which immediately follows absorption, gradually becomes less, espe- cially if the patient be young. For example, in a case attended with large effusion, removing the heart to the right of the sternum (the left side being affected), the contraction after recovery was strongly marked. In the space of four years, the contracted side had ex- panded so as to leave but a slight apparent difference. A similar change, after the lapse of two years, I have noted in another case. In both instances the patients were young. 1 Two cases are to be excepted from this remark, in one dilatation of the bronchial tubes, and in the other partial emphysema being supposed to exist. CHRONIC PLEURITIS. 575 Of fourteen cases the shoulder was depressed in all but three. In one instance it was slightly elevated on the affected side. Of five cases in which the vertical position of the nipple was noted, it was lowered in four and raised in one. In one instance it was an inch lower than its fellow. Its distance from the median line was noted in three cases, and in all it was nearer, the difference varying from a quarter of an inch to an inch. The distance between the lower ribs was compared on the two sides in three cases, and in all it was diminished on the affected side. In one instance the ribs approximated so as almost to overlap. In this case there existed a deep depression on the inferior anterior surface of the chest. In two instances the upper ribs were compared in this respect, and found to be divergent on the affected side. In nine cases the comparative width of the interscapular spaces was noted, and in eight it was lessened on the affected side. In one instance it was one-half less on that side than on the other. The difference was in no case less than one and a quarter inches. In the single excepted instance in which the width was greater on the affected side, this was evidently owing to the existence of spinal curvature, the convexity looking to the opposite side. Projection of the lower angle of the scapula existed in all the cases in which the facts with respect to this point were noted, viz., in four; the same re- mark will apply to lowering of the scapula, which was noted in four cases. Of fourteen cases in which the results of a comparison of the breathing movements on the two sides were noted, in all save one they were more or less diminished on the affected side. This com- parative diminution was evidently in a measure due to an exaggerated expansibility on the opposite side. Dulness on percussion, as compared with the resonance on the side not affected, existed in every instance in which information relative to this point was noted, viz., in thirteen cases. Great clearness of the percussion-resonance was uniformly observed on the opposite side, and this contributed to render the contrast be- tween the two sides more striking. Feebleness of the respiratory sound over the whole of the affected side existed in eleven of thirteen cases. This was rendered more marked by an unusual intensity of the vesicular murmur on the oppo- site side. In one of the two excepted cases, bronchial respiration on the affected side behind, below the scapula, existed, in conjunction 576 DISEASES OF THE RESPIRATORY ORGANS. with marked bronchophony, the respiration being broncho-vesicular, and the vocal resonance comparatively feeble over the scapula. This combination of signs rendered the existence of dilatation of the bronchial tubes probable. In the other case, bronchial respiration and bronchophony existed in the interscapular space on the affected side. The respiration was interrupted on the affected side, at the summit, in one instance. In five cases the respiratory sound pre- sented certain of the characters of the broncho-vesicular respiration, consisting either in the diminished vesicular quality, with elevation of pitch of the inspiration, or a prolonged expiration. The absence of these characters in the other cases is not always stated. The results of a comparison as respects vocal resonance are given in ten instances. In six of these cases the resonance was greater on the affected side; but of these six cases, in three, the right side was the one affected. On the other hand, the four cases in which the vocal resonance was not greater on the affected side, included two in which the left side was the one affected. Of six cases in which the vocal fremitus on the two sides was compared, in four it was greater on the affected side, and in three of these four instances the left side was the one affected. The situation of the apex impulse of the heart was noted in seven cases. It was normal in three instances. In the remaining four in- stances the facts were as follows: in two cases an impulse was per- ceptible between the third and fourth, and also between the fourth and fifth ribs. In one of these instances it was noted that the move- ments in these two situations were in alternation (" quasi undulatory"). In both the left side was the one affected. In one instance the im- pulse was on a line with the nipple, and one and a half inches below it. In the other case a diffused pulsation was apparent over an area three inches in diameter, situated above the nipple. In the two last instances the left side was the one affected. Curvature of the spine was noted in four of seven cases. In three instances the curvature was lateral, and in one instance in an ante- rior direction, causing the patient to assume a stooping gait. The foregoing results are not given as embracing data sufficient for determining the numerical ratio in which the several changes respectively occur. This would be an interesting object of inquiry, and I regret that I have not availed myself of the opportunities that have been presented, to accumulate materials for an analysis with refe- rence to it. In the few cases analyzed, it will be observed that pains were taken to note facts respecting all the points in a small propor- CHRONIC PLEURITIS. 577 tion only, the attention, in most instances, being limited to obvious contraction, a comparison of the expansibility, the percussion-sound, and the intensity of the respiratory murmur. The results, however, are adequate to show the group of characters by means of which the retrospective diagnosis is to be made, for many months or years after recovery from chronic pleurisy. This is the only purpose I have had in view, and these characters, recapitulated, are embraced in the summary which follows. SUMMARY OF CHARACTERS INVOLVED IN THE RETROSPECTIVE DIAGNOSIS OF CHRONIC PLEURISY. Diminished width of the chest, apparent on inspection in the great majority of cases. Depression or flattening at the summit of the affected side, almost invariably observed; but occasionally enlarge- ment, which probably denotes abnormal dilatation of the cells, or emphysema. The reduction in size also shown by mensuration. The shoulder generally depressed; but in some instances this is not apparent, and it may be even raised above the level of that on the opposite side., The nipple usually depressed, but not invariably, and nearer the median line. The lower ribs converging, sometimes almost overlapping; the upper ribs diverging. The distance from the posterior margin of the scapula to the spinal column lessened, often in a notable degree; an exception to this rule obtaining, in some instances, when lateral curvature of the spine takes place, the concavity looking toward the affected side. Projection of the lower portion of the scapula, occurring in a certain proportion of instances; and, also, depression of the inferior angle below the level of that on the opposite side. The respiratory movements almost uniformly diminished in a degree more or less marked; the expansibility on the opposite side being, at the same time, exaggerated. Comparative dulness on percussion; the contrast rendered more striking by the great clearness of the percussion-resonance on the opposite side. A vesiculo-tympanitic resonance at the summit, conjoined with enlarge- ment, denoting the supervention of emphysema. Feebleness of respiratory sound over the entire side, with few exceptions; and on the opposite side, an unusually intense vesicular murmur. A bron- chial respiration sometimes observed in the interscapular space, and in other parts of the side. In the latter, especially if associated with bronchophony, probably denoting dilatation of the bronchial 37 578 DISEASES OF THE RESPIRATORY ORGANS. tubes. The respiration, in a certain proportion of cases, broncho- vesicular. The vocal resonance sometimes greater, but not uniformly. The same remark applicable to vocal fremitus. Curvature of the spine in some cases, the inclination usually lateral, the concavity toward the affected side. The position of the heart frequently normal, but in some instances displacement of this organ; it being found to the left of its natural position and elevated, if the pleuritis be seated in the left side.1 It will be borne in mind that this summary embraces characters observed in persons after complete recovery from chronic pleuritis, and presumed to be entirely free from any existing pulmonary dis- ease, excepting, in some instances, emphysema and dilatation of the bronchial tubes. Empyema. i When the liquid contents of the pleura are purulent, the affection is generally called empyema ; a better term, used by some writers, ispyothorax. Empyema is, in fact, only a variety of pleuritis ; but in view of certain pathological peculiarities, there is a propriety in considering it as a distinct form of the disease. Inflammation, either acute or chronic, in this, as in other situations, evinces in some in- stances a peculiar tendency to the formation of pus. This tendency is independent of the intensity, nor does it depend on the duration of the inflammation or the amount of effused products. The symp- toms denoting a high grade of inflammatory action may be equally absent when the chest is filled with purulent matter, as in ordinary cases of chronic pleuritis ; and death may occur with an accumula- tion of pleuritic effusion of long standing when the chest contains only serum and .lymph. Empyema, therefore, seems to be a species of pleuritic inflammation differing from ordinary pleuritis, ab initio, in a tendency to the formation of pus. Clinically, however, it is by no means easy to distinguish empyema from ordinary chronic pleuritis, and, indeed, a positive discrimina- tion by means of the symptoms and signs is impracticable. The physical phenomena in both are equally those which are due to an accumulation of liquid. There are none which are distinctive of the character of the liquid. Bulging between the ribs, which has been 1 The liability of the heart to be permanently drawn toward the right side after pleuritis affecting that side, has been already adverted to. EMPYEMA. 579 supposed to indicate the presence of pus rather than serous effusion, depends on the quantity of liquid, together with a condition of the intercostal spaces which renders them yielding to pressure, and is significant alike of both varieties. The occurrence of hectic parox- ysms, of more marked and persisting febrile movement, or greater gravity of the local and general symptoms, cannot be relied upon. I have known the fact of an enormous accumulation of liquid, which was found to be purulent, to be discovered accidentally only a few days before death. Cases of empyema, as well as of ordinary chronic pleuritis, are liable to be overlooked, patients being able to go about, and supposed to labor only under general debility, or some malady not seated in the chest. Such instances have fallen under my notice. Assuming it to be determined that the pleural sac is more or less filled with liquid, a point which, as has been seen, by means of phy- sical exploration, may be settled with promptness and certainty, it is highly desirable, with reference to the prognosis and the manage- ment, to decide, if possible, whether the liquid be purulent or not. A rational conclusion may be formed with considerable confidence if, the quantity of liquid being large, it remains stationary, and, more especially, if it continue to increase, in spite of judicious therapeutical measures to promote its diminution by absorption. In the great majority of cases of ordinary chronic pleuritis these measures are, to a greater or less extent, successful: the amount of fluid is reduced, although, after a time, its farther reduction may not be effected. A purulent fluid being with more difficulty absorbed, it is much more likely to remain undiminished or to increase. As regards the relative quantity of liquid at different periods, this can of course be ascer- tained with precision by repeated explorations. But although the physical signs and symptoms are not adequate to afford positive information as to the character of the liquid contained in the pleura, this point may be settled readily and demonstratively by a method involving little or no difficulty or danger. I refer to the use of the exploring canula. The cases reported within the past few years by Dr. Bowditch, of Boston, in which paracentesis thoracis was performed after the plan proposed by Dr. Morrill Wyman, of Cambridge, Mass.,1 show that the operation may be resorted to with ' Vide Am. Jour, of Med. Sciences, April, 1852. The method referred to consists in using a small canula, which is attached by a flexible tube to a suction-pump, so con- structed that the fluid may be removed from the chest through the canula, and discharged from the pump through another aperture. 580 DISEASES OF THE RESPIRATORY ORGANS. ease and safety, in order to determine the nature of the liquid con- tents of the chest. To discuss the merits of this operation, as of other therapeutical measures, does not fall within the scope of this work. With reference to its performance, the importance of being able, by means of physi- cal signs, to determine positively the presence of effusion, is suffi- ciently obvious. Heretofore the question as to the propriety of re- sorting to this operation involved the liability of mistaking ordinary pleuritis or empyema for other affections; and the operation has frequently been performed when there was no liquid within the pleural cavity. An instance of this kind has occurred within my own know- ledge. Uncertainty in diagnosis is no longer a valid reason either for omitting or delaying to puncture the chest. It is chiefly in cases of empyema that the contents of the pleural sac are discharged spontaneously, by means of ulceration and a fistu- lous communication, either directly through the thoracic parietes, or indirectly through some natural outlet. The evacuation may take place through the bronchial tubes, which occurs next in frequency to perforation of the walls of the chest. It has been known to take place into the alimentary canal. The sudden occurrence of a copi- ous purulent expectoration, when the chest is known to contain liquid, is evidence that ulceration has ensued, commencing from within the pleural sac; but the phenomena arising from the presence of air and liquid in the cavity of the pleura are speedily superadded;—the affec- tion, in short, becomes pneumo-hydrothorax. When perforation of the thoracic parietes occurs, the purulent fluid collecting beneath the integument forms a fluctuating tumor, evidently situated exterior to the bony wall of the chest. If the pre- existence of an accumulation of liquid has not been ascertained, this tumor may be regarded as simply an abscess, not communicating with the interior of the chest. I have known this mistake to be committed by those who were not accustomed to employ physical exploration. The coexistence of the physical signs of a large accu- mulation of liquid in the pleural sac, renders the connection of the subcutaneous collection with empyema altogether probable. But this connection may be established by compression of the tumor. If it be simply an abscess beneath the integument, it is irreducible by pressure ; but if the fluid be derived from the chest through a perforation, it may be made in a great measure to disappear, by forcing its contents into the thoracic cavity. Again, a tumor con- EMPYEMA. 581 taining a fluid which communicates freely with liquid in the chest, will be observed to rise and fall with the successive acts of inspira- tion and expiration. Moreover, an abscess developed exterior to the chest would involve, generally at least, acute inflammation, accom- panied by pain, swelling, heat, and redness, prior to fluctuation. These local phenomena do not precede the appearance of a fluctua- ting tumor, due to perforation in the course of empyema. If the tumor be opened, under the erroneous impression that it is nothing more than a subcutaneous abscess, the great abundance of the purulent discharge will be likely to lead to a discovery of the error. A fluctuating tumor beneath the integument, due to perforation in empyema, is sometimes found to pulsate synchronously with the beating of the heart. This may, at first, excite a suspicion of aneu- rism. The tumor is too rapidly developed, its liquid contents are too superficially situated, and the fluctuation too marked and exten- sive, to be aneurismal. The positive signs of aneurism are wanting, viz., the bellows' murmur and thrill; and the physical signs of an abundant accumulation of liquid in the chest remove all doubt as to its character. A pulsation is occasionally observed more or less diffused over the affected side, in cases of empyema, in which the liquid is retained within the pleural sac. This gives rise to a variety of the disease which has been called pulsating empyema. An instance has fallen under my observation, in which the shock communicated to the walls of the affected side led the attending physician to suppose that the case was one of disease of the heart.1 Moderate hypertrophy of -the left ventricle actually existed, as ascertained after death. The circumstances, in such instance, which authorize the exclusion of aneurism are the absence of its positive signs furnished by ausculta- tion and palpation, viz., the bellows' murmur and thrill, together with the absence of the symptoms due to the pressure of an intra- thoracic tumor on the vessels, nerves, oesophagus, and air-passages— symptoms not belonging to the clinical history of liquid accumula- tion in the pleura, however large. Taken in connection with these negative points, the physical signs of a large quantity of liquid in the chest establishes the diagnosis. 1 Clin. Report on Chronic Pleuritis, p. 47. 582 diseases of the respiratory organs. Circumscribed Pleuritis, with Liquid Effusion. Circumscribed inflammation of the pleura, either without much liquid effusion, called dry pleuritis, or the effusion not confined within the limits over which the inflammation extends, occurs as a complica- tion of other pulmonary affections, and has already been noticed in connection with pneumonitis and pulmonary tuberculosis. But pleu- ritis may be partial or circumscribed, and accompanied by more or less effusion of liquid, which is not diffused, and does not gravitate to the bottom of the sac, but is retained by adhesion at the borders of the area of the inflammation. Under these circumstances, the fluid is, as it were, encysted, occupying between the pleural surfaces a circumscribed space, varying in size and in situation. In some instances there exist several distinct collections of liquid, consti- tuting, if the fluid be purulent, what has been denominated multi- locular empyema. The latter variety, as well as that in which the affection is unilocular, occurs in persons who have previously had general pleuritis, followed by general agglutination of the pleural surfaces, more or less extensive, leaving one or more spaces in which the surfaces did not adhere. Subsequent attacks of inflammation limited to the non-agglutinated portions of the membrane, constitute circumscribed pleuritis, accompanied by an effusion restricted within the boundaries of the space or spaces in which the surfaces are free. These local collections of liquid may occur in different situations. They may be seated between the diaphragm and the base of the lung, or at any point between the costal and pulmonary portions of the pleura, on the anterior, posterior, or lateral surfaces, and they have been known to take place between the lobes, the latter having become adherent at the margins of the interlobar fissure. Circum- scribed inflammation, in these different situations respectively, is distinguished as costo-pulmonary, diaphragmatic, and interlobar pleu- ritis. If acute inflammation be seated in the diaphragmatic pleura, cer- tain symptoms are pointed out as somewhat distinctive, viz., severity of pain, forward inclination of the body, cough remarkably paroxys- mal, predominance of the superior costal type of breathing, hiccough, nausea, and vomiting, jaundice if the right side be affected, and sometimes the risus sardonicus? It may be doubted if these symp- 1 Walshe, op. cit. PLEURITIS WITH LIQUID EFFUSION. 583 toms possess much diagnostic value. They are, however, worthy of being borne in mind, the more because the existence of a circum- scribed collection of fluid between the diaphragm and the base of the lungs is detected by means of physical signs with much greater difficulty than in other situations. In fact, when an accumulation exists in this part of the chest, if small or moderate in amount, a positive diagnosis is hardly attainable. Even with the advantage of the occurrence of perforation of the lung and the discharge through the bronchial tubes of purulent matter, assuming that tuber- culosis and pulmonary abscess are excluded by the negative results of physical exploration, it may be difficult to determine whether the collection of pus has taken place above the diaphragm or in a subja- cent organ. A case which came under my observation several years ago, will serve to illustrate this difficulty. A patient entered a hos- pital with a copious expectoration, apparently of pure pus, which had existed for some time. Ten ounces were expectorated in the space of twenty-four hours. He was not much emaciated; the pulse was 72; the respirations 24; moderate diarrhoea existed, and it was reported that the dejections sometimes contained pus; but the latter point was not satisfactorily ascertained. Physical exploration fur- nished the following results. Emaciation not sufficient to render the outline of the ribs visible. Clear percussion-resonance at the sum- mit of the chest on both sides. Flatness on the right side from the base to the fourth rib in front. Behind, in the interscapular space, resonance clear on both sides. Flatness below the inferior angle and over the lower part of the right scapula. Tenderness on pressure at the lower part of the right side, extending below the boundary of the chest. Respiration on the left side exaggerated; on the right side, above the fourth rib feeble, but vesicular; below the fourth rib absence of respiratory murmur, and a distinct, but not loud friction-sound with both respiratory acts. Behind, on the right side, respiration feeble, bronchial, and accompanied by a fine mucous or sub-crepitant rale. Bronchophony at the angle of the scapula. After the death of this patient, it was ascertained that a pleuritic abscess, as it may be called, was situated at the lower part of the rio-ht side of the chest. Circumscribed inflammation, the pleural surfaces being free, existed over a strip five or six inches in width, at the base of the chest, extending from the lower part of the ster- num quite around the right side. Above this strip the pleural sur- faces were agglutinated. The lower lobe of the right lung was soli- dified ; otherwise the pulmonary organs were free from disease. 584 DISEASES OF THE RESPIRATORY ORGANS. The situation of the circumscribed empyema, in this case, accorded with the physical signs; yet, in view of all circumstances, there being no evidence of general chronic pleuritis or empyema having existed, and balancing probabilities, hepatic abscess, evacuating through the lungs, had been suspected. In the diagnosis of circumscribed collections of liquid situated between the costo-pulmonary pleural surfaces, elsewhere than at the base of the chest, physical signs are more available. Dulness or flatness on percussion will be found over a space corresponding to the area within which the liquid is confined. Effacement of the intercostal depressions and even bulging may be observed in this space. The vocal fremitus may be wanting. The respiratory sound may be feeble or absent, together with abolition of vocal resonance. Surrounding the collection, owing to the pleuritic adhesions and con- densation of lung, the respiratory sound will be more or less deve- loped and broncho-vesicular. The signs just mentioned will be espe- cially marked in cases in which the area of pleuritic surface occupied by the effusion, and the quantity of the latter, are not small; and the diagnosis is made with more positiveness if the situation of the col- lection be in the middle third of the chest, and if there are present the evidences of general pleuritis having existed at some former period. If circumscribed pleuritis exist with a fistulous opening through the thoracic wall, the probe becomes an important instrument in diagnosis. An interesting case of this description, of traumatic origin, was recently under my observation through the kindness of my friend and colleague, Professor Gross. The patient, three months before, had received a wound from a hatchet, penetrating the chest on the left side, between the first and second ribs, about three inches from the median line. Acute general pleuritis followed ; but he was now able to be up and about, presenting a healthy aspect, free from cough or difficulty of respiration, except after active exercise. The left side was considerably contracted. A small fistulous open- ing existed at the place where the wound was received, from which about a table-spoonful of puriform liquid escaped daily. To evacuate the fluid, which he was accustomed to do twice daily, he was obliged to lie upon the floor with his face downward, and the body inclined to the left. A probe introduced into the orifice showed the existence of a circumscribed cavity, the vertical length being about five inches, and the orifice near its upper extremity. On forced expiration, air PLEURITIS WITH LIQUID EFFUSION. 585 was expelled through the aperture with an audible noise; and the patient stated that sometimes when the orifice was first 'opened by detaching the incrusted lymph with which it became sealed, the passage of the air occasioned a loud report. To prevent the accumulation of liquid in the cavity, Professor Gross penetrated it with a trochar at its lower extremity, and esta- blished, by means of a tent, a fistulous orifice in this situation. This treatment speedily effected a cure, the cavity becoming obliterated in a few weeks. The existence of several, or multilocular, collections was presumed in a case which came under my observation five years since, of which the following is a brief account. The patient, a girl fourteen years of age, had been subject for several years to a loud, hard cough, with a small, transparent, frothy expectoration. Five weeks pre- vious to the date of my examination, she had suddenly expectorated a quantity of purulent matter. She continued to expectorate the same matter for a day or two, and it then ceased. Afterward, during the five weeks, she had several similar attacks. The general health was not much impaired. On examination of the chest, there was moderate dulness on percussion at the summit of the right side, with no distinct abnormal modification of the respiratory sound. Abso- lute flatness existed over the lower and most of the middle third on the right side, with absence of respiration in front and laterally. Be- hind, on the right side, the percussion-resonance was clear to the base. No rales, nor either bronchial or cavernous respiration. Ten- derness on percussion was observed over the right mammary region. Nine months afterward, this patient seemed quite well, but on slight examination flatness over the lower part of the chest on the right side still existed. She had at that time had no purulent expectora- tion for some time. Interlobar pleuritis with liquid accumulation presents difficulties in the way of diagnosis still greater than when the collections are situated between the costo-pleural surfaces. The pressure of the liquid here is not directly upon the thoracic parietes. Pulmonary substance, more or less compressed, intervenes between the liquid and the walls of the chest. The percussion-resonance will, therefore, be more or less dull, but not flat; and effacement of the intercostal depressions, or bulging, will not be likely to occur. The respiratory sound will be feeble" and more or less broncho-vesicular, or even bron- chial, from the presence of condensed lung. Dr. Walshe mentions 586 DISEASES OF THE RESPIRATORY ORGANS. the fact of the accumulation being in the line of the interlobar fissure, as a point* having a bearing on the diagnosis. Circumscribed pleuritis with liquid effusion is by no means of fre- quent occurrence. It is only now and then that cases occur to puzzle the diagnostician. Hydrothorax. Serous effusion within the pleura, not due to inflammation, consti- tutes the affection called hydrothorax. The effusion is purely serous, i. e. serum unmixed with inflammatory products. The affection is never primitive or idiopathic. It occurs always as an effect or com- plication of some other disease; and in the great majority of cases it coexists with general dropsy incident to structural lesions of the heart or kidneys. The diagnosis claims but a few words. Its pathological connections constitute a diagnostic point. We look, as a matter of course, for more or less effusion into the chest in cases of cardiac or renal dropsy. The affection is always double. The causes act equally on both sides, their modus operandi being purely mechanical. For this reason it is impossible that the quantity of effusion should ever be sufficient completely to fill the chest. A near approach to this amount of ac- cumulation in both sides would be incompatible with life. And in consequence of the affection being double, a moderate amount of effu- sion is productive of far greater disturbance of the respiratory func- tion, as induced by accelerated breathing, dyspnoea, lividity, etc., than belongs to cases of chronic pleuritis in which the whole of one side is filled with liquid. Moreover, the pathological conditions asso- ciated with hydrothorax, such as ascites, hydro-pericardium, organic disease of heart, general debility, render the system less able to bear up under a diminution of the respiratory function, than in the majority of cases of chronic pleuritis. Except in degree, the positive symptoms offer nothing distinctive of hydrothorax. Negatively it is distinguished from pleuritis by the absence of the symptomatic phenomena due to inflammation, viz., lan- cinating pain, tenderness on pressure, and cough. These phenomena, present to a greater or less extent in many cases of pleuritis, are wanting in hydrothorax, or, at least, do not constitute a part of its semeiological history. hydrothorax. 587 The physical signs representing a certain quantity of liquid in the pleural sac, displacing the lung, perhaps occasioning some enlarge- ment of the inferior portion of the cjiest, and depressing the dia- phragm, are essentially the same in hydrothorax as in pleuritis. It is unnecessary to recapitulate them in this connection. There are, however, certain distinctive points pertaining to the physical pheno- mena, which possess diagnostic significance. The visible changes in size, form, and expansibility, resulting from a very large accumulation of liquid, which are observed, in cases of chronic pleuritis, are of course never exhibited in cases of hydrothorax, because a similar amount of accumulation in both sides is incompatible with life. This has less clinical value as a distinctive feature than those which remain to be mentioned. In hydrothorax, friction-sounds do not occur. The condition for their production, viz., roughening of the pleural sur- faces by a deposit of lymph, is incident to inflammation, and does not obtain in a purely dropsical affection. This is a negative point. A positive point is, that in cases of non-inflammatory serous effusion, the liquid, as a rule, if not invariably, can be made to change its level by varying the position of the patient; the quantity of liquid never becoming very large, and the pleural surfaces remaining free, this test of the existence of effusion is always or generally available, while in pleuritis it is employed successfully in a certain proportion of cases only. The points thus briefly adverted to, pertaining to the symptoms and signs, taken in connection with the existence of effusion on both sides, and the fact that the affection occurs only as a complication of other diseases, which give rise at the same time to general dropsy, render the diagnosis of hydrothorax easy and positive. Pneumothorax—Pneumo-Hydrothorax. An abnormal condition, consisting in the accumulation of air or gas within the pleural sac, unaccompanied by liquid effusion, is de- nominated pneumothorax. Thus defined, the affection may be said to be almost infinitely rare. The secretion or exhalation of air or gas from the pleural surfaces, must be regarded as extremely problematical. Pleural rupture over the dilated cells in vesicular em- physema, or of the blebs which are occasionally formed in the inter- lobular variety of this disease, is an accident which has been known 588 DISEASES OF THE RESPIRATORY ORGANS. to occur in a few instances, giving rise to an accumulation of air in the pleura, unaccompanied, for a time, at least, by any morbid pro- duct ; but, under these circumstances, inflammation is likely soon to supervene, and liquid effusion follows. Whenever air or gas gains access within the pleural cavity, by other modes, the accumulation of liquid either precedes or speedily ensues, and the coexistence of air or gas and liquid, let the character of the latter be what it may, gives rise to the affection called pneumo- hydrothorax. From what has been said, it follows that, although pneumothorax may exist as an affection distinct from pneumo-hydro- thorax, the latter, in a clinical point of view, is chiefly important. In relation to diagnosis, it will suffice to consider both affections under the head of pneumo-hydrothorax, making incidental mention of the circumstances which characterize the presence of air without liquid—in other words, pneumothorax. It is to be remarked that our knowledge of this, as of several pulmonary affections, is to be dated from the researches of the illustrious discoverer of auscultation. Pneumo-hydrothorax is always either of traumatic origin, or an effect of some antecedent morbid condition. It is never a primitive affection. And with reference to its discrimination, it is important to bear in mind the various modes in which it originates. Moreover, circumstances pertaining to its different pathological connections, affect materially both the symptoms and signs, more especially the latter, by which the diagnosis is established. In by far the larger proportion of cases it occurs as an accidental complication of pulmonary tuberculosis, being produced by perfora- tion of the lung resulting from rupture of the pleura over a cavity or a collection of softened tubercle. The rupture generally takes place during an act of coughing. Pneumothorax, then, becomes suddenly developed, and is speedily followed by acute pleuritis, with liquid accumulation. The size of the perforation, the persistency of a fistulous opening, and the freedom of communication established between the pleural cavity and the bronchial tubes are circumstances having important bearings on the development of certain physical signs. Statistics show that this accident is much more liable to occur on the left than on the right side. The situation at which it is oftenest found to take place, may also be borne in mind with refe- rence to physical exploration. According to Walshe, it is on the postero-lateral surface between PNEUMOTHORAX. 589 the third and sixth ribs.1 Its occurrence in the progress of tubercu- losis is extremely rare. Several instances, however, have fallen under my observation. It is liable to occur in connection with circumscribed gangrene of the lung, the pleura giving way over the eschar, inducing, in like manner, perforation and pleuritis. This is a rare result of a rare form of disease. I have met with two instances. Perforation of the lung takes place still more rarely in connection with pulmonary apoplexy, tuberculous affection of bronchial glands, opening into the bronchial tubes and pleura, abscess, cancer, and hydatids. And it may be produced by an ulcerative process, taking its point of departure from the pleura, and extending to the bronchial tubes, in cases of chronic pleuritis and empyema. Perforation of the thoracic parietes may lead to the admission and accumulation of air within the pleural cavity. This takes place in certain cases of empyema. Abscesses situated in the walls of the chest may result in an external communication with the pleural cavity. Thus produced, cases of pneumo-hydrothorax are distinguished from those involving perforation of the lung, and communication with the bronchial tubes, by the absence of certain physical phenomena which involve the latter anatomical conditions in their production. Penetrating wounds of the chest, on the one hand, and, on the other hand, injuries of the lung from the fractured extremities of ribs, or contusion, are the modes by which the affection is produced trau- matically. Instances have occurred of a fistulous communication between the alimentary canal (oesophagus and stomach) and the pleural sac, through which the gases from the former escape into the latter situation. Finally, in some very rare instances, chemical decomposition of liquid contained in the pleural sac takes place sufficiently to occasion development of gas, without perforation either of the lung, thoracic parietes, stomach, or oesophagus. In such cases, the phenomena which involve the admission of air from the bronchial tubes into the pleural cavity are of course wanting. In this category may be placed the transient production of gas, in some mode not easily accounted for, in connection with pneumonitis, of which an instance was reported by Dr. Graves, and another by 1 This is quoted as more correct than the statement made by some writers, that it is most liable to occur near the apex of the lung. The pleural adhesions so uniformly occurring at the summit render it less liable to occur in that situation. 590 DISEASES OF THE RESPIRATORY ORGANS. Valleix. These cases are so remarkable that if they rested on the testimony of less competent observers, the accuracy of their observa- tion might well be questioned. Rupture of the lung in connection with emphysema, of which a few cases are on record, has already been referred to. The physical conditions incidental to pneumo-hydrothorax pro- duced in the various modes just mentioned, which are represented by physical signs, are the following. The presence of air or gas and liquid, in greater or less abundance, and in both varied and varying relative proportions. Perforation of the thoracic parietes, in some cases giving rise to fluctuations as respects the quantity, absolute and relative, of air and liquid. Communication with the bronchial tubes, in other cases, by which air enters more or less freely into the pleural cavity in respiration. To these conditions are to be added, those proper to the different antecedent diseases of the lung or pleura of which the pneumo-hydrothorax is a complication. Physical Signs.—The physical signs in pneumo-hydrothorax are highly distinctive. Over a space commensurate with that occupied by air or gas, the chest yields on percussion a marked degree of sonorousness, which is purely tympanitic in quality, and high in pitch, approaching fre- quently, in intensity as well as "character, the sound in abdominal tympanitis. This clear hollow resonance is always found at or near the summit of the chest, extending downward a greater or less dis- tance, unless the lung be attached at its upper portion, so as to pre- vent its compression and the ascent of the gaseous fluid. The presence of the condensed lung, situated usually at the superior and posterior portion of the chest, may give rise to dulness in that situation. If air or gas be present without liquid effusion, the tympanitic sonor- ousness may be diffused over the greater part of the affected side. But as more or less liquid is almost invariably present, the sonorous- ness extends to a certain point, and below this point there is flatness on percussion. The spaces, relatively, which are occupied by the tympanitic resonance and the flatness due to liquid effusion, will be likely to vary at different times, especially if there exist a free com- munication either with the bronchial tubes, or, externally, by an out- let through the thoracic parietes. The escape of fluid by expectora- tion, or by external discharge, will of course affect the quantity retained within the chest, and thus occasion fluctuation in its amount. PNEUMOTHORAX. 591 The introduction of air, also, is liable to variations, from obvious causes, as well as the production of gas by chemical changes. Ac- cording to Skoda, the boundary line at which the tympanitic sound ceases and flatness begins, does not mark with accuracy the level of the liquid, the former being propagated for a certain distance below this level. Skoda, indeed, states that we may reckon the quantity of liquid present as about double that indicated by percussion. Another fact has been pointed out especially by the author just named. It is, that when the accumulation of air or gas is large, owing to the tension of the thoracic "wall the sonorousness is dimi- nished, and the sound may even become dull, the tympanitic quality being of course preserved. The tympanitic sound in some instances has a ringing, metallic tone, resembling that produced by percussion over the stomach, and which may be imitated by striking either the back of the hand when the palmar surface is applied firmly over the ear, or after the illustration given by Dr. Williams, a caoutchouc bottle held to the ear. This modification is sometimes discovered by practising auscultation and percussion simultaneously, when it is not rendered apparent by the latter alone. The line of demarcation between tympanitic sonorousness and flat- ness varies with the position of the patient, owing to variation of the level of the liquid. This test of the presence of liquid is more uni- formly available in pneumo-hydrothorax than in simple pleuritis. It is rarely the case that it is not available in the former affection. Over the portion of the chest in which tympanitic sonorousness exists, the thoracic parietes are found to be highly elastic. On the other hand, below the level of the liquid effusion, there is deficiency of elasticity, and a marked sense of resistance felt on percussion or pressure. The diagnostic evidence afforded by percussion alone, is quite con- clusive in cases of pneumo-hydrothorax. The tympanitic resonance occasionally observed in connection with other morbid conditions can hardly lead to the error of confounding them with this affection. A marked tympanitic sonorousness on the left side is sometimes due to the presence of gas in the stomach. The character of the gastric sound is distinctive ; but, aside from this, it is most marked at the lower portion of the chest, gradually diminishing as percussion is made toward the summit. Precisely the reverse obtains in pneumo- hydrothorax ; the sonorousness exists above, and the percussion-sound is rendered flat below by the presence of liquid. 592 DISEASES OF THE RESPIRATORY ORGANS. The tympanitic sonorousness which is found in a certain propor- tion of cases of simple pleuritis over the compressed lung, above the level of the liquid, is never so strongly marked as in most cases of pneumo-hydrothorax. If the quantity of liquid be moderate, the sound is not purely tympanitic, but vesiculo-tympanitic. The relative situations of sonorousness and flatness are not altered to the same extent by changes of posture. The walls of the chest are not so elastic. However, auscultation shows, in the one case, the lung to be in contact with, and in the other case to be removed from, the walls of the chest above the liquid. The same remarks are applicable to the tympanitic resonance sometimes observed over lung solidified by inflammatory exudation. In the latter case, the bronchial respiration and bronchophony will be discovered by auscultation to be associated with the tympanitic sonorousness, and this combination, as will be seen presently, is proof not less against pneumo-hydrothorax than for the existence of pulmo- nary solidification. The exaggerated resonance in emphysema is not purely tympanitic, but vesiculo-tympanitic, and in this affection the evidence of liquid in the chest is wanting. On auscultation, the respiratory sound, as a rule, is feeble, distant, and frequently suppressed over the space occupied by the gaseous accumulation, except a free communication exists between the pleural cavity and the bronchial tubes. When the latter condition obtains, the cavernous and amphoric respiration may be discovered. It is in cases of pneumo-hydrothorax especially, that the amphoric modifica- tion of the cavernous respiration is most marked. These respiratory sounds are not constantly present, even when the anatomical condi- tion just mentioned, which is necessary for their production, exists. The perforation may at times be situated below the level of the liquid or the orifice, or the tubes leading thereto, are liable to become obstructed; either of these circumstances will prevent their develop- ment. The opening into the pleural cavity may be too small for their production. Other things being equal, their intensity will be pro- portionate to the size of the fistula, and the calibre of the bronchial tubes to which it leads. Skoda, explaining these signs by the theory of consonance, contends that communication is not necessary; a thin stratum of tissue not preventing the production of the sounds. He is peculiar in entertaining the belief that the communication very rarely becomes persistent, the opening almost invariably being PNEUMOTHORAX. 593 closed, partly by the compression of the lung, and partly by the effusion. The cavernous and amphoric sounds when present are not diffused equally over all the space occupied by air, but are either limited to a circumscribed area, or heard at a certain point with an intensity which gradually diminishes as the ear is removed from it. Their maximum of intensity is, of course, over the site of the perforation; and they are therefore to be sought for in cases of tuberculosis where rupture is most apt to occur, viz., postero-laterally, between the third and sixth ribs. The respiratory sound is suppressed over the space occupied by liquid effusion. This space will extend from the base of the chest upward to a distance proportionate to the quantity of liquid. At the summit, especially behind, the bronchial respiration may be discovered over the lung, which is not only condensed by pressure, but in addi- tion, generally solidified by tuberculous deposit. It is, however, rarely, if ever, loudly developed. According to Stokes, the existence of tuberculous cavities in the compressed lung may sometimes be ascertained by their physical signs. On the healthy side, the respi- ratory sound is exaggerated. The vocal phenomena vary not only in different cases, but in dif- ferent parts of the chest in the same case. Absent below the level of the liquid effusion, the resonance may be wanting, feeble, or more or less marked, over the space occupied by air or gas, with an amphoric intonation, under the circumstances which give rise to amphoric respiration. At the summit, over the compressed lung, we may expect to find, more or less frequently, marked resonance; per- haps bronchophony, and possibly pectoriloquy. An adventitious sound incident to the respiration, voice, and cough, is almost pathognomonic of pneumo-hydrothorax. This is metallic tinkling. It is a pretty constant sign, at least in cases involving perforation of lung. Exclusive of this affection, it is never met with, except, very rarely, in large tuberculous excavations. A sound somewhat analogous is sometimes produced within the stomach. The latter is occasional, and is readily distinguished by the fact that it occurs irrespective of the respiration, voice, or cough. For an account of the characters belonging to this sign and the circum- stances (so far as known) connected with its production, the reader is referred to Part I.1 It is found generally over the middle third of 1 Vide page 282, et seq. 38 594 DISEASES OF THE RESPIRATORY ORGANS. the chest; sometimes limited to the summit, and occasionally diffused over the greater part of the affected side. It has been known to accompany the act of deglutition, as well as the acts of breathing, speaking, and coughing. Inspection and mensuration furnish signs of importance. The affected side is permanently expanded, and its movements are accord- ingly limited. Frequently the accumulation of air and liquid leads to great dilatation and complete immobility, even with forced breath- ing. The intercostal spaces are widened and pushed outward, some- times beyond the level of the ribs; the diaphragm is depressed, the mediastinum displaced, and the heart dislocated, being transferred, in some instances, to the right of the sternum—in short, the same appearances are presented as in cases of chronic pleuritis or emphy- sema. The signs furnished by inspection and mensuration alone would not enable the observer to distinguish between pneumo-hydro- thorax and chronic pleuritis or empyema. Percussion and ausculta- tion, however, at once supply differential characters. In chronic pleuritis and empyema with dilatation, the affected side is flat on percussion, with absence of respiratory sound in the great majority of instances, except over a small space at the summit. The strongly marked tympanitic sonorousness, extending over more or less of the affected side, cavernous, or amphoric respiration, and metallic tinkling, are wanting. Dilatation does not uniformly occur in pneumo-hydrothorax. Liquid and air or gas may exist in the pleural sac, compressing the lung, without manifest enlargement. Cases, however, in which mor- bid changes in size and motion are not available in the diagnosis are exceptional. Palpation furnishes signs which belong alike to chronic pleuritis and empyema, viz., diminution or abolition of vocal fremitus and fluctuation. Finally, it is in this affection that succussion is available as a method of exploration. When air and liquid are contained in the pleural cavity, moving the trunk of the person to and fro, with the ear applied to the chest, produces a splashing noise, resembling that caused by shaking a bottle partly filled with water. This " Hippo- cratic succussion-sound," as it is frequently called, from the fact that it arrested the attention of the ancient father of medicine, is almost pathognomonic of pneumo-hydrothorax. The conditions under which it is presented, exclusive of this affection, occur only in PNEUMOTHORAX. 595 pulmonary tuberculosis; and in the latter disease their occurrence is extremely rare. A very large excavation, partially filled with liquid, combines the circumstances necessary for its production. In this connection, however, the associated signs and symptons, in con- junction with the history, are so distinctive of tuberculous disease, that the presence of the sign, should it happen to be discovered, can hardly prove a source of any perplexity as to the diagnosis. For a farther account of this sign, as incidental to the affection under con- sideration, the reader is referred to the chapter in Part I, which treats of succussion.1 Diagnosis.—The symptoms of pneumo-hydrothorax, taken in con- nection with collateral circumstances, frequently are quite significant. In a very large majority of cases, the affection occurs in the course of pulmonary tuberculosis, and results from perforation of the lung. This accident, generally taking place during an act of coughing, is signalized by sudden acute pain in the chest, speedily followed by great dyspnoea, hurried respiration, frequency of the pulse, prostra- tion, lividity, perspiration, diminished or suppressed expectoration, occasionally loss of voice, and an expression of great anxiety. When a case of phthisis offers this group of symptoms, manifested abruptly, perforation should be strongly suspected. At first, and for a brief period, the affection may be simply pneumothorax, but as acute pleuritis is generally quickly developed, with more or less liquid effusion, the disease soon eventuates in pneumo-hydrothorax. If, however, the physician rely exclusively on the symptoms, he will be likely to fall into errors of diagnosis; for the development of simple pleuritis may give rise to a group of phenomena, not unlike that just mentioned, and perhaps accompanied by a feeling, on the part of the patient, that something has given way in the chest; so that, as remarked by Dr. Stokes, the thorax is sometimes explored with a strong expectation of finding the evidence of perforation, when the result is negative. And, on the other hand, perforation is not always attended, in a marked degree, by the symptoms which have been enumerated. In some instances it is not immediately followed by notable disturbance, either of the respiratory function or of the system at large. In these cases, either the perforation is so small that the air and morbid products escape slowly into the pleural sac, inflammation becoming gradually developed; or extensive pleuritic 1 Vide chap, vii, page 330. 596 DISEASES OF THE RESPIRATORY ORGANS. adhesions offer a mechanical obstacle to the accumulation of air and liquid. Even when intense dyspnoea, etc., immediately follow the occurrence of rupture, generally, after a time, the severity of the distress is considerably diminished. The functions of respiration and the circulation become adjusted to the morbid condition, and although afterward the accumulation of air may be greater than at first, and liquid effusion be added, the patient is perhaps comparatively com- fortable. In the majority of cases, whether occurring as a complica- tion of phthisis or of other affections, it runs rapidly on to a fatal issue. But there are exceptions to this rule. Although not probable, recovery is possible; and patients have been known to live for years, preserving sufficient health and strength to take active exercise, and even to pursue laborious occupations. An instance has fallen under my own observation, in which the patient, a female, was able to ride and walk without difficulty for several months, there being habitually no embarrassment of the respiration. Occurring from perforation of the lung, in phthisis, gangrene, empyema, or other pulmonary affections which have been mentioned, as well as from traumatic causes; from perforation of the chest by ulceration, abscess, or wounds; from ulcerative communication with the stomach or oesophagus, and from chemical decomposition of liquid in the pleural cavity, the signs are so distinctive and readily ascertained, that a positive diagnosis is rarely attended with any real difficulty, assuming the practitioner to be acquainted with the characteristics derived from the combined physical phenomena. The more important of the points involved in the discrimination from other affections have been noticed already, incidentally, in treating of the physical signs which belong to the affection. It seems, there- fore, unnecessary to make the differential diagnosis the subject of formal consideration. SUMMARY OF THE PHYSICAL SIGNS BELONGING TO PNEUMO-HYDRO- THORAX. Tympanitic sonorousness, usually intense, at the upper part of the chest, except in some instances, in which the ascent of air or gas is prevented by pleuritic adhesions; the tympanitic sonorousness ex- tending for a greater or less distance downward, and if the accumu- lation be sufficient to produce lateral displacement of the medias- tinum, being sometimes apparent beyond the sternum on the opposite PLEURALGIA. 597 side. The percussion-sound sometimes presenting a metallic ringing tone. Flatness at the base of the chest extending upward in propor- tion to the quantity of liquid effusion. Marked elasticity of the thoracic parietes accompanying the tympanitic resonance, and an abnormal sense of resistance below the level of the liquid. Change of level of the liquid with different positions of the trunk. The respiratory sound feeble, distant, and often suppressed, if free communication between the cavity of the pleura and the bronchial tubes, does not exist. With such a communication, the cavernous and amphoric respiration frequently discovered. Possibly, in some instances, these signs are produced when a perforation which has taken place becomes closed by a thin stratum of false membrane. The cavernous and amphoric respiration oftenest heard, or the inten- sity greatest, between the third and sixth ribs, on the postero-lateral surface of the chest. Suppression of respiratory sound below the line of flatness, denoting the level of the liquid. Bronchial respira- tion, bronchophony, and possibly cavernous respiration and pecto- riloquy, over the compressed lung at the summit of the chest. Exaggerated or supplementary respiration on the healthy side. Vocal resonance, over the space yielding tympanitic sonorousness on percus- sion, either wanting, or feeble, with an amphoric intonation in some cases in which the respiration is amphoric. Over the space yielding a flat percussion-sound, absence of vocal resonance. Metallic tinkling frequently discovered, especially when the affec- tion coexists with perforation of lung, and if produced within the pleura, pathognomonic. Enlargement of the affected side, and diminished motion. Fre- quently great dilatation, involving effacement of intercostal depres- sion or bulging, depression of diaphragm, displacement of medias- tinum, and dislocation of the heart, and, under these circumstances, almost complete immobility even with forced breathing. Diminution or abolition of vocal fremitus, and in some cases fluc- tuation, ascertained by palpation. Hippocratic succussion-sound, or splashing. Pleuralgia. Under this head I shall refer not alone to neuralgia affecting the intercostal nerves, to which, perhaps, the term pleuralgia, in a rigor- 598 DISEASES OF THE RESPIRATORY ORGANS. ous sense, should be restricted, but to an affection resembling rheu- matism of the muscular or fibrous structures of the thoracic parietes, to which the term pleurodynia is usually applied. A truly rheumatic affection is comparatively rare. I shall also allude to the neuralgic affection called angina pectoris. Without contending for the noso- logical propriety of this arrangement, it is adopted for the sake of convenience, the diagnostic points by which these are discriminated from other affections applying to all of them alike, so far as con- cerns physical exploration. The characters distinguishing them from each other will be noticed incidentally. The local symptoms characterizing intercostal neuralgia and pleurodynia are, in some respects, very analogous to those which belong to acute pleuritis. The differential diagnosis from other affec- tions relates almost exclusively to their discrimination from the latter disease. And it will suffice to point out the distinctive characters involved in this discrimination. Pain is the prominent feature in both the neuralgic and rheumatic affection. In its character and situation, the pain may simulate closely that which is due to acute inflammation of the pleura. Vary- ing in degree in different cases, it may be considerable or intense, even exceeding the pain usually experienced in acute pleuritis. It is frequently lancinating in character, and may be felt especially in inspiration. Acts of coughing or sneezing occasion sometimes excru- ciating suffering. It is generally referred to the lower portion of the chest, in front and laterally,—the seat of pain in many cases of acute pleuritis. It is accompanied by tenderness on percussion or pressure. Guided solely by the rational or vital phenomena, it is sufficiently easy to confound intercostal neuralgia or pleurodynia with acute pleuritis; and this error, in fact, is not infrequently committed. More- over, in both affections, the physical phenomena which belong to the first stage of acute pleuritis may be equally present. The move- ments of the affected side are restrained; a disparity in this respect, and even a slight difference in width, may be apparent. The respi- ratory murmur is feeble and interrupted. Percussion may possibly elicit, comparatively, slight dulness. How, then, is the discrimina- tion to be made ? It involves attention both to symptoms and signs, together with the circumstances under which the affection is pre- sented ; and, with proper care and knowledge, a positive diagnosis cannot always be at once established. Intercostal neuralgia, except as an occasional coincidence, is unat- PLEURALGIA. 599 tended by febrile movement, which is wanting also in the great, ma- jority of the cases of pleurodynia. On the other hand, acute inflam- mation of the pleura gives rise to well-marked and more or less intense symptomatic fever. This is an important point of distinction. The absence of febrile movement is evidence against acute pleuritis, if we observe the disease at its commencement, or shortly after the attack. But the presence of febrile movement is not to the same extent evidence against intercostal neuralgia and pleurodynia, because it may accidentally coexist with these affections. The extreme severity of the pain, and the exquisite sensitiveness of the side to the touch, in some cases, militate strongly against the idea of acute inflammation, provided symptomatic fever be absent. In neuralgia affecting the walls of the chest, the tenderness is more superficially situated; the contact of the hand or slight pressure is not so well borne as in cases of acute inflammation, while firm steady pressure made with the open palm occasions a disproportionally less amount of suffering. Movements of the trunk and upper extremities produce distress in a severe attack of neuralgia frequently greater than in acute pleuritis, the respiratory movements being more espe- cially the cause of pain in the latter. The pain at the same time in neuralgia is more independent of respiration and the motions of the body. It is less uniform, marked remissions and sometimes distinct intermissions occasionally occurring. When this is the case it is quite distinctive. It may be sometimes promptly and effectually relieved by a full opiate; while the pain from acute inflammation may in this way be perhaps mitigated but not controlled. Cough is a more constant and prominent symptom in acute pleuritis. It is often wanting in intercostal neuralgia and pleurodynia. Both neuralgia and rheumatism, when seated in the thoracic walls, may be associated with similar affections manifested at the same time in other parts of the body. This is ground for a presumption as to the character of the chest-affection. In herpes zoster the acute pains in the chest may be presumed to be neuralgic, because severe thoracic pains are well known to accompany this affection without involving inflammation. The pathological association thus in this case becomes diagnostic. MM. Bassereau and Valleix have called attention to characteris- tics of intercostal neuralgia which are important in a diagnostic point of view,1 and which serve to distinguish this affection from pleurodynia. 1 Valleix, op. cit. 600 DISEASES OF THE RESPIRATORY ORGANS. On careful examination of the chest by palpation, the soreness is found to be not diffused, but confined to certain isolated points. These points, according to the observers just named, -are pretty uni- formly three in number, viz., 1st, By the side of one or more of the dorsal vertebrae; 2d, over one or more, usually two or three, of the intercostal spaces generally of the sixth, seventh, and eighth ribs, about midway between their two extremities; and 3d, over the costal cartilages or in the epigastric region. The tenderness in these three situations is often extremely circumscribed. The points correspond to branches of the dorsal nerves which have a superficial distribution.1 Pressure on the first point, viz., by the side of the vertebral spines, is most constantly and in the most marked degree productive of pain. The frequent coexistence of this, as of other neuralgic affections, with tenderness on pressure over certain of the vertebrae, is a fact with which practitioners are familiar in this country, where the phenomena incident to what is usually called spinal irritation are probably more common than in France. When, as is not unusual, pressure over a tender portion of the spinal column provokes a paroxysm of pain in the affected part, and especially if the nerves distributed to the latter are connected with the medulla spinalis at the portion corresponding to the seat of tenderness, the neuralgic character of the affection is altogether probable. Shifting of the locality of the pain is another diagnostic trait. This is apt to occur in neuralgic and rheumatic affections, while in pleuritis, the pain is more fixed in the same situation. In some cases of pleuralgia, the pain is seated in both sides. This is signifi- cant of its neuralgic or rheumatic character.2 But a positive diagnosis rests on the absence of the physical signs denoting the presence of inflammatory products within the pleural sac. A well-marked intra-thoracic friction-sound is conclusive as to the existence of pleuritis; but its absence is not negative proof of a neuralgic or rheumatic affection, for this sign is not uniformly, and, indeed, but rarely, discovered in the early stage of pleuritic inflam- mation. Acute pleuritis, however, is accompanied by more or less liquid effusion, giving rise to a series of physical phenomena which have been described. If these phenomena are not developed after a certain time from the date of an attack of acute pleuritic pain, the diagnosis of a neuralgic or a rheumatic affection is settled, reasoning 1 Grisolle, Pathologie Interne t. ii, p. 584. 2 A neuralgic affection seated in both sides is significant of some lesion of the spinal cord. PLEURALGIA. 601 by way of exclusion. In cases, therefore, in which the symptoms and associated circumstances leave room for doubt, it is prudent to defer an absolute conclusion for two or three days, when, from the absence of the evidence of effusion, the non-existence of acute pleuritis is almost certain. The difficulty thus attending the discri- mination of intercostal neuralgia and pleurodynia from acute pleu- ritis, pertains chiefly to the dry or plastic stage of the latter affec- tion. So soon as it may be decided that, assuming acute inflammation to exist, effusion should have taken place, the differential diagnosis ceases to be an intricate or doubtful problem. This result, it is to be borne in mind, usually follows speedily the access of inflammation; and it is certainly extremely rare, that an amount of effusion easily detected fails to occur within the first three or four days. In the majority of instances, probably, this is the case as early as the second day. A fact stated in connection with the subject of acute pleuritis may be here repeated. This disease is occasionally preceded by neuralgic pain in the chest, more or less severe and persisting, for several days before the symptoms denote an inflammatory attack. Two cases, illustrating this fact in a striking manner, already referred to, have fallen under my observation. It is stated by some writers that liquid effusion, and all the pheno- mena denoting acute pleuritis, may result from a rheumatic affection within the chest. This, in effect, is saying that acute inflammation of the pleura may be developed in connection with the morbid condi- tion of the system in which consists the essential pathology of rheu- matism. In other words, such cases, clinically, are neither more nor less than cases of acute pleuritis. To cases of this kind I have not, of course, had reference in the foregoing remarks.1 The occasional development of pleuritis during the course of acute rheumatism, is a fact to be borne in mind. The occurrence, under these circumstances, of the symptoms of pleurodynia, is by no means proof of the non-existence of veritable inflammation. Careful and repeated explorations of the chest are to be made, and equally in cases in which circumstances point to intercostal neuralgia, in order to determine as regards the presence or absence of the physical signs of pleuritis. In view of the liability to pleuritis in the progress of 1 Were discussions respecting the seat and nature of diseases embraced within the scope of this work, the question would arise, whether pleurodynia is not, in the sense in which it is practically regarded, oftener. a neuralgic than a rheumatic affection, or both affections combined. 602 DISEASES OF THE RESPIRATORY ORGANS. rheumatism, without the information to be obtained by physical ex- ploration, the existence of inflammation, as well as simple pleuro- dynia, might be incorrectly inferred. It is hardly necessary to refer to the possibility of attributing to pleuritic inflammation the pain sometimes incident to an affection of the heart, occurring in rheuma- tism. This would more properly have been noticed under the head of Pleuritis. The positive signs referable to the heart, and the absence of the signs of inflammation of the pleura, suffice to obviate error with respect to this point. A subacute but persisting neuralgic affection is very frequently met with in females, the pain referred to the lower part of the chest on one or both sides. It is not severe, but of indefinite duration. It occurs especially in anaemic or chlorotic persons, associated fre- quently with disorder of the menstrual function, and generally with tenderness over the spinal vertebrae. The circumstances just men- tioned embrace certain positive characters by which it may be distin- guished ; but the absence of the physical signs of intra-thoracic disease confirms its neuropathic character. The symptomatic phenomena of angina pectoris are so peculiar and distinctive that, as regards the possibility of confounding it with any other affection referable to the chest, it claims but a passing notice. Its paroxysmal recurrence; the pain shooting in various directions, and especially into the left upper extremity; the difficulty of respiration, palpitations, great anxiety, and sense of impending dissolution, together with the physical signs of an organic affection of the heart, characterize this affection, so as to render the diagnosis sufficiently easy. Diaphragmatic Hernia. In consequence of the congenital absence of a portion of the dia- phragm, perforation by rupture and wounds, or a yielding of this sep- tum at certain points, and sometimes over its whole extent on one side, the stomach, intestines, and other of the abdominal viscera, may either be contained within or encroach more or less on the thoracic space. This transposition of organs gives rise to certain phenomena, dis- covered by a physical examination of the chest. Diaphragmatic hernia—a term which, with strict propriety, is applied only to pro- trusion through the diaphragm of parts situated below it—is ex- tremely rare, but the physician is liable at any moment to meet DIAPHRAGMATIC HERNIA. 603 with an instance, although I believe no one has ever reported more than a single case. The very infrequency of the affection renders it peculiarly interesting to the diagnostician; and it is desirable for him to be prepared to recognize it, should an instance happen to fall under observation. An affection so rare that it can hardly be expected ever to occur more than once within the experience of a lifetime, must, of course, be studied by means of cases contributed by numerous observers. For this reason it has heretofore received but little attention. A distin- guished American physician, Dr. Bowditch, of Boston, has recently, in connection with the report of an interesting case observed by himself, gathered nearly if not quite all the cases contained in the annals of medical literature (88 in number), and subjected them to an elaborate numerical analysis.1 The present brief consideration of the subject will be based on the results contained in this valuable paper. The different varieties of diaphragmatic hernia may be classified as follows: 1. When parts of the abdominal viscera are forced through some one of the natural openings of the diaphragm, viz., that of the aorta, vena cava inferior, an intercostal nerve, or the oesophagus. 2. When portions of the diaphragm are wanting. This results from an arrest of development, and is, of course, congenital. 3. Hernia from accidental wounds or lacerations. 4. When one side of the diaphragm is violently forced up into the chest, so that the lung is compressed, and all the signs of the affection, as seen in the other classes, are observed. This, strictly speaking, is not hernia, but from the similarity as respects the physical conditions and phe- nomena, it may be included in the same category. In their relative frequency of occurrence the four classes rank in the following order: (a) hernia from accidents, constituting more than one-half of the number of cases; (b) from malconstruction, about one-third; (c) ' " Peculiar Case of Diaphragmatic Hernia, in which nearly the whole of the left side of the diaphragm was wanting; so that the stomach and a great part of the intestines lay in the left pleural cavity; compressing the left lung, and forcing the heart to the right side of the sternum. This condition, evidently congenital, existed in a man who died at the Massachusetts General Hospital, with fracture of the spine, caused by a heavy blow upon it; to which is added an analysis of most, if not all, of the cases of diaphragmatic hernia found recorded in the annals of medical science. By Henry J. Bowditch, Member of the Boston Society for Medical Observation. Presented to the Society in 1847." Published in the Buffalo Medical Journal, June and July, 1853 ; and issued by the author in a separate publfcation. 604 DISEASES OF THE RESPIRATORY ORGANS. from dilatation of natural openings, about one-twelfth; (d) from diaphragm being pushed up, about one in thirty cases. The affection occurs much oftener on the left than on the right side (41 out of 59 cases); a disparity for which anatomical reasons may be offered. It is evident that the abdominal parts contained within the chest will be covered by the pleura and peritoneum in some, and not in other cases. When thus invested, the hernia is said to be sacculated. Sacculated hernias are vastly more frequent on the right than on the left side (3 only out of 11 cases of hernia on left side were sacculated, and 11 of 18 cases on the right side). The weakness of the diaphragm on the right side at a point just to the right of the ensiform cartilage, affords an explanation of this fact. The particular parts of the abdominal viscera which are con- tained within the chest, and the extent of the malposition, will, of course, depend on the situation and size of the opening. The solid organs, viz., the liver and spleen, as well as the hollow viscera, are liable to hernial protrusion. Strangulation at the orifice is liable to occur. The parts may pre- sent, or not, in cases examined after death, evidences of inflamma- tion, recent or more or less remote, affecting either the pulmonary or abdominal organs, or both. In several instances all these parts presented a healthy appearance. The coexistence of tubercles is rare. The lungs are of necessity compressed in proportion as the thoracic space is occupied by the abdominal viscera. Frequently the compressed lung, exclusive of condensation, is found to be healthy, and is readily inflated. Solidification from pneumonitis has been observed. The heart is frequently displaced, generally to the right. Pleuritic effusion exists in a certain proportion of cases. Physical Signs.—The cases on record of diaphragmatic hernia afford few data for determining, by means of numerical analysis, the physical phenomena which belong to the affection. Many of the cases were observed prior to the discovery of auscultation, and in most of those reported since that era, exploration of the chest during life was either performed imperfectly or altogether neglected. Laennec never met with an instance of the affection, but it did not escape his attention, and he suggested that it might be recognized by absence of the respiratory murmur, and the presence of borbo- rygmi in the chest. In the case observed by Dr. Bowditch, the signs were carefully noted, and in a few of the cases analyzed by him DIAPHRAGMATIC HERNIA. 605 more or less of the physical phenomena were ascertained. Upon these facts, together with the inferences which may be rationally predicated on the anatomical conditions, must rest, with our existing knowledge, an account of the physical signs. Of the cases analyzed by Dr. Bowditch, in five percussion was resorted to. Of these five cases dulness over the back on the affected side existed in four. But in three of four cases there was either pneumonitis or pleuritic effusion; and in the fourth case the liver, colon, and omentum were embraced in a sacculated protrusion. In Dr. Bowditch's case percussion elicited a highly marked tympanitic sonorousness. It is evident, that in proportion to the amount of the hollow viscera contained within the chest will be the degree and the extent of the tympanitic resonance. And this resonance, both in degree and extent, will be likely to present at different times fluctua- tions dependent on the varying quantity of the stomach or intestines within the chest, and the greater or less distension of these parts from gas. The presence of the solid organs, the liver and spleen, must give rise to dulness. Liquid effusion will lead to the same result. In any case, at the upper and posterior part of the chest, over the compressed lung, the percussion-sound will be likely to be dull; and the more, if the lung be solidified by inflammatory exudation. A satisfactory account of the auscultatory phenomena, with a single exception, appears not to be contained in any of the cases, save the one observed by Dr. Bowditch. In these two cases the respiratory murmur over the greater part of the affected side was wanting, and on the opposite side it was exaggerated. In Dr. Bow- ditch's case the respiratory murmur was heard perfectly vesicular and pure above the second rib. Aside from these cases, in three a sub-crepitant rale was noticed; but in all the existence of pneumonitis was found at the autopsy. The most significant of the signs, as anticipated by Laennec, are the peculiar gastric or intestinal sounds diffused more or less over the affected side. Dr. Bowditch describes these sounds as gurgling, whistling, and blowing, and although excited at times by the act of respiration, they were heard when the patient held his breath. Metallic tinkling was occasionally observed; such as is sometimes heard over the stomach. Dr. Bowditch suggests that auscultatory phenomena may probably be produced by pressing suddenly on the abdomen, and thus forcing air into the intestines while in the pleural sac. 606 DISEASES OF THE RESPIRATORY ORGANS. If the heart be displaced, the cardiac sounds will, of course, be transferred to an abnormal situation. In three of five cases in which the chest was examined by inspec- tion, there was more or less enlargement of the affected side. That this is generally incident to the affection may reasonably be inferred, from the large proportion of instances in which the accumulation of abdominal viscera within the chest is sufficient to induce great com- pression of the lung. In fifty-five of eighty-eight cases the lungs were found to be much compressed. Diminished motion or immo- bility of the affected side must necessarily accompany its dilatation. These signs will be likely to vary from time to time, in accordance with varying conditions as respects the amount of hernial protrusion and of gaseous distension of the protruded viscera. Liquid effusion in some cases must concur in producing dilatation and diminishing the mobility of the affected side. It is superfluous to add, that in determining these changes, mensuration, as well as inspection, may be employed. By means of palpation the abnormal position of the heart may be ascertained. It is probable that the vocal fremitus will be diminished or abolished on the affected side; but observation has not been directed to this point. Diagnosis.—The symptomatic phenomena which are in any manner distinctive of the affection, relate to the respiration. The analysis by Dr. Bowditch shows that at least three-fourths of cases of the different varieties of diaphragmatic hernia are characterized by more or less embarrassment of respiration, consisting of oppression, increased frequency, dyspnoea, and in one case orthopnoea. Posture has been observed to exert a marked influence on the symptoms referable to the respiration. In some instances the difficulty of breathing was greatly increased in the recumbent posture, which is explained by the tendency, from gravitation, to a greater protrusion either of the viscera or their contents within the chest. Irrespective of position, the fluctuating conditions as regards the quantity of hollow viscera protruding through the diaphragm, and their distension with gas, will account for the difficulty of breathing occurring paroxysmally, or being much greater at some times than at others—a fact repeatedly observed. But embarrassment of the respiration is not always a prominent symptom, even when one side of the chest is nearly filled with abdominal viscera. This is shown by the case reported by Dr. Bowditch. In this case, the patient, aged 17, was able to perform DIAPHRAGMATIC HERNIA. 607 the duties of a laborer, and died, not from this affection, but from fracture of the spine produced by a blow from a heavy piece of timber. Moreover, the characters belonging to the embarrassment of respiration, when present, do not possess much significance. Judged by past experience the diagnosis would appear to be extremely difficult, for of all the cases collected by Dr. Bowditch the nature of the affection had been determined before death in but a single instance. This instance came under the observation of Mr. Lawrence, of London. In the case observed by Dr. Bowditch the diagnosis was made. This difficulty is, however, more apparent than real. From its great infrequency the affection is not suspected or even thought of; and the physical signs have been but little studied, and are yet to be fully settled by observation. Upon the latter it is sufficiently clear the diagnosis depends : the existence of the affection can never be positively ascertained by the symptoms alone. With the symptoms and signs combined, Dr. Bowditch is probably correct in saying that " the diagnosis of diaphragmatic hernia is as easy as that of almost any other chronic, and possibly acute disease." Dyspnoea, either constant or produced by exertion, and more espe- cially when it comes on suddenly and as suddenly goes off, should suggest the idea of diaphragmatic hernia, provided it be not explicable by the existence of some other affection the nature of which is posi- tively ascertained. If the affection be congenital, in most cases more or less embarrassment of respiration will be found to have existed from birth. If due to a rupture or wound, the difficulty will date from some accident, which may assist in the diagnosis. In connection with embarrassed respiration to a greater or less extent, the following signs, in combination, constitute the physical characters by which the affection is to be recognized. Tympanitic percussion-resonance; absence of respiratory murmur; the presence of sounds identical with those observed over the stomach and intestines, viz., borborygmi and metallic tinkling, both taking place when breathing is suspended; dilatation of the affected side in the majority of instances, with defi- cient motion or immobility, and probably absence of vocal fremitus. Assuming this group of signs to be present, diaphragmatic hernia can be confounded only with emphysema and pneumo-hydrothorax. The differential diagnosis from these two affections involves points which are sufficiently distinctive. Emphysema is generally accom- panied by paroxysms of asthma, the symptomatic characters of which will serve to distinguish it. It is accompanied by more or less cough and expectoration, these symptoms being only occasionally present 608 DISEASES OF THE RESPIRATORY ORGANS. in diaphragmatic hernia. But physical exploration in emphysema shows a sonorousness not purely tympanitic, but vesiculo-tympanitic; dilatation and deficient motion especially marked at the upper part of the chest in the majority of instances ; bronchial rales or»a modi- fied respiratory sound generally more or less diffused, together with the absence of borborygmi and metallic tinkling. Pneumo-hydrothorax in nine cases out of ten is suddenly developed as the result of perforation of the lung in the course of phthisis, the existence of which has been established. Or it occurs from perfora- tion taking its point of departure from within the pleura, in the course of chronic pleuritis, the latter affection having been previously ascertained to exist, if the case have been under observation. It is only in cases in which these antecedents cannot be ascertained, that diaphragmatic hernia is to be suspected. As respects physical signs, the two affections are in several respects similar. Tympanitic reso- nance, absence of respiratory murmur, dilatation and deficient mo- bility, abolition of fremitus, and displacement of the heart, are com- mon to both. But each affection has its positive signs. In the majority of cases of pneumo-hydrothorax metallic tinkling occurs in connection wTith the respiration, voice, and cough ; and in many in- stances the cavernous and amphoric respiration and voice are present. The succussion-sound may be pretty uniformly produced. Absence of fluctuation is often discovered. In diaphragmatic hernia borborygmi constitute a positive and strikingly peculiar sign ; and tinkling or amphoric signs are found to occur, not in synchronism with acts of breathing, speaking, or coughing, and irrespective of the movements of the body. The discrimination must be based on the presence of the latter phenomena, and the absence of the signs and the circumstances relating to the previous history, which characterize pneumo-hydro- thorax. Farther clinical observation of diaphragmatic hernia, especially as respects the results of physical exploration, may lead to the know- ledge of new diagnostic points, which cannot now be foreseen. At a future period some one, imitating the zeal and industry of Dr. Bow- ditch, will be able to gather together and analyze an extended series of cases, in which the signs, as well as symptoms, have been carefully observed and noted; but in the meantime it is important that the affec- tion be recognized, not merely for the gratification afforded by skill in the diagnosis of rare and curious forms of disease, but because much may be done by judicious management to contribute to the comfort and safety of the patient. CHAPTER VIII. DISEASES AFFECTING THE TRACHEA AND LARYNX—FOREIGN BODIES IN THE AIR-PASSAGES. In its application to the diagnosis of tracheal and laryngeal affec- tions, physical exploration is far less important than when the lungs are the seat of disease. The symptomatic phenomena belonging to pulmonary affections are never to be dissociated, clinically, from the physical signs, but, relatively, the latter are in general much more distinctive and reliable. It is otherwise in diseases affecting the air-passages above the bifurcation of the trachea. Here the symptoms are mainly to be relied on, the results of physical exami- nation holding a comparatively subordinate rank. This being the case, I shall not, as hitherto, consider the different affections in- cluded in this group under separate heads, but refer to them, indivi- dually, in an incidental manner, in treating of the general application of the principles and practice of physical exploration to diseases affecting the trachea and larynx. Another reason for pursuing this course is, the same physical signs will be found to be common to different affections, and the general principles regulating the prac- tice of exploration are in a great measure applicable alike to all. Of the different methods of examination, auscultation is alone adapted to the investigation of morbid conditions seated in the trachea or larynx. Dr. Stokes has suggested that percussion may in some instances furnish results worthy of attention.1 He does not, however, present any facts illustrative of its value in this application. The inventor of mediate percussion, and the ardent advocate of its capabilities, Piorry, assigns to it a very limited scope of availability in these affections. He claims in behalf of this method, that it may sometimes be useful in determining the precise line of direction of the trachea and larynx, when they are buried beneath or imbedded in a large tumor on the neck. The percussion-sound may also afford some aid in estimating the distance of the tube from the surface. 1 Diseases of the Chest, etc. 39 610 DISEASES OF THE RESPIRATORY ORGANS. An amphoric resonance, attributed by Piorry to the presence of air and liquid, he thinks denotes the presence of secretions in this situa- tion ; but this view of the significance of the sound is, as already stated, more than questionable. Finally, in a case of subcutaneous emphysema, in which very marked resonance exists over the neck, there is ground for the suspicion that rupture of the larynx has taken place, giving exit to air into the surrounding areolar tissue.1 The discoverer of auscultation attached very little importance to the application of this method to the diseases of the windpipe. Of those who since the time of Laennec have given special attention to physical exploration, few have deemed this branch of the subject deserving of consideration ; and the sum of what is at present actually known, is probably embraced in the writings of Dr. Stokes,2 and in two papers contributed by M. Barth, of Paris.3 The materials for the few remarks which are to follow, will be chiefly obtained from the sources just referred to. Physical exploration, in diseases affecting the trachea and larynx, admits of a direct and indirect application. By the term direct, I mean to refer solely to auscultation of the windpipe. The foregoing remarks have related to physical exploration as thus restricted. Indirectly, the physical exploration of the chest is applicable, in order to determine whether pulmonary disease coexists or not. The importance of physical signs is much greater in the latter than in the former application. Indeed, the examination of the chest in connection with diseases affecting the trachea and larynx is often of very great importance. We will consider first, direct exploration; in other, words, the physical signs developed by auscultation of the trachea and larynx ; and, second, indirect exploration, or the exami- nation of the chest in the investigation of diseases seated in these parts. 1. Auscultation of the Trachea and Larynx.—The results ob- tained by auscultation in health have been considered in Part I.4 Briefly, also, the adventitious sounds or rales produced in this situa- tion, have been adverted to.5 It remains to notice here the relations of pathological phenomena to the different forms of disease. The 1 Traite Pratique d'Auscultation, etc., par Barth & Roger, 1854, p. 704. 2 On Diseases of the Chest. 3 Archives Generates de Me lecine, Juillet, 1838, et Juin, 1839; also. Traite Pratique d'Auscultation, etc. par Barth and Roger, 1854, p. 255. 4 Vide page 137. 5 Vide page 217. DISEASES AFFECTING THE TRACHEA AND LARYNX. 611 anatomical conditions, giving rise to auscultatory signs, are the fol- lowing. 1. Diminution of the calibre of the tube, either at certain points, or, in some instances, over its whole extent. This occurs in connection with various affections, viz., swelling of the lining mem- brane and submucous infiltration in laryngitis ; oedema of the areolar tissue above the vocal chords (oedema glottidis); spasm of the glottis and laryngismus stridulus (false croup) ; the exudation of lymph on the mucous surface (true croup); accumulation of viscid adhesive mucus ; tumefaction of the margins of ulceration; vegetations or morbid growths, and the pressure of an aneurismal or other tumor. 2. Loss of substance by ulceration from tuberculous or syphilitic disease. 3. Membranous deposit becoming loose and partially de- tached, and a pedunculated polypus admitting of change of position. 4. Accumulation of liquid, mucous, purulent, serous, or bloody. The presence of foreign bodies will be noticed under a distinct head. Contraction of the space within the tube from the several causes just enumerated, may give rise to abnormal modifications of the respi- ratory sound, consisting of augmented intensity, roughness of quality, and marked elevation of pitch, or adventitious vibratory sounds (dry rales) may be developed. The latter may be on a high or low key, and they frequently have a musical intonation. They represent, on an exaggerated scale, the bronchial sibilant, and sonorous rales. They are often sufficiently loud to be heard at a distance, constituting stridor or stridulous breathing, but when not thus apparent they may be discovered with the stethoscope applied over the larynx or trachea. Do these diversities of modified and adventitious respiratory sounds possess, respectively, special diagnostic significance ? Observation, as yet, has furnished but little ground for an affirmative answer to this question. They appear to belong alike to the different forms of disease, inducing the same anatomical condition, viz., diminution of the calibre of the tube. Barth has observed, in some cases of laryn- geal ulcerations with tumefied borders, involving obstruction, a pecu- liarly loud sonorous rale (cri sonore) in inspiration, giving the impres- sion of the rapid passage of air through a narrow orifice, which he regards as distinctive of the morbid condition just mentioned. It is, however, difficult to obtain from his description, a very clear idea of the special character of sound to which he refers. The same observer thinks that a sonorous rale, presenting a strongly marked metallic quality, like a sound produced within a tube of brass, is heard oftener in croup than in other affections which diminish the calibre 612 DISEASES OF THE RESPIRATORY ORGANS. of the windpipe. Stokes describes a rale produced within the larynx, resembling " the rapid action of a small valve, combined with a deep humming sound,"1 which he regards as peculiar and quite character- istic of chronic laryngitis with ulceration. He states that this rale may exist on one side of the larynx without being perceptible on the other, its situation perhaps corresponding to a circumscribed ulcera- tion. With reference to this sign, the same remark is applicable as to the loud sonorous rale (cri sonore) above mentioned. In both in- stances, the data are insufficient to establish a pathological signifi- cance. It is not improbable that farther clinical study may lead to distinctive characters pertaining to particular sounds. As already intimated, I have nothing to contribute to this branch of the subject from my own observation. The situation of the auscultatory signs which have been mentioned, may furnish information as to the seat of the disease and its extent. They may be limited to a small space. If they are persistingly heard in the same spot, there is reason to suppose that the local affection is thus circumscribed. This may possibly be found to be useful, with reference to the feasibility of making topical applications, and may serve as a guide in the direction of the instrument used for that purpose to the proper place. If the abnormal sounds be not thus localized, they may be found to present at some point, dis- tinctly, a maximum of intensity. This may equally indicate either the seat of the disease, or the point at which it is greatest in amount. To serve as a guide to the locality of disease, the abnormal sounds must be repeatedly or constantly found to be circumscribed, or to have their maximum of intensity well defined and in the same situa- tion, for in certain instances the sounds are due to transient physical conditions, viz., spasm, or the accumulation of viscid mucus. The laryngotracheal sounds are sometimes so intense and diffused as to be transmitted over the chest, obscuring the pulmonary sounds and liable to be mistaken for the latter. This source of error has been already referred to. A tremulous, flapping sound (tremblotement) has been observed by Barth in cases of croup, at a period of the disease when it was sup- posed to indicate a loosened and partially detached condition of the false membrane. He regards this sign as affording valuable informa- tion in cases of croup, denoting, in the first place, progress in the 1 Dr. C. J. B. Williams suggests that the humming sound may have been produced in the jugular vein. (On Diseases of the Respiratory Organs. American ed. 1S45, p. 131.) DISEASES AFFECTING THE TRACHEA AND LARYNX. 613 processes by which the exudation is detached; and, in the second place, enabling the auscultator to judge respecting the extent over which the exudation is diffused. If the vale be limited to the larynx, it is a favorable sign, showing that the false membrane is probably confined to this part, and that the conditions are favorable for its speedy removal by expectoration; but if it extend over the trachea and especially to the bronchi, the prognosis is rendered unfavorable by this evidence of the extension of the disease. Theoretically, we may suppose that a pedunculated tumor within the larynx or trachea, moving to and fro in the respiratory acts, might occasion a sound of friction, which, taken in connection with the symptoms, should render probable the nature of the affection. In a case reported by M. Ehrmann, of Strasburg,' a valvular sound {bruit de soupape), was heard distinctly in a forced respiration. Erosive ulcerations, which sometimes destroy, to a greater or less extent, the vocal chords, it may be presumed must give rise to modi- fications of the respiratory sound, more especially in expiration, by enlarging the space at the glottis. The contraction at this point, from the approximation of the chords in the expiratory act not taking place, one of the conditions upon which probably depend, in health, the intensity and elevation of pitch of the laryngo-tracheal sound in expiration, is wanting; and under these circumstances it may be anti- cipated that this sound will become relatively feeble and low in pitch. This is an interesting point to be settled by observation. The foregoing remarks have had reference to abnormal modifications of the respiratory sounds together with dry or vibrating rales. Bub- bling or gurgling sounds attest the presence of liquid in the trachea and larynx. Owing to the size of the tube, and the force of the column of air which traverses it in respiration, the presence of a considerable accumulation of mucus, or other liquid, is indicated by loud rales, heard at a distance, and commonly known as the tracheal rattle, or (since such an accumulation very rarely takes place except toward the fatal termination of disease), the " death rattle." These sounds are not distinctive of any affection of the windpipe; they de- note deficient sensibility and loss of muscular power to such an extent, that either efforts are no longer made or they prove insufficient to expel the accumulated matter by expectoration. But moist rales may be discovered in some instances by stethoscopic examination when they are not apparent at a distance, and to some extent they 1 Valleix, op. cit. 614 DISEASES OF THE RESPIRATORY ORGANS. may be made available in diagnosis. Thus it is suggested by Piorry that in certain cases of haemoptysis, a humid rale localized in the larynx, provided no rales are found at the lower part of the trachea and over the pulmonary organs, is evidence that the hemorrhage has taken place from within the larynx.1 Again, Barth and Roger state that in cases of ulcerations in the larynx, a gurgling or bubbling sound found at a particular part of the organ, may point to the seat of these ulcerations, or the maximum of the intensity of the sounds may indi- cate the side on which the ulcerations are most numerous and exten- sive. These sounds are most likely to be produced, and to be avail- able in localizing ulcerations, when the latter are situated at the bottom of the ventricles of the larynx. In conclusion, auscultation in affections of the trachea and larynx furnishes certain physical phenomena, but, with our present know- ledge, these phenomena embrace very few characters which are dis- tinctive of particular forms of disease. They show the calibre of the tube to be diminished, but not the cause of the contraction, nor do they, in general, afford definite information as to the amount of obstruction. The latter point is determined, as will be seen presently, much better, indirectly, by an examination of the chest. They show the presence or absence of liquid; and in croup, information may sometimes be obtained which is of aid in forming an opinion as to the condition of the false membrane, and the distance to which it extends below the larynx. The seat of inflammation or ulceration may in some cases be ascertained, by finding that the morbid pheno- mena are persistingly fixed in a particular part, perhaps even confined to one side of the larynx; or, if more extended, by observing that at a certain point sounds have distinctly a maximum of intensity. These few words comprise the summary of what is actually known. The other points mentioned in the preceding remarks require to be confirmed by farther observation. It is by no means improbable that clinical investigations may hereafter develope facts, which will render the direct application of physical exploration to the diagnosis of dis- eases affecting the trachea and larynx of much greater importance than it is with our present knowledge of the subject. 2. Examination of the chest in the investigation of diseases affect- ing the trachea and larynx.—Examination of the chest in cases of laryngotracheal affections, as already remarked, is of much impor- ' Barth and Roger, op. cit. p. 263. DISEASES AFFECTING THE TRACHEA AND LARYNX. 615 tance. Grave errors of diagnosis may be thereby avoided. Lobular pneumonitis and capillary bronchitis are sometimes mistaken for croup, and treated with repeated emetics and topical applications to the larynx, when the phenomena revealed by thoracic exploration would show the existence of these affections. It is true that the existence of one or the other of these affections does not constitute conclusive proof that croup does not exist, for they are sometimes associated with the latter. Taken in connection, however, with other points, the greater importance of which will be admitted, they are to be taken into account as affording an adequate explanation of certain of the symptoms which might otherwise be referred to the larynx. To determine whether pulmonary disease coexists, or not, with an affection of the trachea or larynx, is a grand object in examining the chest. In cases of the affection just cited, croup, it is very desirable to settle this point, with reference to the prognosis, to the treatment to be pursued, and especially when it becomes a question as to the propriety of resorting to tracheotomy. The advantages of this know- ledge in these relations is sufficiently obvious. In cases of chronic laryngitis, the question arises as to its coexist- ence with tuberculous disease of the lungs. Pathological observa- tions have established the fact that in the vast majority of cases the laryngitis is a complication of an antecedent pulmonary tuberculosis, and that the laryngeal affection is, in fact, tuberculous. But this rule is not invariable. The affection may have a syphilitic origin. The law of probabilities will not then suffice for the diagnosis; and the symptoms are not alone adequate to settle the question, the more because the most prominent, viz., the cough and expectoration, may be attributed to the laryngitis. It is not uncommon for practitioners who do not avail themselves of physical exploration, in cases of phthisis complicated with laryngitis, to persuade themselves and their patients that the disease is seated exclusively within the larynx. It is by means of the precision given to the early diagnosis of pulmonary tuberculosis, that the consecutive occurrence of the laryngeal affection has been established, and that an extension of disease from the larynx to the lungs, as implied in the term laryngeal phthisis, very rarely, if ever takes place. A persisting chronic laryngitis, then, warrants a strong presumption of a deposit of tubercle in the lungs, but the proof positive is the evidence afforded by the presence of the physical signs revealed by an examination of the chest. On the other hand, 616 DISEASES OF THE RESPIRATORY ORGANS. the non-existence of tubercle is to be inferred from the negative results of physical exploration. The syphilitic origin of a laryngeal affection may in some instances be inferred in connection with the results of an examination of the chest. This conclusion may be reasonably entertained, when the affection is found not to be associated with pulmonary tuberculosis, and the patient is known to have been affected with syphilis. Another grand object to be attained by an examination of the chest in the various forms of disease affecting the trachea and larynx, is to determine the actual amount of obstruction to the passage of air. This important point can be settled vastly better by an exploration of the chest than by auscultation directly of the windpipe, and fre- quently more satisfactorily than by the symptoms. The evidence of the amount of obstruction is the degree of diminution or the suppres- sion of the vesicular murmur. This diminution or suppression, when the obstruction is seated in the trachea or larynx, will, of course, be uniform on the two sides of the chest. In fact, the existence of some affection of the air passages above the tracheal bifurcation is to be suspected, even should the symptoms not point to disease in that direction, if the vesicular murmur is found to be equally diminished on both sides in a notable degree, or suppressed, provided the phy- sical signs of emphysema of the lungs are wanting. The error of attributing the diminution or suppression of the vesicular murmur, duetto an obstruction above the tracheal bifurcation, to emphysema, is to be guarded against by attention to the other signs, which serve by their presence or absence to establish or exclude that affection. Whatever may be the disease which diminishes the calibre of the windpipe, so long as the vesicular murmur continues to be tolerably developed, the patient is not in immediate danger from suffocation, notwithstanding the manifestations or expressions of suffering. The progress of the disease, as regards its dangerous effects, may thus be ascertained from time to time, and the fact of an actual improvement may be established more positively by an increased development of the vesicular murmur than by an apparent relief from the labor and distress attending respiration. In acute or dangerous affections, then, of the larynx, viz., acute laryngitis, croup, and oedema of the glottis, vastly more importance belongs to auscultation of the chest than of the larynx itself; and, in fact, the predictions of the physician, his hopes and fears, as well as the therapeutical measures which he DISEASES AFFECTING THE TRACHEA AND LARYNX. 617 employs, must be influenced in no small measure by the pulmonary signs. Exploration of the chest assists the auscultator in determining whether an obstruction seated in the larynx be due either exclusively or in part to spasm of the glottis, or whether it depends entirely on a diminution of the calibre from a physical cause, such as oedema, exudation of lymph, or submucous infiltration. In the former case, the diminution or suppression of the vesicular murmur will be inter- mittent or variable; in the latter, it will be more persisting and uniform. Thoracic auscultation thus affords valuable aid in making the differential diagnosis of spasm of the glottis from other and far more serious affections, with which there is some liability of its being confounded. Moreover, spasm of the glottis forms an important element in other affections of the larynx, viz., laryngitis, true croup, and perhaps oedema. The extent to which the symptoms of suffocation are due to this element, may be fairly estimated by the development of the vesicular murmur under the circumstances in which relaxation of spasm occurs; for example, directly after a fit of vomiting. It is important to determine how much of the obstruc- tion arises from spasm ; not only in order to form a correct opinion as to the immediate danger, but with a view to therapeutical measures. In proportion as spasm predominates, are the indications present for remedies addressed to this element of the affection. Dr. Stokes has pointed out a method, available in certain cases, by which pressure on the trachea of an aneurism, or other tumor, may be distinguished from laryngeal obstruction. In the former case it frequently happens that the direction of the pressure is upon one of the bronchi, before extending to the trachea; and if explora- tion of the chest be practised while the effect is limited to the bronchus, the consequent diminution or suppression of the vesicular murmur will be confined to the corresponding side of the chest. Subsequently, when the tumor increases sufficiently to diminish the calibre of the trachea, the vesicular murmur is lessened or lost on both sides. On the other hand, an obstruction seated in the larynx or in the trachea, will, from the first, affect equally the vesicular murmur on the two sides. Diminution or suppression of the vesi- cular murmur, then, first on one side, and afterwards extending to the other, provided pulmonary disease and the presence of a foreign body'in the air-passages are excluded, indicates an aneurismal or 618 DISEASES OF THE RESPIRATORY ORGANS. other tumor, originating below the bifurcation, and extending gradu- ally upward. To recapitulate the several points of view in which an examina- tion of the chest is useful, in the investigation of diseases affecting the trachea and larynx, it may prevent the error of attributing to a morbid condition of the windpipe, phenomena belonging to a pulmo- nary affection; it enables the physician to determine whether, or not, a laryngo-tracheal affection, e. g. croup, is complicated with a disease of the lungs, which will influence the prognosis and treat- ment ; it furnishes evidence, or otherwise, of the coexistence of pulmonary tuberculosis with chronic laryngitis, and, by its negative results, may warrant the conclusion that the laryngeal affection is syphilitic; it furnishes the most reliable index of the amount of obstruction incident to the various forms of disease which diminish the calibre of the laryngo-tracheal tube, and it affords evidence that the deficiency of respiration proceeds from an obstruction in the tube, and not from a morbid condition of the pulmonary organs; it is a means of ascertaining whether an obstruction be due to spasm, and in cases of affections which involve a spasmodic element, of estimating the relative importance attributable to this element; and it supplies a method of distinguishing, in some cases, an aneurism or other intra-thoracic tumor, extending upward and making pressure on the trachea, from an obstruction seated in the larynx. Foreign Bodies in the Air-Passages. Foreign bodies occasionally slip from the pharynx into the orifice of the larynx. This accident is not very infrequent, occurring oftener in children than in adults. The bodies which have been known thus to become lodged in the windpipe, form a heterogeneous, motley collection—morsels of food, coins, grains of corn, seeds of various kinds, nuts, teeth, bullets, nails, etc. etc. Their size is often greatly disproportionate to the aperture at the glottis as ob- served in the dead subject, so that it has been difficult to account for the manner in which they gain entrance into the air-passages. This difficulty is removed by our present knowledge of the respiratory movements of the glottis. It has been fully demonstrated that dila- tation and contraction of the space at the glottis occur in regular alternation during the respiratory acts, the first in inspiration and FOREIGN BODIES IN THE AIR-PASSAGES. 619 the second in expiration. When dilated with the act of inspiration, the size of the rima glottidis is nearly double that which it has in a state of rest.1 Now it is in the act of inspiration, at a moment when the epiglottis fails to protect the laryngeal opening, that the foreign body is drawn into the air-tube instead of passing down the oeso- phagus. The approximation of the vocal chords with the consequent contraction of the outlet in the expiratory act, and still more in the act of coughing, constitutes an obstacle to the expulsion of the for- eign body after it gains admission into the windpipe, and hence, in a large proportion of cases, a surgical operation becomes necessary to effect its removal. The presence of a foreign body in the air-passages gives rise to serious effects, according to its situation, size, form, and character. More or less disturbance of respiration, and disease of the air-tube or lungs, almost inevitably follow. Frequently it occasions great ob- struction to the passage of air, and not infrequently, unless speedy relief be obtained, it proves fatal by inducing asphyxia. The reader is referred to the valuable monograph by Prof. Gross for a digest and analysis of nearly all the cases that are to be found in the annals of medicine, in addition to those occurring under his own observation and communicated to him by his professional friends, together with deductions pertaining to the effects, symptoms, diagnosis, and treat- ment of this accident.3 Physical exploration furnishes frequently important information in cases of foreign bodies in the air-passages. 1. It assists in deter- mining the fact of the presence of a foreign body, in some instances where it is a matter of question whether the symptoms are due to this cause or to a morbid condition. Cases have been reported in which patients with a foreign body in the windpipe have been treated for croup, ordinary laryngitis, and spasm of the glottis; and, on the other hand, in cases of these affections the presence of a foreign body is sometimes suspected. The importance, in a practical point of view, of settling this question is sufficiently obvious. In the former instance, there is great danger that life will be lost for the want of proper surgical interference ; in the latter instance, a severe and dangerous operation may be needlessly performed, and other inappropriate measures of treatment resorted to. 2. It indicates the 1 Vide Introduction, page 52. 2 A Practical Treatise on Foreign Bodies in the Air-passages, by S. D. Gross, M.D, Professor of Surgery in the University of Louisville, etc. 1854. 620 DISEASES OF THE RESPIRATORY ORGANS. situation of the foreign body, whether in the larynx, trachea, or one of the bronchi. A foreign body may be lodged in each of these situations, and the relative proportion of instances in which it is found in each, is a point of importance with reference to the diagnosis. Of 21 cases proving fatal without a surgical operation, which were analyzed by Prof. Gross,1 in 11 the foreign body was found in the right bronchus; in 4 Avithin the larynx; in 3 within the trachea; and in 1 partly within the larynx and in part within the trachea. In no instance was it found in the left bronchus; but examinations made during life show that it does occasionally become fixed in that situation. The fact that in the vast majority of instances it falls into the right rather than the left bronchus, is to be borne in mind. The anato- mical reasons for this fact, which are fully presented by Prof. Gross, have been already mentioned.2 3. The physical signs show the changes in the situation of the foreign body which are liable to occur. Prof. Gross states that in several instances falling under his own observation a change of place occurred, and in one case it was trans- ferred from the right to the left bronchus. The same fact has been observed by others. The movableness of the body may also be ascer- tained by physical exploration ; and this is an important point with reference to the probability of its being removed by a surgical opera- tion. It has been known to become permanently fixed and encysted at some point in the air-passages. 4. The effect produced on the respiratory function, as determined by auscultation, authorizes an opinion as to the size of the foreign body, or, at all events, it shows the amount of obstruction which it produces, and the consequent im- mediate danger. Physical exploration in cases of foreign bodies, as in diseases affect- ing the trachea and larynx, may be said to have a direct and an in- direct application. Using these terms in the same sense as heretofore, in its direct application it furnishes certain signs emanating from the windpipe itself; indirectly, it ascertains the phenomena which represent the effects produced on the lungs. Here, also, as in dis- eases affecting the trachea and larynx, the information obtained by an examination of the chest is often much more important than that derived from direct exploration of the windpipe. Proceeding to notice the physical signs, we will consider them in the order just mentioned, but without a formal division. Percussion over the trachea or larynx is of little or no avail, but, 1 Op. cit. p. 49. 2 Introduction, p. 48. FOREIGN BODIES IN THE A IR-P AS S A G E S. 621 in addition to auscultation, palpation is sometimes resorted to with advantage. Mainly, however, auscultation is to be relied upon, so far as physical exploration, in its direct application, is concerned. In auscultating both the windpipe and the chest, much difficulty will be likely to be experienced, in children, from their resistance, and the restlessness occasioned by their distress. Prof. Gross suggests, that to secure a satisfactory exploration, chloroform may with propriety be employed. The objections to this measure, if there are any, are yet to be ascertained by experience. A dry rale may be produced at the point of lodgment of the foreign body, which may present either the sonorous or sibilant character. This sign was observed in several of the cases analyzed by Prof. Gross. The sound is described by different observers as whizzing, whistling, cooing, whiffing, puffing, and snoring. These terms, with the exception of the last, denote a high-pitched or sibilant rale. Diversities in the audible characters are unimportant. The intensity, pitch, or quality of the sound give to it no special significance. The practical importance of the rale consists, first, in the fact of its ex- istence, and, second, in its being either limited to a particular part of the Avinclpipe, or the maximum of its intensity being found at a certain point. The situation of the foreign body, it may be pre- sumed, corresponds to the part where the rale is heard, or where it is most intense, especially if other signs, to be presently referred to, are in accordance with this conclusion. Thus, the rale may be observed only over the larynx, or if it be sufficiently loud to be propagated downward, it may be decidedly more intense over the larynx. The same may be true of the trachea; but in the vast majority of in- stances, if the foreign body be not detained in the ventricle of the larynx, it becomes lodged in one of the bronchi, and almost invariably in the right bronchus. A rale may then be heard near the sterno- clavicular junction on one side, or more marked in that situation on one side than on the other, indicating the bronchus in which it is situated. A curious phenomena was observed in a case reported by Prof. Macnamara, of Dublin.1 A boy while occupied in whistling through a plum stone, perforated on each side, and the kernel removed, by a strong inspiration drew the stone into the larynx, where it be- came fixed transversely, without occasioning much inconvenience for several days. During this period the passage of the air through the perforation produced a sound as when the stone was placed across ' Gross on Foreign Bodies, p. 110 : Stokes on the Chest, p. 253. 622 DISEASES OF THE RESPIRATORY ORGANS. the lips, and the boy for some hours went about pleased Avith this novel and convenient method of whistling. The stone Avas localized by means of this sound, and an operation performed. The trans- ference of a rale from one part to another, warrants a suspicion of a change of place of the foreign body; but this point, as Avill be seen presently, is ascertained more positively by an examination of the chest. If the foreign body be lodged in one of the ventricles of the larynx, it is not improbable that the presence of a rale on one side and not on the other, or a greater intensity of the sound on one side, may indicate in which of the ventricles it is situated. When the foreign body remains in a certain position for some time, it produces local irritation, inflammation, or even ulceration of the mucous membrane. A moist or mucous rale may then become developed ; and the same inferences are to be drawn from its being limited to one part, or from the maximum of intensity being local- ized, as in the case of a dry or vibrating rale. If the foreign body be lodged in one of the bronchi, inflammation is apt to extend to the bronchial subdivisions, giving rise to bronchial rales, either dry or moist, or both combined, over the chest, to a greater or less extent, on the corresponding side. A flapping or valvular sound on auscultating the trachea and larynx, has been observed in some instances, due to the movements of the foreign body to and fro in the tube, by the current of air in the respiratory acts. The shock occasioned by the impulsion of the substance against the vocal chords in acts of coughing has also been found to be distinctly appreciable by the touch. And it is in such a case that palpation may prove a valuable method of exploration. In a case reported by the late Mr. Bransby B. Cooper, this tactile sign was so well marked in a boy who had inhaled a pebble into the wind- pipe, that the presence of the foreign body was predicated mainly upon it, the symptomatic phenomena being slight, and an operation successfully resorted to.1 It is of course only in certain cases that this sign is available; but Avhen present, it is highly significant of a hard, movable substance, like a pebble or shot, within the trachea. An examination of the chest often affords evidence of the presence of a foreign body, and of its situation, more definite and reliable than the signs obtained by direct exploration of the Avindpipe. As already remarked, the results of the former of these two applications of physical exploration is much the more important. The pulmonary 1 Gross on Foreign Bodies, etc. p. 111. FOREIGN BODIES IN THE AIR-PASSAGES. 623 phenomena are made to supply positive proof with reference to the points just mentioned, by a simple process of reasoning. If a foreign body be lodged within the larynx or trachea, in proportion as it pre- sents an obstacle to the passage of air, the ATesicular murmur will be rendered feeble, or it may be suppressed; and assuming that there exists no affection of the lungs, the percussion-sound not only remains undiminished, but it may even be increased. Under these circum- stances, the diminution or suppression of the vesicular murmur, co- existing with a clear resonance on percussion, will be found equally on both sides of the chest. Now, if it be known that a foreign body is contained somewhere within the air-passages, the combination of signs just stated, viz., the vesicular murmur diminished or suppressed equally on both sides, and a clear percussion-sound, indicates with positiveness that it is situated above the bifurcation, either Avithin the trachea or larynx. But we will suppose that the presence of a foreign body is not known, and the question is as to the diagnosis, being assured that the lungs themselves are free from disease, and assuming that there has suddenly occurred marked diminution or sup- pression of the vesicular murmur, the inference is positive that either there is a foreign body in the Avindpipe, or that there exists some disease of the laryngo-tracheal tube which involves obstruction, such as acute laryngitis, oedema glottidis, spasm of the glottis, or croup. We have then only to decide from the history and symptoms that none of these affections are present, in order to reach, by way of exclusion, the fact of the existence of a foreign body. The differential diagnosis of a foreign body in the larynx or trachea from the different diseases seated in the windpipe, is to be based on the vital phenomena and pathological laws which characterize respectively these diseases. To consider the distinctive points would render it necessary to treaty of their diagnostic features. It must suffice to say that, in discriminating between them and the presence of a foreign body, they are to be ex- cluded, and the characteristics derived from symptoms and patho- logical laws which belong to each, are, in general, sufficiently con- stant and striking to constitute, when present, evidence of its existence, and, conversely, when absent, to warrant its exclusion. In one of the affections named, viz., oedema glottidis, the touch is often, if not generally, available as a means of diagnosis. But in a large majority of instances, the foreign body does not remain in the larynx or trachea. It becomes lodged in one of the bronchi, generally the right bronchus. In this situation, according 624 DISEASES OF THE RESPIRATORY ORGANS. to its size and form, it produces either more or less obstruction, or complete occlusion of the bronchial tube. In proportion to the amount of obstruction, the vesicular murmur on the corresponding side Avill be diminished, and if there be occlusion, the murmur Avill be suppressed. If the lung be free from disease, the percussion- resonance will continue unaffected, unless the occlusion lead to more or less collapse of the lung. The latter effect, it is stated, may follow, and then there will be dulness in proportion as the volume of the lung is diminished, together with contraction and lessened mobility of the affected side.1 This, hoAvever, is probably only an occasional result. The respiratory function of the lung on the oppo- site side Avill be increased, giving rise to a vesicular murmur, exag- gerated in proportion as the function of its felloAV is compromised. Here, then, Ave have an assemblage of pulmonary signs Avhich point with certainty to the situation of the foreign body, assuming its presence in the air-passages to be known. A vibrating rale, heard exclusively, or with its maximum of intensity, over the bronchus, is a confirmatory physical sign. The same may be said of a mucous rale, in like manner circumscribed or diffused to a greater or less extent over the affected side. N Even if the presence of a foreign body somewhere in the air- passages be not known, the combination of physical signs just mentioned is almost proof positive of its existence, provided it be ascertained that they haAre been suddenly developed. As remarked by Stokes, there are but three affections capable of producing a similar assemblage of signs, viz., pressure on a bronchus by an aneu- rism or some other tumor; obstruction of the tube by hypertrophy of the mucous membrane, and its occlusion by an accumulation of viscid mucus. The symptoms and the previous history will rarely, if ever, leave much room for doubt, when it is a problem of diagnosis to decide between the presence of a foreign body in the bronchus, or the existence of one of these three morbid conditions. Evidence still more demonstrative of the presence of a foreign body is afforded when it is found to shift its place, being removed from its situation in the bronchus by an act of coughing, and carried upward into the trachea, or perhaps transferred to the bronchial tube on the opposite side. Its dislodgment from the bronchus is imme- diately followed by the reappearance or the normal development of the vesicular murmur on the side where it had been found to be Vide Gross on Foreign Bodies, p. 107. FOREIGN BODIES IN THE AIR-PASSAGES. 625 abnormally feeble or suppressed. If the body be easily displaced, and hence thrown upward from time to time, the physical evidence of obstruction of the bronchus will be intermittent; and if the body occasionally be transferred to the other bronchus, as has been repeat- edly observed, the two sides will be found to present the character- istic combination of signs in alternation. Under these circumstances nothing could be added to render the diagnostic proof more positive. On this point Dr. Stokes remarks : " There is not in the whole range of stethoscopy more striking phenomena than the sudden rush of air into the lung, on the foreign body passing into the windpipe, or the equally sudden disappearance of all sound of expansion, natural and morbid, when the bronchus becomes again obstructed." The effect is, of course, more striking when the foreign body produces sufficient closure of the tube to arrest all respiratory sound, but the evidence is equally clear when there is obstruction enough to cause a notable diminution in intensity of the vesicular murmur. It is obvious on comparing the phenomena furnished by an exami- nation of the chest in cases in which the foreign body is seated in the larynx or trachea, with those which indicate its situation to be in the bronchus, that the diagnostic evidence in the latter is more striking and positive. In connection with this fact it is to be borne in mind that of a given number of cases, in vastly the larger propor- tion the foreign body falls into the right bronchus. In the diagnosis of foreign bodies in the air-passages, not only are the physical signs to be associated with the symptoms, but in many if not most instances, as regards their relative rank, they are subor- dinate to the latter. In treating of this subject, however, as of the diseases affecting the trachea and larynx, my purpose was to con- sider it only in its relations to the principles and practice of physical exploration. SUMMARY OF THE PHYSICAL SIGNS OF FOREIGN BODIES IN THE AIR-PASSAGES. A sibilant or sonorous rale, either limited to the larynx, trachea, or bronchus, or having its maximum of intensity over one of these portions of the air-passages, and in some instances changing its place from one portion to another. After a time a mucous rale in either of the same situations; occasionally a valvular or flapping 40 626 DISEASES OF THE RESPIRATORY ORGANS. sound. Motion of the foreign body sometimes perceived during acts of coughing by palpation. Feebleness or suppression of the vesicular murmur equally on both sides, if the foreign body be situated within the larynx or trachea; the percussion-resonance remaining clear. If the foreign body be situated in a bronchus, the vesicular murmur on the corresponding side enfeebled or suspended, the percussion-resonance remaining clear, except collapse of the lung be induced. Feebleness or sup- pression of the murmur sometimes suddenly giving place to a well- evolved and normal respiratory sound, after an act of coughing, which dislodges the foreign body, and carries it upward into the trachea. Occasionally feebleness or suppression of the vesicular murmur transferred from one side to the other, indicating a removal of the foreign body from the bronchus of one side to that of the other side. Exaggerated vesicular respiration on the side opposite to that on which the murmur is found to be diminished or suppressed. Dry and moist bronchial rales, after a time, more or less diffused over the side corresponding to the bronchus in which the foreign body is lodged. * APPENDIX. ON THE PITCH OF THE WHISPERING SOUFFLE OVER PULMONARY EXCAVATIONS. In the foregoing pages, I have repeatedly referred to the souffle accompanying the act of Avhispering, as a sign of pulmonary con- densation, especially from inflammatory, tuberculous, or other soli- difying deposit. Since the chapter on Tuberculosis was written, my attention has been directed to the whispering souffle over exca- vations in that affection. In several instances I have found within a circumscribed space Avhere other cavernous signs were present, a souffle more or less intense and low in pitch, contrasting in this particular strongly with the normal bronchial souffle, as Avell as with that significant of solidification, the latter being heard around the circumscribed space. For example, in a case at this moment under observation, the cavernous respiration exists at the summit of the chest on both sides. Surrounding the site of the cavity on either side the whispering souffle is acute or high, and within the area to which the cavernous respiration is limited (a space not more than an inch in diameter), the souffle becomes abruptly and notably low in pitch—the contrast, in fact, being more marked than between the cavernous and the surrounding bronchial respira- tion. A low-pitched cavernous souffle would be rationally antici- pated ; for the sound, as has been more than once remarked, is none other than that incident to a forcible expiration; and the expiration being low in the cavernous as contrasted with the bronchial respira- tion, it might be presumed that a similar disparity would be appa- rent in the act of whispering. This process of reasoning, however, never occurred to me till the disparity had been noticed. If the fact of this disparity be found to hold good after repeated observa- tions, a new and an important cavernous sign is acquired, viz., a low-pitched whispering souffle. It is not, however, to be expected 628 APPENDIX. that this sign will always be available when cavities exist. For the same reason that the bronchial respiration may predominate, and mask the caArernous, the bronchial souffle may continue to be heard, notwithstanding the existence of an excavation. It is also probable that, as the bronchial and cavernous respiration are sometimes com- mingled, forming what I have called the broncho-cavernous respira- tion, so the bronchial and cavernous souffle may be combined in different cases in varying proportions. I have felt the need of a term to designate the souffle incident to solidification. Whispering bronchophony would be appropriate, especially as we have already the term whispering pectoriloquy. Adopting this title, and limiting it to the acute souffle emanating from the bronchial tubes and constituting the sign of solidification, another is wanted to distinguish the sound produced in an excava- tion. I can suggest no better term expressive of the latter than cavernous whisper. This simple name accords with the term cavernous respiration. Whispering pectoriloquy, according to my experience, is by no means reliable as a sign of excavation. I have observed it repeatedly over solidified lung. But from the results just gi\~en, it may be inferred that the pitch of the vocal sound accompanying the transmitted speech, will furnish a test to determine Avhether the pectoriloquy be or be not cavernous in its source. / INDEX, A. Abdominal respiration, ... 24 Absence of percussion-resonance {vide Flatness), .... 99, 108 Acoustics, importance of, in study of physical exploration, ... 66 Adventitious respiratory sounds (vide Rales),......216 jEgony,......273 iEgophony,.....267 mechanism of, . . . . 274 in pneumonitis, . • . 419 in pleuritis, . . 553,566,568 Air-cells, description of, . . . 41 Amphoric voice, ..... 263 percussion-resonance, . . . 119 respiration, . . . . . 208 in pulmonary tuberculosis, . 482 in pleuritis, . . . 547, 549 in pneumo-hydrothorax, . 592 Apoplexy, pulmonary, . . . 521 physical signs of,. . . • 522 diagnosis of, .... 522 summary of physical signs of, . 524 Aran, Dr., observations on tympanitic percussion-resonance in pleuritis. . 115 Asthma,......397 physical signs of, . . . • 397 diagnosis of, .... 398 summary of physical signs,. . 400 Atelectasis, . . . • 432 physical signs and diagnosis of, . 435 Attrition-sounds, (vide Friction- sounds), ......242 Auscultation, definition of, . 66, 126 mediate and immediate, . . 126 rules for performing, . . 131,133 phenomena furnished by, . .134 in health,.....*36 in disease,.....175 history of,.....292 signs correlative to, . • • 342 in bronchitis, . 354, 363, 371, 373 in bronchial catarrh, . . • 37S in dilatation of bronchia, . . 384 in contraction of bronchia, . . 394 in pertussis, .... 3% in asthma,.....39/ in pneumonitis, .... 40H 469 513 in pulmonary tuberculosis, . in oedema, .... Auscultation in gangrene, . . . 517 in pulmonary apoplexy, . . 522 in cancer of the lungs, . 526, 533 in atelectasis, .... 435 in collapse, ..... 436 in lobular pneumonitis, . . 437 in chronic pneumonitis, . . 441 in vesicular emphysema, . . 445 in interlobular emphysema, . 457 in acute pleuritis, . . . 545 in chronic pleuritis, . . 565, 568 in pneumo-hydrothorax, . . 592 in diaphragmatic hernia, . . 605 in diseases affecting the trachea and larynx, .... 610 Autophonia, ..... 275 Axillary region, . . . . .61 percussion-resonance in, . . 92 respiratory phenomena in, . .162 vocal resonance in, 173 B. Barth, M., on exploration of trachea and larynx,..... Barth and Roger on bronchial respira- tion in pleuritis, . Beau and Maissiat's division of types of breathing,..... Bellows arterial sound, . . in pulmonary tuberculosis, . in cancer, . of heart, in pleuritis, . Bennett, Dr. J. Hughes, on cirrhosis of lungs,..... Blowing respiration (vide Bronchial Respiration, . . • . • Borborygmi in diaphragmatic hernia, Bowditch, Dr. H. I., on tuberculosis, on diaphragmatic hernia, Bronchi, description of, Bronchia, description of, dilatation of, physical signs of, . diagnosis of, summary of the more important of the diagnostic characters of, contraction of, ... . Bronchial catarrh, . . . . cough, ...... 610 547 25 291 479 533 557 383 187 607 501 603 47 37,40 380 383 385 391 391 378 279 630 INDEX. 354, Bronchial septum, .... 48 respiration, normal, . . . 140 abnormal, .... 187 in dilatation of bronchia, . 384 in pneumonitis, . . . 412 in pulmonary tuberculosis, . 477 in cedema, .... 513 in cancer, . . . 526,533 in gangrene.....517 in pulmonary apoplexy, in atelectasis, in collapse, . in lobular pneumonitis, in chronic pneumonitis, in acute pleuritis, . in pneumo-hydrothorax, Bronchial rales, . in bronchitis, in dilatation of bronchia, in pneumonitis, signs correlative to, in pulmonary tuberculosis, in cedema, in gangrene,. in pulmonary apoplexy, in cancer, in emphysema, in pleuritis, . Bronchial phthisis, Bronchiectasis, . Bronchioles, description of, Bronchitis, .... divisions of, . acute, .... physical signs of, . diagnosis of,. summary of physical signs of, capillary..... physical signs and diagnosis of, 362 summary of physical signs of, 369 pseudo-membranous or plastic, . 369 physical signs and diagnosis of, 371 summary of physical signs of, 372 chronic, physical signs of, . diagnosis of, . summary of physical signs of, secondary, . Broncho-cavernous respiration, Broncho-vesicular respiration, in pneumonitis, . signs correlative to, in pulmonary tuberculosis, in cedema, . in pulmonary apoplexy, in atelectasis, in collapse, . in lobular pneumonitis, in acute pleuritis,. Bronchophony, . mechanism of, in dilatation of bronchia, in pneumonitis, . in pulmonary tuberculosis, in pulmonary apoplexy, in gangrene, in cancer, in pleuritis, . in pneumo-hydrothorax, 522 435 436 438 44] 546 593 218 371 . 384 . 411 . 344 474,478 . 513 . 517 . 522 526, 533 . 447 549,565 . 509 . 380 . 40 . 352 . 353 . 353 . 353 . 357 . 362 . 362 373 373 375 377 377 . 482 . 197 . 414 . 345 . 469 . 513 . 522 . 435 . 436 . 438 . 545 . 251 . 257 . 384 . 416 . 480 . 522 . 517 . 526 552, 566 . 593 Bruit de pot fell (vide Cracked-metal sound), . . . . • • Bruit de soupape in plastic bronchitis, in pedunculated tumor within tra- chea, ..... 119 371 613 Callipers,......312 Cammann's stethoscope, . . 130,485 Cancer of the lungs, .... 524 in mediastinum, .... 531 physical signs of, . . . . 532 diagnosis of, .... 534 Capillary bronchial tubes, . . 40 Carnification, ..... 433 Carr, Dr. E. A., explanation of crepi- tant rale,.....234 Catarrh, bronchial, .... 378 Cavernous cough, .... 280 whisper (Appendix), . . . 627 Cavernous rale, ..... 235 in pneumonitis, .... 425 Cavernous respiration, . . . 202 signs correlative to, . . . 345 in dilatation of bronchia, . . 385 in pneumonitis, .... 425 in pulmonary tuberculosis, . . 481 in gangrene, .... 518 in pleuritis,.....547 in pneumo-hydrothorax, . 592, 593 Cavernous voice, .... 263 in pneumonitis (vide Pectoriloquy), 425 Chest, exploration of, in health, . 71 size of, in health, ... 33 topographical divisions of, . . 54 morbid appearances pertaining to size and form, .... 297 in pneumonitis, .... 420 in dilatation of bronchia, . . 381 variations of size in various dis- eases, ..... 316 in cancer, .... 526,533 in emphysema, .... 449 in pleuritis, . . 554, 566,567 in pneumo-hydrothorax, . . 594 in diaphragmatic hernia, . . 606 exploration of, in diseases of tra- chea and larynx, . . 614 in foreign bodies in air-passages, 622 Chest-measurer, . . .29, 317 Chordce-vocales, .... 51 Cirrhosis of lungs, .... 381 Clavicular region, .... 56 percussion-resonance in, . . 81 Cogged- v/heel respiration (vide Inter- rupted Respiration),. . . 215 Collapse of lung, .... 433 physical signs and diagnosis of, . 435 Consonance, theory of, . . . 192 Contraction of chest (uide Chest). Corrigan, Dr., on cirrhosis of lungs, . 381 Costal respiration, ... .23 cartilages, description of .18 Costo-pulmonary pleuritis, . . 582 Cough, phenomena incident to, in health......174 in disease......279 INDEX. 631 . 279 . 280 . 120 . 466 . 545 . 239 . 473 . 228 . 409 . 473 . 513 . 522 . 436 . 437 . 518 228, 233 . 410 . 611 . 238 . 473 Cough, bronchial, cavernous, . Cracked-metal percussion-sound in tuberculosis, . in pleuritis, . Crackling, .... in pulmonary tuberculosis, Crepitant rale, . in pneumonitis, . in pulmonary tuberculosis, in cedema, . in pulmonary apoplexy, in atelectasis and collapse, in lobular pneumonitis, in gangrene, Crepitant rale redux, in pneumonitis, . Cri sonore in disease of larynx, Crumpling, pulmonary, in pulmonary tuberculosis, D. Dalton, Prof. John C, experiments on the respiratory movements of the glottis,...... Deferred inspiration, .... in emphysema, .... Diagnosis of diseases of respiratory organs, general remarks on, Diaphragm,..... displacement of, in pleuritis, 558, Diaphragmatic hernia, physical signs of, diagnosis of, Diaphragmatic breathing, . pleuritis, Dilatation of bronchial tubes, of chest (vide Chest). Diminished intensity of vesicular mur mur, .... in bronchitis, in asthma, . signs correlative to, in pneumonitis, . in oedema, . in cancer, in atelectasis, in emphysema, . in acute pleuritis, Diminished vesicular resonance (vide Dulness), . Diminished vocal resonance, . 250, Dryness of respiratory sound, Dulness of percussion-sound, . 99, in dilatation of bronchia, in pertussis,. in bronchitis, in pneumonitis, . in pulmonary apoplexy, in cedema, . in gangrene, in cancer, .... 525, in atelectasis, in collapse, . . . in lobular pneumonitis, in chronic pneumonitis, in pleuritis, . 52 210 446 351 20 567 602 604 606 24 582 380 180 356 397 342 408 514 525 435 445 545 99 261 188 102 383 395 353 404 522 513 517 532 435 436 438 441 540 E. Echo, metallic, .... , 208 Emphysema, .... 443 vesicular, .... 443 physical signs of, 444 diagnosis of, ... 452 summary of physical signs of 455 interlobular, 455 Empyema...... pulsating, .... 578 324 581 multilocular and unilocular, 582 Enlargement of chest (vide Chest) Exaggerated respiration, . 177 in pneumonitis, 416 signs correlative to, . 342 in cancer, .... 526 in tuberculosis, . 472, 478 in lobular pneumonitis, 438 in pleuritis, .... 549 566 in pneumo-hydrothorax, 593 Exaggerated vesicular resonance, 99, 100 177 in pneumonitis, . 416 ,408 Exaggerated vocal resonance, . 251 249 in pulmonary tuberculosis, . 475 apoplexy, 522 in oedema, .... 514 in gangrene, 517 in cancer, .... 525 in vesicular emphysema, 444 in interlobular do., . 437 in pleuritis, .... , 566 Expiration, .... 31 prolonged, .... 211 Feeble respiration (vide Diminished Vesicular Murmur), . . . 180 Flatness, on percussion, ... 99 in pneumonitis, .... 404 in cancer, .... 525, 532 in pleuritis, .... 542, 565 in pneumo-hydrothorax, . . 590 Fluctuation in cancer, . . . 533 in pleuritis, .... 559, 567 Foreign bodies in the air-passages, . 618 exploration of trachea and larynx, 620 of chest, .... 622 summary of physical signs, . . 625 Fournet, on exaggerated respiration, 178 on pneumonitis, .... 408 Fremitus, vocal (vide Vocal Fremitus), 326 tactile, in pleuritis, . . . 568 Friction-sounds, pleural, . . . 242 signs correlative to, . . 347 in pneumonitis, .... 412 in pulmonary tuberculosis, . . 478 in pleuritis, .... 550, 568 G. Gangrene of lungs, .... 515 physical signs of,. . . . 516 diagnosis of, .... 518 summary of physical signs of, . 520 632 INDEX. Glottis.......51 respiratory movements of, . . 52 Graves' observations on tympanitic resonance in pneumonitis, . . 115 Gross on foreign bodies in air-pas- sages, .....49,619 Gurgling,.....219, 235 in dilatation of bronchia, . . 385 in pulmonary tuberculosis, . . 483 in gangrene, .... 5J8 in diaphragmatic hernia, . . R)5 H. Hardness of respiratory sound, . . 188 Haemoptoic infarctus, . . . . 521 Heart, abnormal transmission of sounds of, . . . .289 in pleuritis, .... 546 in pulmonary tuberculosis, 475, 479 in cancer, .... 526 dislocation of, in cancer, . . 533 in pleuritis, .... 557, 566 in pneumo-hydrothorax, . . 594 in diaphragmatic hernia, . . 606 Hepatic flatness, line of, . . . 87 Honore, discoverer of friction-sounds, 248 Hooping-cough, . ... physical signs and diagnosis of, . Hutchinson on vital capacity of lungs, Hydrothorax,..... Hypervesicular respiration (vide Ex- aggerated Respiration, . 395 395 44 586 177 Increased intensity of respiratory sound (vide Exaggerated Respira- tion), ......177 Indeterminate rales, . . . 219,237 Infra-axillary region, . . . .61 percussion-resonance in, . . 92 respiratory phenomena in, . . 162 vocal resonance in, 173 Infra-clavicular region, . . .56 percussion-resonance in, . . 81 comparison of respiratory sound in health on the two sides, . 155 vocal resonance in, . . 171 Infra-mammary region, . . .59 percussion-resonance in, . . 87 respiratory phenomena in, . . 160 vocal resonance in, . . . 173 Infra-scapular region, ... 60 percussion-resonance in, . . 91 respiratory phenomena in, . . 160 vocal resonance in, . 172 Inspection,..... 66, 295 in health, . . . ; .296 in disease,.....297 summary of signs pertaining to, . 308 history of, . . . . .311 in dilatation of bronchia, . . 384 in pneumonitis, .... 419 in pulmonary tuberculosis, . . 485 in cancer, .... 526, 533 in cedema, ..... 514 in atelectasis, .... 435 Inspection in emphysema, . 447 in pleuritis, .... 554 ,566 in pneumo-hydrothorax, 594 Inspiration, .... 31 shortened, .... 210 in emphysema, , 446 Insufflation in atelectasis and collap se, 433 Intercellular passages, 40 Intercostal spaces, 19, 2 in pneumonitis, . 420 in cancer, .... 526 533 in emphysema, . 450 451 in pleuritis, .... 554 555 in pneumo-hydrothorax, 594 Intercostal neuralgia, diagnosis of 597 Interlobar fissure, 36 mode of delineating on chest, by percussion, 109 in pneumonitis, 407 by auscultation, 415 418 pleuritis, .... 585 Interlobular septa, 39 Interrupted or jerking respiration, 214 in pulmonary tuberculosis, . 472 in pleuritis, 545 Inter-scapular region, 60 percussion-resonance in, 91 Jackson, Dr. James, Jr., on prolonged expiration,..... L. Laryngophony, .... Larynx, description of, superior aperture of, . inferior space, diseases of, .... Lawson on friction-sound produced by miliary tubercles, . Liquid, in pleural cavity, mode of de tecting by percussion, Lobes, description of, Lobular pneumonitis (vide Pneumo nitis). Lobules, description of, M. 211 164 49 50 53 609 247 110 36 38 Mammary region, percussion-resonance in, respiratory phenomena in, . vocal resonance in, Measurement of the chest in health, Mediastinum, displacement of, in pleuritis, .... 544, 545, 567 Mensuration, .... 66, 312 summary of facts pertaining to, . 320 in pneumonitis, . in pulmonary tuberculosis, in emphysema, . in cancer, in pleuritis, . in pneumo-hydrothorax, Metallic respiration, . 57 84 160 173 21 420 . 486 . 451 . 534 554, 566 . 594 . 188 INDEX. 633 Metallic tinkling, .... summary of facts pertaining to, . in dilatation of bronchia, in pulmonary tuberculosis, . in pneumo-hydrothorax, in diaphragmatic hernia, Monneret and Barthez on cavernous respiration in pleuritis, . Mucous rales,..... in pulmonary tuberculosis, . in cancer,..... in pulmonary apoplexy, in diseases of larynx and trachea, in foreign bodies in the air-pas- N. Neuralgia, intercostal, Nipple, elevation of, in pleuritis, 0. CEdema of lungs (vide Pulmonary CEdema). Oval fossa of larynx, . P. 282 289 385 483 593 605 547 223 474 526 522 614 622 597 566 50 Palpation, . 66, 323 summary of facts, 329 history of, . 329 in pneumonitis, 420 in pulmonary tuberculosis, . 487 in cancer, .... 526 ,533 in emphysema, 451 in pleuritis, .... 556, 566 in pneumo-hydrothorax, 594 in foreign bodies in air-passages, 621 Pectoriloquy, .... 165 263 whispering, .... 266 mechanism of, 266 in dilatation of bronchia, 385 in pulmonary tuberculosis, . 483 in gangrene, 518 in cancer, .... 533 in pleuritis, .... 552 in pneumo-hydrothorax, 593 Pennock's flexible stethoscope, 129 Percussion, .... 65, 1 immediate, . 75 mediate, 75 mode of performing, 77 auscultatory, 78, S in health, 78 rules of performing, 94 in praecordia, 85 in disease, . 98 deep and superficial, 86 summary of facts, 122 history of, 124 signs correlative to, 338 sense of resistance in, 97 in bronchitis, . 353, 363 371 , 373 in dilatation of bronchia, 383 in contraction of bronchia, . 394 in asthma, . 397 Percussion in cedema, in pneumonitis, in pertussis, .... in pulmonary tuberculosis, . in gangrene, in pulmonary apoplexy, in cancer of the lungs, in cancer of the mediastinum, in atelectasis, in collapse, .... in lobular pneumonitis, in vesicular emphysema, in interlobular emphysema,. in acute pleuritis, in chronic pleuritis, 513 404 395 461 517 522 525 532 435 436 438 444 457 540 565, 568 577 590 605 in retrospective diagnosis of, in pneumo-hydrothorax, in diaphragmatic hernia, in diseases of the trachea and larynx,.....609 in foreign bodies in air-passages, 620 Percussors, ..... 76 Pertussis.......395 Phthisis, acute (vide Tuberculosis, Acute), . . . . . .503 Physical diagnosis, definition of, . 66 Physical exploration, definition of, . 65 methods of,.....65 advantages of, . . . .68 different aspects of, . 71 mode of studying, ... 73 in diseases affecting the trachea and larynx, .... 609 in foreign bodies in the air-pas- sages, .....618 Physical signs, definition of, . 66, 71 recapitulatory enumeration of, . 333 correlation of, ... 336 Piorry's " water sound," . . . 120 Pitch of percussion-sound,. . . 108 in bronchial respiration, . . 188 in broncho-vesicular or rude respi- ration, . . . . .198 in cavernous respiration, . . 203 in prolonged expiration, . . 214 in cavernous whisper (Appendix), 627 Pleura.......34 Pleuralgia,......597 Pleuritis, acute,.....538 physical signs of, . . . . 540 diagnosis of, .... 559 summary of physical signs of, . 562 chronic, ..... 564 physical signs of, . . . . 565 diagnosis of, . . . . 568 retrospective diagnosis of, . . 572 summary of characters, . . 577 circumscribed, .... 582 Pleurodynia (vide Pleuralgia), . . 597 Pleximeters,.....75 Pneumonitis, acute lobar, . . . 401 typhoid,.....402 catarrhal,.....402 traumatic......402 bilious,......402 latent.......402 double.......402 stages of,.....403 physical signs of, . . . . 404 diagnosis of,.....42i 41 631 INDEX. Pneumonitis, summary of physical signs of, . . • ■ .431 lobular,.....432 physical signs and diagnosis of, . 435 chronic,.....440 Pneumorrhagia (vide Pulmonary Apo- plexy).......521 Pneumo-thorax pneumo-hydrothorax, 587 physical signs of, . . . . 590 diagnosis of,.....595 summary of physical signs of, . 5i?6 Post-clavicular region, . . .56 percussion-resonance in, . . 80 respiratory phenomena in, . . 155 Praecordia, clearness of percussion- sound in, in emphysema, . . 445 Prolonged expiration, . . .211 Puerile respiration (vide Exaggerated Respiration)......177 Pulmonary cedema, .... 512 physical signs of, . . . . 513 diagnosis of,.....514 summary of physical signs, . . 515 organs, description of, . . 34 tuberculosis (vide Tuberculosis). Q. Quain's stethometer, . R. 30, 318 216 Rales, definition of, . table showing number, names, and anatomical situations of, . tracheal,..... sonorous...... sibilant, ..... mucous, ..... sub-crepitant, .... cavernous or gurgling, indeterminate, .... dry crepitant with large bubbles, crumpling, . crackling, ..... table exhibiting distinctive cha- racters and diagnostic indica- tions of, .... . signs correlative to, . enumeration of, in cases of foreign bodies in air-passages, Rattles (vide Rales). Regions,......55 anterior, .... 55, 56 posterior, . . . . 55,60 lateral,.....55, 61 Resistance on percussion (vide Sense of Resistance), Resonance on percussion, vesicular, . 79 tympanitic (vide Tympanitic Re- sonance), . . . . 9, 111 signs correlative to, . . 341 comparison in different regions, . 80 exaggerated vesicular, signs correlative to, diminished vesicular, . signs correlative to, absence of, . signs correlative to, 219 217 221 220 223 226 235 237 237 238 239 240 346 621 100 338 102 339 108 340 Resonance, gastric tympanitic, . . 89 tubular,.....89 liver, spleen, and heart, . . 90 amphoric......119 cracked-metal.....120 Respiration, types of, . . . .25 phenomena of, in health, . . 137 tracheal, . . . . . 137 normal bronchial, . . . 140 vesicular,.....146 comparison of tracheo-bronchial and vesicular, . . . 149 in right and left infra-clavicu- lar regions, . . 155 in right and left upper scapu- lar regions, . . . 156 in right and left lower scapu- lar regions, . . . 158 in right and left infra-scapular regions, .... 160 in axillary and infra-axillary regions, ..... 162 in mammary region, . . . 162 phenomena incident to, in disease, 175 abnormal modifications of, . . 176 exaggerated, .... 177 signs correlative to, . . 342 feeble or weak, .... 180 signs correlative to, . . 343 suppressed, ..... 185 signs correlative to, . . 343 bronchial, ..... 187 signs correlative to, . . 344 broncho-vesicular, . . . 197 signs correlative to, . . 345 cavernous, ..... 202 signs correlative to, . . 345 amphoric, . . . . . 208 tabular view of abnormal modifi- cations of,.....209 interrupted, jerking, and wavy, . 214 frequency of, in health, . . 305 Respiratory apparatus, components of, 17 sounds, adventitious (vide Rales), 216 Respiratory movements, . 22, 29, 30, 304 in the female, .... 26 influence of age on, ... 28 in cancer, ..... 526 in pneumonitis, . . . .419 in atelectasis .... 435 in tuberculosis, .... 486 in emphysema, . . . 448, 450 in pleuritis, . . . 554, 566, 567 in pneumo-hydrothorax, . . 594 in diaphragmatic hernia, . . 606 Rhonchal fremitus, .... 328 Rhonchi (vide Rales). Ribs, direction of, etc., . 18 divergence and convergence in pleuritis,.....566 Roger, Dr. Henri, on tympanitic per- cussion-resonance in pleuritis, 114, 544 Rude respiration, . . . 197, 470 in emphysema, .... 446 S. Scapular regions, . . . .60 percussion-resonance in, . . 83 INDEX. 635 Scapular regions, respiratory pheno- mena in, .... 156, 158 vocal resonance in, . . . 172 Sense of resistance in percussion, . 97 in emphysema.....445 in cancer,.....532 in pleurisy, .... 543, 565 in pneumo-hydrothorax, . . 591 in supra-clavicular region, . . 55 Shortened inspiration, . . . 210 Sibilant rales,.....220 in bronchitis, . . . 354, 371 in asthma,.....397 in pneumonitis, .... 412 in capillary bronchitis, . . 363 in emphysema, .... 447 in diseases of trachea and larynx, 611 in foreign bodies in air-passages, 621 Sibson's chest-measurer, . . 28,318 Signs, physical,.....66 Skoda, his views of percussion-sound over solid viscera, ... 90 division of percussion-sounds into empty and full, . . . 100 on tympanitic resonance in pleu- risy, ..... 114, 540 explanation of, . . . .117 theory of consonance, . . . 192 on bronchophony, . . 252,256 on tympanitic percussion-reso- nance in cedema, . . . 513 Sonorous rales,.....221 in bronchitis, . . . 354, 371 in asthma,.....397 in pneumonitis.....412 in emphysema, .... 447 in diseases of trachea and larynx, 611 in foreign bodies in air-passages, Souffle, with whispered words, vide Whispering Souffle ; arterial, vide Bellows Arterial Souffle. Spine, curvature of, in pleuritis, in emphysema, Spirometer, Splashing, . in pulmonary tuberculosis, in pneumo-hydrothorax, Sternal regions, . percussion-resonance in, Stethometer, Stethoscope, different kinds of, Stokes on pleural friction-sound duced by heart, on exploration of larynx an chea, Sub-crepitant rale, in capillary bronchitis, in pulmonary tuberculosis, in cedema, . in pulmonary gangrene, Succussion, summary of facts, history of, . in pneumo-hydrothorax, in pulmonary tuberculosis, Supplementary respiration (vide gerated Respiration), Suppressed respiration, in bronchitis, 621 555 449 44,319 330 488 594 59 89 318 126 128 pro tra Exag 244 610 226 363 474 513 517 66, 330 332 332 594 Suppressed respiration, signs correla- tive to, . . . . • 343 in pulmonary tuberculosis, . . 476 in cedema,.....514 in cancer,.....525 in atelectasis, .... 435 in emphysema, .... 446 in acute pleuritis, . . . 546 in chronic pleuritis, . . . 565 in pneumo-hydrothorax, . . 593 Suppressed vocal resonance, . 250, 261 Suprasternal region.....59 Swett, Prof., on cancer, . . . 533 Symmetry, deviations from, . . 21 Symptoms, definition of, . . . 66 Tape for measuring chest, . . . 314 Thomson on prolonged expiration, . 213 on interrupted respiration, . . 216 Thoracic parietes, description of, . 17 breathing,.....23 Topographical divisions of chest, . 54 Trachea,......46 diseases affecting, . . . 609 Tracheal respiration, .... 137 voice, ...... 164 souffle, ...... 166 rales,......613 Tracheophony, ..... 164 Tremblotement in croup, . . . 612 Tuberculosis pulmonary, . . . 458 stages of,.....460 physical signs of, ... 461 diagnosis of, .... 488 summary of physical signs belong- ing to,.....502 acute,...... 503 retrospective diagnosis of, . . 506 bronchial,.....509 Tubular respiration, .... 187 Tympanitic percussion-resonance, 99, 111 in pleuritis, . . . 114,540,544 in pneumonitis, . . . 115, 405 in dilatation of the bronchia, . 384 in asthma,.....397 in pulmonary tuberculosis, 464, 466 in cedema,.....513 in cancer, .... 526, 532 in vesicular emphysema, . . 444 in interlobular emphysema,. . 457 in pneumo-hydrothorax, . . 590 in diaphragmatic hernia, . . 605 Types of breathing, . . .25, 307 U. Unfinished inspiration, 211 177 185 356, 371 Valvular sound in larynx and trachea, in cases of foreign bodies, . 622 Vesicular murmur, increased intensity of (vide Exaggerated Respira- tion), .....177 636 INDEX. Vesicular murmur, diminished inten- sity of (vide Diminished Intensity of Respiratory Sound and Respira- tion), . . . . . .180 Vesicular respiration, . . • 146 Vital capacity of lungs, ... 44 Vocal fremitus......326 in dilatation of bronchia, . . 384 in pneumonitis, .... 420 in pulmonary tuberculosis, . . 487 in cedema......514 in pulmonary apoplexy, . . 522 in cancer, . . . 526, 533, 534 in lobular pneumonitis, . . 438 in chronic pneumonitis, . . 441 in pleuritis, . . . 557, 567, 568 Vocal resonance, normal vesicular, . 168 comparison of right and left infra- clavicular regions, . . . 171 of scapular regions, . . . 172 of infra-scapular regions, . . 172 of mammary and infra-mammary regions, ..... 173 of axillary and infra-axillary re- gions, .....173 brief summary of facts, . . 173 exaggerated vocal resonance and bronchophony.....251 diminished and suppressed reso- nance, ..... 261 in pulmonary tuberculosis, . 479 in oedema, ..... 514 in pulmonary apoplexy, . . 522 in collapse,.....436 in lobular pneumonitis, . . 438 in chronic pneumonitis, . . 441 in emphysema, .... 447 Vocal resonance, in cancer, . 526, 533 in pleuritis, . . . 552, 566, 568 in pneumo-hydrothorax, . . 593 Vocal signs, summary of facts pertain- ing to, . . ... . 275 Voice, phenomena of, incident to health,.....163 tracheal, ..... 164 phenomena of, incident to disease, 249 classification of morbid pheno- mena, .....249 whispering souffle, . . ■ 260 amphoric,.....263 cavernous,.....263 W. 260 120 Walshe, on theory of consonance, . "Water-sound," .... Wavy respiration (vide Interrupted Respiration), . . . Weak respiration (vide Diminished Vesicular Murmur), Whispering souffle, in dilatation of bronchia, in pneumonitis, . in pulmonary tuberculosis, in tuberculous cavities (Appendix), 628 Whispering bronchophony (Appendix), 628 Williams, explanation of tympanitic resonance over solidified lung, . 118 Woillez, researches relative to devia- tions from symmetry, . . 21 on effects of different diseases on the size of the chest, . . 316 476, 214 180 260 390 419 480 THE END. BLANCHARD & LEA'S MEDICAL AND SURGICAL PUBLICATIONS. TO THE MEDICAL PROFESSION. "he prices on the present catalogue are those at which our books can generally be furnished by booksellers throughout the United States, who can readily procure any which they may not Lave on hand. To physicians who have not convenient access to bookstores, we will, as long as the existing rates of postage remain un- changed, forward them at these prices, free by mail, to any post office in the United States under 1,500 miles. As we open accounts only with booksellers, the amount must in every case, without exception, accompany the order, and we assume no risks of the mail, either on the money or on the books; and as we deal only in our own publications, we can supply no others. Gentlemen desirous of purchasing will, therefore, find it more advantageous to deal with the nearest booksellers whenever practicable. BLANC HARD & LEA. Philadelphia, March, 1862. %* We have now ready a new edition of our Illustrated Catalogue of Medi- cal and Scientific Publications, forming an octavo pamphlet of 80 large pages, containing specimens of illustrations, notices of the medical press, &c. &c. It has been prepared without regard to expense, and will be found one of the handsomest specimens of typographical execution as yet presented in this country. Copies will be sent to any address, by mail, free of postage, on receipt of nine cents in stamps. Catalogues of our numerous publications in miscellaneous and educational litera- ture forwarded ou application. I3P The attention of physicians is especially awl new editions, just issued or nearly ready Ashton on the Rectum, . Bumstead on Venereal. Barwell on the Joints, Condie on Diseases of Children, Churchill's Midwifery, Druitt's Surgery, . • Dallon's Human Physiology, 2d edition, Dunglison's Medical Dictionary, Erichsen's System of Surgery, Flint on the Heart, .... Fownes' Manual of Chemistry, Gross's System of Surgery, Gray's Anatomy, Descriptive and Surgical, 2d Hamilton on Fractures and Dislocations, Hodge on Diseases of Women, Lyons on Fever, ... Meigs on Diseases of Women, Murland on Ursemia, Pan ish's Practical Pharmacy, Snlle'> Therapeutics and Materia Medica Simpson on Diseases of Women, Sargent's Minor Surgery, new edition, Taylor's Medical Jurisprudence, Toynbee on the Ear, Watson's Practice of Physic, . Walshe on the Lungs, Wins low on Brain and Mind. . West on Diseases of Women, . olicited to the following important new works See page 3 « 5 « 6 " S 10 It VI i4 1-1 15 10 17 18 19 21 *1 'A"t 2'A ■si '*! 28 'J8 2'J 30 32 32 editi TWO MEDICAL PERIODICALS, FREE OF POSTAGE, Containing over Fifteen Hundred large octavo pages, FOfS FIVE lM>LI,Ai£» FEIt ANNUM. 15 00 l U0 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Bubject to Dosta^e, when not paid for in advance,....... THE MEDICAL NLWS AND LlbRAUy, invariably in advance, - or both eriodicals mailed, free of postage (as long as the existing rates are maintained), to any post-office in the United States, for Five Dollars remitted in dvance. THE AMERICAN JOURNAlToF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., nublis-hed Quarterly, ou the first oi January, April, July, and October. Each number contains at least two hundred and eighty large octavo pages, handsomely and appropriately illustrated, 2 BLANCHARD & LEA'S MEDICAL wherever necessary. It has now been issued regularly for more than forty years, and it ha> been under the control of the present editor lor more than a quarter ol a century. 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. Its list of Collaborators will be found to contain a large number of the most distinguished names of the pro- fession in every section of the United States, rendering the department devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners. As the aim of the Journal, however, is to combine the advantages presented by all the different varieties of periodicals, in its REVIEW DEPARTMENT will be found extended and impartial reviews of all important new works, presenting subjects of novelty and interest, together with very numerous BIBLIOGRAPHICAL NOTICES, including nearly all the medical publications of the day, both in this country and Great Britain, with a choice selection of the more important continental works. This is followed by the . QUARTERLY SUMMARY, Deing a very full and complete abstract, methodically arranged, of the " IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. This department of the Journal, so important to the practising physician, is the object ol especial care on the part of the editor. It is classified and arranged under different heads, thus facilitating the researches of the reader in pursuit of particular subjects, and will be found to present a very full and accurate digest of all observations, discoveries, and inventions recorded in every branch ol medical science. The very extensive arrangements of the publishers are such as to afford to the editor complete materials for this purpose, as he not only regularly receives ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, but also twenty or thirty of the more important Journals issued in Great Britain and on the Conli. nent, thus enabling him to present in a convenient compass a thorough and complete abstract of every tiling mteresting or important to the physician occurring in any part of the civilized world. To their old subscribers, many of whom have been on their list for twenty or thirty years the publishers feel that no promises for the future are necessary; but those who may desire for the first time to subscribe, can rest assured that no exertion will be spared to maintain the"Journal in the high position which it has occupied for so long a period. By relerence to the terms it will be seen that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber, by paying in advance becomes entitled, without further charge, to ' THE MEDICAL NEWS AND LIBRARY, ... ; ..,—, . , ,......- »~" jvu.o, ouu.-.uiiuiris uave mus receiver, without expense, many works of the highest character and practical value, such as « Watson's Practice," ''Todd and Bowman's Physiology,'' "Malgaigne's Surgery," "West on Children," " West on Females, Part I.," "Habershon on the Alimentary Canal," &c. While the work at present appearing in its columns is CLINICAL LECTURES ON THE DISEASES OF WOMEN. By Professor J. Y. SIMPSON, of Edinburgh. WITH NUMEROUS HANDSOME ILLUSTRATIONS. These Lectures, published in England under the supervision of the Author, carry with them all the weignt of his wide experience and distinguished reputation. Their eminently practical nature and the importance of the subject treated, cannot fail to render them in the highest de°ree satis- factory to subscribers, who can thus secure them without cost. These Lectures are°continued in the "News for 18t>2. It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber will obtain a Quarterly and a Monthly periodical, EMBRACING NEARLY SIXTEEN HUNDRED LARGE OCTAVO PAGES, Those subscribers who do not pay in advance will bear in mind that their subscription of Five Dollars will entitle them to the Journal only, without the News, and that they will be at the exnen-e of their own postage on the receipt of each number. The advantage of a remittance when order- ing the Journal will thus be apparent. Remittances of subscriptions can be mailed at our risk, when a certificate is taken from the Post- master that the money is duly inclosed and forwarded. Address BLANCHARD & LEA, Philadilmha. AND SCIENTIFIC PUBLICATIONS. 3 ASHTON (T. J.), Surgeon to the Blenheim Dispensary, &c. °?PrT™ LEASES, INJURIES, AND MALFORMATIONS OF THE KfcCl UM AND ANUS; with remarks on Habitual Constipation. From the third and enlarged London edition With handsome illustration*. In one very beautifully printed octavo volume, of about 300 pages. (Just Issued.) $2 00. Introduction. Chapter I. Irritation and Itching of the Anus. II. Inflammation and Excoria- tion of the Anus. III. Excrescences of the Anal Region. IV. Contraction of the Anus. V. tissure of the Anus and lower part of the Rectum. VL Neuralgia of the Anus and extremity of the Kectum. VII. Inflammation of the Rectum. VIII. Ulceration of the Rectum. IX. He- morrhoidal Affections. X. Enlargement of Hemorrhoidal Veins. XI. Prolapsus of the Rectum. XII. Abscess near the Rectum. XIII. Fistula in Ano. XIV. Polypi of the Rectum. XV. Stric- vvi.f ^ m' XVL Malignant Diseases of the Rectum. XVII. Injuries of the Rectum. XVI11. hforeign Bodies in the Rectum. XIX. Malformations of the Rectum. XX. Habitual Constipation. The most complete one we possess on the subject, the excellent advice given in the concluding para- Meduo-Chtrurgical Review. graph above, would be to provide himself with a \\ e are satished, after a careful examination of c >py of the book from which it has been taken, and the volume, and a comparison of its contents with diligently to con its instructive pages They mi/ those ot its leading predecessors and contemporaries, secure to him rainy a triumph and fervent blessing .— that the btst way for the reader to avail himself of Am. Journal Med. Sciences. ALLEN (J. M.), M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting. ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, lea- ther. $2 25. We believe it to be one of the most useful works upon the subject ever written. It is handsomely illustrated, well printed, and will be found of con-' venient size for use in the dissecting-room.—Med. Examiner. However valuable may be the " Dissector's Guides" which we, of late, have had occasion to notice, we feel confident that the work of Dr. Allen is superior to any of them. We believe with ttie author, that none is so fully illustrated as this, and the arrangement of the work is such as to facilitate the labors of the student. We most cordiilly re- commend it to their attention.—Western Lamet.. ANATOMICAL ATLAS. By Professors H. H. Smith and W. E. Horner, of the University of Pennsyl- vania. 1 vol. 8vo., extra cloth, with nearly 650 illustrations. H3F5" See Smith, p. 331 ABEL (F. A.), F. C. S. AND C. L. BLOXAM. HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth,, of 662 pages, with illustrations. $3 25. ASHWELL (SAMUEL), M.D., Obstetric Physician and Lecturer to Guy's Hospital, London. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 00. The most useful practical work on the subject in I The most able, and certainly the most standard the English language. — Boston Med. and Surg, and practical, work on female diseases that we have Journal. I yet seen.—Medico-Chirurgical Review. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- tions. $2 50. _________________ BIRD (GOLDING), A. M., M. D., 8cc. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. Edited by Edmund Lloyd Birkett, M. D. A new American from the fifth and enlarged London edition. Witheighty illustrations on wood. In one handsome'octavo volume, of aiout 400 pages, extra cloth. $2 00. (Just Issued.) The death of Dr. Bird has rendered it necessary to entrust the revision of the present edition to other hands and in his performance of the duty thus devolving on him, Dr. Birkett has sedulously endeavored'to earry out the author's plan by introducing such new matter and modifications ol the reputation of the volume as BENNETT (J. HUGHES), M.D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- I OSIS and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken tor or associated with, Phthisis. One vol. 8vo.,extra cloth, with wood-cuts, pp.130. $125 4 BLANCHARD calanln ion ?l " '°r the P^ctitioner, that in presenting a new edition it is only necessary of two rlv.sVnn k ^ ^ex,ended improvements which it has received. Having had the benefit Dr rwJhii°* ™% l& °T "mCe ,he last Ame"°an reprint, it has been materially enlarged, and roiwhlv hrn/iht^n x ?.kTu c,onsclenti(,us industry is a guarantee that every portion has been tho- ^KShP,!-h the latest results of European investigation in all departments of the sci- for th*^mi^«n Ia- nCf- • The,recent date of the last Dublin edition has not left much of novelty nl.hlw,> !!h ,r,t0 introduce, but he has endeavored to insert whatever has since appeared, S,,f ill\ A * "} ,6rS aS tlS exPerie"«e has shown him would be desirable for the American £ th» f«™. *■ S S ?k number of '"""rations. With the sanction of the author he has added £„.!?,!- ,?^anrfPPoudlXL-f,°me,chaPters from a litt)e "Manual for Midwives and Nurses," re- cently issued by Dr. Churchill believing that the details there presented can hardly fail to prove of ffintff u lhu TiW Practmoner- Tne result of all these additions is that the work now con- tains fully one-half more matter than the last American edition, with nearly one-half more illus- trations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid betbre the American profession; while the very low price at which it is offered should secure for it a place in every lecture-room and on every office table. A better book in which to learn these important points we have not met than Dr. Churchill's. Every page of it is full of instruction ; the opinion of all writers of authority is given on questions of diffi- culty, as well as the directions and advice of the Seamed autaor himself, to which he adds the result of statistical inquiry, putting statistics in their pro per place and giving them their due weight, and no more. We have never read a book more free from professional jealousy than Dr. Churchill's. It ap- pears to be written with the true design of a book on medicine, viz: to give all that is known on the sub- ject of which he treats, both theoretically and prac- tically, and to advance such opinions of his own as he believes will benefit medical science, and insure the safety of the patient. We have said enough to convey to the profession that this book of Dr. Chur- chill's is admirably suited for a book of reference for the practitioner, as well as a text-book for the student, and we hope it may be extensively pur- chased amongst our readers. To them we most strongly recommend it. — Dublin Medical Press, June'20, 1860. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. by the same author. (Lately Published.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In one large and handsome volume, extra cloth, of over 700 pages. §3 00, or in leather, $3 25. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, there- fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- rican Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. The most popular work on midwifery ever issued from the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but me work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.—Western Wed. and Surg. Journal. It is impossible to conceive a more useful and slegant manual than Dr. Churchill's Practice of \4idwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on he subject which exists.—N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * # Theclearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the greatamountof statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science. —N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., fcc. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." With nume- rous illustrations. In one large and handsome octavo volume, leather, of 7t>8 pages. $3 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely brought up to the most recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, presenl a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- peared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. It comprises, unquestionably, one of the most ex- act and comprehensive expositions of the present Btate of medical knowledge in respect to the diseases of women that has yet been published.—Am. Journ. Med. Sciences. This work is the most reliable which we possess on this subject; and is deservedly popular with the profession.—Charleston Med. Journal, July, 1857. We know of no author who deserves that appro- bation, on "the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. —Tht Western Journal of Medicine and Surgery. As a comprehensive manual for students, or a work of reference for practitioners, it surpasses any other that has ever issued on the same subject front the British press.—Dublin Quart. Journal. DICKSON (S. H.), M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and handsome octavo volume, of 750 pages, leather. f3 75. (Just Issued.) The steady demand which has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed—aa elementary manual of practice, which should present the leading principles of medicine with the practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority every- where acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose. As the result of a long life de- voted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. DRUITT (ROBERT), M.R. C.S., &c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American from the eighth enlarged and improved London edition. Illustrated with four hundred and thirty-two wood-engravings In one very handsomely printed octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) A work which like Druitt's Surgery has for so many years maintained the position of a lead- ing favorite with all classes of the profession, needs no special recommendation to attract attention to a revised edition. It is only necessary to state that the author has spared no pains to keep the work up to its well earned reputation of presenting in a small and convenient compass the latest condition of every department of surgery, considered both as a science and as an art; and that the services of a competent American editor have been employed to introduce whatever novelties may have escaped the author's attention, or may prove of service to the American practitioner. As several editions have appeared in London since the issue of the last American reprint, the volume has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and improvement. The extent of these additions may be estimated from the fact that it now contains about one-third more matter than the previous American edition, and that notwithstanding the adoption of a smaller type, the pages have been increased by about one hundred, while nearly two hundred and fifty wood-cuts have been added to the former list of illustrations. A marked improvement will also be perceived in the mechanical and artislical execution of the work, which, printed in the best stvle, on new type, and fine paper, leaves little to be desired as regards external finish; while at the very low price affixed it will be found one of the cheapest volumes accessible to the profession. This popular volume, now a most comprehensive work on surgery, has undergone many corrections, improvements, and additions, and the principles and the practice of the art have been brought down to the latest recordand observation. Of the operations in surgeryitisimpossibletospeaktoohighly. The descriptions are so clear and concise, and the illus- trations so accurate and numerous, that the student can have no difficulty, with instrument in hand, and book by his side, over the dead body, in obtaining a proper knowledge and sufficient tact in this much neglected department of medical education.—British and Foreign Mtdico-Chirurg. Review, Jan. I860. In the present edition the author has entirely re- written many of the chapters, and has incorporated the various improvements and additions in modern surgery. On carefully going over it, we find that nothing of real practical importance has been omit- ted ; it presents a faithful epitome of everything re- lating t > surgery up to the present hour. It is de- servedly a popular manual, both with the student and practitioner.—London Lancet, Nov. 19, 1859. In closing this brief notice, we recommend as cor- dially as ever this most useful and comprehensive hand-book. It must prove a vast assistance, not only to the student of surgery, but also to the busy practitioner who may not have the leisure to devote himself to the study of more lengthy volumes.— London Mtd.-Times and Gazette, Oct. 22,1859. In a word, this eighth edition of Dr. Druitt's Manual of Surgery is all that the surgical student or practitioner could desire. — Dublin Quarterly Journal of Med. Sciences, Nov. 1859. AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C), M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. Second edition, revised and enlarged, with two hundred and seventy-one illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $4 00; leather, raised bands, $4 50. (Just Issued, 1861.) The general favor which has so soon exhausted an edition of this work has afforded the author an opportunity in its revision of supplying the deficiencies which existed in the former volume. This has caused the insertion of two new chapters—one on the Special Senses, the other on Im- bibition, Exhalation, and the Functions of the Lymphatic System—besides numerous additions of smaller amount scattered through the work, and a general revision designed to bring it thoroughly up to the present condition of the science with regard to all points which may be considered as definitely settled. A number of new illustrations has been introduced, and the work, it is hoped, in its improved form, may continue to command the confidence of those for whose use it is in- tended. It will be seen, therefore, that Dr. Dalton's best i own original views and experiments, together with efforts have been directed towards perfecting his work. The additions are marked by the same fea- tures which characterize the remainder of the vol- ume, and reuder it by far the most desirable text- book on physiology to place in the hands of the student which, so far as we are aware, exists in the English language, or perhaps in any other. We therefore have no hesitation in recommending Dr. Dalton's book for the classes for which it is intend- ed, satisfied a6 we are that it is better aoap.ted to their use than any other work of the kind to which they have access.—American- Journal of the Med. Sciences, April, 18(51. It is, therefore, no disparagement to the many books upon physiology, most excellent in their day, to say that Dalton's is the only one that gives us the science as it was known to the best philosophers throughout the world, at the beginning of the cur- rent year. It states in comprehensive but concise dictioa, the facts established by experiment, or other method of demonstration, and details, in an understandable manner, how it is done, but abstains from the discussion of unsettled or theoretical points. Herein it is unique; and these characteristics ren aer it a text-book without a rival, for those who desire to study physiological science as it is known to its most successful cultivators. And it is physi- ology thus presented that lies at the foundation of correct pathological knowledge; and this in turn is the basis of rational therapeutics; so that patholo- gy, in fact, becomes of prime importance in the proper discharge of our every-day practical duties. .—Cincinnati Lancet, May, 1861. Dr. Dalton needs no word of praise from us. He is universally recognized as among the first, if not the very fust, of American physiologists now living. The first edition of his admirable work appeared but two years since, and the advance of science, his a desire to supply what he considered some deficien- cies in the first edition, have already made the pre- sent one a necessity, and it will no doubt be even more eagerly sought for than the first. That it is not merely a reprint, will be seen from the author's statement of the following principal additions and alterations which he has made. The present, like the first edition, is printed in the highest style of the printer's art, and the illustrations are truly admira- ble tor their clearness in expressing exactly what their author intended.—Boston Medical and Surgi- cal Journal, March 28, 1861. It is unnecessary to give a detail of the additions; suffice it to say, that they are numerous and import- ant, and such as will render the work still more valuable and acceptable to the profession as a learn- ed and original treatise on this all-important branch of medicine. All that was said in commendation of the getting up of the first edition, and the superior style of the illustrations, apply with equal force to this. No better work on physiology can be placed in the hand of the student.—St. Louis Medical and Surgical Journal, May, 1861. These additions, while testifying to the learning and industry of the author, render the book exceed- ingly useful, as the most complete expose of a sci- ence, of which Dr. Dalton is doubtless the ablest representative on this side of the Atlantic.—New Orleans Med. Times, May, 1861. A second edition of this deservedly popular work having been called for in the short space of two years, the author has supplied deficiencies, which existed in the former volume", and has thus more completely fulfilled his design of presenting to the profession a reliable and precise text-book, and one which we consider the best outline on the subject of which it treats, in any language.—N. American Medico-C hirurg. Review, May, 1661. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. *** This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner The most complete work on Practical Medicine extant; or, at least, in our language.—Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day__as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. The editors are practitioners of established repu- tation, and the list of contributors embraces many of the most eminent professors and teachers of Lon- don, Edinburgh, Dublin, and Glasgow. It is, in- deed, the great merit ot this work that theprincipal articles have been furnished by practitioners who have not only devoted especial attention to the dis- eases about which they have written, but have also enjoyed opportunities for an extensive practi- cal acquaintance with them and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines witli high and just authority .— American Medical Journal. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections In one octavo volume, extra cloth, of 600 pages. $320. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. The last edition. In one volume, octavo, extra cloth, 548 pages. $2 80 DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. $3 00 BLANCHARD fz LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, Src. Notices of Climate and of" Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, fee. With French and other Synonymes. Revised and very greatly enlarged1. In one very large and handsome octavo volume, of 9&2 double-columned pages, in small type; strongly bound in leather, with raised bands. Price $-4 00. Especial care has been devoted in the preparation of this edition to render it in every respee! worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present revision to introduce whatever might be necessary " to make it a satisfactory and desira- ble—if not indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish this, large additions have been found requisite, and the extent of the author's labors may be estimated from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the pa^e. The medical press, both in this country and in England, has pronounped the work in- dispensable to all medical students and practitioners, and the present improved edition will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care has been exercised to obtain the typographical accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With afl these improvements and enlargements, the price has been kept at the former very moderate rate, placing it within the reach of all. This work, the appearance of the fifteenth edition of which, it has become our duty and pleasure to announce, is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use of the pre- ceding editions, where we have never failed to find a sufficiently full explanation of ever} medical term, that, in this edition " about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only neces- sary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, as it is without doubt the best and most comprehensive work of the kind wh ich has ever appeared.—Buffalo Med.Journ., Jan. 1858. The work is a monument of patient research, skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the Ame- rican profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for the wants of the profession than any other with which we are acquainted, and of a character which places it far above comparison and competition.—Am. Joum. Med. Sciences, Jan. 1858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions, may be said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its author, and have furnished us with a volume indis- pensable at the present day, to all who would find themselves au niveau with the highest standards of medical information.—Boston Medical and Surgical Journal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, are the most labor-saving contrivances which lite- rary men enjoy; and the labor which is required to produce them in the perfect manner of this example is something appalling to contemplate. The author tells us in his preface that, he has added about six thousand terms and subjects to this edition, which, before, was considered universall) as the best word of the kind in any language.—Stfliman's Journal, March, 1858. He has razed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects and terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placed before the profes- sion a complete and thorough exponent of medical terminology, without rival or possibility of rivalry. —Nashville Joum. of Med. and Surg., Jan. 1858. It is universally acknowledged, we believe, that this work is incomparably the best and most com- plete Medical Lexicon in the English language. The amount of labor which the distinguished author has bestowed upon it is truly wonderful, and the learning and research displayed in its preparation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.—St. Louis Med. and Surg. Joum., Jan. 1858. ' It is the foundation stone of a good medical libra- ry, and should always be included in the first list ol books purchased by the medical student.—Am. Med. Monthly, Jan. 1858. A very perfect work of the kind, undoubtedly the most perfect in the English language__Med. an4 Surg. Reporter, Jan. 1858. It is now emphatically the Medical Dictionary o4 the English language, and for it there is no substi- tute.— JV. H. Med. Joum., Jan. 1858. It is scarcely necessary to remark that any medi- cal library wanting a copy of Dungli3on's Lexieoa must be imperfect.—Cin. Lemcet, Jan. 1858. We have ever considered it the best authority pub- lished, and the present edition we may safely say ha* no equal in the world.—Peninsular Meet. Journal, Jan. 1858. The most complete authority on the subject to b* found in any language—Va. Med. Journal, Feb. '58. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $5 25. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia, HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled ; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more com- plete repertory of tacts upon the subject treated, can anywhere be found. The author bus, moreover, that enviable tact at description and that facility and ease of expression which render him peculiarly acceptable to the casual, or the studious reader. This faculty, so requisite in setting forth many trraver and less attractive subjects, lends additional charms to one always fascinating.—Boston Med. and Surg. Journal. The most complete and satisfactory system of Physiology in the English language.—Amer. Med Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The present edition the author has made a pciux t mirror of the science as it. is at the present hour. As a work upon physiology proper, the science of the functions performed by the body, the student will find it all he wishes.—Nashville Joum of Med That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now theereatencyelopnedia on the subject, and worthy of a place in every phy- sician's library.— Western Lancet. BY THE same author. (A new edition.) GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. In announcing a new edition of Dr. Dunglison's General Tnerapeutics and Materia Medica, we have no words of commendation to bestow upon a work whose merits have been heretofore so often and so justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judicious analysis, and clearness of ex- pression, is fully sustained by the numerous addi- tions he has made to the work, and the careful re- Vision to which he has subjected the whole.—N. A. Medico-Chir. Review, Jan. 1858. The work will, we have little doubt, be bought and read by the majority of medical students; its size, arrangement, and reliability recommend it to all; no one, we venture to predict, will study it without profit, and there are few to whom il will not be in some measure useful as a workdf ref- r- ence. The young practitioner, more especially, wiil find the copious indexes appendid to this edi.-ion of great assistance in the selection and preparation of suitable formulae.—Charleston Med. Joum. and Re- view, Jan. 1858. BY the same author. (A new Edition.) NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. $3 75. Another edition of the "New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of ihe last edition. The articles treated of in the former editions will be found to have undergone considerable ex- , pansion in this, in order that the author might be enabled to introduce, as far as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection ; and to make the work still more de>erving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume.— Preface. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire t« examine the original papers.—The American Journal of Pharmacy. One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—New York Med. Gazette. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an "Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform The whole accompanied with a few brief Pharmaceutic and Medical Observations. Eleventh edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. (Preparing.) 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, Sec. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries Diseases, and Operations. New and improved American, from the second enlarged and carefully revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume, of one thousand closely printed pages, leather, raised bands. $4 50. (Just Issued.) The verv distinguished favor with which this work has been received on both sides of the Atlan- tic has stimulated the author to render it even more worthy of the position which it has so rapidly attained as a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pages, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little has been added in this country; some few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. step of the operation, and not deserting him until the final issue of the case is decided.—Sethoscope. Embracing, as will be perceived, the whole surgi- It is, in our humble judgment, decidedly the best book of the kind in the English language. Strange lhat just such books are notoftener produced by pub- lic teachers of surgery in this country and Great Britain Indeed, it is a matter of great astonishment. but no less true than astonishing, that of the many works on surgeTy republished in this country within the last fifteen or twenty years as text-books for medical students, this is the only one that even ap- proximates to the fulfilment of the peculiar wants of youngmen justentermgupon the study of thisbranoh ofthe profession.— Western Jour .of Med. ami Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we regard it the mosi serviceable guide which he can consult. He will find afulnessofdetailleadinghim throt-gh every cal domain, and each division of itself almost com- plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express oui estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the best single volume now extant on the subject, and with great pleasure we add it to our text-books.— Nashville Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes ; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.—JV. 0. Med. and Surg. Journal. FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, Sec. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. $3 00. We regard it, in point both of arrangement and of the marked ability of its treatment of the subjects, as destined to take the first rank in works of this class. So far as our information extends, it has at present no equal. To the practitioner, as well as the student, it will be invaluable in clearing up the diagnosis of doubtful cases, and in shedding light upon difficult phenomena.—Buffalo Med. Journal. A work of original observation ofthe highest merit. Werecommend the treatise to every one who wishes to become a correct auscultator. Based to a very large extent upon eases numerically examined, it carries the evidence of careful study and discrimina- tion upon every page. It does credit to the author, and, through him, to the profession in this country. It is, what we cannot call every book upon auscul- tation, a readable book.—Am. Jour. Med. Sciences. by the same author. (Now Ready.) A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 500 pages, extra cloth. $2 75. We do no' know that Dr. Flint has written any- thing which is not first rate; but this, his latest con- tribution to medical literature, in our opinion, sur- passes all the others. The work is most comprehen- sive in its scope, and most sound in the views it enun- ciates. The descriptions are clear and methodical; the statements are substantiated by facts, ai d are mode with such simplicity and sincerity, that with- out them they would carry conviction. The style is admirably clear, direct, and free from dryness With Dr. Walshe's excellent treatise before us, we lave no hesitation in saying that Dr. Flint's book is the best work on the heart in the English language. —Boston Med. and Surg. Journal. We have thus endeavored to present our readers with a fair analysis of this remarkable work. Pre- ferring to employ the very words of thedistinguished author, wherever it was possible, we have essayed to condense into the briefest space a general view of his observations and suggestions, and to direct the attention of our brethren to the abounding stores of valuable matter here collected and arranged for their use and instruction. No medica1 library will here- after be considered complete without this volume; and we trust it will promptly find its way into the hands of every Ameiican student and physician.— N Am. Med. Chir. Review. This last work of Prof. Flint will add much to his previous well-earned celebrity, as a writer of great force and beauty, and, with his previous work, places him at the head of American writers upon" diseases of the chest. We have adopted his work upon the heart as a text-book, believing it to be more valuable for that purpose than any work of the kind that has yet appeared.—Nashville Med. Joum. With more than pleasure do >ve hail the advent of this work, for it fills a wide gap on the list < f text- books for our schools, and is, for the practitioner, the n.ost valuable practical work of its kind.—N. O. Med. New%. In regard to the merits of the work, we have no hesitation in pronouncing it full, accurate, and ju- dicious. Considering the present state of science, such a work was much needed, it should be in the handsof every practitioner.—Chicago Med. Journal. But these are verv trivial spots, and in no wise prevent us fiom declaring our most hearty approval | of the author's ability, industry, and conscientious- ness.—Dublin Quarterly Journal of Med. Sciences. He has laborer1 on wi'h the same industry and care, and his place among theirs* authors of our country is becoming fully established. To this end, the work whose title is given above, contributes in no small degree. Our spa e will not admit of sn extended analysis, »nd we will close this orief notice by commending it without reserve to every class of readers in the profession.—Peninsular Med. Joum. AND SCIENTIFIC PUBLICATIONS. 15 . __4X FOWNES (GEORGE), PH. D., «tc. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. b rom the seventh revised and corrected London edition. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one large royal 12mo volume, of 600 pages. In leather, $1 65; extra cloth, $1 50. (Just Issued.) The death of the author having placed the editorial care of this work in the practised hands of Drs. Hence Jones and A. W. Hoffman, everything has been done in its revision which experience could suggest to keep it on a level with the rapid advance of chemical science. The additions requisite to this purpose have necessitated an enlargement of the page, notwithstanding which the work has been increased by about fifty pages. At the same time every care has been used to maintain its distinctive character as a condensed manual for the student, divested of all unnecessary detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- ment of Organic Chemistry, which has made such rapid progress within the last few years, but yet equal attention has been bestowed on the other branches of the subject—Chemical Physics and Inorganic Chemistry—to present all investigations and discoveries of importance, and to keep up the reputation ofthe volume as a complete manual ofthe whole science, admirably adapted for the learner. By the use of a small but exceedingly clear lype the matter of a large octavo is compressed within the convenient and portable limits of a'moderate sized duodecimo, and at the very low price affixed, it is offered as one of the cheapest volumes before the profession. Dr. Fownes'excellent work has been universally recognized everywhere in his own and this country, as the best elementary treatise on chemistry in the English tongue, and is very generallv adopted, we believe, as the standard text- book in all ( ur colleges, both literary and scientific.—Charleston Med. Joum. and Review. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small Bpace. The author hasachieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without being too dogmatical or general.— Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Scienct FISKE FUND PRIZE ESSAYS —THE EF- FECTS OF CLIMATE ON TUBERCULOUS DISEASE. BvErjwtN Lee,M.R.C.S .London, and THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TUBERCLES By Edward Warren, M. D, of Edenton, N. C. To- gether in one neat 8vo volume, extracloth. »1 00. FRICK ON RENAL AFFECTIONS; their Diag- nosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth 75 cents FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, &c. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $3 00. GRAHAM (THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- tions of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert Bridges, M. D. Complete in one large and handsome octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $4 00. **£ Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be had separate, cloth backs and paper sides. Price $2 50. afford to be without this edition of Prof. Graham's Elements.—Silliman's Journal, March, 1858. From Prof. Wolcott Gibbs, N. Y. Free Academy. The work is an admirable one in all respects,and its republication here cannot fail to exert a positive influence upon the progress of science in this country. From Prof. E. N. Horsford, Harvard College. It has, in its earlier and less perfect editions, been famibar to me, and the excellence of its plan and the clearness and completeness of its discussions, have long been my admiration. No reader of English works on this science can GRIFFITH (ROBERT E.), M. D., «tc. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- lists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M. D. Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large ard handsome octavo volume, extra cloth, of 650 pages, double columns. $3 00; or in sheep, $3 25. This is a work of six hundred and fifty one pages. embracing all on the subject of preparing and admi- nistering medicines that can be desired by the physi- cian and pharmaceutist.— Western Lancet. It was a work requiring much perseverance, and when published was looked upon as by far the best work of its kind that had issued from the American press. Prof Thomas has certainly "improved," as well as added to this Formulary, and has rendered it additionally deserving of the confidence of pharma- ceutists and physicians— Am. Journal of Pharmacy We are happy to announce a new and improved edition of this, one ofthe most valuable and useful works that have emanated from an American pen It would do credit to any country, and will be found of daily usefulness to practitioners of medicine; it is better adapted to their purposes than the dispensato- ries.— Southern Med. and Sut%. Journal. It is one ofthe most useful books a countrv practl tioner can possibly have.—Medical Chronicle. The amountof useful, every-day matter.for a prac- ticing physician, is really immense.—Boston Med and Surg. Journal. This edition has been greatly improved by the re- vision and ample additions of Dr Thomas, and is now, we believe, one of the mosi complete works of its kind in any language. The additions amount to about seventy pages, and no effort has been spared to include in them all the recent improvements V work of this kind appears to us indispensable to the physician, and there is none >ve can more cordially recommend. N Y Journal of Medicine. BLANCHARD & LEA'S MEDICAL GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, Sec. Enlarged Edition—Now Ready, January, 1862. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Opera- tive. Illustrated by Twelve Hundred and Twenty-seven Engravings. Second edition. much enlarged and car-'fully reined. In two large and beautifully printed octavo volumes, of about twenty-two hundred pages; strongly bound in leather, with raised bands. Price $12. The exhaustion in little more than two years of a large edition of so elaborate and comprehen- sive a woik as this is ihe best evidence that the author was not mistaken in his estimate of the want which existed of a complete American System of Surgery, presenting the science in all its necessary details and in all its branches. That he has succeeded in the attempt to supply this want is shown not only by the rapid sale ofthe work, but also by the very favorable manner in which it has been received by the organs ofthe profession in this country and in Europe, and by the fact that a. translation is now preparing in Holland—a mark of appreciation not often bestowed on any scien- tific work so extended in size The author has not been insensible to the kindness thus bestowed upon his labors, and in revising the work for a new edition he has spared no pains to render it worthy of the favor with which it has been received. Every portion has been subjected to close examination and revision ; any defi- ciencies apparent have been supplied, and the results of recent progress in the science and art of surgery have been everywhere introduced; while the series of illustrations has been enlarged by the addition of nearly three hundred wood-cuts, rendering it one of the most thoroughly illustrated works ever laid before 1he profession. To accommodate these very extensive additions, the work has been printed upon a smaller type, so that notwithstanding the very large increase in the matter and value of the book, its size is more convenient and less cumbroos than before. Every care has been taken in the printing to render the typographical execution unexceptionable, and it is confi- dently presented as a work in every way worthy of a place in even the most limited library of the p.actitioner or student. A few testimonials ofthe value ofthe former edition are appended. Has Dr. Gross satisfactorily fulfilled this object ? A caieful perusal of his volumes enables us to give an answer in the affirmative. Not only has he given to the reader an elaDorate and well-written account of his o.vn va?t experience, but he has not failed to embody in his pages the opinions and practice of surgeons in this and other countries of Europe. The result has been a work of such completeness, that it has no superior in the systematic treatises on sur- gery which have emanated from English or Conti- nental authors. It has been justly objected that these have been far from complete in many essentia] particulars, many of them having been deficient in some of the most important points whieh should characterize such works Some of them have been elaborate—too elaborate—with respect to certain diseases, while they have merely glanced at, or given an unsatisfactory account of, others equally important to the surgeon. Dr. Gross has avoided this error, and has produced the most complete work that has yet issued from the press on the science and practice of surgery. It is not, strictly speaking, a Dictic nary of Surgery, but it gives to the reader all the information that he may require for his treat nent of suigical diseases. Having said so much, it might apnear superfluous to add another wjrd; but it is only due to Dr. Gross to state that he has embraced the opportunity of transferring to his pages a vast number ot engravings from English and other au- tnors, illustrative ot the pathology anu treatment of siiieical diseases. To these are added several hun- dred original wood-cuts. The work altogether corn- menus itself to the attention of British surgeons, from whom it cannot fail to meet with extensive patronage.—London Lancet, Sept. 1, 1860. Of Dr. Gross's treatise on Surgery we can say no more than that it is the most elaborate and com- plete work on this branch of tht 1 eating art which has ever been published in any country. A sys- tematic work, it admits of no analytical review; but, did our space permit, we should gladly give some extracts from it, to enable our readers to judge of the c'assical siyle of the author, and the exhaust- ing way in which each subject is treated.—Dublin Quarterly Journal of Med. Science. The work is so superior to its predecessors in matter and extent, as well as in illustrations and style of publication, that we can honestly recom- mend it as the best work of the kind to be taken home by the young practitioner.—Am. Med. Joum. With pleasure we record the completion of this long-anticipsted work. The reputation which the author has for manv years sustained, both as a sur- geon and as a writer, had prepared us to expect a treatise of great excellence and originality; but we confess we were by no means prepared lor the work which is before us—the most complete treatise upon surgery ever published, either in ihis or any otm r country, and we might, perhans, safelv say, the most original. There is no subject belonging pro- perly to surgery which has not received from the authoi a due share of attention. Dr. Grots has sup- plied a want in surgical literature which has long been felt by practitioners; he has furnished us with a complete practical treatise upon surgery in all its departments As Airienciiis, we are proud of the achievement; as surgeons, we are most sincerely thankful to him for his extraurd nary labors in our benalf—N. Y. Monthly Review and Buffalo Med. Jouma,1. BY THE SAME AUTHOR. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings. Prii-e in extra cloth, 94 7.r>; leather, raised bands, SH 25. (Lately Published.) The very rapid advances in the Science of Pathological Anatomy during the last few years have rendered essential a thorough modification of this work, with a view of making it a correct expo- nent of the present state of the subject. The very careful manner in which this task has been executed, and the amount of alteration which it has undergone, have enabled the author to say thai " with the many changes and improvements now introduced, the work may be regarded almost as a new treatise," while the efforts of the author have been seconded as regards the mechanical execution of the volume, rendering it one of the handsomest productions of the American press. We most sincerely congratulate the author on the successful manner in which he has accomplished his proposed object. His book is most admirably eal oulated to fill up a blank which has long been felt to exist in this department of medical literature, and as such must become very widely circulated amongst all classes of the profession.— Dublin Quarterly Joum of Med. Science, Nov. 1857. We have been favorably impressed with the. gene- ral manner in which Dr Gross has executed his task of affording a comprehensive digest of the present state of the literature of Pathological Anatomy, and have much pleasure in recommending his work to our readers, as we believe one well deserving of diligent perusal and careful study.—Montreal Med. Chron., Sept. 1857. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp.468. $2 75. AND SCIENTIFIC PUBLICATIONS. 17 GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE UKINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. Tn leather, raised bands, $5 25; extra cloth, $4 75. Philosophical in ts design, methodical in its ar- agree with us, that there is no work in the English rangement,ample and sound in its practical details, it may in truth be said to leave scarcely anything to be desired on so important a subject.—Boston Med. and Sure Journal Whoever will peruse the vast amount of valuable practical information it contains, will, we think, anguage which can make any just pretensions to be its equal.—/V. Y. Journal of Medicine. A volume replete with truths and principles of the utmost value in the investigation of these diseases.— American Medical Journal. GRAY (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London, Sec. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M. D.,late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly by the Author and Dr. Carter. Second American, from the second revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 large and elaborate engravings on wood. Price in extra cloth, $6 25; leather, raised bands, $7 00. (Now Ready, 1862.) The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe- cution have been found to present superior practical advantages in facilitating the study of Anato- my. In presenting it to the profession a second time, the author has availed himself of the oppor- tunity to supply any deficiencies-which experience in its use had shown to exist, and to correct any errors of de'ail, to which the first edition of a scientific work on so extensive and complicated a science is liable. These improvements have resulted in some increase in the size ofthe volume, while twenty-six new wood-cuts have been added to the beautiful series of illustrations which form so distinctive a feature of the work. The American edition has been passed through the press under the supervision of a competent professional man, who has taken every care to render it in all respects accurate, and it is now presented, without any increase of price, as fitted to maintain and extend the popularity which it has everywhere acquired With little trouble, the busy practitioner whose to exist in this country. Mr. Gray writes through knowledge of anatomy may have become obscured by want of practice, may now resuscitate his former anatomical lore, and be ready for any emergency. It is to this class of individuals, and not to the stu- dent alone, that this work will ultimately tend to be of most incalculable advantage, and we feel sat- isfied that the library ofthe medical man will soon be considered incomplete in which a cony of this work does not exist.- Madras Quarterly Journal of Med. Science, July, 1861. This edition is much improved and enlarged, and contains several new illustrations by Dr. Westma- cott. The volume is a complete companion to the dissecting-room, and saves the necessity of the stu dent possessing a variety of" Manuals."—The Lon- don Lancet, Feb. 9, 1861. The work before us is one entitled to the highest praise, and we accordingly welcome it as a valu- able addition to medical literature. Intermediate in fulness of detail between the treatises of S lar pey and of Wilson, its characteristic merit he-p in the number and excell-nce of the engravings it contains. Most of these are original, of much larger than ordinary size, and admirabiy executed. The various parts are also letiered after the plan adopted in Holden's Osteology. It would be diffi- cult to over-estimate the advantages offered by this mode of pic.onal illusi ration Bones, ligamfnts, muscles, bloodvessels, and nerves are each in turn figured, and marked with their appropriate names; thus enabling thestudent to cemprehendata glance, what would otherwise often be ignored, or at any rate, acquired only by prolonged and irksome ap- plication. In conclusion, we heartily commend the Work of Mr. Gray to the attention of the medical profession, feeling certain tiiat it should be regarded as one. of the most valuable contriDutions ever made L educational literature -N. Y. Monthly Review. Dec. 1859. In this view, we regard the work of Mr Gray as far better adapted to the wants of the profession, and especially of the student, than any treatise on anatomy yet published in this country. 11 is destined we believe, to supersede ill others, both as a manual Tf ejections, and a standard of reference to the student of general or relative anatomy.-iV. Y. Journal of Medicine, Ne>v. ia59. For this truly admirable work the profession is indebted to the distinguished author of " Gray on the Spleen." The vacancy it fills has been long felt out with both branches of his subject in view. His description of each particular part is followed by a notice of its relations to ne parts with which it is connected, and this, too, sufficiently ample for all the purposes of the operative surgeon. After de- scribing the bones and muscles, he gives a concise statement of the fractures to which the bones of the extremities are most liable, together with the amount and direction of the displacement to which the fragments are subjected by muscular action. The section on arteries is remarkably full and ac- curate. Not only is the surgical anatomv given to every important vessel, with directions for its liga- tion, but at the end of the description of each arte- rial trunk we have a useful summary of the irregu- larities which may occur in its origin, course, and termination.—AT. A. Med. Chir. Review, Mar. 1859. Mr. Gray's book, in excellency of arrangement and completeness of execution, exceeds any w.>rk on anatomy hitherto published in the English lan- guage, affording a complete view of the structure of the human body, with especial reference to practical surgery. Thus the volume constitutes a perfect book of reference for the practitioner, demanding a place in even the most limited library of the physician or surgeon, and a work of necessity for the student to fix in his mind what he has learned by the dissecting knife from the book of nature.—The Dublin Quar- terly Journal of Med. Sciences, Nov. 1858. In our judgment, the mode of illustration adopted in the present, volume cannot but present many ad- vantages to the student of anatomy. To the zealous disciple of Vesalius, earnestly desirous of real im- provement, the book will certainly be of immense value; but, at the same time, we must also confess that to those simplv desirous of "cramming" it will be an undoubted godsend. The peculiar value of Mr. Gray's mode of illustration is nowhere more markedly evident than in the chapter on osteology, and especially in those portions which treat of the bones of the head and of thsir development. The study of these parts is thus made one of comparative e«se, if not of positive pleasure; and those bugbears of the student, the temporal and sphenoid bones, are shorn of half their terrors. It is, in our estimation, an admirable and complete text-book for the student, and a useful work <|f reference for the practitioner; its pictorial character forming a novel element, to which we have already sufficiently alluded.—Am. Joum. Med. Set., July, 1859. IS BLANCHARD & LEA'S MEDICAL GIBSON'S INSTITUTES AND PRACTICE OF Sl"RGERY. Eighth edition, improved aiid al tered. With thirty-fourplates. In twohandsome octavo volumes, containing about 1,000 pages, leather, raised bandi. $6 50. GARDNER'S MEDICAL CHEMISTRY, for the use of Students and the Profession. In one royal UJmo. vol., cloth, pp. 396, with wood-cuts. SI. GLUGE'S ATLAS OF PATHOLOGICAL HIS- TOLOGY. Translated, with Notes and Addi- HOLLAND'S MEDICAL NOTES AND RE- FLECTIONS. From the th»d London edition. In one handsome octavo volume, extra cloth. S3. HORNER'S SPECIAL ANATOMY AND HiS- tions. by Joseph Leidt, M. D. In one volume, very large imperial quarto, extra cloth, with 320 copper-plate figures, plain and colored, $5 00. HUGHES' INTRODUCTION TO THE PRAC- TICE OF AUSCULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS IN DIS- EASES OF THE LUNGS AND HEART. Se- cond edition 1 vol. royal Initio., sx. cloth, pp. 304. $1 00. TOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, ex- tra cloth, of more than 1000 pages, with over 300 illustrations. $6 00. HAMILTON (FRANK H,), M. D., Professor of Surgery in the Long Island College Hospital. A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. Tn one large and handsome octavo volume, of over 750 pages, witli 289 illustrations. $4 25. (Now Ready, January, 1860.) opinion may be gathered as to its value.— Boston Medical and Surgical Jourral, .March 1, 1860. The >vork is concise, judicious, and accurate, and adapted to the wants of the student, practitioner, and investigator, honorable to the author and to the profession.—Chicago Med. Journal, March, 1860. We reeard this work as an honor not only to its author, but to the profession of our country. Were we to review it, thoroughly, we could not convey to the mind of ihe reader more forcibly our honeBt opinion expressed in the few words—we think it the best book of its kind extant. Every man interested in surgery will soon have this work on his desk. He who does not, will be the loser.—New Orleans Medical News, March, 1860. Now that it is before us, we feel bound to say that much as was expected from it, and onerous as was the undertaking, it has surpassed expectation, and achieved more than was pledged in its behalf; for its title does not express in full the richness of its contents. On the whole, we are prouder of this work than of any which lias for years emanated from the American medical press; its sale will cer- tainly be very large in this country, and we antici- pate its eliciting much attention in Europe.—Nash- ville Medical Record, Mar. 1S60. Every surgeon, young and old, should possess himself of it, and give it a careful perusal, in doing which he will be richly repaid.—St. Louis Med. and Surg. Journal, March, 1860. Dr. Hamilton is fortunate in having succeeded in filling the void, so long felt, with what cannot fail tobeatonceacceptedas a model monograph in some respects, and a work of classicil authority. We sincerely congratulate the profession of the United States on the appearance of such a publication from one of their number. AVe have reason to be proud of it as an original work, both in a literary and sci- entific point of view, and to esteem it as a valuable guide in a most difficult and important branch of study and practice. On every account, therefore, we hope that it may soon be widely known abroad as an evidence of genuine progress on this side of the Atlantic, and further, that it may be still more widely known at home as an authoritative teacher from which every one may profitably learn, and as affording an example of honest, well-directed, and untiring industry in authorship which every surgeon may emulate.- Am. Med. Journal, April, 1860. Among the many good workers at surgery of whom America may now boast tot the least is Frank Hast- ings Hamilton; and the volume before us is (we say it with a pang of wounded patriotism) the best and handiest book on the subject in the Eiglish lan- guage. It is in vain to attempt a review of it; nearly as vain to seek for any sins, either of com- mission or omission. AVe have seen no work on practical surgery which we would sooner recom- mend to our brother surgeons, especially those of '' the services," or those whose practice lies in dis- tricts where a man has necessarily to rely on his own unaided resources. The practitioner will find in it directions for nearly every possible acjiuent, easily found and comprehended ; and much pleasant reading for him to muse over in the after considera- tion of his cases.—Edinburgh Med. Joum. Feb. 1861. This is a valuable contribution to the surgery of most important affections, and is the more welcome, inasmuch as at the present time we do not possess a single complete treatise on Fractures and Dislo- cations in the English language. It has remained for our American brother to produce a complete treatise upon the subject, and bring together in a convenient form those alterations and improvements that have been made from time to time in the treatment of these affections. One great and valuable feature in the work before us is the fact that it comprises all the improvements introduced into the practice of both English and American surgery, and though far from omitting mention of our continental neighbors, the author by no means encourages the notion—but too prevalent in some quarters—that nothing is good unless imported from France or Germany. The latter half of the work is devoted to the considera- tion of the various dislocations and their appropri- ate treatment, and its merit is fully equal to that of the preceding portion.—The London Lancet,May 5, 1860. ' It is emphatically the book upon the subjects of which it treats, and we cannot doubt that it will continue so to be for an indefinite period of time. When we say, however, that we believe it will at once take its place as the best book for consultation by the practitioner; and that it will form the most complete, available, and reliable guide in emergen- cies of every nature connected with its subjects; and also that the student of surgery may make it his text- book with entire confidence, and with pleasure also, from its agreeable and easy style—we think our own HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the"American Journal ofthe Medical Sciences." In one large royal 12mo. volume, leather, of over 500 double columned pages. $1 50. To both practitioner and student, we recommend use ; embracing every department of medical science this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation— Charleston Med. Joum. We know of no dictionary better arranged and adapted. Itisnotencumbered with theobsoleteterms of a bygone age, but it contains all that are now in down to the very latest date.—Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 19 HODGE (HUGH L.), M.D., Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, &c. ON DISEASES PECULIAR TO WOMEN, including Displacements of the Uterus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 pages, extra cloth. $3 25. (Now Ready.) We will say at once that the work fulfils its object capitally well j and we will moreover venture the assertion t^iat it will inaugurate an imnroved prac- tice throughout this whole country. The secrets of the author's success are so clearly revealed that the attentive student cannot fail to insure a goodly por- tion ot similar success in his own practice. It is a credit to all medical literature; and we add, that the physician who does not place it in his library, and who does not faithfully con its pages, will lose a vast deal of knowledge that would be most useful to himself and beneficial to his patients. It is a practical work ofthe highest order of merit; and it will take rank as such immediately.—Maryland and Virginia Medical Journal, Feb. 1861. This contribution towards the elucidation of the pathology and treatment of some of the diseases peculiar to wooien, cannot fail to meet with a favor- able reception from the medical profession. The character of the particular maladies of which the work before us treats; their frequency, variety,and obscuiity ; the amount of malaise and even of actual Buffering by which they are invariably attended; their obstinacy, the difficulty with which they are overcome, and their disposition again and again to leeur—these, taken in connection with the entire competency of the author to render a correct ac- count of their nature, their causes, and their appro- priate management—his ample experience, his ma- tured judgment, and his perfect conscientiousness- invest this publication with an interest and value to which few of the medical treatises of a recent date can lay a stronger, if, perchance, an equal claim.— Am. Joum. Med. Sciences, Jan. 1861. Indeed, although no part of the volume is not emi- nently deserving of perusal and study, we think that the nine chapters devoted to this subject, are espe- cially so, and we know of no more valuable mono- graph upon the symptoms, prognosis, and manage- ment of these annoying maladies than is conttituted by this part of the work. AVe cannot but regard it as one of the most original and m )st practical works of the day ; one which every accoucheur and physi- cian should most carefully read; for we are per- suaded that he will arise from its perusal with new ideas, which will induct him into a more rational practice in regard to many a suffering female, who may have placed her health in his hands.—British American Journal, Feb. 1661. Of the many excellences of the work we will not speak at length. We advise all who would acquire a knowledge of the proper management of the mala- dies of which it treats, to study it with care. The second part is of itself a most valuable contribution to the practice of our art.—Am. Med. Monthly and New York Review. Feb. 1861. The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. HABERSHON (S. O.), M. D., Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES OF THE ALIMENTARY CANAL, OESOPHAGUS, STOMACH, CAECUM, AND INTES- TINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra cloth $1 75. (Now Ready.) JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised London edition, wilh additions by Edward Hartshorne, M. D., Surgeon to Wills Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. JONES (C. HANDFIELD), F. R. S., & EDWARD H. SIEVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, leather. 93 To. As a concise text-book, containing, in a condensed form, a complete outline of what is known in the domain of Pathological Anatomy, it is perhaps the best work in the English language. Its great merit consists in its completeness and brevity, and in this respect it supplies a great desideratum in our lite- rature. Heretofore the student of pathology was obliged to glean from a great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. As a simple work of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.—Western Lancet. KIRKES (WILLIAM SENHOUSE), M.D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, Sec. A MANUAL OF PHYSIOLOGY. A new American, from the third and imnroved London edition. With two hundred illustrations. In one large and handsome royal 12mo. volume, leather, pp. 586. $2 00. (Lately Published.) This is a new and very much improved edition of Dr Kirkes' well-known Handbook of Physiology. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busy practitioner.—Dublin Quarterly Journal. One of the very best handbooks of Physiology wt nossess— presenting just such an outline of the sci- ence as the student requires during his attendance unon a course of lectures, or for reference whilst preparing for examination.— Am. Medical Journal Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs. Kirkes and Paget, have the gift of telling us what we want to know, without thinking it necessary to tell us all they know.—Boston Med. and Surg. Journal. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know.—Charleston Med. Journal. 20 BLANCHARD & LEA'S MEDICAL KNAPP'S TECHNOLOGY ; or, Chemistry applied to the Arts and to Manufactures. Edited by Dr. Ronalds, Dr. Richardson, and Prof. W. R. Johnson. In two handsomi 8vo. vols., withabout 500 wood engravings. $6 00. LAYCOCKS LECTURES ON THE PRINCI- PLES AND METHODS OF MEDICAL OU- SERVATION AM) RESEARCH. For th? Use of Advanced Siudents and Junior Practitioners. In one royal l'imo. volume, extra cloth. Price $1. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHCEA. By M. Lallemand. Translated and edited by Henry J McDougall. Third American edition. To which is added-----ON DISEASES OF THE VESICUL^E SEMINALES; and their associated organs. With sp.-cial refer- ence to the Morbid Secretion* of the Prostatic and Urethral Mucous Membrane. By Marris Wilson, M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.) LA ROCHE (R.), M. D., &c. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination ofthe connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages, plantations, and farm- houses; that it is treated with scarcely better suc- Fro»n Professor S. H. Dickson, Charleston, S. C'., September 18, 1855. A monument of intelligent and well applied re- search, almost without example. It is, indeed, in itself, a large library, and is destined to constitute the special resort as a book of reference, in the subject of which it treats, to all future time. We have not time at present, engaged as we are, by day and by night, in the work of combating this very disease, now prevailing in out city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, that this, the most malig- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this ible and comprehensive treatise will be vtry gene- rally read in the south.—Memphis Med. Recorder. BY THE SAME AUTHOR. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In oi e handsome octavo volume, extra cloth, of 500 pages. $3 00. LAWRENCE (W.), F. R. S., «tc. A TREATISE ON DISEASES OF THE EYE. A, new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. LUDLOW (J. L.), M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume, leather, ol 816 large pages $2 50. We know if no better companion for the student I crammed into his head by the various professors to during the hours spent in the lecture room, or to re- whom he is compelled to listen.— Western Lancet, fresh, at a glance, his memory of the various topics | May, 1857. LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. $6 00. The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch of the subject on which it treats.—Edinburgh Journal of Medical Science. The most important contribution as yet made to Physiological Chemistry__Am. Journal Med. Sci- tnces, Jan. 1856. by the same author. (Lately Published.) MANUAL OF 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 Samtjel Jackson, M. D., of the University ol Pennsylvania. With illus- trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. Prom Prof. Jac&son's Introductory Essay. In adopting the handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their more mature studies, the high value of his researches, and the great weigfttof his. autho- rity in that important department of medical science,are fully recognized. AND SCIENTIFIC PUBLICATIONS 21 LYONS (ROBERT D.), K. C. C, Late Pathologist in-chief to the British Army in the Crimea, &c. A TREATISE ON FEVER; or, selections from a course of Lectures on Fever. Being part of a course of Theory and Practice of Medicine. In one neat octavo volume, of 362 pages, extra cloth; $2 00. (Now Ready.) From the Author's Preface. "lam induced to publish this work on Fever with a view to bring within the reach ofthe student and junior practitioner, in a convenient form, the more recent results of inquiries into the Pathology and Therapeutics of this formidable class of di:-eases. " The works ofthe great writers on Fever are so numerous, and in the present day are scattered in so many languages, that they are difficult of access, not only to students but also to practitioners. I shall deem myself fortunate if I can in any measure supply the want which is felt in this respect. We have great pleasure in recommending Dr. Lyons' work on Fever to the attention of the pro- fession. It is a work which cannot fail to enhance the author's previous well-earned reputation, as a diligent, careful, and accurate observer.—British Med. Journal, March 2, 1861. Taken as a whole we can recommend it in the highest terms as well worthy the careful perusal and study of every student and practitioner of medi- cine. AVe consider the work a most valuable addi- tion to medical literature, and one destined to wield no little influence over the mind of the profession.— Med and Surg. Reporter, May 4, 1861. This is an admirable work upon the most remark- able and most important class of diseases to which mankind are liable.—Mtd. Joum. of N. Carolina, May, 1861. MEIGS (CHARLES D.), M. D., Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia, OBSTETRICS: THE SCIENCE AND THE ART. Third edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. Though the work has received only five pages of enlargement, its chapters throughout wear the im- press of careful revision. Expunging and rewriting, remodelling its sentences, with occasional new ma- terial, all evince a lively desire that it shall deserve to be regarded as improved in manner as well as matter. In the matter, every stroke of the pen has increased the value of the book, both in expungings and additions —Western Lancet, Jan. 1857. The best American work on Midwifery that is accessible to the student and practitioner—N. W. Med. and Surg. Journal, Jan. 1857. This is a standard work by a great American Ob- stetrician. It is the third and last edition, and, in the language of the preface, the author has "brought the subject up to the latest dates of real improve- ment in our art and Science."—Nashville Joum. of Med. and Surg., May, 1857. by the same author. (Just Issued.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lec~ tures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume, leather, of over 700 pages. $3 60. In other respects, in our estimation, too much can- not be said in praise of this work. It abounds with beautiful passages, and for conciseness, for origin- ality, and for all that is commendable in a work on the diseases of females, it is not excelled, and pro- bibly not equalled in the English language. On the whole, we know of no worK on the diseases of wo- men which we can so cordially commend to the ■ tudent and practitioner as the one before us.—Ohio Med. and Surg. Journal. The body of the book is worthy of attentive con- sideration, and is evidently the production of a clever, thoughtful, and sagacious physician. Dr. Meigs's letters on the diseases of the external or- gans, contain many interesting and rare cases, and many instructive observations. We take our leave of Dr. Meigs, with a high opinion of his talents and originality.—The British and Foreign Medico-Chi- rurgical Review. Every chapter is replete with practical instruc- tion, and bears the impress of being the composition of an acute and experienced mind. There is a terse- ness, and at the same time an accuracy in his de- scription oi symptoms, and in the rules for diagnosis, which cannot fail to recommend the volume to the attention of the reader.—Ranking's Abstract. It contains a vast amount of practical knowledge. 3y one who has accurately observed and retained the experience of many years.—Dublin Quarterly Journal. Full of important matter, conveyed in a ready and agreeable manner.—St.Louis Med. and Surg. Jour. There is an off-hand fervor, a glow, and a warm- heartedness infecting the effjrt of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct impressions upon the mind and memory ofthe reader. — Tht Charleston Med. Journal. BY THE SAME AUTHOR. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 50. The instructive and interesting author of this I lectable book. * * * This treatise upon child- work whose previous labors have placed his coun- bed fevers will have an extensive sale, being des- rrvme'n under deep and abiding obligations, again tined, as it deserves, to find a place in the library challenges their admiration in the fresh and vigor- of every practitioner who scorns to lag in the rear.— ous attractive and racy pages before us. It is a de- I Nashville Journal of Medicine and Surgery. BY THE SAME AUTHOR ; WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style ol art. In one handsome octavo volume, extra cloth. $4 50. 22 BLANCHARD in the possession of every phys.cian as the subject will engage them more closely or profitably; and j is one of great and increasing importance to the none could be offered to the busy practitioner of j public as well as to the profession.—Si Louis Med either calling, for the purpose of casual or hasty and Surg. Journal. reference, that would be more likely toafford the aiu desired. We therefore recommend it as the best and : This work of Dr. Taylor's is generally acknow- safest manual for daily use.—American Journal oj \ ledgtd to be one of the ablest extant on the subject Medical Sciences. j ot medical jurisprudence, it is certainly one ot tne It is not excess of praise to say that the volumt most attractive books that we h»ve met with ; sup- before us is the very best treatise extant on Medical P'yng so niucn both to interest and instruct, that Jurisprudence. In saying this, we do not wish to Wemdo not ne*ltilte to ««/'" that after having once be understood as detracting from the merits of the commenced its perusal, few could be prevailed upon excellent works of Beck/Ryan, Traill, Guy, and t«d«=«st before completing it. In the last Lonu.m others j but in interest and value we think it must „ ,'"',aU lh? Mv>}y t,b?trved and accurately re- be conceded that Taylor is superior to anything that h ed 'acts have been inseited, including much has preceded it.—JV.V Medical and Surg, lournal ! Hldf ls re(;ent of Chemical, Microscopical, and Pa- '. . . . , thological research, besid. s papers on numerous It is at once comprehensive and eminently prac- subjects never before published__Charleston Med tical, and by universal consent t tanas at the head of I Journal and Review. by the same author. (New Edition, just issued.) ON POISONS, IN KELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Second American, from a second and revised London edition. In one large octavo volume, ol 755 pages, leather. $3 50. Since the first appearance ol this work, the rapid advance of Chemistry has introduced into use many new substances which may become fatal through accident or design —while at the same time it has likewise designated new and more exact modes of counteracting or detecting tho-e previously treated of. Mr. Taylor's position as the leading medical jurist of England, has during this period conferred on him extraordinary advantages in acquiring experience en these subjects nearly all cai-es of moment being referred to him lor examination, as- an expert whose testimony is geneially accepted as final. The results of his labors, therefore, as gathered together in this volume, carefully weighed and sifted, and presented in the clear and intelligible style for which he is noted, may be received as an acknowledged authority, and as a guide to be followed with implicit confidence. AND SCIENTIFIC PUBLICATIONS 29 TODD (ROBERT BENTLEY), M. D., F. R. S. Professor of Physiology in King's College, London; and WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, leather. Price $4 50. f3F Gentlemen who have received portions of this work, as published in the " Medical News and Library," can now complete their copies, if immediate application be made. It will be fur- nished as follows, free by mail, in paper covers, with cloth backs. Parts 1., II., III. (pp. 25 to 552), $2 50. Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00. Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25. A magnificent contribution to British medicine, and the American physician who shall fail to peiuse it, wil. have failed to read one of the most instruc- tive books of the nineteenth century.—N. O. Med and Surg. Journal. It is more concise than Carpenter's Principles, and more modern than tne accessible edition of Muller'e Elements; its details are brief, but sufficient; its descripiions vivid ; its illustrations exact and copi- ous ; and ils language terse and perspicuous.— Charleston Med. Journal. We know of no work on the subject of physiology so well adapted to the wants of the medical student. Its completion has been thus long delayed, that the authors might secure accuracy by personal observa- tion.—St. Louis Med. and Surg. Journal. Our notice, though it conveys but a very feeble and imperfect idea of the magnitude and importance of the work now under consideration, already tran- scends our limits ; and, with the indulg* nee of our readers, and the hope that they will peruse the book for themselves, as we feel we can with confidence recommend it, we leave it in their hands. — The Northwestern Med. and Surg. Journal. TODD (R. B.) M. D., F. R. S., &c. CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one octavo volume, 284 pages, $1 50. by the same author. (Now Ready.) CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat octavo volume, of 320 pages, extra cloth. $1 75. TOYNBEE (JOSEPH), F. R. S., Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- nosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one very handsome octavo volume, extra cloth, $3 00. (Just Issued.) The work, as was stated at the outset of our no- tice, is a model of its kind, and every page and para- graph oi it are worthy of the most thorough study. Considered all in all—as an original work, well written, philosophically elaborated, and happily ll- lusirated with cases and drawings—it is bv far the ablest monograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable contributions to theart and science of sur- gery in the nineteenth century.—N. Amer. Medico- Chirurg Review, Sept. 1860. To recommend such a work, even after the mere hint we have given of its original excellence and value, would be a work of supererogation. We are speaking within the li.nits of modest acknowledg- ment, and with a sincere and unbiassed judgment, when we affirm that as a treatise on Aural Surgery, it is without a rivt 1 in our language or any other.— Charleston Med Joum and Review, Sept. I860. The work of Mr. Toynbet is undoubtedly, upon the whole the most valuable production of tne kind in any language. The author has long oeen known by his numerous monographs upon subjects con- nected with disease* of the ear, and is now regarde J as the highest authority on most points in his de- partment of science. Mr. Toynbee's work, as we have alreauy said, is undoubteuly the most reliable guide for the study of the diseases of the ear in any language, and should be in the library of every pn> - sician.— Chicago Med. Journal, July, 1860. WILLIAMS (C. J. B.), M.D., F. R. S., Professor of Clinical Medicine in University College, London, &c. PRINCIPLES OF MEDICINE. An Elementaiy View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre- servation of health. A new American, from theihird and revised London edition, in one octavo volume, leather, of about 500 pages. $2 50. (Just Issued.) We find that the deeply-interesting matter and style of this book have so far fascinated us, that we have unconsciously hung upon its pages, not too long, indeed, for our own profit, but longer than re- viewers can be permitted to indulge. We leave the further analysis to the student and practitioner. Our jud-inent of the work has already been sufficiently expressed. It is a judgment of almost unqualified praise.—London Lancet. A text-book to which no other in our language is comparable.—Charleston Medical Journal. No work has ever achieved or maintained a more deserved reputation.— Va. Med. and Surg. Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority ofthe London Society for Medical Observation. A new American, from the second and revised London edition. In one very handsome volume, royal 12mo., extra cloth. 51 00. To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner we and precision to carelessness, this little book is :u- have ever seen.—Peninsular Journal of Midicint. valuable.—N. H. Journal of Medicin*. I 30 BLANCHARD & LEA'S MEDICAL New and much enlarged edition—(Just Issued.) WATSON (THOMAS), M. D., &c, Late Physician to the Middlesex Hospital, &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of " A Practical Treatise on the Diseases of Children," &c. With one hundred and eighty.five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type; the whole strongly bound in leather, with raised bands. Price 94 25. That the high reputation of this work might be fully maintained, the author has subjected it to a thorough revision; every portion has been examined with the aid of the most recent researches in pathology, and the results of modern investigations in both theoretical and practical subjects have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the editor has likewise introduced whatever possesses immediate importance to the American physician in relation to diseases incident to our climate which are little known in England, as well as those points in which experience here has led to different modes of practice; and he has also added largely to the series of illustrations, believing fhat in this manner valuable assistance may be conveyed to the student in elucidating the text. The work will, therefore, be found thoroughly on a level with the most advanced state of medical science on both sides of the Atlantic. The additions which the work has received are shown by the fact that notwithstanding an en- largement in the size of the page, more than two hundred additional pages have been necessary to accommodate the two large volumes of the London edition (which sells at ten dollars), within the compass of a single volume, and in its present form it contains the matter of at least three ordinary octavos. Believing it to be a work which should lie on the table of every physician, and be in the hands of every student, the publishers have put it at a price within the reach of all, making it one of the cheapest books as yet presented to the American profession, while at the same time the beauty ol its mechanical execution renders it an exceedingly attractive volume. The fourth edition now appears, so carefully re- vised, as to add considerably to the value of a book already acknowledged, wherever the English lan- guage is read, to be beyond all comparison the best s) stematic work on the Principles and Practice of Physic in the whole range of medical literature. Every lecture contains proof of the extreme anxiety of the author to keep pace with ihe advancing know- ledge of the day, and to bring the results of the labors, not only of physicians, but of chemists and histologists, before his readers, wherever they can be turned to useful account. And this is done with such a cordial appreciation of the merit due to the industrious observer, such a generous desire to en- courage younger and rising men, and such a candid acknowledgment of his own obligations to them, that one scarcely knows whether to admire most the pure, simple, forcible English—the vast amount of useful practical information condensed into the Lectures—or the manly, kind-hearted, unassuming character of the lecturer shining through his work. —London Med. Times and Gazette. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judgment, erudite cultivation, clearness, and eloquence, with which they were from the first invested, but yet richer than before in the results of more prolonged observation, and in the able appreciation of the latest advances in pathology and medicine by one of the most profound medical thinkers of the day.— London Lancet. The lecturer's skill, his wisdom, his learning, are equalled by the ease of his graceful diction, his elo- quence, and the far higher qualities of candor, of courtesy, of modesty, and of generous appreciation of merit in others. May he long remain to instruct us, and to enjoy, in the glorious sunset of his de- clining years, the honors, the confidence and love gained during his useful life.—N. A. Med.-Chir. Review. Watson's unrivalled, perhaps unapproachable work on Practice—the copious additions made to which (the fourth edition) have given it all the no- velty and much of the interest of a new book.— Charleston Med. Journal. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of anew—a fourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank him for having, in the trouble and turmoil of a large practice, made leisure to supply the hiatus caused by the exhaustion of the publisher's stock of the third edition, which has been severely felt for the last three years. For Dr. Watson has not merely caused the lectures to be reprinted, but scattered through the whole work wc find additions or altera- tions which prove that the author has in every way sought to bring up his teaching to the level of .lie most recent acquisitions in science.—Brit, and For. Medico-Chir. Review. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London, &c. A PRACTICAL TREATISE ON DISEASES OF THE LUNGS; includiog the Principles of Physical Diagnosis. A new American, from the third revised and much en- larged London edition. In one vol. octavo, of 468 pages. (Just Issued, June, 1860.) $2 25. The present edition has been carefully revised and much enlarged, and may be said in the main to be rewritten. Descriptions of several diseases, previously omitted, are now introduced; the causes and mode of production of the more important affections, so far as they possess direct prac- tical significance, are succinctly inquired into; an effort has been made to bring the description ol anatomical characters to the level of the wants of the practical physician ; and the diagnosis and prognosis of each complaint are more completely considered. The seciions on Treatment and the Appendix (concerning the influence of climate on pulmonary disorders), have, especially, been largely extended.—Author's Preface. ^*% In press, by the same author, a volume on Diseases of the Heart and Aorta, to match the above. WILSON (ERASMUS), F. R. S., Lecturer on Anatomy, London. THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged, by William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2 00. AND SCIENTIFIC PUBLICATIONS. 31 New and much enlarged edition—(Just Issued.) WILSON (ERASMUS), F. R. S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- vised American, from the last and enlarged English Edition. Edited by W. H.Gobrecht, M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. Illustrated with three hundred and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume, of over 600 large pages; leather. $3 25. The publishers trust that the well earned reputation so long enjoyed by this work will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to introducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appro- priate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye ofthe student everything of interest or importance. It may be recommended to the student as no less distinguished by its accuracy and clearness of de- scription than by its typographical elegance. The wood-cuts are exquisite.—Brit, and For. Medical Review. An elegant edition of one of the most useful and accurate systems of anatomical science which has been issued from the press The illustrations are really beautiful. In its style the work is extremely concise and intelligible. No one can possibly take up this volume without being struck with the great beauty of its mechanical execution, and the clear- ness of the descriptions which it contains is equally evident. Let students, by all means examine tne claims of this work on their notice, before they pur- chase a text-book of the vitally important science which this volume so fully and easily unfolds.— Lancet. We regard it as the best system now extant for students.—Western Lancet. It therefore receives our highest commendation.— Southern Med. and Surg. Journal. BY THE SAME AUTHOR. (Just Issued.) ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. The writings of Wilson, upondiseases ofthe skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The present edition is a great improv e- ment on all its predecessors. To dwell upon all the great merits and high claims of the work before us, seriatim, would indeed be an agreeable service; it would be a mental homage which we could freely offer, but we should thus occupy an undue amount of space in this Journal. We will, however, look at some of the more salient points with which it abounds, and which make itincompuraoiy superior in excellence to all other treatises on the subject of der- matology. No mere speculative views are allowed a place in this volume, which, without adoubt, will, for a very long period, be acknowledged as the chief standard work on dermatology. The principles of an enlightened and rational therapeia are introduced on every appropriate occasion.—Am. Jour. Med. Science, Oct. 1657. ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re- presentations of about one hundred varieties of disease, most of them the size of nature. Price in cloth $4 25. In beauty of drawing and accuracy and finish of coloring these plates will be found equal to anything of the kind as yet issued in this country. We have already expressed our high appreciation of Mr. Wilson's treatise on Diseases of the Skin. The plates are comprised in a separate volume, which we counsel all those who possess the text to purchase. It is a beautiful specimen of color print- ing, and the repiesentations of the various forms of skin disease are as faithful as is possible in plates of the size.—Boston Med. and Surg. Journal, April 8, 1858. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delineation and perfect accuracy of illustration are concerned.—Medico-Chirurgical Review. Of these plates it is impossible to speak too highly. The representations of the various forms of cutane- ous disease are singularly accurate, and the color- ing exceeds almost anything we have met with in point of delicacy and finish.— British and Foreign Medical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with fourexquiMte colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25. BY THE SAME AUTHOR. HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12mo.; extra cloth, of about 300 pages, with numerous illustrations. $1 00 ; paper cover, 75 cents. WHITEHEAD ON THE CAUSES AND TREAT- MENT OF AUORTION AND STERILITY. Second American Edition. In one volume, octa- vo extra cloth, pp. 308. $1 75. 32 BLANCHARD & LEA'S MEDICAL PUBLICATIONS. WINSLOW (FORBES), M. D., D. C. L., &.c. ^W * ON OBSCURE DISEASES OF THE BRA.IN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. In one handsome octavo volume, of nearly 600 page*. (Just Issued.) $3 00. We close this brief and necessarily very imperfect notice of Dr. Winslow's great and classical work, by expressing our conviction that it is long since so important and beautifully written a volume has is- sued from the British medical pre«s.—Dublin Med. J'ress, July 25,1660. We honestly bel ieve this to be the best book of the season.—Ranking's Abstract, July, 1860. It cairied us back to our old days of novel reading, it kept us from our dir.ner, from our business, and from our slumbers; in short, we laid it down only when we had got to the end of the last paragraph, and ev<*n then turned back to the repeiusal of several passages which we had marked as requiring further study We have failed entirely in the above notice to give an adequate acknowledgment of the profit and pleasure with which ive have perused the above worx. We can only say to our readers, study it yourselves; and we extend the invitation to unpro- fessional as well as professional men, believing that it contains matter deeply interesting not to physi- cians alone, but to all who appreciate the truth that: " The proper study of mankind is man."—Nashville Medical Record, July, I860. The latter portion of Dr. Winslow's work is ex- clusively devoted to the consideration of Cerebral Pathology. It completely exhausts the subject, in the same manner as the previous seventeen chapters relating to morbid psychical phenomena left nothing unnoticed in reference to the mental symptoms pre- monitory of cerebral disease. It is impossible 10 overrate the benefits likely to result from a general perusal of Dr. Winslow's valuaale and deeply in- teresting work—London Lancet, June 23, 1860. It contains an immense mass of information.— Brit, and For. Med.-Chir. Review, Oct. lfcGO. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, Sec. LECTURES ON THE DISEASES OF WOMEN. Second American, from the second London edition. In one handsome octavo volume, extra cloth, of about 500 pages; price $2 50. (Now Ready, July, 1861.) *#* Gentlemen who received the first portion, as issued in the "Medical News and Library," can now complete iheir copies by procuring Part II, being page 309 to end, with Index, Title matier, &c, 8vo., cloth, price $1. We mustnowconclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical phybician is apparent on every page.—N. Y. Journal of Medicine, March, 1858. We know of no treatise of the kind so complete anl yet so compact.—Chicago Med. Journal, Janu- ary, 1858. ' A fairer, more honest, more earnest, and more re liable investigator of the many diseases of women and children is not to be found in any country.— Southern Med. and Surg. Journal, January 1858. We gladly recommend his Lectures as in the high- est degree instructive to all who are interested in obstetric practice.—London Lancet. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language ; and that it stamps Dr. West us the facile princeps of British obstetric authors.—Edinb. Med. Joum. As a writer, Dr. West stands, in our opinion, sec- ond only to Watson, the " Macaulay of Medicine;'' he possesses that happy faculty of clothing instruc- tion in easy garments; cambining pleasure with profit, he leads his pupils, in spite of the ancient proverb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a can- did, sate, and valuable guide. We anticipate with pleasure the appearance of the second part of the work, which, if it equals this part, will complete one of our very best volumes upon diseases of fe- males —iV. A. Med -Chirurg. Review, July, 1858. Happy in his simplicity of manner, and moderate in his expression of opinion, the author is a sound reasoner and a good practitioner, and his book is worthy of the handsome garb in which it has ap- peared from the press of the Philadelphia publishers. — Virginia Med. Journal. We mu»t take leave of Di. West's veiy useful work, with our commendation oi the clearness of its style, and the im ustry and sobriety of judgment of which it gives evidence.—London Med Times and Gazette. Sound judgment and good sense pervade every chapter ot the book. From its perusal we have de- rived unmixed satisfaction.—Dublin Quart. Joum BY THE same author. (Just Issued.) LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD Third American, from the fourth enlarged and improved London edition. In one handsome octavo volume, extra clotn, of about six hundred and fifty pages. 9* 75. The three former editions ofthe work now before us have placed the author in the foremost r«nk of those physicians who have devoted special attention to tne diseases of early life We attempt no ana- ljsisof thisedition.but may refer the reader to some of the chapters to which the largest additions have been made—those on Diphtheria, Disorders of the Mind, and Idiocy, for instance—as a proof that the work is really a new edition; not a mere reprint. In its preient shape it will be lound of the greatest possible service in the every-day practice of nine- tenths of the profession.—Med. Times and Gazette, London, Dtc. 10, 1859. All things conssid red this book of Dr. West is by far the best treatise in our language upon such modifications of morbid action and disease as are witn. bsed when we have to deal with infancy and childhood. It is true that it confines itself to such disorders as come within the province of the phy- sician, and even with respect to these it is unequal as regards minuleniss of consideration, and some diseases it omits to notice altogether. But those who know anything of the present condition of paediatrics will readily admit that it would be next to impossible to effect more, or effect it better, than the accoucheur of/Sc. Bartholomew's has done m a single volume. The lecture (XVI.) upon Disoitc rs of the Mind in children is an admirable specimen of the value ot the later information convejed in the Lectures of Dr. Charles West.—London Lancet, Oct. 22, 1859. Since the appearance of the first edition, about eleven years ago, the experience of the author has doubh-d; so that, whereas the lectures at first wera founded on six hundred observations, and one hun- dred and eigniy dissections made among nearly four- teen thousand children, they now embody the results of nine hundred observations, and two hundred and eighty-eight post-mortem examinations made among nearly thirty thousand children, who, during tne past twenty years, have been undei his cure__ British Med. Journal, Oct. 1, 1859. BY THE SAME AUTHOR. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. NLM032776116