RESPIRATORY MURMURS. 
BY . 
JAMES R. LEAMING, M. D., 
ONE OP THE VISITING PHYSICIANS TO ST. LUKE’8 HOSPITAL, NEW YORK. 
[REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, MAY, 1672.] 
I). APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1872. 
NEW YORK: AD VERTlSEMEiS 'i S. 
NEW MEDICAL WORKS IN PRESS. 
I. 
A TREATISE 
on 
OVARIAN TIJMORS, 
THEIR PATHOLOGY, DIAGNOSIS, AND TREATMENT, 
OVARIOTOMY. 
WITH REFERENCE ESPECIALLY TO 
By E. R. PEASLEE, M. D., LL. D., 
Professor of Diseases of Women in Dartmouth College; one of the Consulting 
Surgeons to the N. Y. State Woman’s Hospital; formerly Pro- 
fessor of Obstetrics and Diseases of Women in the 
N. Y. Medical College; Corresponding Mem- 
ber of the Obstetrical Society of 
Berlin, etc., etc., etc. 
On Puerperal Diseases. 
xx. 
CLINICAL LECTURES DELIVERED AT BELLEVUE HOSPITAL. 
By Fordyce Barker, M. D., Clinical Professor of Midwifery and Diseases of 
Women, in the Bellevue Hospital Medical College; Obstetric Physician to Belle- 
vue Hospital; Consulting Physician to the New York State Woman’s Hospital, 
and to the New York State Hospital for Diseases of the Nervous System; Hon- 
orary Member of the Edinburgh Obstetrical Society, etc., etc. 
in. 
A Treatise on Diseases of the Eones. 
By Thomas M. Markoe, M. D., Professor of Surgery in the College of Physicians 
and Surgeons, New York, etc., etc. 
ON THE 
x'sr. 
Treatment of Pulmonary Consumption, 
BY HYGIENE, CLIMATE, AND MEDICINE. 
JAMES HENRY BENNET, M. D. 
IIOOND ID I TI ON, REVISED AND ENLARGED. 
D. APPLETON & CO., Publishers, 
549 & 651 BROADWAY, NEW YORK- RESPIRATORY MURMURS. 
• JAMES E. LfeSSfENTG, M. D., 
ONE OF THE VISITING PHYSICIANS TO ST. LUKE’S HOSPITAL, NEW YOKK. 
BY 
[REPRINTED FROM TEE NEW YORK MEDICAL JOURNAL, MAY, 1S72.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1872. RESPIRATORY MURMURS.1 
Since the time of Laennec, those engaged in investigating 
physical conditions of the chest have ever united in looking to 
the breath-sounds for the elementary key. 
Able and distinguished men have given much of their 
lives to the consideration and practice of auscultation, hut 
certainty in diagnosis in incipient disease is yet vainly desired. 
It must be that the method of study has been faulty, or that 
attention has been wrongly directed. Under these circum- 
stances, presumption may he pardoned, even if it should fail 
in the attempt to show a better way. 
Laennec recognized both bronchial and pulmonary breath- 
sounds, and explained them as being caused by air-friction. 
In describing pulmonary respiration, he says: “ On applying 
the cylinder, with its funnel-shaped cavity open, to the breast 
of a healthy person, we hear, during inspiration and expira- 
tion, a slight but extremely distinct murmur, answering to the 
entrance of the air into and expulsion from the air-cells of the 
lungs. This murmur may be compared to that produced by 
a pair of bellows whose valve makes no noise, or, still better, to 
that emitted by a person in a deep and placid sleep, who takes 
now and then a profound inspiration” (Forbes’s Laennec, p. 
29); and the translator adds in a foot-note : “ It will he most 
easily and distinctively perceived by applying the naked ear to 
the chest of a child.” Laennec’s view is theoretical, not based 
on a careful study of all the facts. Indeed, at that time the 
1 Read before the Academy of Medicine, January 4, 1872. 4 
minute anatomy of tlie lung, and tlie constitution of the resid- 
ual air, were not known. Subsequent opinions have been in- 
fluenced more or less by Laennec’s, especially in this, that all 
respiratory murmurs are considered to be air- and tube-friction 
sounds. Many differ from him as to the seat, but all agree 
with him as to the mechanism. M. Beau, of Paris, placed 
its seat in the pharynx; Dr. Sanderson, of Edinburgh, in the 
rima glottidis. Skoda, of Vienna, considered vesicular mur- 
mur as occurring only in inspiration, and being caused by air- 
friction, and he likened it to the noise one makes in forcing 
the air through the nearly-closed lips. He denies that the re- 
spiratory murmur has any thing to do with tlie vesicular 
breathing, which, he says, is a purely bronchial sound. An- 
dral called it a sound of pulmonary expansion or vesicular res- 
piration, thus designating its seat, and giving it name. 
Many speak of vesicular and respiratory murmurs as inter- 
changeable terms. The late Dr. Hyde Salter placed the seat 
of the respiratory or vesicular murmur in the convective sys- 
tem, and mostly in the sub-pleural, minute bronchioles (Brit- 
ish and Foreign Med.-CKir. Rev., July, 1861). Dr. Waters, 
of Liverpool, whose prize essay on the minute anatomy of 
the human lunar has done so much to increase our knowledge 
on this subject, describes the mode of connection of the bron- 
chioli with the air-sacs. The opening sometimes is, as it were, 
a hole punched out, clean and round, and the air, passing in 
and out, must make a sound much in the same way as is done in 
a toy tin whistle. The late Dr. Cammann, of this city, 
the cause of the murmur to be the passage of air into the air- 
sacs and out again. Dr. Williams, after speaking of portions 
of the chest where blowing sounds are heard, gobs on to say : 
“ Then there is the vesicular respiration, which is heard in 
most other parts of the chest; it is a diffused murmur caused 
by the air penetrating through the minutest tubes, and into 
their numerous vesicles or cells.” Dr. Gerhard, of Philadel- 
phia (“ Lectures on the Diagnosis, Pathology, and Treatment of 
Diseases of the Chest ”), says: “ The sound of air entering the 
vesicles is different from that caused by its passage through 
the tubes, and the former is, therefore, known as the vesicular 
sound, the latter as the tubal or blowing sound. The vesicu- 
lar sound is often called a murmur, from its softness and diffu- 5 
sion over a large space, and cannot be produced unless tlie 
vesicles are healthy or nearly so.” And again he says the 
cause of difference “ seems to be the different manner in which 
the air impinges upon the vesicles and tubes. But the vesicu- 
lar sound is in part owing to the vibration of the air, and in 
part to the noise produced by the dilating of the vesicles them- 
selves.” 
Dr. Walshe represents the natural respiratory murmurs as 
caused by inspiration and expiration, for which there is usu- 
ally a healthy type, “commonly termed—pulmonary or ve- 
sicular ; 5, bronchial; c, tracheal; d, laryngeal; e, pharyngeal, 
according to the part of the respiratory apparatus from which 
the sounds audible externally are transmitted.” Dr. Corri- 
gan divides the sounds heard in auscultation into “simple 
sounds or murmurs, and compound sounds or rattles. . . . All 
the sounds heard in the chest belong to one or the other of 
those two kinds; and, if, when you hear a sound, the exact 
nature of which you may be in doubt, you will first refer it to 
its class, your labor in determining what it is will be very 
much diminished.” The American editor of “ Stokes on the 
Chest” describes vesicular murmur as that “of a soft and 
gentle, or, as it has been otherwise described, a mellow, con- 
tinuous, gradually-developed, breezy murmur, unattended 
with a sensation either of dryness or humidity; and we are 
properly cautioned by M. Fournet and his reviewer not to 
expect a character of sound which conveys the notion of a 
successive dilatation of separate vesicles, or, as it is sometimes 
called, pure and vesicular.” Dr. Hyde Salter says: “ There is 
another reason, to which I have not referred, which makes me 
think that the respiratory murmur must have a tubular or quasi 
tubular seat, and cannot be formed in the air-cells; it is, that 
fine crepitation, such as that of pneumonia, supplants it; it does 
not merely drown it, it supplants it, the two do not coexist; ” 
and farther on: “ If, then, pneumonic crepitation is a veritable 
tube-sound, and its seat the microscopical tubes immediately 
subtending the air-cells, the supplanting and destruction of 
the respiratory murmur by it would show that this latter has 
an identical seat, and is therefore a tube-sound.” This ex- 
plains Dr. Salter’s views as to the seat and cause of the mur- 
mur. He believes it to be caused by the passage of air through 6 
these microscopic air-tubes, just before they reach the vesicles; 
and, as he is one of the latest and most brilliant writers on 
this subject, perhaps he represents the more advanced views 
of the profession. lie does not deny that sounds formed any- 
where in the convective system, from the mouth or nose to 
the smaller bronchiae, mingle with and enter into the compo- 
sition of the respiratory murmur, but he denies that the air- 
vesicles or alveoli have any thing to do in forming the sound, 
lie believes the sound is formed in the bronchioles, immedi- 
ately subtending the pulmonary pleura. 
Carefully examining tlie opinions of different writers, it is 
evident that some consider the respiratory murmur as having 
a single seat and cause, while others recognize its composite 
character. Yet, I am not aware that any one has ever at- 
tempted to analyze the murmur, and study its constituents 
separately as well as together. They speak of the vesicular 
character, the pulmonary quality of the respiration, hut they 
attempt no analysis. To show that this may, and ought to he 
done, in order to attain unto a higher grade of excellence in 
diagnosis, is the main object of this paper. A clear under- 
standing of this whole matter will make it necessary, as pre- 
liminary, to look at the minute anatomy of the tissue of the 
lungs, and of the bronchial system; secondly, the circulation of 
the lungs and of the bronchial system; and, thirdly, the char- 
acteristics and constitution of the residual air, its object and 
office. The bronchial system may be, and is frequently, called 
the convective or the broncho-respiratory system, and the pul- 
monary is called the true respiratory system. They differ in 
almost every respect. The office of the broncho-respiratory is 
to convey air into the true respiratory system, while the 
true respiratory system is where the great function of vitaliz- 
ing the blood is perfected. The bronchial system is charac- 
terized by cartilage in its fibrous sheath. In the upper part, 
where it is necessary to prevent collapse of the tubes, the car- 
tilage is in nearly perfect rings, but as the tubes pass into the 
lung-structure, where they are occupied by the residual air, 
the cartilage gradually loses the character of rings, and ap- 
pears merely as deposits occurring at irregular intervals, down 
so far as the bronchial arteries extend, to where the bronchial 
veins commence to carry back the blood that has passed through the capillaries of the bronchial mucous membrane. > 
The mucous membrane also, of the bronclio-respiratory sys- 
tem, is different from that of the true respiratory system, in 
this, that it is ciliated epithelial mucous membrane, while the 
other is of tesselated basement epithelium. The circulation 
also is entirely different. The convective system is supplied 
by the bronchial arteries; the pulmonary substance by the 
pulmonary artery, and by the nutrient arteries of the lungs, 
which are the connecting link between the two systems. The 
nutritive arteries arise from the bronchial arteries, but have 
no accompanying veins. Thus, blood, after performing the 
proper office of nutrition in the pulmonary tissue, is at once 
reaerated, and passes into the venous radicles of the pulmonary 
vein prepared for systemic circulation. 
The bronchial arteries have been called the nutritive ar- 
teries by anatomists, but they have not dwelt upon the fact 
that the vence comites do not attend these arteries into the 
pulmonary structure, and that, consequently, this gives them 
a peculiar character. The bronchial veins return all the blood 
of the bronchial arteries; the nutritive arteries have no veins. 
Their blood is reaerated where they do their work, and it finds 
its way into the venous radicles of the pulmonary vein as ar- 
terial blood. This anomaly in the circulation is of great 
interest in explaining physiological causes and pathological 
effects. In pneumonia, it is the nutrient artery, accompanied 
with its plexes of ganglia of the organic nerve, lymphatics, 
etc., that preserves the life of the part, and governs the whole 
process of resolution. We can all remember the anxiety of 
practitioners, in the past, to prevent abscess and gangrene of 
the lung after inflammation. But [time, and a more careful 
study of the natural history of the disease, have proved to us 
that gangrene and abscess are rare accidents, even when no 
treatment at all is had. This peculiar arrangement of the 
nutrient artery gives us an early knowledge, in many cases, of 
commencing phthisis. Occupation of the air-sacs by tubercle 
ii terferes with the circulation, and blood is thrown back upon 
tli3 bronchial artery, and the result is bronchorrhagia, a con- 
servative act; for, like the application of leeches, it sets the 
absorbents actively at work to remove the cause—the new tu- 8 
bercle. And, in this way, cases of early phthisis are self-cured, 
or, at all events, ameliorated, and the physician is guided in 
his treatment. 
This singular fact in the circulation was discovered by the 
late Dr. Cammann, in making his experiments to prove the 
non-anastomosis of the arteries of the lung. Using a colored 
fluid suitable for fine injections, he found that, when he in- 
jected the pulmonary artery, the fluid returned easily by the 
pulmonary vein; but, injecting the pulmonary vein, the fluid 
not only passed into the pulmonary artery, but, if the injection 
was carefully continued, it would also find its way into the 
bronchial arteries. Then, again injecting the bronchial ar- 
teries, he found that the fluid after a little time passed into 
the pulmonary vein; this proved that there was communica- 
tion between the bronchial arteries and the pulmonary vein, 
but not with the pulmonary artery. This was shortly after 
1840, and before, I believe, any experiments had been made in 
Europe, in regard to this circulation. Since then, several 
observers have come to nearly the same conclusion. Drs. 
"Williams and Adriani believe “ the vessels of the bronchial 
mucous membrane terminate in the pulmonary veins, and 
those of the deeper plexus in the bronchial veins.” Dr. 
Waters says, after explaining his experiments, which were 
very full and minute: “ That a distinct and free communica- 
tion exists between the bronchial vessels and the pulmonary 
veins, admits of ocular proof. I have seen, with the aid of 
the dissecting microscope, the small vessels passing from the 
outer surface of the bronchial tubes, and forming a small 
trunk, which terminated in a pulmonary vein.” Dr. Waters 
also says: “It may be said that such a view militates against 
the generally-received opinion of the purity of the blood re- 
turned to the left side of the heart, for, if the bronchial blood 
is poured into the pulmonary veins, it is returned to the left 
auricle without undergoing the process of aeration. I would 
answer that the view I have taken is supported by anatomical 
facts, a basis on which all physiological theories should l»e 
founded.” I remember that Dr. Cammann, also, could rot 
reconcile the incongruity of the apparent fact that venous 
blood passed directly into the aerated blood of the pulmorary 
vein, and then to the left heart. Both of these gentlemen 9 
overlooked the truth that the blood from the nutrient artery 
passes through capillaries in the true respiratory system on its 
way to the radicles of the pulmonary vein, and, of course, is 
reaerated. Dr. Robert Lee, if my memory serves me (for I 
have not the paper at hand), says that the extension of the 
bronchial artery, after it has quit company with the vein, re- 
ceives additions from the mammary and intercostal arteries, 
and has the proper title of nutrient artery. I do not quote his 
wmrds, but the substance as I remember it. 
I believe, then, I am warranted in holding that there is a 
complete difference in the blood-vessels of the convective and 
of the pulmonary systems. The nutrient arteries of the bron- 
chial system have their venae comites; the nutrient arteries of 
the true respiratory system have no accompanying veins, but 
pass their blood reaerated directly into the pulmonary vein, 
prepared for systemic circulation. The nutrient artery is no 
exception to the rule of complete difference in the two sys- 
tems, for in its office it belongs wholly to the true respiratory. 
The vessels of the bronchial system are the bronchial arteries 
and veins; the vessels of the true respiratory are the pulmo- 
nary artery and vein, and the nutrient artery of the lungs. 
Where the bronchial system ends the pulmonary begins, 
and the division is sufficiently marked—it is where cartilage 
ceases and alveoli commence. The structure of the true re- 
spiratory system is composed of terminal bronchii, in which are 
developed alveoli and the air-sacs, that is, wherever alveoli are 
found. Its whole object or office is aeration of the blood of 
the body. It is greatly distensible, and in this differs from 
the convective system, which is but little so, and its formation 
evidences design in the economy of space and for its especial 
purpose. The bronchioles have alveoli developed in their 
sides, but not to the same extent as in the air-sacs, which are 
but a skeleton net-work for the convenient spreading out of 
alveoli, with their rete mirabile of capillaries, for the aeration 
of the blood. The terminal bronchus enlarges at its end, and 
the air-sacs are developed from this enlargement, according to 
Dr. Waters, as a cluster of leaves are, sometimes from the end 
of a twig. From six to thirteen of these air-sacs are in con- 
nection with the enlarged end of a terminal bronchus, and 
this little cluster forms a lobulette—a complete type of the . 10 
whole lung. Each lobulette has its terminal bronchus and air- 
sacs for the development of alveoli, its twig of pulmonary 
artery and vein, its branch of nutrient artery, with the accom- 
panying ganglise of organic nerve, lacteals, absorbents, etc. 
A collection of lobulettes form a lobule, and a number of 
these constitute a lobe. The fibrous bands of the bronchial 
sheath are continued, though with great tenuity, through the 
terminal bronchi into the air-sacs, both of the white and 
yellow variety. They surround the mouth of each air-sac, 
and give firmness to the frame of each alveolus. Muscular 
fibres also accompany these bands, though their presence is 
doubted on account of their extreme tenuity. Niemeyer 
speaks of muscular fibres as present in the true respiratory 
system. In emphysema, the air-sacs lose their power of con- 
traction, and become dilated, causing great suffering and dis- 
ability to the patient. Time and freedom from catarrh allow 
the function of contraction, which is a muscular habit, to re- 
turn. 
Physiologists describe residual air as filling the respira- 
tory system as high up a3 the third or fourth divisions of the 
broncliise. It not only fills the true respiratory system, but 
distends it. The elements of the distending force are : atmos- 
pheric pressure, muscular contraction, rarefaction, and the 
laws of diffusion of gases, and that of affinitive attraction 
between oxygen and venous blood. The residual air occupies 
its position with such persistence as to be with difficulty dis- 
lodged after death, even with much pressure. It keeps its 
place with vastly greater tenacity, during life, when each ele- 
ment of force is in active operation. 
During inspiration, the contraction of the diaphragm in- 
creases the capacity of the chest, and at the same time the epi- 
glottis is raised, and the weight of the atmosphere operates 
actively in dilating the lungs. Rarefaction of the newly-in- 
spired air takes place upon inspiration, owing to its imme- 
diate and intimate admixture with the residual air, and is the 
third element of dilating force. The residual air is estimated 
to be 170 cubic inches, and the inspired air at 20. At each 
inspiration, therefore, the residual air will be increased about 
one-tenth part in dilating power, plus the rarefaction of the 11 
inspired air. But the peculiar elements of this expanding torce 
are, the laws of the diffusion of gases, and that of the affini- 
tive attraction between the unaerated blood-globules, in the 
capillaries of the rete mirabile of the alveoli, and the oxygen, 
which is equally distributed throughout the residual air. 
Chemistry demonstrates that gases differently constituted in 
certain relations instantly intermix when brought together. 
The inspired air and the residual air present these differences. 
Air entering the convective system moves in a body through 
the bronchial tubes, till it meets the residual air, when, the 
law of the diffusion of gases operating, immediate admixture 
takes place. The residual air is instantly renewed with oxy- 
gen, in accordance with this law. The inspired atmospheric 
air moves through the convective system, as far as the fourth 
division of the hronchiae, with no other resistance than the 
friction of the tubes. When it meets the residual air, it is im- 
mediately consumed, as it were, and does not accumulate, 
causing resistance. On this account the inspired air moves 
with increasing velocity, producing air- and tube-friction mur- 
mur. Tidal air in health is only heard in inspiration. Telo- 
city of the moving air in the tube is the cause of murmur. 
Any one may demonstrate this fact by breathing through a 
tube gently, when there will be no murmur, hut, if he increase 
the velocity of the moving air, he will get sound, which will 
be increased in sonority and raised in pitch just in accordance 
with the rate of motion. In health, in unconscious breathing, 
expiration is not heard, and we know by experience that, 
when it is heard in unconscious breathing, there is disease; it 
may he phthisis, or it may he emphysema—other conditions 
must determine which. A murmur may be produced at will, 
by hurrying the respiration. It is heard in systemic diseases 
like cholera, or in diseases of particular organs, as in cardiac 
apncea, or Bright’s small kidney. The cause of murmur, in 
air moving in a tube, no matter what are the other conditions, 
or the disease, is the velocity, increasing the air- and tube-fric- 
tion. 
Prof. John W. Draper lias given a convincing explana- 
tion, based on accurate experimentation of affinitive attrac- 
tion in the systemic capillaries', as one of the efficient causes 12 
of the circulation. The same power operates in the pulmonic 
circulation, but with this important addition, that the attrac- 
tion is not alone in the pulmonic tissues and the blood, but 
principally in the venous blood and the oxygen of the re- 
sidual air. This is the cause that brings the venous blood 
and oxygen together, in order that the blood may be purified 
and fitted to continue the life of the body. Let us endeavor 
to comprehend the intricate mechanism of the respiratory act. 
Inspiration has taken place—twenty cubic inches have been 
added to the residual air, evenly and equally admixed—dila- 
tation has taken place with force, and is continued and in- 
creased by the rarefaction of heat. The true respiratory sys- 
tem, by its muscular power, contracts forcibly, antagonizing 
the dilating residual air. Each particle of pure air, acknowl- 
edging its attraction for the venous blood, presses up to the 
alveolus, through the struggling mass, and rushes to the blood- 
globule in the capillary—makes the interchange—gives up its 
oxygen, and receives in return detritus and carbon materials, 
loses its attraction, becomes passive, but is crowded back by 
other eager particles pressing forward, until finally it finds 
itself well up in the bronchus, with its filthy load, whence it 
is expired. The blood-globule from the pulmonary artery, 
entering the capillary of the alveolus, hurries along through 
the rete mirabile, drawn by its affinity for oxygen, till it meets 
a particle of pure air, makes the interchange, loses its ac- 
tivity, but is pushed onward by other globules pressing for- 
ward from behind, till it finds itself in the venous radicle of 
the pulmonary vein, fitted for systemic circulation. The 
movement of the blood-globules is much assisted by the con- 
traction and relaxation of the muscular fibres of the true re- 
spiratory system. Different bundles of these fibres, contracting 
and relaxing in succession, give not only a living vibratory 
motion, which assists in hurrying the globules along, but pro- 
duce a susurrus, which, being heard at the chest-wall in mul- 
titudinous concert, is true respiratory murmur. These facts 
in minute anatomy and physiology (and they hardly admit of 
any dispute) prove that the residual air, as a body, has no 
more motion than has the bottom of the deep sea. No change 
can occur except molecular, and none other is necessary. The 13 
law of diffusion of gases assures the comparative purity of 
the residual air, as well as its constant and guarded impurity, 
which is so necessary for the accomplishment of the vital act. 
The circulation would not go on, if each blood-globule should 
immediately come in contact with pure air, for then it would 
lose its impelling force, and, all of the globules alike losing 
their attraction, there would be stasis. Instead of this, both in 
the blood and the residual air each globule and each air-par- 
ticle moves in perfect order, never in each other’s way. This 
shows how the individual may live in bad air for a time, resist- 
ing its evil tendencies, and even that of poisonous gases. It 
shows also why medical inhalations fail in their object. Medi- 
cated vapors have little or no admission into the residual air. 
Even oxygen gas, which is sometimes serviceable, can only 
supply atmospheric deficiencies. It can neither do the harm 
nor the good that has been predicated for it. An animal may 
even live for a time in pure oxygen gas, the active interchange 
taking place between the gas and the blood restoring the 
necessary grade of impurity in the residual air. 
If, then, the only change or motion that is possible in the re- 
sidual air be molecular, what becomes of the theories of air- and 
tube-friction murmurs, whether in the smaller bronchise or the 
air-sacs and alveoli, as cause of the so-called vesicular murmur ? 
They are physical impossibilities. And, too, what becomes of 
the theories of the mechanism of crepitant rale f If there 
is no motion but the molecular, there can be no bursting of 
bubbles in the microscopic tubes, and that theory falls. If the 
residual air constantly and forcibly distends the true respira- 
tory system, how can the bronchioles and air-sacs come to- 
gether, to be separated by each inspiration of fresh air, so as 
to produce fine crepitant rale ? This theory, likewise, sup- 
poses a physical impossibility. All theories, whether of ve- 
sicular murmur or crepitant rale, which ignore the presence of 
the residual air, are of necessity incompetent. The fact that 
residual air has none but molecular motion may be demon- 
strated by a distensible bag, as of India-rubber. While it is 
being forcibly filled with air, there will be air- and tube-fric- 
tion murmur at the mouth only, where the air moves in a 
body with velocity. The body of air in the bag will be in- 14 
creased by particles of air sliding in among each other and 
without sound. But there will be resisting vibratory sound 
in the walls of the tense dilating bag; different, however, from 
that of the contracting true respiratory murmur in this, that 
it is only heard during dilatation, while the other is continu- 
ous, because owing to active muscular contraction. Dr. Hyde 
Salter Bays, after speaking of the occupancy of the true re- 
spiratory system by residual air, and that about twenty cubic 
inches of atmospheric air are added at each inspiration : 
“ Each air-cell is, therefore, a tenth larger at inspiration than 
at expiration. How, it is inconceivable that this slight varia- 
tion in the capacity of these shallow open concavities should 
be attended with any sound. I cannot conceive it possible. 
For, be it remembered that the air-cells are not nearly-closed 
cavities communicating by constricted orifices with the general 
cavity of the lobular passage, but wide-mouthed and patu- 
lous like a teacup. And be it remembered, too, that in res- 
piration the air is not pumped out of and into the cells, but, 
as they undergo this slight change of volume, a small part of 
their contents passes just without them, and then again, on 
their recovering their capacity, from without just within 
them, if one can speak of £ within ’ and ‘ without,’ in ref- 
erence to such slight interchange of situation. For, really, 
the renovation of the air in the tissues of the lung does not 
depend on its actual removal, but upon the law of the diffu- 
sion of gases.” 
This reasoning is cogent and unanswerable. It proves 
beyond cavil that there is no motion in the air-sacs and alveoli 
to produce air- and tube-friction sound, and yet he attempts to 
show that there is such motion in the smaller bronchise and 
intralobular passages. lie says: “ But while the movement 
of the air at each alveolus would be so slight, so almost inap- 
preciable, the collective expansion of all the alveoli common 
to a lobular passage, and the consequent abstraction of air 
from the general cavity, would be considerable, and would 
create a considerable rush of air into the lobular passage to 
supply its place, for the modicum of air, however small, appro- 
priated by each dilating air-cell, would of course be multiplied 
by the number of cells communicating with the common axial 
cavity of the lobular passage.” 15 
Dr. Salter’s able reasoning shows that there is not enough 
motion in the alveoli or air-sacs to cause sound, and the same 
reasoning applies with equal force to the air in the bronchioles 
and intralobular passages. The residual air occupies these 
passages just as well as it does the air-sacs; one-tenth is added 
at each inspiration to the whole body of residual air, and Dr. 
Salter himself has said that these small bronchial tubes were 
largely distensible, consequently the velocity of motion in 
these passages where alveoli are developed must be too little, 
if there be any at all, to produce any sound. There certainly 
can be no rush; indeed, I have already shown that there can 
be no motion, except the molecular. But, for argument’s sake, 
if there should be motion in these minute tubes, as Dr. Salter 
claims, it could not possibly have the velocity necessary to 
cause sound. Dr. Salter’s argument to prove that the seat 
of crepitant rale and the seat of respiratory murmur are the 
same—“ The rale supplants the true respiratory murmur, the 
two do not coexist ”—heretofore quoted, is convincing. Had 
he placed the seat in the air-sacs and alveoli as well as in the 
terminal bronchioles, he would have been correct, for then he 
must have acknowledged that it could not be by tube- and air- 
friction, and he would have been forced to accept the true ex- 
planation, that of dilatation and contraction. Crepitant r&le 
indicates the commencement of the process of inflammation, 
and it supplants the true respiratory murmur. Let us study 
the evidence in the light of the true respiratory murmur. 
If you have lately examined the chest of a person in 
health, and have noted the murmur in its fulness and perfec- 
tion, and should be called to see him suffering from a chill, 
with pain in the head, back, limbs, etc., and should again 
examine the respiration carefully, you will still hear the true 
respiratory murmur, but it will he obscured or muffled. All 
the capillaries of the lung are crowded with blood, and this is 
the explanation of the muffled murmur. If you wait a few 
hours, and again examine him, you find the true respiratory 
murmur absent, and, in place of it, the fine crepitant rale. 
The congestion of the capillaries of the lung still remains; 
there is scarcely a perceptible difference in the percussion- 
note ; the residual air still occupies its seat in the true respir- 16 
atory system, and it still continues to dilate' the air-sacs, al- 
veoli, and terminal tubes. Whatever change has taken place, 
must have been at the seat of the true respiratory murmur. 
In tissues that may be seen, what is the first result of in- 
flammation? Is it not that plastic material is thrown out 
into the connective tissue ? This, also, must take place in the 
lungs. The connective tissue of the lungs, delicate as it is, 
has been filled with plastic material. It has become thickened 
and stiffened, it cannot contract, and the true respiratory 
murmur is gone, but it must yield, though unwillingly, to 
the dilating force of the residual air, increased one-tenth at 
each inspiration, separating newly-formed plastic exudations, 
causing sound, which we hear as fine crackling, and call it 
crepitant rale. If we wait a few hours more, and examine 
again, we will find that crepitant rale as "well as true respira- 
tory murmur has gone, and all is silent, or there may be 
bronchial or tubular breathing. Exudation has been poured 
into the true respiratory system, and consolidation is the re- 
sult. The seat of crepitant rale is now become the seat of 
exudation. 
If I have studied this matter as correctly as I have carefully, 
this is the process gone through with, and is the true mechan- 
ism of crepitant rale. In this paper I have endeavored to show 
that the bronchial respiratory system is entirely different from 
the true respiratory system in anatomy, physiology, object, 
and use, and that the physical signs of pathological change 
are equally distinct and different. That the residual air, oc- 
cupying, as it does, the true respiratory system with force, 
precludes the idea of currents of air within the lungs, and con- 
sequently the accepted theories of the vesicular or respiratory 
murmurs and of the formation of crepitant rale are necessarily 
incompetent. If my points are well taken, and the proof con- 
vincing, the profession will eventually sustain the truth, and 
much that has been received as settled literature will be swept 
away as rubbish, to give room for truer and better grounds of 
faith. 
The composite character of the respiratory murmur must 
be made evident, analytically as well as synthetically. The 
two elements, different in cause, character, and seat, must be individually studied in order that we may correctly understand 
their significance in pathological changes. We may present 
their union and the result to the eve, thus: 
Br on ch o • resp iratory 
murmur. 
Respiratory murmur. 
True respiratory 
murmur. 
The reasons for introducing a new terminology are, that 
broncho-respiratory and true respiratory are descriptive, and 
indicate the seat of the murmurs. The term vesicular mur- 
mur was applied by Andral, supposing that it described the 
minute anatomy of the seat of the murmur. 
Later investigations show that the term is misapplied, for 
there are no structures that may properly be called vesicles in 
the lungs. Again, the terms vesicular and respiratory have 
been applied indiscriminately, and their present use would 
lead to confusion and misapprehension. 
In order to practically study these murmurs, it will best be 
done by selecting a healthy person about twenty-five years of 
age, with perfectly-developed chest and with muscles not hard- 
ened by manual labor. 
Placing the ear lightly yet firmly to the chest, allowing 
the head to rise and fall with the respiration, listen to the 
breath-sounds. The tidal-air murmur will first catch the ear 
as modified by the true respiratory murmur, and, as has been 
described, is like the sighing of the trees over our heads in the 
forest, when the boughs are gently stirred by the breeze. The 
character and quality of the respiratory murmur depend upon 
the absence or excess of one or the other of the composing ele- 
ments. If the true respiratory murmur be maximum in ful- 
ness, the tidal-air sound will be short, only heard in inspira- 
tion, and will be of the soft, breezy character described as gen- 
tly sighing. 
While, if the broncho-respiratory be in excess, the tidal-air 
sound will be harsh, raised in pitch, and will be heard both in 
inspiration and expiration, and becomes a sign of disease as 
the other is of health. 
2 
RES PIRATORY MURMURS. 18 
BRONCHO-RESPIRATORY MURMUR. 
Broncho-respiratory murmur may be studied by forcing the 
breathing, when it will be heard in both inspiration and expi- 
ration, and its harshness, loudness, and pitch, will depend upon 
the force given to the respiration. This murmur may be heard 
in its perfection, in the chest of a child, before the true re- 
spiratory murmur has been developed. 
TUUE RESPIRATORY MURMUR. 
The ear accustomed to auscultation, after a few moments 
of concentration of the attention upon the respiratory murmur, 
will recognize its dual composition. If the chest be perfect 
in condition, the tidal-air sound will be heard in inspiration 
only—Soft and short, like breathing gently through the closed 
teeth—while the true respiratory murmur will be continuous, 
increasing in fulness in inspiration and diminishing in expira- 
tion. It is of low pitch, and is like the roaring of the sea at a 
distance, the waves breaking on an even shore of sand ; or, 
better still, like the sound made by bees in cold w7eather, when 
the hive is tapped with the finger. It is like the innumerable 
vibrations of the w'ings of bees, increasing to maximum in 
inspiration like the coming waves on the sea-shore, and de- 
creasing in expiration as they recede. If the breath be held, 
this murmur may be heard without admixture, for there can 
then be no bronchial murmur. The sound is the susurrus of 
the delicate muscular fibres of the true respiratory system, con- 
tracting and relaxing over the dilating and resisting residual 
air. If the breath be held after a full inspiration, the murmur 
will beat its maximum; if it be held after expiration, it will be 
at its minimum fulness. It cannot be exaggerated, as has been 
said of the so-called vesicular murmur. If the true respiratory 
system be unduly dilated, it loses its power to contract on the 
residual air, and the murmur wholly ceases. This is a sign of 
emphysema, and is proof of the muscular cause or origin of the 
sound which may return again after rest. 
This murmur only commences to be developed in the child 
at eight years of age, becomes recognizable at twelve, but is 
only fully developed at maturity. A beginner in auscultation 
may recognize true respiratory murmur in a good subject with 19 
ease. But, when the chest has lost its excellent quality as an 
acoustic chamber by physical changes, resulting from inflam- 
mation, or when, from disease of the lung itself, the natural 
respiratory murmur has been altered or lost, or when the chest, 
although in its natural conditions, may be covered by thick 
and hardened muscles, the trained expert ear only can arrive 
at diagnostic truth. 
Many love and enjoy music, and may assist in producing 
it, but the trained expert alone can lead an orchestra, and har- 
monize each instrument into a body of perfect song. 
These facts, instead of being a matter of discouragement, 
should induce beginners to pursue auscultation with untiring 
assiduity, knowing that the end will crown them as masters in 
physical diagnosis. The ability to recognize true respiratory 
murmur under any conditions, to analyze its quality, and 
measure its power, gives its possessor the means of knowing 
even the approach of that most insidious disease, phthisis, and 
suggests the method of prevention. The true respiratory sys- 
tem, air-sacs, alveoli, nutrient artery, ganglia of the organic 
nervous system, with absorbents, etc., all require active use 
for the prevention of disease. Phthisis does not begin in the 
lower part of the lungs, which are constantly and actively in 
motion. If we insure the same kind of exercise in the upper 
part, we prevent and may even arrest incipient disease. 
For more than ten years respiratory murmurs have occu- 
pied my diligent attention. The views put forth in this paper 
were not hastily formed. Some of them are new, and may re- 
ceive the harsh judgment innovations ever provoke. I do not 
deprecate criticism, and I am not insensible to the opinions of 
my professional brethren. I earnestly desire their approval. 
Many, on whose judgment I rely, believe in true respiratory 
murmur as well as myself. But, wishing, above all things, for 
the establishment of truth, I submit the whole subject to this 
learned Academy, and through it to the profession. Medical Works pished by D. Appleton & Co 
Anstie on Neuralgia. 1 vol., 12mo. Cloth, $2.50. 
Barker on Sea-Sickness. 1 vol., 16mo. Cloth, 75 cents. 
Barnes’s Obstetric Operations. 1 vol., 8vo. Cloth, $4.50. 
Bellevue and Cliarity Hospital Reports. 1 vol., 8vo. Cloth, $4. 
Rennet's Winter and Spring on the Mediterranean. 1 
vol., 12mo. Cloth, $3.50. 
Bennet on the Treatment of Pulmonary Consumption. 
1 vol., 8vo. $1.50. 
Billroth’s General Surgical Pathology and Therapeu- 
tics. 1 vol., 8vo. Cloth, $5.00. 
Combe on the Management of Infancy. 1 vol., 12mo. Cl., $1.50. 
Davis’s (Henry G.) Conservative Surgery. Cloth, $3.00. 
Elliot’s Obstetric Clinic. 1 vol., 8vo. Cloth, $4.50. 
Flint’s Physiology. (Vols. IV. and V. in press.) 8vo. Cloth, per vol., $4.60. 
Flint’s Manual on Trine. 1 vol., 12mo. Cloth, $1.00. 
Flint’s Relations of Urea to Exercise. 1 vol., 8vo. Cloth, $2. 
Hammond’s Diseases of the Nervous System. 1 vol., 8vo. 
Cloth, $5.00. 
Hammond’s Physics and Physiology of Spiritualism. 
1 vol., 12mo. Cloth, $1.00. 
Holland’s (Sir Henry) Recollections of Past Fife. 1vol., 
12mo. Cloth, $2.00. 
Howe on Emergencies. 1 vol., 8vo. Cloth, $3.00. 
Huxley on the Anatomy of Vertebrated Animals. 1 vol. 
Cloth, $2.50. 
Huxley Sc Youmans’s Physiology and Hygiene. 1 vol., 
12mo. Cloth, $1.75. 
Johnston’s Chemistry of Common Fife. 2 vols., 12mo. Cloth, $3. 
Fetterman’s Recollections of the Army of the Potomac. 
1 vol., 8vo. Cloth, $1.00. 
Lewes’s Physiology of Common Fife. 2 vols., 12mo. Cloth, $3. 
Markoe on Diseases of the Bones. 1 vol., 8vo. Cloth, $4.50. 
Mandsley on the Mind. 1 vol., 8vo. Cloth, $3.50. 
Mamlsley’s Body and Mind. 1 vol., 12mo. Cloth, $1.00. 
Meyer’s Electricity. 1 vol., 8vo. Cloth, $4.50. 
Nicmeyer’s Practical Medicine. 2vols.,8vo. Cloth, $9 ; sheep, $11. 
Neftel on Galvano-Therapeutics. 1 vol., 12mo. Cloth, $1.50. 
Nightingale’s Notes on Nursing. 1 vol., 12mo. Cloth, 75 cents. 
Neumann on Skin Diseases. 1 vol., 8vo. Cloth, $4.00. 
Pereira’s Materia Medica and Therapeutics. 1 vol., 8vo. 
Cloth, $7.00; Sheep, $8.00. 
Sayre’s Club-loot. 1 vol., 12mo. Cloth, $1.00. 
Stroud’s Physical Cause of the Death of Christ. 1 vol., 
12mo. $2.00. 
Swett on Diseases of the Chest. 1 vol., 8vo. Cloth, $3.50. 
Simpson’s (Sir Jas. Y.) Complete Works. Vol. I. Obstetrics 
and Gvnmcology. 8vo. Cloth, $3.00. Vol. II. Anaesthesia, Hospitalism, 
etc. 8vo. Cloth, $3.00. Vol. III. The Diseases of Women. (In press.) 
Tilt’s Uterine Therapeutics. 1 vol., 8vo. Cloth, $3.50. 
Van Buren on Diseases of the Rectum. 1 vol., 12mo. $1.60. 
Vogel’s Diseases of Children. 1 vol., 8vo. Cloth, $4.50. 
Barker on Puerperal Diseases. (In press.) 
Peaslee on Ovarian Tumors. (In press.) 
Van Buren on Surgical Diseases of the Male tjonito- 
Urinary Organs. (In press.) 
Schroeder on Obstetrics. (In press.) 
Frey’s Histology and Histo-Cheiuistry of Man. (In press.) 
Weils on Diseases of the Ovaries. (In press.) 
*** Any of these works will he mailed, post free, to. any part of the United States, on re- 
ceipt of the price. Catalogues forwarded on application. 
D. APPLETON & 00., 549 & 551 Broadway, N. Y. rr u jk 
NEW YORK MEDICAL JOURNAL. 
EDITOR 8, 
JAS. B. HUNTER, M. I)., WILLIAM T. LUSK, M. D. 
A Journal of Rare Excellence, containing Contributions from Leading Members of the 
Profession. 
Terms, $4 per annum. Specimen numbers sent by mail on receipt of 25c. 
“One of the best Medical Journals, by-the-bv, published on the American Conti- 
nent.”—London Medical Times and Gazette, Feb. 29, 1868. 
“ A very high-class journal.”—London Medical Mirror, March 1, 1869. 
“ The editor and the contributors rank among our most distinguished medical men, 
and each number contains matter that does honor to American medical literature.”— 
Boston Journal of Chemistry. 
THE JOURNAL OF 
Psychological Medicine: 
A QUARTERLY REVIEW OF 
Diseases of the Nervous System, Medical Jurisprudence, 
and Anthropology. 
EDITED BY 
WILLIAM A. HAMMOND, M. D., 
Professor of Diseases of the Nervous System and of Clinical Medicine in the Bellevue Hospital 
Medical College ; Physician-in-Chief to the New York State Hospital for 
Diseases of the Nervous System, etc., etc. 
EVERY PHYSICIAN AND LAWYER SHOULD READ IT. 
Terms, $5.00 per annum. Specimen numbers, by mail, $1.00. 
“ To the physician interested in the higher manifestations of the wonderful organic 
functions of human life, as well as in practical teachings of pathology and therapeutics, 
and the bearing of the law upon facts that may be subject to medico-legal inquiry, this 
journal of Dr. Hammond is of special value. Rut it is scarcely less interesting to live 
men of other professions, as is evident from a survey of its contents.”—Franklin Re- 
pository. 
“ In it likewise will be found a department set aside for medical jurisprudence, which 
will be found interesting to those learned in the law. We have yet much to learn in 
this country of that branch of knowledge with which the barristers of the Old World 
have been long familiar. Many of the articles, however, will attract the attention of non- 
professional readers.”—Philadelphia Age. 
“A Quarterly that does honor to the professions to whom it is chiefly addressed.”— 
New York World. 
“ It is open to new truth, new demonstration, new theory. It is unimpassioned and 
unprejudiced as science itself.”—New York Times. 
CLUB RATES. 
New York Medical Journal and Psychological Journal $8 00 
New York Medical Journal and Appletons’ Weekly Journal 7 00 
Psychological Journal and Appletons’ Weekly Journal 8 00 
Psychological* N. Y. Medical, and Appletons’ Weekly Journal 10 00 
Psychological, N. Y. Medical, Appletons’ Weekly, and Popular Science Monthly, 15 00 
Commutation given with any medical Journal now published. 
Subscriptions should be addressed by registered letter or money order, to the Pub- 
1 i a Vi puq 
D. APPLETON & CO., 
649 & 551 Broadway, New York.