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AUSCULTATION AND PERCUSSION. 
 
AUSCULTATION
PERCUSSION,
               (
BY  <i }
DR. JOSEPH  SKODA.
TRANSLATED FROM THE FOURTH EDITION,
W. 0.  MARKHAM, M.D.,
  ASSISTANT PHYSICIAN TO ST. MART'S HOSPITAL.
/f /€> -S- v:f;
       PHILADELPHIA:
LINDSAY AND BLAKISTON.
           1854. 

Fr-n ^STM, i).5 
PREFACE
TO THE FOURTH EDITION.
  This edition is essentially the same as the third.
A few unimportant observations have been added
to  the  chapter on Percussion, and  an  alteration
has been  made  in  the division of the thoracic
voice,  loud  bronchophony  having been  divided
into clear and dull.
  I have examined most of the new theories which
have been propounded since 1844, respecting the
causes  of  the  impulse, the sounds,  and the mur-
murs of the heart, but the present edition of this
work was printed before I received Professor von
Kiwisch's " New Researches into the Causes of the
Sounds produced in  the circulating Organs;"  I
must, therefore, here  make a few remarks on the
views therein contained.
  Professor von Kiwisch found, that if water was
forced through a caoutchouc tube, murmurs were
not produced, unless the tube was of unequal bore
at different parts.  The murmur invariably oc-
curred at the wider part, immediately beyond the
narrow, and never at  the narrow part itself;  and
it  disappeared, whenever an obstruction was of-
fered to  the passage of the  water through  the
wider  part.   Considerable  prominences  on  the
inner  surface of the tube gave rise to a murmur, 
iv
PREFACE.
but a merely  roughened surface was  never ob-
served to do so.
  These facts are explained by Professor von Ki-
wisch in the following manner: Water flowing out
from a pipe, preserves to a certain distance the
form of the pipe's outlet; in this way the  stream,
flowing from the narrow into the wider part of the
tube, retains to a certain distance the form of the
narrow part, provided it  has met with no particu-
lar obstruction.  Now, in consequence of the pres-
sure of the air, the walls of the  wider part of the
tube have a tendency to  adapt themselves to the
narrow stream of water, but their elasticity offers
a continual resistance to the pressure of the air,
and accordingly an expansion of the stream takes
place.  Under these  conditions, the  tube,  alter-
nately compressed  by the  atmosphere, and ex-
panded by its own  elasticity, is made to vibrate,
and by its vibrations a murmur is produced.
  From these experiments  and their  interpreta-
tion, as well as from known related physiological
and  pathological phenomena  observable in the
living body, the following conclusions  may, ac-
cording to Professor von Kiwisch, be drawn  re-
specting the formation of sounds in the circulating
organs of man:
   " The first sound of the heart is produced by the
expansion of the auriculo-ventricular valves; the
second sound, by the expansion of  the semilunar
valves.   No  second sound arises  in  the  heart
itself,  and no first sound  in  the  arteries.  The
sound which is  occasionally heard  accompanying
the pulse in the carotid and femoral arteries, does 
PREFACE.
V
not proceed from these vessels, but is caused by
the vibrations  excited in the  air of the stetho-
scope, and of the ear, by the beat of the arteries.
  " Murmurs arising in consequence of  defect of
the valves of the heart, are produced in part by
the vibrations of the rigid valves, but more par-
ticularly after the manner described in the experi-
ments with caoutchouc tubes.   Thus, through de-
fective closure  of the valves, several narrow open-
ings are  formed, and through these a stream of
blood is forced, with a diminished diameter, into a
wide cavity: the more forcible the stream, and the
less perfectly the cavity be filled—i. e. the less the
opposition to the entrance of the blood—the more
powerful and the more extensive will be the vi-
brations excited in that cavity.
   "Murmurs are produced in  arteries  after the
manner  described in the  caoutchouc tubes,  and
never in consequence of the presence of any rough-
nesses on their inner  surface.   Pressure upon an
artery causes a murmur just beyond the  spot com-
pressed, never at that spot; and the murmur  is
more prolonged,  in  proportion as the  muscular
fibre of  the individual examined is lax, and his
blood poor.  The so-called Nun's murmur—bruit
de diable—is invariably formed in the carotid ar-
tery, and not in the cervical veins; it is caused, in
fact, by the  compression of the  carotid by the omo-
hyoideus muscle.   Muscular, or any other kind  of
pressure, will in  like manner produce this murmur
in other arteries, of persons whose  blood is impo-
verished; but it  never arises in veins."
                       1* 
vi
PREFACE.
  It is possible that this explanation of the mode
of the production of murmurs in caoutchouc tubes
may be correct;  still, I do not consider it applica-
ble to the murmurs heard in the heart and arteries.
  If the diameter of an artery be diminished by
external  pressure, the artery does not on  that ac-
count lose  its contractility; and that portion of
the artery  which lies beyond the spot compressed
will scarcely fail to contract, its contraction being
in some degree solicited by the narrowed stream
of blood, now flowing into it in  consequence of
the pressure upon the part above.
  But the in-pressing stream of blood, even though
it were smaller than the arterial tube, cannot make
this emptier: on the  contrary, every artery is in-
variably  widened  by the  pressure  of the  blood
flowing into it; for its diameter is proportioned to
the resistance which is to be overcome, in the dis-
tant parts of the arterial system, in the capillary
vessels, and the  veins, and this resistance will of
necessity be increased by the in-pressure of a  new
quantity  of blood.
  That, when the mitral valves are  defective, the
left auricle does not become emptier at each  sys-
tole, but  is more fully distended, and filled by the
regurgitating  blood; and  that, when the aortic
valves are defective, the blood regurgitating  into
the left ventricle does not tend to contract, but
rather to dilate  that ventricle—are facts so well
known, as not to require any comment.
                                 THE AUTHOR.
  Vienna, March, 1850. 
TRANSLATOR'S  PREFACE.
  The author of the following treatise has long held a
high position as a clinical teacher in Germany.   The no-
velty of the opinions which he professes on many points
connected with auscultation and percussion, has  excited
the attention and evoked the criticisms of late writers on
thoracic diseases, both here and in France; and his name
has in consequence become familiar to the student of me-
dicine in this country.  His doctrines, as well as those of
the modern German school, upon the same subjects, have
been prominently brought before the profession, through
the excellent work of Dr. Davies.
  I  have undertaken this translation of Skoda's work,
from a conviction that a more general diffusion of its con-
tents can scarcely fail to  contribute to the advancement
of the special methods of diagnosis of which he treats.  I
have certainly formed a very high opinion of its merits; I
would almost venture to assert, that it is the most valuable
treatise on auscultation  which has appeared since the time
of Laennec; it contains  a philosophic  investigation of
many of the leading facts connected with  the study of
auscultation and percussion, and is something more than
a mere manual.  The reader feels that he is in the hands
of a deep and an original  thinker, and of a most cautious 
viii          translator's preface.

and a clear-seeing observer—of one, indeed, who has had
vast experience, and who manifests  the rare quality of a
will and a power to subject theory to the results of prac-
tice and experiment.   Skoda will not be found to offer
vague opinions, or to indulge  in flights of fancy; he comes
before us "les pieces a la main;" the grounds on which
his doctrines rest are plainly  exposed, so that there is op-
portunity for those who reject  them  to show, either that
his experiments or his data are faulty, or that  his deduc-
tions are not warranted by his premises; happily, his ex-
periments are generally of such a character as to permit
of being readily repeated  by any one possessed of an or-
dinary degree of skill.
  It is certainly no slight testimony in favour of the value
of Skoda's opinions,  that  they  should, after having  been
overlooked,  or ignored  as theoretical and imaginative,
during the long period which has elapsed since the publi-
cation  of the first edition of  his treatise,  have  quietly
worked  their way, and, as it were, forced themselves upon
the attention of medical observers; in this respect, at least,
his work offers a marked contrast to many modern ephe-
meride.1  I might also add, that those who  are  best ac-
quainted with his labours, appear also to be his warmest
admirers.
  No one, I should  imagine, can have paid  much atten-
tion to the subject of physical examination of diseases of
the thorax, without feeling that a vast deal of difficulty
and obscurity is still attached  to  it (more, indeed, than
our pride willingly permits us to confess,) and that we
1 "Was glanzt, ist fur den Augenblich geboren,
   Das Aechte bleibt der Nachwelt unverloren."
                                       Goethe. 
translator's preface.
IX
have much to learn, and perhaps much to unlearn, before
we can hope for anything like perfection, in our diagnosis
of these diseases.  How often has the  most skilful and
practised observer to do penance for his errors, before facts
revealed by the knife of the anatomist!  Is it not reason-
able to suppose, that our principia  must be somewhere
faulty ?
   Skoda would seem to have felt these doubts and diffi-
culties, and to have therefore entered  into a critical ex-
amination of some of those leading doctrines of ausculta-
tion, which have hitherto, since  Laennec wrote, received
almost universal assent.  Laennec's vast authority would
naturally tend to immortalize even error, when it proceed-
ed from himself.  From certain of the doctrines of this
great man, Skoda dissents; he gives his reason for so doing:
and I can scarcely believe that it is possible for any un-
prejudiced person to peruse the  following pages, without
arriving at the  conviction, that many of Laennec's opi-
nions, and therefore, generally speaking, the opinions  of
the present  day, require modification, and that some  of
them must be rejected altogether; even those who refuse
the theories  offered by Skoda in their place, must admit
 this much.   If our author has done no more  than clear
 away errors  which encumber progress, he has surely done
 much—no superstructure can be secure, whilst its basis
 rests on untruth.
   I do not  intend  to enter here into any examination of
 the particular doctrines which Skoda holds; they must be
 studied in extenso, before they can be fairly appreciated.
 I am  sure that  a  partial consideration of them has led
 more than one of his critics, and consequently those readers
 who gain  their knowledge  of them through such critics,
 into an erroneous  interpretation of  their real meaning.
 If obscurity attaches itself to isolated portions of an au- 
X
TRANSLATORS PREFACE.
 thor's reasonings on any particular subject (and, in some
 rare instances, this fault may perhaps be objected to Skoda,)
 it is evident that the reader should endeavour to seek his
 real meaning in a fair consideration of the whole of the
 argument, and not by  partial views of it.
   In making this remark, I would  particularly refer to
 Skoda's explanation of bronchophony by the theory of
 consonance—a subject in connexion with which his name
 is most generally associated in this country.   I will  here
 give a short  sketch of  this theory, and of the arguments
 by which Skoda supports it: for its  full comprehension,
 I must beg the  reader  to study the author's own account
 of it.

   .... The voice passes into the parenchyma of the lungs
 through the  medium of  the  air in the trachea and  the
 bronchial tubes, and is not propagated along their walls;
 it traverses healthy, as  readily as it does hepatized lung,
 and even somewhat more readily: consequently, broncho-
 phony does not depend upon an increase of the sound-con-
 ducting power of consolidated pulmonary tissue; moreover,
 when the lung is consolidated, the thoracic voice increases
 and diminishes in force,  without any concurrent  change
 taking place in  the condition of the  lung: this variation
 in its strength evidently results from the circumstance of
 the bronchial tubes being at one moment  blocked up by
 mucus, etc., and at another freed therefrom by the cough
 and expectoration, etc.:  if the bronchophony depended
upon conduction of sound, it would be a matter of indif-
ference whether the tubes contained air or fluids.  It must
not be forgotten, that,  according to the ordinary laws of
reflection of sound, the more solid the  parenchyma  the
more difficult does the passage of the sound  from the air
into it become. 
translator's preface.
xi
  That the air in the mouth and nasal cavities consonates
with sounds formed in the larynx, is proved by the fact of
the changes which the voice undergoes  through opening
and closing  the  mouth and nose, whilst the condition of
the larynx remains unaltered; just in the same way does
the air in the trachea and bronchial tubes consonate with
the laryngeal sounds.  Now, air consonates only in a con-
fined space, and the force of the consonance depends upon
the form and size of the space, and upon the nature of the
walls forming it: the more solid the walls, the more com-
pletely will  the sound be reflected, and  the more forcible
the consonance.   The  cause of the loud voice  produced
by  a speaking-trumpet is  well-known.   But the air will
consonate with  certain sounds only; in the trachea and
bronchial tubes, it becomes consonant with the  laryngeal
voice, in so far as their walls  have a like or an analogous
character to the walls of the larynx, of the mouth, and of
the nose.  Within the cartilaginous walls of the trachea
and the bronchial  trunks, the voice consonates  nearly as
forcibly  as in the larynx; but as the bronchial tubes
divide in the lungs, they lose their cartilaginous character,
becoming at last merely  membranous in structure, and
therefore very ill-adapted for consonance; when, therefore,
the consonance is increased in these latter tubes, we may
be sure, either that the membrane forming them has be-
come very dense or cartilaginous, or that the tissue around
them is condensed and deprived of air, whereby the sound-
reflecting power  of the tubes is increased.   Of course the
communication  between the air in the tubes and the  air
in the larynx must be uninterrupted.
  The walls of a confined space frequently vibrate in unison
with sounds excited within it, as  do those of  an organ-
pipe, or of a speaking-trumpet.  The larynx vibrates with
every sound, and its  vibrations are perceptible at a consi- 
Xll
translator's preface.
 derable distance from their point of origin; so, also, must
 the  walls of the bronchial tubes, which  are  distributed
 through the parenchyma of the lungs, vibrate when  the
 voice consonates within them; and the vibrations thus ex-
 cited will extend  to  the surface of the thorax,  passing
 through several inches of thick fleshy parts, or of fluids,
 and  manifest themselves there  as the consonating sounds
 of the bronchial tubes.....

  Such is a general account of Skoda's theory of the cause
 of the bronchophonic voice.  The critical manner in which
 it has been brought before the profession, has certainly
not much  aided in its propagation;  and I suppose, with
the great majority  of physicians amongst us the theory in
 question is looked upon as little more than a piece of Ger-
man mysticism: the reason of this, in my opinion, is, that
the subject has come before them in partibus,  and not as
a whole.   Whatever may be  the ultimate fate  of  this
theory, one  thing  may be fairly predicted to result from
Skoda's enunciation of it, and from a consideration of  the
experiments and reasonings on which  he bases  it,  and
that  is, a recognition of the fact, that Laennec's explana-
tion  of bronchophony, by the increased sound-conducting
power of consolidated  pulmonary  tissue,  is not true,  at
least, in every case.
  It is scarcely possible, moreover, that the  remarkable
results  which  have in  other respects rewarded Skoda's
labours, so  completely opposed as  they  often  are to  the
opinions which men, since the time of Laennec, have held
as undeniable, should fail in other hands to produce fresh
additions to our knowledge; what, for  instance, is more
opposed to our preconceived notions respecting the con-
ducting power of pulmonary tissue, than  the  statement
that  sound  passes more readily, and is heard to a  greater 
translator's preface.
xiii
distance, through healthy than through hepatized tissue ?
What, again, can appear  more contradictory than an as-
sertion of this kind: that a cavity, such  as the  stomach
or the thorax, when its walls are tensely inflated with air,
yields a  dull, non-tympanitic percussion-sound, but that
when its walls are lax, the sound becomes distinctly tym-
panitic ?
   The work is throughout of a suggestive character, and
in such a point of view cannot, I believe,  fail to be of ser-
vice to the thoughtful  student; it certainly is not to be
regarded merely as a hand-book of details: in this respect,
it might perhaps be considered as somewhat defective, for
there are certain subjects in it which have been but lightly
touched upon, and are meager in description.   I might in-
stance the chapter on percussion of the abdominal organs,
and the account of aneurisms.  I once had an idea of at-
tempting to fill up what I believed was wanting, with the
hope of rendering the book  more complete for the hands
of the student; but upon reflection, I have thought it better
that the work should retain its  original form;  its defi-
ciencies  may be readily supplied from  numerous  other
sources, and further additions of the kind referred to, might
perhaps  only detract from the character and peculiar value
of it.
   Neither have  I thought it advisable to omit any of the
controversial portions  of the work; these may here and
there seem over long, perhaps even wearisome, but to have
passed them over would  have hardly been doing justice to
their author.  The general tenour of them is undoubtedly
excellent: Skoda's argument is straightforward and good,
logical, consequent, and  to the point, and he has on more
than one occasion left the battle field strewn with the dis-
jecta membra of many of those authorities whose opinions
he has assailed.
         2 
XIV
translator's preface.
  Skoda has also done excellent service by attempting to
reduce to their real practical value, the results of ausculta-
tion and percussion, affixing to each sign its true signifi-
cation, and by  drawing distinction between those  signs
which have, and those which have not, special indications;
in truth, throughout, this  seems to have been one of the
main objects which  he keeps constantly before him.   He
certainly cannot be accused of drawing pale and  sickly
conclusions from  his observations: whatever is not  clear
and manifest on the  face of it, is at  once classed by him
as indeterminate  and as incapable of  service in the field
of medical observation, and as such  to be rejected from
our catalogue of  signs and  symptoms; that is, in so far
as drawing practical conclusions from them is concerned.
  The crime of endless subdivision, which is often charged
to the account" of the German school, cannot be laid at his
door; rather, I fear, will he be accused of a certain  skep-
ticism, of a barrenness of faith, which has brought him to
give too little  credence to the value of those minutiae of
detail, in which men  now-a-days are wont so frequently
to indulge.  It is really strange to find an observer, an
acknowledged  master of his subject, unrivalled  in powers
of diagnosis, as they who have witnessed his skill tell us
that he  is; it  is  strange, I say, to find such a man on
almost  every  occasion warning  his  readers, when   they
have in any particular case obtained  all the information
which auscultation can afford them, still, before they con-
clude their diagnosis, to  pause, and  to lay hand  upon
every other aid which other sources can supply; as if he
thought and felt that the  observer may  be falling into
error, even  then when he  thinks himself most secure.
Surely the inference from this is manifest, viz.: that men
are wont to force from the physical examination of diseases
of the  thorax, consequences which are not  legitimately
produced by it. 
translator's preface.
XV
   The truth of the inference I most  thoroughly believe,
and if I might venture, out of my own experience, to offer
advice to those commencing  the study of auscultation, I
would strongly warn  them  from putting their confidence
in that kind of teaching which  boasts that auscultation
can demonstrate the  hidden workings of  the thoracic
organs, with something of the same  degree of certainty
as if they were the direct objects of the vision.   I would
rather say,  approach the subject with a caution somewhat
akin to fear and trembling; fix your faith as clearly as you
please on clear, broad, and manifest positions,  whenever
you are certain that you have gained them, but play the
skeptic's part with doubtful signs;  assign them what-
ever legitimate value  may fairly attach  them, but never
let them rule your judgment, for you  will find them only
too apt to do so when the diagnosis is difficult.   I would
not venture to offer such  advice, if  it had been drawn
from the experience of my own errors; but I take for the
grounds of my warning the mistakes of  far  more skilful
observers than myself.   I cannot refrain from noticing the
subject, when I see the unhesitating manner  in  which
conclusions are so  frequently drawn from these indefinite
signs, and  the  practical applications which  men found
upon  them  and teach others to found  upon them.
   If I am  asked to what I refer when speaking of doubt-
ful signs, I answer, every sign  which does not present
itself  clearly and manifestly to the sense, as the acknow-
ledged exponent among  ordinarily skilled observers, of
certain special conditions of the  internal organs.
   The recognition of pathognomonic signs in auscultation
by authors, especially of the French  school, has been, I
believe, one great source of the mischief I refer to. The
classification  of  auscultatory sounds according  to the
stages and processes of diseases which produce them, is 
xvi
translator's preface.
manifestly erroneous, and cannot fail  to leave faulty im-
pressions on the minds of those who put their trust in it;
as an example of what I mean, I would point to the flatu-
lent  nosological vocabularies of writers like  M. Fournet:
this author wishes his readers to believe, that every dis-
eased condition of the lungs has its appropriate sign, and
every part of the lungs its peculiar rale, and he tells with
the most perfect gravity of rales such as these:
   "Rale humide  a bulles continues de la congestion san-
guine.
   "Rale sous-crepitant de l'oedenie pulmonaire.
   "Rale sous-crepitant du catarrhe pulmonaire aigu ca-
pillaire.
   "Rale sous-crepitant ou crepitant de retour de la pneu-
monic
   "Rale crepitant primitif de la pneumonic"
   Now,  all this  is  evidently  a misconception; for,  as
Skoda justly observes, there is assuredly no distinct rale
peculiar to  any of these morbid  states of the  lungs  to
which  Fournet alludes.  That the varieties of rales de-
scribed by him  may have a real existence, Skoda does not
deny;  he says, indeed,  that many more might be added
to them; but  as external manifestations of the special
pathological conditions of the lungs which  they pretend
to indicate,  he  utterly rejects them.

   Perhaps  no  one thing has more tended to impede the
progress of  auscultation,  than  the vagueness  and diver-
sity, I might say the repulsiveness, of the terms employed
by different authors to indicate its phenomena: such is the
confusion thereby introduced into  medical literature, that
I feel convinced that the idea conveyed to the mind of the
reader, is frequently different from that  intended by the
writer   How  can it be otherwise so long as authors use 
               translator's preface.          xvii

the same term in different senses ?  Ask a dozen physi-
cians what they mean by muco-crepitant rale, and I very
much doubt whether any two will give the same account
of it.
  The introduction into our language of a plain practical
nomenclature of auscultation is much required, and would
be a great boon  conferred upon the science.   Skoda's
nomenclature  is eminently plain  and to the purpose,  but
unfortunately  it is in part  based  upon his theory of con-
sonance:  he speaks, for instance, of consonating rales:
so that its adoption can, I fear, hardly be hoped for until
such time, at least, as his theory has met with more  ge-
neral approbation.
   I cannot, however, refrain from calling attention to the
simplicity and  practical value of his method, based as it
is on strictly  philosophical principles.   The respiratory
murmurs and the rales, according to his division of them,
fall into  two distinct categories, viz., rales and murmurs
which are the indicators of certain conditions of the organs
of respiration, and rales and murmurs which indicate no-
thing special;  the  latter he calls indeterminate, and  for
practical  purposes sets them aside,  as being valueless in
a diagnostic point of view.   The rales  he divides as fol-
lows :
   Vesicular rales.
   Consonating rales.
   Dry crepitating rale with large bubbles.
   Rales accompanied by metallic tinkling and  amphoric
echo.
   Indeterminate  rales.
   I  have already mentioned the value  to be attached to
the latter sort, the  indeterminate.
   The vesicular  rale arises in the  finer bronchial tubea
and air-cells, and indicates the presence there of mucus,
                          2* 
xviii          translator's preface.
blood, serum, etc., and the  passage of air  into them, ex-
cluding therefore all  those diseased conditions, by which
the entrance  of air is prevented; but it indicates nothing
more than this.
   Consonating rales occur when that condition of the lung
is  present which gives  rise to bronchial breathing and
bronchophony, and  they have therefore  the same indica-
tions.
   The dry crepitating rale of Laennec, Skoda retains, but
he looks upon it as of little value.   He attributes its cause
to  the distention  of the  walls  of the  air-cells, bronchial
tubes, and cavities  during inspiration, when they  have
lost their natural contractility, and simply collapse during
expiration.
   The nature of the rales accompanied by metallic tink-
ling and amphoric echo  is sufficiently indicated by their
title.
   All these rales have more or less a character of moist-
ness.  The dry sounds heard during respiration, etc., are
placed apart  from them, and are designated by Skoda as
hissings, whistlings, and  snorings; they arise for the most
part as follows: the snorings in the large bronchial tubes,
the whistling in tubes of a lesser diameter, and the hiss-
ings in the finest portions of the air-passages;  they are
produced by the passage of the air through the  tubes when
narrowed, etc.  For their value as diagnostic signs, I refer
the reader to Skoda's account of  them.
   Equally simple and philosophic, is his division of the
murmurs heard during respiration :—
   Vesicular  breathing.
   Bronchial  breathing.
   Amphoric echo and metallic tinkling.
   Indeterminate respiratory murmurs.
   His division of the thoracic voice is founded  on the 
translator's preface.            xix
same principles;  it is carried only so far as it has a prac-
tical bearing.   Laennec's bronchophony and pectoriloquy
are rejected because they represent one and the same phe-
nomenon, and  I  believe justly so.   Is there one man of
experience in fifty who can deny that the sign called pec-
toriloquy has not been at some time or other a stumbling-
block and a source of error to him; that it has not, in fact,
been the cause of his  diagnosing the existence of a pul-
monary cavity, when none existed ?1
   iEgophony is also excluded as being a sign of no espe-
cial value, it is occasionally heard in connexion with the
consonating voice, but  has no necessary relation with the
existence of fluid in the pleura.
   I have dwelt somewhat long  upon this subject; but I
have done so from conviction that an adoption of Skoda's
simple  and philosophic method of dealing with it,  or of
some similar method, would be a great source of relief to
the perplexed mind of the student, and would introduce
something of order  into the endless  confusion of terms,
which hovers like an incubus over the study of ausculta-
tion.   How is it possible that precise ideas of the value
of a particular sign can fix themselves in  the student's
mind, when the sign is represented  to  him by different
authors under such a variety of terms ?  Here, for instance,
  1 Skoda tells us, that percussion and auscultation afford very
few certain signs of the presence of a cavity, viz., amphoric echo
and metallic tinkling, and the cracked-pot sound, and that these
signs are not frequently met with, because the conditions neces-
sary  for their production occur exceptionally, and not  as the
rule; so that in the majority of cases of phthisis, it is by infer-
ence only that we can foretell the presence of a cavity; experi-
ence teaching us, that tubercular masses rarely exist for any
length of time without  producing cavities. 
XX
translator's preface.
 are a few of those by which the "rale crepitant humide"
 of Laennec is known amongst us: moist crepitous rhon-
 chus,  crepitation,  crepitating  rale,  crepitant  rhonchus*
 crepitant rale,  minute  crepitations,  crackling  of  pneu-
 monia, small crepitations, vesicular  rale,  rale  sous-cre-
 pitant du catarrhe pulmonaire  aigu  capillaire.    In the
 present  state of our  nomenclature,  again, how can the
 reader, when  he meets  with expressions like  the follow-
 ing, be sure that he is interpreting them according to the
 writer's  meaning? large  crepitating  rale,  mucous  rale,
 bubbling rale,  sub-crepitant rhonchus, muco-crepitant
 rale, sub-mucous rhonchus, dry mucous rhonchus, cavern-
 ous rhonchus,—for what standard  have we by which to
 measure their true signification?1
   It surely is unnecessary to waste  the time of the reader
by any further illustrations  of the confusion which per-
 vades this subject  of  nomenclature, and which taints the
 whole study of auscultation.

   The portion of Skoda's work devoted to the phenomena
presented by the organs of circulation, will be found not
  1 I cannot leave this subject without referring to the earliest
of Dr. Latham's admirable little volumes on "Subjects connected
with Clinical Medicine."  He is the first English author, so far
as I am aware, who has endeavoured to throw a little Saxon sim-
plicity into the study of auscultation, and to divest it of some of
its Gallic exuberances.  « Auscultation," he writes in his preface
''is capable, I have thought, of being greatly simplified for prac-
tical purposes.    At all events, unless it be'so, it can never be
successfully taught; the knowledge derived from it must be con
fined to a few physicians of hospitals, and the profession at large
can never expect much benefit from  it."
  Further on, he tells the student  to «guard himself   ^
over-refinement," in studying the facts of auscultation. 
translator's preface.           xxi
less valuable than his account of the phenomenon  pre-
sented by the organs of respiration.   Dr. Davies bears
testimony to its excellence in terms of the highest praise.
The same  caution is here  displayed  in drawing conclu-
sions, and the same endeavour to reduce to their  just
value the signs which offer themselves to the observer;
and the whole subject is treated of in a precise  and me-
thodical manner.
   The following is a short  summary  of some of Skoda's
opinions respecting the sounds, the murmurs, and the im-
pulse of the heart.
   The impulse of the heart  depends upon a variety of
causes; the  force which  moves  Segner's wheel (better
known in this country as Barker's mill) is one: this is the
theory as it is called of  Gutbrod;1 but another cause is
the lengthening of the aorta and pulmonary artery, which
takes place when  the blood is forced into them at each
systole of the heart; something of the impulse  may also
be attributed  to the  change of form, and the  rigidity
which the heart undergoes  during its contraction.  The
contraction of the papillary muscles  takes no part in its
production.   All  the causes  of the impulse are not yet
known.
   No exact conclusion as to  the  condition of the heart
can be drawn from  the force  of its impulse, so many are
the disturbing causes by which it is modified: for instance,
a ventricle hypertrophied and  dilated  is peculiarly fitted to
produce a strong impulse, but it will not do so unless the
heart's action be rapid and complete; and so again, the
beat of an hypertrophied heart may at one moment cause
  i Some of Skoda's critics have led their readers to believe,
that he adopts this theory, as the only cause of the heart's im-
pulse. 
xxii           translator's preface.
 violent concussion of the thoracic walls, and at another be
 almost imperceptible.
   It is difficult to determine the direction which the heart
 takes during  its systole.  The contractions of the right
 and left ventricles tend to force the heart in different direc-
 tions;  its actual motion  is in the diagonal of the two
 forces.   The  abnormal positions of neighbouring  organs
 also tend to give the heart either a horizontal or a verti-
 cal position.   The statement made by Laennec and others,
 that the impulse is felt on the left side when the left ven-
 tricle is hypertrophied, and behind  the sternum when the
 right ventricle is hypertrophied, is incorrect.
   The impulse of the heart offers three different degrees
 of force: viz., first, when it does not shake the head of the
 auscultator; secondly, when it imparts a concussion to the
 head, but does not raise the thoracic walls;  and thirdly,
 when it both  imparts a concussion and raises the walls.
 The first degree, as a sign, is of little value, for its exist-
 ence is compatible  as well with an hypertrophied and
 dilated as with a normal heart;  the second degree is also
 indefinite, for it  may be  occasioned by a healthy heart, or
 may indicate hypertrophy of  one  or both  sides of  the
heart;  the third degree requires for its production hyper-
trophy and dilatation of both ventricles.  The impulse of
a healthy heart is not felt over more than one, or at most,
 two intercostal spaces.
  The aorta, when enlarged, will communicate an impulse
to the thorax,  where it comes in contact with its walls •
the pulsations  of the pulmonary artery may be felt  when
a consolidated  portion of the lung (either from tubercle or
 pneumonia) intervenes between it and the thorax
  The character of the  heart's sounds varies much- the
variation depends upon many different circumstances
  In the production of the sounds of the heart  the
ven- 
               translator's preface.          xxiii

tricles, the aorta, and the pulmonary artery, severally con-
tribute a share.
  The first sound of the ventricles is, for the most part,
produced by the sudden impulse of  the blood against the
mitral and tricuspid valves, when  they are distended and
oppose its reflux into the auricles; by the state of tension
into which the valves are thrown;  and by the impulse of
the heart  against  the walls of the  thorax.   But these
causes are  insufficient to  explain  the cause in  every in-
stance.
  Greater  difficulties surround  the  explanation  of  the
second sound of the ventricles; we cannot be sure that it
is always formed in  the ventricles, although it is often
louder at the apex than at  the base of the heart; it seems
pretty certain that it sometimes arises in the arteries.   It
may occasionally be caused by the impulse of the blood
against the ventricles during the diastole.
  The sounds accompanying the pulsations of the arteries
may be explained by the  sudden  tension of  their coats.
The second sound heard over  the aorta  and pulmonary
artery, is produced by the impulse of  the regurgitating
blood upon the semilunar valves.
  The murmurs are,  for the most  part, associated with
changes of the heart's structure; but they are sometimes
observed in the course of certain diseases, chlorosis, fevers,
etc., when  no appreciable  alteration exists.   A murmur
also arises, when a rapid  current  of  blood is directed
against blood that  is quiescent, or moves less rapidly, or
in a contrary direction.  Murmurs which cannot be attri-
buted  to organic changes of the heart, doubtless depend
chiefly upon  friction between the  blood and  the walls of
the heart.  The opinion that they arise through particular
conditions  of the blood is  hypothetical.   It  is not true
that a watery state  of the blood occasions them. 
xxiv          translator's preface.
   Every kind of murmur heard over the ventricles may
 be heard in the aorta; and murmurs are often heard over
 the carotid and subclavian arteries, when their coats are
 perfectly healthy.   The  placental bruit,  as  it is called,
 arises, according to Kiwisch, in the epigastric artery.  It
 is difficult to say whether  these  arterial murmurs are
 caused by friction of the blood against the walls of the
 arteries, or by vibrations  excited through their distention.
   There is no endocardial  murmur, excepting the whis-
 tling, which may not be imitated by a pericardial murmur,
 and  no pericardial which may not resemble an endocar-
 dial ; we have no sign by which to distinguish them, ex-
 cepting this, that the internal murmurs correspond pretty
 correctly to the rhythm and natural sounds of the heart, the
 pericardial seeming rather to follow upon  its movements.
 A friction-sound exactly coinciding with the heart's move-
 ments, and differing in no respect from a murmur formed
 within the pericardium,  may arise from rubbing of the
 roughened pleural surfaces, which cover the free portion of
 the  pericardium, either  against the  thoracic  walls,  or
 against the surface of the lungs.
   The cause of the production of the bruit de  diable in
 the jugular veins  is not very clear; it does not  appear to
 be a sign of anaemia or of spanaemia, for  it may be fre-
 quently observed in the young and healthy.
   Such are the outlines of the opinions which Skoda pro-
 fesses concerning the sounds and murmurs of the heart.
 Of his rules for the diagnosis, and for the interpretation
 of them, it is impossible to give any summary account;
 these rules have evidently been proved by, and are offered
 as the result of, his own great experience.
   The second part of his treatise contains an account of
the phenomena elicited by auscultation and percussion in
the different normal and abnormal  conditions of the tho-
racic and  abdominal organs, and the application of the 
               translator's preface.           XXV

principles laid down in the former part of the work.   This
part is itself a summary of facts.
  Before concluding, I must  beg leave to observe, con-
cerning the translation, that I believe I  can venture to
assure the reader that it conveys a correct  interpretation
of Skoda's ideas : in a literary point of view, I fear I must
crave  his indulgence, for the text will be often found not
to run pleasantly to the ear: somewhat of this fault must
be attributed to a constant desire of following our author
very closely, and of never sacrificing the sense to the sound,
le fond pour la forme, and somewhat perhaps to the pe-
culiar style of the Viennese professor.
  I feel pleasure in acknowledging the advice and  assist-
tance  which I have received from my friend and colleague,
Dr. Sieveking, while engaged upon it.
                                 W. 0.  Markham.
3 
 
CONTENTS.
PART I.
DESCRIPTION OF  THE PHENOMENA OBSERVABLE  B? THE  AID OF
             AUSCULTATION AND PERCUSSION.
                    CHAPTER I.

Percussion,    .....
The percussion sound,
Varieties of the percussion sound, and the conditions
      on which they depend,
    Full—Empty,    ....
    Clear—Dull,     ....
    Tympanitic—Non-tympanitic,
    High—Low,      ....
    The metallic ringing percussion sound,  .
    Piorry's son humorique, .
    The cracked-pot sound,  .
    Piorry's hydatid sound,  .
The Jesistance felt in percussion,
PAGE
 35
 38

 38
 42
 44
 46
 53
 54
 54
 54
 56
 57
CHAPTER II.
Auscultation,
60 
xxviii                contents.
                      CHAPTER III.
 The auscultatory phenomena of the  organs of respi-
        ration,  ......
 I. Auscultation of the voice,   ....
     The strength and clearness of the thoracic voice,
     Variations in the strength  and clearness of the
       thoracic voice cannot be explained by the laws
       of conduction of sound,
     The variations in strength  and clearness of the
       thoracic voice explained by the laws of conso-
       nance,  .....
     Diseased conditions of the  respiratory  organs,
       which, in  accordance with the preceding ex-
       planations, will produce an increase in strength
       or clearness of the thoracic voice,
     Experiments in support of the explanations of-
       fered above, respecting the causes of the varia-
       tions which occur in the strength and clearness
       of the thoracic voice,  .
The timbre (klang)  of the thoracic voice,
The pitch of the consonating voice,
The articulation of the consonating voice,
Laennec's division of the thoracic voice
    Laennec's Pectoriloquy and Bronchophony
    Laennec's iEgophony,
The author's division of the thoracic voice,
    Loud bronchophony,
    Loud clear bronchophony,
    Loud dull bronchophony,
    Weak bronchophony,
    Indistinct  humming, with  or without a
      perceptible concussion on the ear
II. Murmurs caused by the motion of  the air
      respiration,
    The respiratory  murmur
    Determination of the differences 'in the Respira-
      tory murmurs, .                       r
barely

during
65
65
66
68
73
77
  83
  87
  89
  89
  90
  90
  94
108
109
109
111
111

115

115
116

119 
contents.
xxix
      Character of the  respiratory  murmurs  of the
        larynx,  of the  trachea,  and  of  the  large
        bronchi,        .
      Character of the respiratory murmur of the air-
        cells and finer bronchial tubes,
      Changes which the respiratory murmurs undergo,
        when propagated to a distance,
      Conditions under which  an increase  by conso-
        nance of the laryngeal,  tracheal, and bronchial
        murmurs takes place within the lungs; and
        the  difference between the consonating and
        non-consonating  tracheal murmurs, as  heard
        over the thorax,
 Laennec's division of the respiratory murmurs,
     Pulmonary—Vesicular—Respiratory murmur,
     Bronchial respiration,
     Cavernous respiration,
     Blowing (sovfflante) respiration,  .
 The author's division of the respiratory murmurs,
     Vesicular breathing,
     Bronchial breathing,
     Indeterminate respiratory  murmur,
 Rales,  ......
     Causes of the rales, and their varieties,  .
     Moist and dry rales,
     Size of the bubbles,
     Amount of rales present,
     Strength of the rales,
     Clearness or distinctness of rales,
     Pitch of the rales,
Laennec's division of the rales:
    Laennec's moist crepitating rale,
    Laennec's mucous rale,  .
    Laennec's dry crepitating rale, with large bubbles
       (craquement,)  ....
Fournet's division  of the rales,
The author'6 division of the rales,
                           3*
120

120

121
 123
 124
 124
 126
 128
 131
 134
 135
 142
 144
 147
 147
 149
 149
 150
 151
 152
 153

 155
 157

 158
159
164 
XXX
contents.
    Vesicular rale,    ....
    Consonating rale,
    Indeterminate rale,
    Sonorous, whistling, and hissing sounds,
ITT. The amphoric echo and metallic tinkling,
IV. The  simultaneous existence of the  respiratory
      murmurs, rales, and sonorous sounds,
 V. Auscultation of the cough,
VI. Friction sounds, produced by the roughened sur
      faces of the pleura during the respiratory move
      ments, .
164
165
165
166
167

174
176
178
                     CHAPTER IV.
Auscultatory phenomena presented by the organs of
      circulation,     .       .      .      .       .181
  I. The impulse of the heart,       .      .       .181
    Cause of the heart's impulse,   .       .       .181
    The force and extent of the heart's impulse,   .    200
    The direction in which the  heart moves during
      its systole, and the  part where the impulse is
      felt>   ••••..    203
    Different degrees of force in  the heart's impulse,    205
 II. The pulsation of the arteries,    .       .       .208
III. The sounds and murmurs heard in the region of
      the heart, and over different arteries,  conse-
      quent upon the heart's movements,   .       .    209
The sounds of the heart,     .                         21f)
    Cause of the sounds,    .                         2]0
    The  author's views respecting the cause of the
      sounds,
                           •       .      .           216
    Variations in the character of the sounds,           2q7
The murmurs of the heart,   .
    Murmurs arising within the cavities of  the heart,'    243
    Murmurs arising in the arteries, .                  1*
    Murmurs arising in the pericardium
    Murmurs arising in the jugular veins,
248
251
255 
                      contents.                 xxxi

    Rules for the diagnosis and determination of the
      sounds and murmurs of the heart, the pericar-
      dium, the aorta, and pulmonary artery,      .   257
    Signification of the sounds and murmurs heard
      over the ventricles, the aorta, and pulmonary
      artery,  ......   262
IV. The rhythm of the  heart's movements,  .      .   282
                     PART  II.

DESCRIPTION OF THE PHENOMENA, OBTAINABLE BY THE AID OF
     AUSCULTATION AND  PERCUSSION, APPERTAINING  TO
          SPECIAL CONDITIONS OF THE ORGANS OF
               THE THORAX AND ABDOMEN.

                     CHAPTER  I.
Normal condition  of the thoracic and  abdominal or-
      gans,    ......
Phenomena obtained by percussion,  .
    Variations of  the sound, as heard in different re-
      gions of the thorax,   ....
    Variations of  sound, as observed in different in-
      dividuals,      .....
    Percussion of the  abdomen,
Auscultatory phenomena,    ....
    Auscultation of the respiratory organs,   .
    Auscultation of the heart, of the arterial trunks,
      and of the veins,      ....
    Auscultation of the gravid uterus,

                     CHAPTER II.
Abnormal conditions of the thoracic and abdominal
      organs,       .....
Abnormal position of these organs,   .
Abnormal conformation of the walls of the thorax, .
285
285

285

288
289
289
289

292
294
296
296
297 
XXX11
contents.
Abnormal conditions of the thoracic and abdominal
      organs, ...•••
 I.  Diseases of the bronchial tubes, .
II.  Diseases of the parenchyma of the lungs,
    Pneumonia,      .....
    Signs of pneumonia, when the lung-tissue is per-
      meable to  air—i. e. at the commencement of
      pneumonia, and during its resolution,  .
    Signs of pneumonia, when the inflamed tissue is
      impermeable to air—Hepatization,
    Phenomena attending  inflammation limited to a
      small portion  of lung, ....
    Phenomena attending the induration which occa-
     sionally remaius  subsequent to an attack of
     pneumonia; the cavities formed  therein;  and
     the widening  of the  bronchial tubes,   .
   The  auscultatory signs  of  pneumonia,  as  de
     scribed by Laennec,
   Gangrene of the lungs,   .
   Laennec's pulmonary apoplexy,
   (Edema of the lungs,
   Emphysema of  the lungs,
   Hypertrophy of  the lungs,
   Atrophy of the lungs,
   Tubercles of the lungs,   .
   Solitary tubercles,
  Tubercles congregated  together in masses, and
     tubercular infiltration,  .
  Tubercular cavities,
  Fournet's signs of tuberculosis,
  Diseases of the pleura,    .
  Pleuritis,
  Serous effusions  in the  pleura, not occasioned
     by pleuritis—Hydrothorax,
  Pneumothorax,   .
  Tubercular  and  encephaloid  diseases  of  the
     pleura, .
Ill
299
299
303
303
 304

 307

 313



 313

 314
 323
 324
 326
 327
 330
 331
 332
 332

 335
 338
 341
 345
 345

353
353

355 
contents.
xxxiii
363
IV. Diseases of the pericardium,     .       .       .355
    Pericarditis,      .....   355
    Effusions in the pericardium not caused by peri-
      carditis,        .....   359
    Pneumo-pericardium,    ....   359
    Adhesion between the  surfaces of the pericar-
      dium,  ......   360
    Tubercular disease of the pericardium,  .       .361
    Encephaloid disease of the pericardium,       .   362
 V. Abnormal conditions of  the  substance of  the
      heart,......362
    Hypertrophy with dilatation of both ventricles,  .   362
    Hypertrophy  of  the  ventricles without  dilata-
      tion,   ......
     Dilatation of the ventricles without hypertrophy,    363
     Hypertrophy with dilatation of the right ventricle,
      the left ventricle remaining normal,  .      .363
     Hypertrophy with dilatation of the left ventricle,
      the right ventricle being normal,      .      .    364
     Diminution of the capacity of the right ventricle,
       its  walls  being hypertrophied, atrophied, or
       normal,        .....    364
     Diminution of the capacity of the  left ventricle,
       with hypertrophy, atrophy, or normal condition
       of its walls,    .....   365
     Inflammation of the muscular substance  of the
       heart,  ......   365
     Softening  or hardening of the substance  of the
       heart. Calcareous concretions within its sub-
       stance.  Ossification of the  coronary arteries,   366
  VI. Abnormal conditions of the endocardium,     .   366
     Endocarditis,     .....   366
     Defect of the valves,     ....   367
 VII. Abnormal conditions of the aorta and pulmonary
       artery, etc.,    .       .       .       .      .371
     Unevenness of the internal surface of the ascend-
       ing portion of the aorta,       .       .       .371 
XXXI v
contents.
    Widening of the ascending aorta,
    Constriction of the ascending aorta,
    Widening of the descending aorta,
    Aneurism of the pulmonary artery,
VIII. Diseased conditions of the abdominal organs
    Enlargement of the liver,  .
    Diminution of the liver,  .
    Enlargement of the spleen,
    Abnormal conditions of the stomach,  the intes
      tines, and the peritoneum,
    The pancreas,
    Enlargement of the kidneys,
    Aneurisms of the abdominal aorta, coeliac axis
      etc.,    ....
    Enlargement of the uterus and ovaries,
    Distention of the bladder, and  its enlargement
     from thickening of its coats,   .
    Calculus in the  bladder,  .
paob
 371
 372
 372
 373
 375
 375
 375
 376

376
378
378

379
379

380
380 
PART  I.
DESCRIPTION OP THE PHENOMENA OBSERVABLE BY THE AID
         OF PERCUSSION AND AUSCULTATION
                CHAPTER I.
                  PERCUSSION.
   It is well known, that  percussion of the abdo-
men has long  been practised, for the purpose of
ascertaining the presence of air  in the intestines.
   Auenbrugger taught the use of  percussion in
diagnosis of diseases of the thorax, and thus  laid
the foundation of those beautiful discoveries, which
have since  enriched  our diagnosis of the diseases
of the  thoracic and abdominal organs.
   Auenbrugger, Corvisart,  and Laennec did not
use a pleximeter, but practised percussion with the
fingers only.   The pleximeter was first introduced
by Piorry.  Piorry also pointed out, that in addition
to variety of character in the percussion-sound, a
resistance, sensible to the finger, was offered by the
organs beneath the parts percussed: and that indi-
cations, as  to  the  condition of these organs, were
derivable as well from the nature of this resistance,
as from the quality of the percussion-sound. 
36
THE PHENOMENA
    The pleximeter renders percussion much less irk-
 some to the patient, and the sounds more distinct;
 it also facilitates investigation, for we are able, by
 its aid, to recognise differences in sound, which are
 not otherwise perceptible. It enables us, moreover,
 to compress the thick layers of the soft parts spread
 over the thorax and abdomen, and to percuss even
 the deep-seated  regions  of the abdomen, which
 would not be practicable without  this instrument.
   Piorry's pleximeter is made of ivory, and there
 is no necessity for our using any other; it consists
 of a round disk, one and a half or  two inches in
 diameter, and so thick as not to bend:  to prevent
 its slipping, and for its more steady application, it
 has either a raised border two or three lines deep,
 or two small projecting edges of  the  like  depth,
 opposite each other.
   When used, the pleximeter should be closely ap-
 plied to the part percussed, and lightly or firmly
 pressed, according to circumstances; it  should be
 so fixed, as  not to be displaced by the percussion
 stroke.   The blow should fall upon its centre, and
 be made by the middle or fore-finger, or both these
fingers together, bent in a half circle; care  being
taken not to strike the ivory with the nails.  The
 motion  should be communicated from the  wrist-
joint,—not from the shoulder, elbow, or finger-joint,
 —whereby the loudest sound will be produced, and
the patient suffer the least inconvenience.  When
the motion is made from the elbow or shoulder-joint,
it is much less abrupt, and therefore the sound pro-
 duced  is not so loud, and a blow, with the whole 
OP PERCUSSION.
37
weight of the arm in it,  falls  upon the patient.
The motion made from the finger-joints is seldom
powerful enough to produce a clear sound.
  Louis uses a caoutchouc pleximeter, four to six
lines in thickness, but it does not produce so clear
and well-defined a sound as the ivory pleximeter.
  Many physicians object to the pleximeter, that it
is inconvenient, and excites the patient's fears, and
they therefore use the finger instead.   The sound
produced with the finger is very nearly as clear as
that with the ivory pleximeter; but whoever prac-
tises percussion extensively, will prefer the use of
the pleximeter, on account of the pain occasioned
by constant percussion upon the finger.  The finger
must be always used whenever, through unevenness
of the surface, the pleximeter cannot be well applied.
  Dr. Winterlich, of Wiirzburg, uses an ivory disk
and a small steel hammer, into the head of which
a thickish layer of caoutchouc is fixed.  With this
instrument a louder sound is produced than by any
other, and  as no particular dexterity is required in
managing it, any one may, without previous prac-
tice, bring out a good sound with it.  According to
the observations which I have made, it does not ap-
pear that this method of percussion conduces more
to  correct conclusions, than percussion with the
fingers.  (Schmidt's Jahrb'dcher, 1841, 3 B., 2 H.)
   Dr. J. Burne makes use of a disk of thick leather
as  his pleximeter, and a steel hammer: the head of
the hammer  holds a firm cylinder of leather, which
projects about half an inch; the disk of leather being
fixed by screws  on a moveable  steel ring, to which
       4 
38
THE PHENOMENA
  a handle is attached.  It is  unnecessary to show
  that such  an instrument has no  distinct object.
  The pleximeter of Br. Aldis, and the modification
  of Piorry's by Mailliot Leon, are still more useless.
  (Tide Canstatt's Jahresbericht, 1843, p. 332.)

              THE PERCUSSION SOUND.
   Sound is propagated, according to the same
 laws, through organic as through inorganic matter,
 through living as through  dead  bodies;  but the
 present state of our knowledge of these laws does
 not enable us to explain  satisfactorily all the dif-
 ferences of sound which we meet with in percussion
 of the thorax and abdomen: for this purpose fur-
 ther researches  are  necessary: we must first de-
 termine every possible variety of percussion-sound,
 and ascertain the conditions on which each variety
 depends, and  then endeavour to reconcile our ob-
 servations with the well ascertained laws of sound
 It is evident, that for the  solution of this question
 a vast number of experiments  must be made, upon
 persons both in health and in  disease, and on the
 body after death.

 VAKIETIES 0F THE MMUMIOH-BOUKB, AND THE CONDITIONS ON
               WHICH THEY DEPEND.
   With the exception of distended membranes and
  sflu'r' e,dSOffSS"eS n°tcMtoi-«gair, as well
as funds, y eld, when percussed, a completely dull
and scarcely audible sound,  which  may be exem
phfied by percussing the  thigh.  There is no Z
ference a the percussiomsound by which we can 
OP PERCUSSION.
39
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 s6und  as a
soft liver, a hard  spleen  as a soft spleen,—except
when these  organs contain bony or chalky mate-
rials,—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, simi-
larly supported, and in sufficient quantity, may also
be  percussed by aid of a pleximeter, carefully ap-
plied to their surface.
   The  sound, thus obtained  from these  bodies, is
scarcely audible,  has no  tone (Klang,) no .distinct
pitch, and no timbre, &c.
   Bones and  cartilages, when immediately per-
cussed, yield a peculiar  sound, but when covered
by soft tissues, the sound they yield is less  distinct,
and altogether disappears, if the tissues are  tole-
 rably thick.
   Every sound, produced by percussion of the tho-
 rax or  abdomen, which  differs in character  from
 the percussion  sound of  the thigh, or of bone, evi-
 dences the presence of air, or other gaseous bodies,
 in the parts beneath.1
  1 Dr. C. J. B. Williams, in his Lectures on Diseases of the
Chest, endeavours to prove that the percussion-sound is not pro-
duced by the air within the  thorax,  but by the thoracic walls
themselves. He explains the variations in the percussion-sound, 
40
THE PHENOMENA
   It may be proved  by experiments on the  dead
 body, that the soft  parts of the thorax and abdo-
 men must be  made highly tense, to produce any
 other sound than the one peculiar to all soft parts.
   The sound of the ribs is rarely heard, except in
 thin individuals, but that of the sternum,  and the
 collar-bone, somewhat more frequently.  The liver,
 the  spleen, the heart, the  kidneys,  blood, water,
 etc., which yield  to immediate  percussion a  com-
 pletely dull  sound,  or, what is equivalent to it, no
 sound at all, likewise produce no sound when the
parts, under which  they lie in the thorax and ab-
domen, are percussed.  The walls of the stomach,
and  intestines, must be in a high state of tension,
to yield sound when percussed, and  the same re-
mark is true of the  parenchyma  of the lungs.
  The different sounds which percussion produces
over the regions of  the liver, the spleen, the heart,
the lungs, and the  stomach, do  not  depend upon
any peculiarities in these organs, but upon varia-
tions in the quantity, distribution, and tension of
by supposing that the vibrations of the walls of the thorax are
not interfered with by the air and healthy lung-parenchyma,
but that they are impeded, or altogether destroyed, by infiltra-
tions  into  the lung-tissue, by pleuritic effusions,  etc.,  by the
heart, liver,  etc., and  are also altered  by variations  in the
thickness and tension  of the thoracic walls.  I cannot admit
these views.   Different sounds are heard at different parts of
the thorax, and  the thorax does not sound as a whole  If the
thoracic walls themselves produced the  sounds,  they would
yield the same sounds  when detached; but individual parts of
the thorax, when thus separated, yield  the dull  percussion-
sound of the thigh. 
OP PERCUSSION.                41
the air present in the regions in  which they lie,
and upon the force of the percussion stroke.
   There is no such thing as a liver-, spleen-, heart-,
lung-, or stomach-sound: the  sound over the lung
may, under certain circumstances, be exactly similar
to the sound produced by percussion over the liver.
   The various percussion sounds of the thorax and
abdomen cannot be arranged together in one class,
comprising every degree of sound: it  is necessary
to distinguish four principal varieties: the extremes
of these varieties,"between which there  are nume-
rous gradations, may be represented by the follow-
ing terms:1—
   1.  Full—Empty.
  1  Laennec and Piorry divided the sounds of percussion into
two classes, the clear and the dull.  The latter, however, intro-
duced numerous gradations of these divisions, and termed them:
thigh-sound, liver-sound, spleen-sound, kidney-sound, intestine-
sound, stomach-sound;  and besides these, he describes a bone-
sound,  a water-sound,  an  hydatid-sound,  and a broken-pot-
sound.   As we  have  already  said, the thigh, the  liver, the
heart, the spleen, the kidneys,  etc., all yield a similar sound,
so that we cannot  speak of degrees of sound in them.   The
lungs, as a rule, give a different sound  from the stomach; but
the  stomach-sound may  exactly resemble  that of the lungs.
The sound of the lungs, of  the intestines, and of the  stomach,
is very different, and, as we have already shown, the difference
depends upon the air contained in them, and is never  produced
by the parenchyma of  the lungs, or the coats of  the stomach
and intestines.   Piorry's division of  sound is therefore not
practical,  and altogether unfounded in fact:  it has caused
many physicians, who have not had an opportunity of investi-
gating the principles of percussion, to mistake his  views- en-
tirely.
                        4* 
42
THE PHENOMENA
   2. Clear—Dull.
   3. Tympanitic—Xon-tympanitic.
   4. High—Low.
A full percussion-sound may be clear or dull, tym-
panitic  or non-tympanitic,  high  or low; and  the
same is  true, as regards an  empty sound.
   First Class :—Percussion-sounds. Full—Empty.
—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 magnitude; the loudest ring of a little bell
misleads no one as to its smalln.ess: neither do we
judge of the dimensions of bodies from the pitch
of their  sounds.
   There is no good general term to designate that
quality of sounds which characterizes the size of
bodies.  I believe that in singing, and instrumental
music, the word full, or full-toned, or sonorous, is
used: I shall therefore borrow the expression, in
speaking of the percussion-sound.  When any one
percusses, with equal force, different parts  of  the
thorax and  abdomen,  he will find that  in some
places the sound appears  more persistent, and, as
it were,  spread over a larger surface, than it does
in others:  the first kind of sound, I  call  the full;
the second, the less full, or empty  percussion-sound.
  A cavity, superficially situated in  the lungs, of
moderate size, and surrounded by thickened  paren-
chyma, yields a very distinct percussion-sound, but
of an empty character.  The  stomach distended
with air  gives a full—the small intestines, an
empty sound.  We  do not, however, obtain siuii- 
OP PERCUSSION.               43
lar full sounds in different individuals, even though
the superficial extent of their lungs, and the amount
of air contained in them, be exactly alike; for the
sounds are modified by the state of the walls of the
thorax.   The more yielding the walls, the greater
is the effect of the stroke upon the contained air,
and the more extensive the vibrations of the air
thereby produced; but when the walls of the tho-
rax are unyielding, it  is  difficult to obtain any
sound, even from the  parts which lie  most  super-
ficially beneath them.
  Let any one percuss  portions of lung  or intes-
tines, when taken out of the body, and he will soon
convince himself that it is impossible to determine
with accuracy the size of the lungs, or  the width of
the intestines, by the aid of the varying full  sound.
It is only when the most marked differences exist,
between the  full and the empty sound, that any
certain conclusions can be drawn; and  the same re-
mark must be true of these organs, when percussed
within the body.   A full sound, produced by per-
cussion of the thorax  or abdomen, indicates  the
existence of air beneath, through a space of at least
several inches in  extent, in  every direction.   A
thoroughly empty sound, resembling the percus-
sion-sound of the thigh, shows that there is neither
air, nor any other gaseous  body, beneath the per-
cussed spot, but that solid fleshy bodies, or fluids,
are present there.
  The quantity of fluid, etc., necessary to make the
percussion-sound, of any particular part of the tho-
rax or abdomen, resemble the percussion  sound of
the thigh, depends upon the elasticity of the walls 
 44              the phenomena

 of the thorax and  the abdomen, at the point per-
 cussed, and upon the condition of the parts in the
 space behind the fluid, etc.   The more elastic the
 walls are, the more readily will vibrations spread
 through the subjacent fluid, etc., into any space con-
 taining air, behind or around the fluid, etc.; the
 greater this space is, the louder will the sound be.
   The  completely  empty percussion-sound — the
 thigh-percussion-sound—heard at any yielding part
 of the walls  of the thorax, or the abdomen, indi-
 cates that no air is present in that part, for a space
 several inches in depth, and one inch or more in
 circumference.
   Of this fact we may obtain the proof, by placing
 a portion of lung, or intestine, which contains air,
 under water, and then percussing its surface by the
 aid of  the  pleximeter: it will be found that the
 lung, or the intestine, yields its proper sound, even
 though  it be sunk  several inches deep;  but the
 nearer it is brought up  to the surface, the more
 distinct the sound becomes.
 Second Class :—Percussion-sounds. Clear—Dull.
—The  words clear and dull, or  muffled, will be
taken in their usual significations.  The sound of
a drum becomes duller when covered by cloth;  in
the same way, we find the percussion-sound of the .
walls of the thorax and abdomen clear, in propor-
tion as  they  are  thin and elastic.  When air is
present beneath a thin and elastic portion of the
thoracic walls, through a space about an  inch in
breadth, and  not  more than a few lines deep, and
the remainder of  the thoracic cavity is filled with 
OF PERCUSSION.
45
fluid, or consolidated lung-parenchyma, the percus-
sion-sound over that portion will be perfectly clear,
but very empty.  On the other hand, any portion of
the lung, situated immediately beneath the thoracic
walls, which has a surface not less in circumference
than a pleximeter, and half an inch of thickness, will
yield  a full  but  quickly muffled percussion-sound,
if it be deprived of air, whilst the rest of the tho-
rax is filled  with the normally distended lung.
  A small portion of intestine, lying against the
abdominal walls, and filled with air (the air having
been expelled from the remainder of the intestines
by  peritoneal effusion,)  yields a  very  clear but
empty sound.  A portion of intestine, containing
air, which lies in part beneath the liver, and in part
in contact with the abdominal walls, yields, when
percussion is practised over the border of the liver,
a muffled sound; but when the pleximeter is placed
beneath the  border of the liver, the sound becomes
perfectly clear.
  The truth of the above statements may be readily
shown by experiments on the dead .body. A hepa-
tized  lung taken out of the body, yields the thigh-
percussion-sound; but if only a small part of it con-
tain air, and this part be percussed, it gives a clear,
but very abrupt sound, having little resonance, and
which, according to my views, must be called empty.
Percussion of a superficially infiltrated  portion of
lung, if it be equal in size to a pleximeter, and the
lung otherwise healthy, yields a duller sound than
the rest of the surface; and the thicker the portion
deprived of air, the duller is the sound.  The hepa- 
46
THE PHENOMENA
 tized part of the lung may be as much as six inches
 thick, before the sound of the portion of lung be-
 neath  it, which contains air, is altogether oblite-
 rated, and  before the sound becomes as dull as the
 thigh-percussion-sound.  A portion of intestine con-
 taining air, and placed under water, so as to remain
 partially exposed to the air at the surface, yields,
 when percussed there, as  clear a sound as though
 no part of  it were covered by water; the sound of
 the intestine immersed in the  water, and percussed
 through the water, is muffled, and becomes more^o,
 in proportion as the intestine is sunk deeper.
   From all this it is evident  that the expressions,
 full and clear, dull and empty, have different signi-
 fications. A percussion-sound  may be full and clear,
 and also full and dull, empty and clear, and empty
 and dull. A completely dull, and completely empty
 sound, have naturally the same significance,  and
 they are represented by the thigh-percussion-sound.
 As a sound becomes duller, it at the same time al-
 ways becomes emptier.   A less full sound, how-
 ever, is not necessarily a dull  sound; a sound  may
 be very empty, and yet perfectly clear.
  The  degree of dulness of the percussion-sound
 does not always enable us to judge accurately of the
 thickness of the non-resonant parts, beneath  the
 spot percussed; for  the  dulness depends in part,
 also, upon the thickness  and elasticity of the parts
 percussed, and  upon the condition of the space  con-
 taining air, behind the non-resonant parts.
  Third Class -—Percussion-sounds.  Tympanitic.
-Mn-Tympanitic.    The tympanitic percussion- 
OF PERCUSSION.
47
sound  passes  gradually into the non-tympanitic,
just as the full into the empty, and the clear into
the dull; no distinct line of demarkation can be
drawn between them.
  The non-tympanitic is represented by the sound
which  percussion produces at  those parts of the
thorax, beneath which lies healthy lung, normally
distended by air.  An abnormally distended lung,
as in vesicular emphysema, gives us at one time a
tympanitic, at another, a non-tympanitic sound.  A
partial emphysema in the midst of lung deprived of
air (as happens in pneumonia, where not unfrequent-
ly the tissue around the hepatized portion, and espe-
cially at the borders of the lung, is emphysematous)
generally produces a tympanitic sound; but if the
whole of the lung is emphysematous, the sound is
seldom distinctly tympanitic.   If the lung contain
less than its normal quantity of air, it yields a sound
which approaches to the tympanitic, or is distinctly
tympanitic.  The sound is, moreover, in many cases
remarkably tympanitic, even when the diminution
of the quantity of air in the lung is the effect of an
increase in its fluid or solid constituents; and this,
too, whether the lung retains its normal volume, or
becomes  larger than natural.   When the lung is
much reduced  in volume by compression, but still
contains air, its sound is invariably tympanitic.
  That the lungs partially deprived of air, should
yield a tympanitic, and when the quantity of air in
them is increased, a  non-tympanitic sound, appears
opposed to the laws of physics.   The fact however is
certain, and is corroborated  both by experiments on 
48
THE PHENOMENA
the dead body (which will be presently referred to,)
and also by this constant phenomenon, viz.: that when
the lower  portion of a lung is entirely compressed
by any pleuritic effusion, and its upper portion re-
duced in volume, the percussion-sound  at the upper
part of the thorax is distinctly tympanitic.1
  When the walls of the thorax are thin and yield-
ing, the percussion-sound may remain tympanitic,
even though  the quantity of air in the lung be very
small:  this fact we  occasionally observe in cases of
pneumonia and  tubercular  infiltration.  The con-
densed portions of lung, beneath the thoracic walls
thus  thin  and yielding, give, in some cases,  a dis-
tinctly tympanitic, though very empty, and not very
loud sound.  The percussion-sound is  seldom tym-
panitic when the walls  of  the  thorax are  dense
and unyielding.
  When we  percuss  a   lung — which contains  a
  1 Dr. C. J. B. Williams  (Lectures on Diseases of the Chest)
gives a different explanation of the tympanitic sound thus pro-
duced.  He says: We shall understand how the sound arises, by
observing the tracheal-sound, which is produced by percussing
the trachea with the finger above the sternum.  The trachea
passes behind  the sternum, and there divides  into  two large
branches, which lie about one or two inches beneath the cla-
vicles :  they are here covered by porous lung, and percussion
over  them  consequently  excites no  resonance.  But if this
portion of the  lung should either be condensed by effusion, or
hepatized, then percussion at once gives us a  hollow tubular
sound.   The reason why we do not more frequently meet with
the  phenomenon is, that  the compression, or consolidation of
the upper lobe of the lung, is seldom complete  enough to pro-
duce  it.—Direct experiments  prove that this explanation is in-
correct. 
OF PERCUSSION.
49
greater quantity of air in some parts of its structure
than in others, that is, in which groups of strongly
distended air-cells are mingled with others that are
less distended, or contain scarcely any air—we find
that it yields a sound in part tympanitic, and in
part non-tympanitic.
  Cavities of the lungs that contain air, lie near the
surface, and are about equal to the size of a plexi-
meter, invariably  yield a tympanitic sound,  when
surrounded by consolidated lung-tissue; but  when
they are surrounded  by healthy lung-tissue, the
sound is less tympanitic, or even non-tympanitic.
  In pneumothorax, the walls of the thorax, if
they are not much distended, yield  a  tympanitic
sound; but if much distended, their sound is almost
constantly non-tympanitic.
  When the intestines contain gas, but are not forci-
bly distended by it, nor compressed by the abdominal
walls, they always render the  percussion-sound of
the abdomen tympanitic; but if they  are much dis-
tended, or compressed by the muscles of the  abdo-
men, the sound becomes less, or even non-tympanitic.
  What has been here said respecting the causes
which render percussion-sound tympanitic or non-
tympanitic,  may  be  proved  by experiments.  A
healthy lung taken out of the body,  and  fully dis-
tended with  air, when percussed through a  plexi-
meter, yields a clear, full, non-tympanitic sound;
but when not inflated, though it contain  little air,
and be even somewhat collapsed, it  gives a clear,
full, and tolerably distinct tympanitic sound. The
percussion-sound   is  tympanitic  also when water,
       5 
50
THE PHENOMENA
 even to a considerable amount, has been injected,
 but not  too  forcibly, into a collapsed or inflated
 lung: if the quantity of water, however, be much
 increased, the sound becomes emptier and less clear.
 An emphysematous lung, which remains distended
 when taken out of the body, but is not otherwise
 changed in structure, has the same sound as  a
 healthy  inflated  lung.  Interlobular emphysema
 gives a decidedly non-tympanitic, and less clear
 sound, than a healthy inflated lung.
   The sound of any part of a lung, which is infil-
 trated with serum, blood, or tubercular matter, but
 not entirely deprived  of  air, is  tympanitic, and
 more  or less empty and dull, according to the quan-
 tity of air present in it.  The sound of a lung, con-
 taining merely a  few solitary tubercles, does not
 differ from that of a healthy lung.
   An inflated lung percussed through the medium
 of a  piece  of liver, sounds non-tympanitic, a col-
 lapsed lung containing air, tympanitic; but in both
 cases, the dull and empty character of the sound
 is  proportionate to the thickness of the  liver em-
ployed; and this must be very thick before the tym-
panitic sound disappears.   The same results ensue,
when  a piece of hepatized  lung is used instead of
liver,  or when the lung is placed under water, and
percussion made on the surface of the water.
  A  healthy lung  strongly inflated  within the
thorax, so  as  to  be made to  press  against its
walls, gives a full, clear, but non-tvmpanitic sound
at  every part where it comes in contact with the
walls.  In performing this experiment, it is neces-
sary to make one or more  openings into the tho- 
OF PERCUSSION.
51
rax, in order to insure the inflation of the lung and
its contact with the walls, by letting out any gases
which  may have been accidentally evolved after
death.
  If water be forced through  the  trachea into a
lung, inflated in the manner described above, or
after the lung has  agam"collapsed and a portion of
its air  escaped—so as to cause a kind of  artificial
oedema of  the  lungs—it will be found, that  the
sound  remains much the same as in a lung contain-
ing no water; and that a very  considerable quan-
tity  of water must be thrown into the lung before
any dulness can be detected in its percussion-sound.
Whatever  be the  amount of the water  injected,
the sound never becomes completely dull.
   The  percussion-sound invariably becomes  full
and clear, and  at  the same time either slightly or
markedly tympanitic, whenever air is forced into
the pleural cavity, so as to compress the  lung.  If
water  be thrown  into the pleura, the percussion-
sound is clear,  and either approaches the tympani-
tic,  or is distinctly tympanitic, at every point at
which the lung touches the walls  of the thorax:
where the water  comes in contact with the walls,
the  sound is dull,  and in proportion to the  amount
of water present.   If the quantity of water be not
very considerable, the sound is often tympanitic.
   Strong inflation of the stomach, or of  a  portion
 of intestine, causes these organs, when percussed,
 to yield a dull sound, approaching the non-tympa-
 nitic; but when gently inflated, they give  a clear
 tympanitic sound, if care be  taken not to press the
 pleximeter so firmly as to distend  their  coats.  A 
52
THE PHENOMENA
 stomach, or portion of intestine, filled in part with
 air and  in part with  water, yields the same sound
 as it would do if entirely filled with air; but here,
 also, a  clear tympanitic sound will not  be pro-
 duced, if the coats have been rendered tense.
   When we  percuss an intestine, through the me-
 dium of non-resonant organic bodies, as through por-
 tions of liver or spleen, or through water, we find
 the sound  behaves itself exactly as in the experi-
 ment referred to with the lung.   Percussion of an
 intestine, through  the medium of a healthy portion
 of lung, produces a modified sound, composed of the
 sound of the lung, and of the sound of the stomach,
 and generally of a tympanitic character.
  A dull sound, either slightly or not at all tympa-
 nitic, is produced  by percussion of the abdominal
 walls, when they are stiffened after death, and firmly
 compress the intestines, even though these last con-
 tain a considerable quantity of gas, and gave a dis-
 tinctly tympanitic  sound before death, i. e., when
 they were not so firmly compressed.   If the abdo-
 minal walls be lax after death, then  the sound is
 tympanitic, and it remains so, although a consider-
 able amount of fluid be present in the peritoneal
 cavity: the same thing may be observed when per-
 cussion is made over the liver, a portion of intestine
 which contains air, lying behind it.
  It is thus proved, both by observations on the living
 body and by researches in the dead, that the percus-
 sion-sound is  invariably tympanitic, when the pa-
 rietes of the organ, which contains the air, are not
stretched; but that, on the contrary, when they are 
OF PERCUSSION.
53
firmly stretched, the percussion-sound becomes less,
or not at all tympanitic, and even dull.
   Thus the fully distended  stomach, the strongly
inflated lungs, the tense thorax (as in pneumotho-
rax,) the firmly  contracted abdominal  walls, pro-
duce a  non-tympanitic or merely an indistinctly
tympanitic sound; whilst, on the other hand, the re-
laxed stomach, the collapsed lungs, the compressible
abdominal walls, give a distinctly tympanitic sound.
Respecting the cause of these remarkable facts, it
may be observed, that the tympanitic  percussion-
sound  approaches in  character to a tone (Klang,)
the non-tympanitic, to a murmur (Gerdusch.)   A
greater homogeneity of vibrations appears neces-
sary for the production of a tympanitic, than of a
 non-tympanitic  sound. When percussion  is made
upon a non-distended  stomach, it is the air alone
within it which  produces the sound; but if the sto-
mach be strongly distended, its coats also vibrate,
and these vibrations  seem to  interfere with those
 of the contained air, and thus to be the cause of
 the dull non-tympanitic sound.1
   Fourth Class:—Percussion  Sounds,—High—
 Low.—Variations in pitch are most readily detect-
  1 Dr.  Kiirschner (Schmidt's Jarbiicher, 32 B., 1 H.) explains
the cause of the tympanitic, and  the non-tympanitic sounds,
by an observation of Savart's.  Savart found that the more a
membrane was stretched, the less  readily could vibrations be
excited in it.  The stomach containing air sounds tympanitic,
when its coats are so slack that no sonorous vibrations can
be excited in them. — I still believe that my explanation is
correct.
                       5* 
54
THE PHENOMENA
 ed in sounds which are clear; but they are of little
 value in practice.  This fact may be readily shown
 by experiments. A narrow intestine gives a deeper
 sound  than a wide one, but its pitch varies with
 every change in the condition of the intestine. The
 same fact is observed in  percussion of the lungs.
 It is worthy of remark, however, that a change in
 the pitch of the sound—generally an elevation of it
 —often precedes the conversion of a non-tympani-
 tic lung-sound into a tympanitic: this sign may be
 of value, if there be no other difference observable
 in the percussion-sound.   In fact, it occasionally
 happens, that the presence of tubercles in the up-
 per part of a lung may be  diagnosed  by the dif-
 ferent  pitch of the percussion-sound over the cor-
 responding part of the other lung.
   The  Metallic Ringing Percussion-sound, and the
 Cracked-pot-sound.—These sounds cannot be classed
 in any of the foregoing divisions.
   Piorry calls the metallic ringing  percussion-
 sound,  " water-sound "—son humorique, hydropneu-
matique,— from a belief that the presence of air and
water together, is necessary to produce it. It is the
sound which we elicit by striking empty or nearly
empty vessels. That the presence of water is not re-
quired for its production, may be demonstrated by
percussing (either with or without a pleximeter) a
stomach filled with air, and not containing one drop
of water: this experiment succeeds best when the
coats of the stomach are not made too tense.   But
the sound is also heard when the stomach contains
both air and water, and may be also produced  in 
OF PERCUSSION.
55
wide, and even  narrow portions  of intestine.  It
may be frequently observed over large thoracic
cavities which contain air, and also when air, or
other gases, are  present in the pleural cavity.
  The cracked-pot-sound may be  closely imitated,
by percussing a portion of intestine inflated with
air, pressing it at the same time with  the plexime-
ter, so as to make its anterior wall approach the
posterior;  and also, by bringing  the palms of the
hands together,  and then striking the back of one
of them against  the knee.
  The cracked-pot-sound  is heard in the thorax,
over  tolerably large and  superficially situated ca-
vities, which  contain air,  and  communicate with
the bronchial tubes.  When the  percussion is for-
cible, or the thoracic walls flexible,  the cavity is
compressed at each stroke, and  a portion  of air
suddenly driven out of it into the bronchial  tubes;
the hissing murmur, caused by the escaping air, is
mixed up  with  the ordinary  percussion-sound of
cavities, and this sound represents the cracked-pot-
sound.  The air driven out sometimes  passes
through fluids,  or the  fluid in the  cavity  is dis-
turbed by the percussion-stroke, and a sound, simi-
lar to the movement of saliva in the mouth, is then
produced.
   It  is said,  that the  cracked-pot-sound may be
heard in children in whose lungs there are no ca-
vities.   I  have  never observed it  there myself.   It
 cannot be produced, unless the  person percussed
 keeps his mouth open; it is not heard, if the mouth,
 and more  particularly if, with the mouth, the nos- 
56
THE PHENOMENA
trils also be closed; closure of the mouth and nos-
trils must  have a tendency to prevent that slight
depression which is caused by each percussion-
stroke.
  Besides these sounds, Piorry describes another—
the hydatid-sound.   This is, in fact, not a sound; it
arises from certain vibrations, the presence of which
may be ascertained  by the hand, or  the points of
the fingers.1  An excellent notion of Piorry's hy-
datid-sound may be obtained by percussing a sto-
mach completely filled with water, and held free
in the air.   Tapping a repeater, held in the hand,
also produces it, that is to say, the vibrations of its
main spring are thereby rendered sensible.  Piorry
and Briangon assert, that these peculiar  vibrations
are only to be observed  over hydatid  cysts, and
depend upon the tremulous  movements  of the hy-
datids.  I do not know if any one else  has made
similar observations.   The experiment with the
stomach shows that the presence of hydatids is not
necessary for the production of the sound.   It may
also almost invariably be observed, in cases of pe-
ritoneal effusions, when the abdomen is  tense, and
its walls not very thick.   The conditions necessary
for  the production of this sound are not so often
met with in ovarian dropsy, as in  ascites:  an hy-
datid cyst, giving rise to it, must be  looked upon
as a phenomenon of very rare occurrence.
1 A dull sound is heard through the stethoscope. 
OF PERCUSSION.
57
     B.   THE RESISTANCE FELT IN PERCUSSION.
  Piorry was the first observer who pointed out the
fact, that in percussing the various organs, different
degrees of resistance are felt by the fingers; and it
would seem as though he considered this resistance
of more importance than the percussion-sound.
  The various degrees of resistance, offered by the
different organs when percussed, may be  learned
on  the  dead  body.  An healthy, air-containing
lung, offers no resistance when  the pleximeter is
so held  as merely to touch, without pressing upon
its surface; but if the lung has been rendered dense
and firm, through infiltrations of serum, blood, or
tubercular matter, the resistance becomes percep-
tible, and is greater in proportion as these matters
are more abundant, and the quantity of air in the
lung diminished.  A hardened lung offers a greater
resistance than a soft lung.
  Resistance is not felt in percussion of the stomach
and intestines, unless the coats of these organs are
tense; the resistance increases with the tension.
  The resistance of organs not  containing air, is
regulated by the degree of their firmness; that of
the thoracic walls  is greater, per se, in proportion
to the thickness and unyielding  nature of the ribs,
and the narrowness of the intercostal spaces.  The
resistance of the abdominal walls is increased by
their tension and firmness.  The  thicker and firmer
the ribs, the  narrower the intercostal  spaces, and
the tenser the abdominal walls, the less will be the
difference  between the degree  of resistance felt 
58
THE PHENOMENA
over the organs of the thorax and  abdomen,  in
their normal  condition, and  the resistance which
they offer in their abnormal conditions.
  The healthy lung offers no resistance; the resist-
ance felt at all parts of the thorax, wherever healthy
lung comes in contact with its walls, is caused by
the walls themselves.  Air present in cavities,  or
in the pleura, likewise offers no resistance, except
in those cases in which it causes distention of the
thoracic walls.
  When the intercostal  spaces are enlarged, as  in
pneumothorax, or in  emphysema of the lungs, we
find that the thoracic walls are sensibly depressed
at each percussion-stroke, but quickly regain their
previous form, the thorax being more elastic than
usual.   The  same thing is  observed,  even in  a
healthy condition of  the lungs, when the  ribs are
thin and the intercostal spaces large; only, in this
case, the resistance is less than in pneumothorax
and emphysema of the lungs.  Should it happen in
pneumothorax, or, what is rarer, in pulmonary em-
physema, that the intercostal spaces are  not en-
larged, or that, notwithstanding such enlargement,
the ribs  themselves  are inflexible, then no sensa-
tion of any yielding can be felt.
   The lungs  become resistant to percussion, when
infiltrated with  blood, serum, tubercular matter,
etc.; but it is impossible to define accurately what
degree of distention and consistence of the infil-
trated lung is  necessary to render this resistance
perceptible through the thoracic walls, as  so much
depends  upon their  flexibility.  When an entire 
OF PERCUSSION.               59
lung, or a considerable portion of it, is hepatized,
or infiltrated with tubercle, from before backwards,
and solidified, the resistance felt at the correspond-
ing parts of the thoracic walls is aS great, or even
greater, than that felt over the hepatic region, in
ordinary enlargement of the liver.
  The resistance offered by the thorax is greatest
when its walls are  rendered tense, and  its inter-
costal spaces distended by pleuritic effusions; little
resistance is caused by effusions which do not make
tense the walls which contain them.
  The resistance of the heart, the liver, and the
spleen, increases in proportion to their solidity,
and to the force with which they are pressed against
the walls of the  thorax.
  The difference of resistance felt  in percussion
enables us to decide whether an abdominal swelling
is caused  by the presence of air in the intestines,
or of  fluid  in the  peritoneum.   Encysted fluids,
which  render the walls of the cyst which contains
them tense, offer, through the abdominal walls, the
same resistance  as tolerably firm, fleshy bodies. 
60
                CHAPTER II.

                 AUSCULTATION.
   The sounds produced in the thorax by the move-
 ment of the organs within it, are seldom so loud as
 to be perceptible until the ear is placed in contact
 with its walls.  Those very rare cases in  which
 the sounds are audible at a distance from the tho-
 rax, do not seem to have attracted the attention of
 early observers; and this is not surprising, so long
 as physicians, in their interpretation of the  pheno-
 mena of diseases, did  not proceed  by special in-
 vestigation of the conditions of the different organs
 of the human body.
   The want of some new method  of investigating
 the abnormal conditions of the internal organs, was
 made manifest by the progress of pathological ana-
 tomy:  this was the reason that  rendered  Auen-
 brugger's " lnventum Novum " so welcome to Cor-
 visart, who first brought it  into general notice.
 Previously to  him, Auenbrugger's discovery had
 been thought  of little  value, and  was, indeed, al-
most forgotten.   Corvisart was well acquainted
with the morbid  anatomy of the heart, and of the
organs of  respiration, but he was  ignorant of the
signs by which to discriminate the different diseased
conditions of these hidden organs.  Auenbrugger's 
                 AUSCULTATION.              61

discovery, therefore, which so essentially aided the
diagnosis of diseases of the thoracic organs, could
not be otherwise than most welcome to him.
  Corvisart was  accustomed,  in  cases where  the
movements of the heart could  not be satisfactorily
ascertained by the hand, to place his ear over the
cardiac region; and thus he practised immediate
auscultation. His pupils followed his example; but
this new method of diagnosing the heart's move-
ments does not appear, for a long period, to have
been of much general benefit, on account probably
of its being but little practised.  The immense im-
portance of auscultation was at length demonstrated
to the world by Laennec, who, after spending three
years in the investigation of its phenomena, pub-
lished those results which have made his name im-
mortal. His labours  gave a new direction  and a
new impulse  to the spirit of investigation in  the
physicians of France, and afterwards of most other
countries.   His observations  and  theories have
been, and  will  be again and  again, subjected to
criticism;  and it becomes the duty of every physi-
cian who has the opportunity, to distinguish in them
what is certain  from what is doubtful or incorrect.
  Laennec, at first, considered auscultation by the
stethoscope as a method of investigation totally dis-
tinct from immediate auscultation; but he appears
to have afterwards  modified  this  opinion, still,
however, believing that he who did not use the  ste-
thoscope,  but trusted  to the  unaided ear, could
never attain  to any certainty  in diagnosis.  Not-
withstanding this, immediate auscultation has been
       6 
62
THE phenomena
practised  by many physicians, and has even been
thought to have advantages over mediate auscul-
tation.
  I do not think it is necessary to repeat all that
has been  said, from time  to  time, respecting  the
advantages and disadvantages of these two methods
of auscultation.  Sounds are heard louder by the
unaided ear, than through  the stethoscope; but the
ear cannot be applied to every part of the thorax,
and the disease may be of  such a character, or the
person to be examined  in such a condition, as to
render immediate  auscultation very repulsive to
the physician.
  My own opinion  is, that  the stethoscope is indis-
pensable, and that every physician must make him-
self acquainted with its use; but he must, neverthe-
less, also  study immediate auscultation, for it  fre-
quently happens, from the  situation of the patient,
or the position of his bed, that the ear can be more
readily applied to  the chest than the stethoscope.
Physicians, therefore, must practise both mediate
and immediate auscultation.
  I do not myself agree  with  Laennec, that  the
auscultatory sounds, which have reference to the
voice, are rendered more distinct by the stethoscope
than they are without it; nor do I find that patients
dread the use of the stethoscope more than they do
the application of the ear to the thorax; or that this
last procedure is more agreeable to them than the
employment of the stethoscope.   When the patient
lies in bed, the physician will, with very few excep-
tions, find it most convenient to use the stethoscope; 
OF AUSCULTATION.             63
but if the patient sits or stands, immediate ausculta-
tion, particularly of the  back,  is very easily per-
formed.
  The form of the stethoscope, and the nature of
the wood  it is made of, are often objects of much
attention with those who are not well acquainted
with auscultation; but  in  regard to  conducting
power  at least, the choice of  the wood is quite in-
different, for the greater part of the sound traverses
the air in the stethoscope, and not the wood.  The
lighter the wood, the more  convenient is the in-
strument, both for the physician and  the  patient.
Whether it be long or short, formed of one or two
pieces, screwed or  slipped  together, is equally
matter of indifference as respects hearing.  The
funnel-shaped end should not have too large a dia-
meter, for in such case, it cannot be accurately ap-
plied to the chest; and  besides, too great hollow-
ness may produce  modifications in certain sounds.
It is sufficient, if the funnel has a diameter of about
one inch.  The ear-piece may be convex, concave,
or  plane, provided the disk forming it  be large
enough to close the ear completely.  The shortness
of Piorry's instrument often renders its application
difficult, and at times impossible; and this is found
to be particularly the case inpatients whose move-
ments are not free; on this account, I use a stetho-
scope  about a foot long.
   Whether the auscultation be mediate or imme-
diate,  every care should  be taken not to render it
wearisome to the patient; and no more  pressure
should be made by the ear, or  by the stethoscope, 
64
AUSCULTATION.
 than is necessary to exclude all communication with
 the external air.
   Beginners, especially, should  be cautioned not
 to press heavily; while listening to the sound, they
 are apt to forget their  position, and  to allow the
 whole weight of the head to fall upon the chest of
 the patient, which would  be sufficient to impede
 respiration, even in the healthy, and much more so
 in those suffering from disease: the  stethoscope,
 moreover, is liable to produce pain, in consequence
 of the small extent of surface which receives its
 pressure.  By paying attention  to his position, in
 using the stethoscope, the  auscultator will cause
 little annoyance, even to the  most sensitive indi-
 vidual, provided the latter be neither prejudiced
 against, nor dreads its use.
  In order to derive all the information from aus-
 cultation which it can afford us, we  must not be
contented with the examination of one, or even of
several, parts of the thorax; every part must be ex-
amined, and a comparison then made of the results
obtained. 
65
              CHAPTER III.

 THE AUSCULTATORY PHENOMENA OF THE ORGANS
               OF RESPIRATION.
  The phenomena observable  in  the  respiratory
organs by auscultation, are: the thoracic voice; the
murmurs caused by the passing to and fro of the
air during inspiration and expiration; and the mur-
mur produced by the rubbing of roughened pleural
surfaces.

        I. AUSCULTATION OF  THE VOICE.
   The observer soon learns by experience, that the
thoracic voice is heard very differently in different
individuals: in one it will be found strong and clear;
and in another, who speaks equally loud, it will be
merely represented by an indistinct humming (Sum-
men,) or perhaps no trace whatever of the voice will
be audible.  The voice of the same individual,
whether his thoracic organs be healthy or unhealthy,
is not heard equally loud at all parts of the thorax.
   Auscultation teaches  us that the voice may be
heard  in the thorax, in the most  varying degrees
of strength and clearness, and  even up to a point
where it seems to pass directly  into the ear  of the
auscultator;  numerous other  variations  in the
timbre, etc., of the voice are also  to be remarked.
                       6* 
66         AUSCULTATION OF THE VOICE.
   The Strength and Clearness of the Thoracic Voice.
 —It is  necessary  to  make a distinction between
 strength and clearness  of the voice.   The voice
 may be distinctly heard in the thorax, without being
 strong; and, on the other hand, a strong voice is not
 necessarily  a clear one.
   There are several degrees, both in strength and
 clearness of the thoracic voice; the voice, as heard
 over the larynx, may be taken as a standard  by
 which to measure these degrees.   Generally, the
 voice over the thorax is less strong and clear than
 it is over the larynx; it  is seldom equally strong
 and  clear, and very rarely is it stronger and clearer.
 I divide the thoracic voice, in respect to strength,
 into weak and strong; and I call it strong, when it
 not only  emits  sound, but also produces a degree
of concussion in the ear.   If this concussion does
not strike deep into the ear, I term the voice weak.1
  1 The vibrations felt by the hand, when laid upon the thorax
of a person speaking,  have not the same significance, as the vi-
brations communicated to the ear, in auscultation of the thoracic
voice.   In persons whose voices are deep, the vibrations may be
often felt very strong,  and yet no voice, but merely an indistinct
humming, is appreciable  by auscultation, and no vibrations pass
into the ear.  On the other hand, in  persons whose voices are
high, scarcely any vibration  of the thorax  can be felt by the
hand,  although, by auscultation,  the  thoracio voice  may be
clearly heard, and penetrate far into the ear.
  These phenomena are  in unison with the  known facts, that
the sonorous vibrations of solid bodies  are more readily sensible
to the touch, the lower the tones are which produce them • and
that vibrations may be felt by the hand, when they are not rapid
enough to communicate sound to the ear.  The vibrations of the 
AUSCULTATION OF THE VOICE.         67
  We have no such standard by which to mark the
clearness and the dulness  of  the  thoracic voice.
The voice, however, may be always called clear
when its articulation  is audible.  Yet the voice
may be very clear, though the articulation be not
particularly distinct.
  In the normal state of the respiratory organs of
many individuals, we  hear  no thoracic voice, but
merely a humming;  this humming is loudest be-
tween the scapulae and the vertebral column, less
loud beneath the clavicles, and it becomes gradu-
ally lost as we pass down towards the lower parts
of the thorax.   When the voice is deep, and the re-
spiratory organs  healthy,  it is  frequently heard
strong, and tolerably clear, between the upper half
of  the scapulae  and  the vertebral column, but is
rarely  attended  with any distinct articulation.
When the voice is acute, it is frequently also weak
and clear.
   The voice, again, often appears less strong  and
clear beneath the clavicles  (the respiratory organs
being healthy,) than between the scapulas and verte-
bral column; and still weaker and  duller in the
axillaa.  In other parts of the thorax, no voice, but
merely a humming, is heard, and sometimes not
even a humming.
   When the respiratory organs are diseased, there
thoracic walls are communicated to the ear, and may be slow or
rapid;  but if they are not appreciable as a tone, or form only a
very weak tone, no sensation of vibration will pass deep into the
ear; a sense of concussion only being felt in the external ear, or
in the head. 
68        AUSCULTATION OF THE VOICE.
are no parts of the thorax, where the voice may not
be heard strong and clear; generally speaking, it is
so heard at those parts where cavities, pneumonic
or tubercular infiltrations, or pleuritic effusions ex-
ist; but this does  not happen in every case, nor
during the whole period of the existence of  such
diseased conditions of the organs.
   Variations in the Strength and Clearness  of the
Thoracic Voice cannot be explained by the Laws of
Conduction of Sound.—Laennec attributed the va-
riations observed in the strength and clearness of
the thoracic voice to changes in the sound-conduct-
ing power of the lung-parenchyma:  he considered
the lung, in its normal state, to be a bad conductor
of sound, but that its conducting power was in-
creased by its consolidation and infiltration, or by
the presence of fluids in the pleura—an explanation
quite in accordance with the generally received opi-
nion, that solid bodies conduct sound better than air.
  This opinion has prevailed in France up  to the
present time.
  Now, if we repeatedly auscultate the thorax of a
person suffering  from  hepatization of a lung, we
shall find that the thoracic voice is at one time in-
creased, and at another diminished in force, without
any alteration—discoverable by percussion or other
means—having taken  place in the condition of the
hepatized part. This alternate presence and absence
of the thoracic voice at the same parf of the thorax,
when  the lung is hepatized, is a well-known and
common occurrence.  Every one who has had much
experience  in the auscultation of pneumonia, must 
AUSCULTATION OF THE VOICE.        69
have observed the increased voice, bronchophony,
to appear and disappear several times in the course
of a few minutes.
  The phenomenon is opposed to  the idea of the
bronchophony depending upon a superior conduct-
ing power of sound, inherent in-hepatized lung;
and whoever maintains the correctness of such an
idea, is bound to explain this anomaly.
  The voice, as we all know, though it may have
disappeared, will return after a deep-drawn breath,
and still more readily if the patient coughs; and it
will again disappear if he  remain tranquil for a
short time,  without  coughing  or expectorating.
The conclusion to be drawn from this is, that the
voice is heard through the  hepatized parts, when
the bronchial tubes  passing into them are not ob-
literated by fluids, but contain air; and that, on the
other hand, it disappears when the tubes are blocked
up by mucus, etc.  This explanation of the absence
and presence of  the thoracic voice, in  no way re-
moves the difficulty as to the increased sound-con-
ducting power of the hepatized lung; if this power
were really increased, it would become a matter of
indifference whether the bronchial tubes contained
air or fluids.
  It also appears doubtful—as in the case of hepa-
tization of the lung—whether an  increase in the
sound-conducting power of the lung takes place in
the course of pleuritic effusions; for the voice be-
comes weaker in  proportion  as the effusion pro-
gresses, the reverse of which ought to happen, if
the effusion were a better conductor of sound.
  The following remarks on the sound-conducting 
 70         AUSCULTATION OF THE VOICE.

 power of bodies and its conditions, do not justify
 the supposition that  bronchophony depends  upon
 an increased sound-conducting power  of the  hepa-
 tized lung  and of fluids.  The human voice, and
 every other sound which is formed or  propagated
 in the air, is heard furthest in the air.   A sound ex-
 cited in the air, is heard very indistinctly, or not at
 all,  by a person under water; and  a sound in one
 room passes with difficulty into another, being in-
 terrupted by the walls. Any one wishing to weaken
 his hearing, stops his ears.
   On the other hand, the slightest scratching at one
 end  of a  long rod may be  heard, if  the  ear be
 brought in contact with the other; while no sound
 whatever is audible in the air, although the ear be
 brought much nearer to that end of the rod whence
 the sound proceeds.  The sound caused  by striking
 two stones together, under water, is distinctly heard
 there,  and  even causes a  disagreeable sensation;
 whilst, out of the water, it can be scarcely recog-
 nised.
   These facts show that sound does not pass readi-
ly from dense bodies into the air, or from  the air
into  dense  bodies.   Physics,  also,  teach us  that
sound is always reflected, in passing from one me-
dium into another, and that less sound  enters into
the new medium than would have been propagated
through a corresponding space of the one in which
it was originally excited; the more  dissimilar the
media are, in respect of density and cohesion the
greater is the reflection of the sound, and the'less
freely does it pass from the one into the other
  The ticking of a watch is heard to a greater dis- 
AUSCULTATION OF THE VOICE.        71
tance through a rod, than through the air, because
no part of the sound passes off from the rod into
the surrounding air, but remains wholly concen-
trated in it; the sound, on the contrary, which passes
immediately from the watch into the air, spreads out
in every direction, and thus impinges upon a greater
extent of matter.   The experiment with the rod,
however, does not prove that wood is a better con-
ductor of sound than air.  The difference in the
conducting power of air, wood, and other bodies,
has  not been experimentally determined.   Re-
searches made for this purpose, must be of such a
nature as to show the results of one and the same
sound in two or more media, which have like form
and volume, and are placed in a similar relation to
the parts surrounding them; the distances at which
the sounds are heard through each medium,  and
their force, must also be compared.
  Let any one, for example, so place the end of a
wooden tube  on a watch, that the whole rim may
be in contact with it, and then listen at the other
end;  he will hear the ticking at the same moment
through the wood, and through the air in the tube.
If a solid cylinder of wood be now fitted into the
tube, and it be placed  as before, the ticking will
be heard passing through the wood of the tube, and
through that of the solid cylinder.   Now, if wood
were a better conductor of sound than air, the tick-
ing  ought  to be  heard  more clearly in the latter
than in the former case; but any one may readily
convince himself that the reverse of this is the fact.
   It is a remarkable circumstance, that auscultators 
72        AUSCULTATION OF THE VOICE.
 should  make  use of a hollow tube, and not of a
 solid cylinder, and yet assert that dense bodies are
 better conductors of sound than air.
   There is no doubt that the voice passes into the
 parenchyma of the  lungs through  the  medium of
 the air contained in the trachea and bronchial tubes;
 for if it were propagated along the walls of the tra-
 chea, it would spread equally well through the ge-
 neral coverings over the thorax.  When the lungs
 are healthy, and the air passes uninterruptedly into
 the air-cells, the voice reaches further  than when
 the lung is hepatized, or compressed by fluids, that
 is, than when the air-cells and finer bronchial tubes
 contain no air. The more solid a body is, the more
 difficult is the passage of sound from the air into
 it; and hence sound passes more readily from the
 air of the air-cells and bronchial tubes into the pa-
 renchyma of a healthy lung, than it does from the
 air of the larger bronchial tubes into the consoli-
 dated tissue of a hepatized lung.
  The conducting power of healthy and of hepatized
 lung, and of fluids,  may be readily shown in the
 following manner.   Let one person direct his voice
 into  a stethoscope placed upon a healthy lung, re-
 moved from the body, while another auscultates
 with a second stethoscope: by gradually placing the
stethoscopes at different  distances, the  exact dis-
tance through  which the voice can be heard in the
 lung, will be at  last ascertained; similar experi-
ments maybe afterwards performed with hepatized
lung, and lung compressed by fluids.
  Repeated  experiments  of  this nature have in-
variably demonstrated to me that  sound is heard 
AUSCULTATION OF THE VOICE.         73
somewhat further  through healthy than through
hepatized lung.   The difference in this respect is
remarkable.
  In accordance with the above facts, I have come
to the conclusion  that: Variations in the strength
and clearness of the  thoracic voice cannot  be ex-
plained by differences  in the sound-conducting
power of normal and abnormal lung parenchyma.
  The Variations in  Strength and Clearness of the
Thoracic Voice explained by the Laws of Consonance.
—If a sound  is heard as distinctly at a distance
from, as at the spot where it originates, one of these
two things must have happened; either its diffusion
has been prevented, and  it has remained concen-
trated in the passage, or it has been reproduced by
consonance, and thus increased in strength; and if
the sound be heard louder at a distance from, than
at its origin, it must also have gained increase by
consonance.
  Consonance is  a well  known  phenomenon.   A
guitar-string yields  a musical note, when a similar
note  is sounded  upon another instrument in its
neighbourhood, or even by the  human voice.   A
tuning-fork held in  the air sounds much more fee-
bly than when laid on a table; the table strength-
ens the tone, and yields similar vibrations, and thus
consonates with the  tuning-fork.
   The sound of a jew's-harp is scarcely heard in
the open air, but becomes distinctly audible when
made  to vibrate within the mouth—its sound is
strengthened, in  consequence of the air  in  the
mouth consonating with its vibrations.
       7 
74        AUSCULTATION OF THE VOICE.
  When, as occasionally happens, the voice is heard
louder at  some part of the thorax than over the
larynx, it must have derived its increased strength
from consonance within the thorax.  Variations in
the strength and clearness of the thoracic voice may
thus be  explained  by changes  in  the force of its
consonance within  the thorax; and it therefore be-
comes necessary for us  to inquire here, what parts
within the thorax  consonate with the  voice, and
what circumstances cause variations in  the  conso-
nance.
  The voice, as it proceeds from the mouth, is form-
ed of the original sounds of the larynx, and of the
consonant sounds of the throat and of the cavities of
the mouth and nose. This we learn from the changes
which the voice undergoes by opening and closing
the mouth or the nose,  while the condition  of the
larynx remains unaltered. It is well known, that the
pitch of the voice is determined by the larynx, and
that it is not affected by the opening or closing of the
mouth or nose; but the articulation of the voice
takes place in the mouth, and certain modifications
in its timbre depend upon the form and size of the
mouth and nasal cavities, and particularly upon the
circumstance of their being opened or closed.
   Now, since it is evident that the air in the throat,
the mouth, and the nasal cavities, consonates with
the  sound formed  in the larynx,  we cannot doubt
that the air in the trachea, the bronchial tubes, etc.,
may likewise become consonant with sounds origi-
nating in the larynx. The air in the thorax, and not
the  parenchyma of the  lungs, is the consonating 
AUSCULTATION OF THE VOICE.        75
body; the parenchyma is ill-adapted for consonance,
being neither firm nor tense in structure.
  Those bodies in which musical vibrations are most
readily excited, such as the air, musical chords,
membranes, bars, plates, etc., also  consonate most
readily.
  Air  only consonates when confined  in a given
space.   The human voice, and every other sound, is
much weaker in the open air than in a room.   The
air contained within the sounding-board of a guitar,
a violin, or a clavier, consonates with the tones pro-
duced by their strings, but the  free air around does
not strengthen their tones.
  The force of the consonance  depends upon the
form and size of the enclosed space, and upon the
nature of the walls forming it; the consonance, for
example, is stronger, the more completely the sound
is reflected by the walls; hence a  space bounded
by solid walls yields the loudest consonance, whilst
those formed of linen, as in a tent, add little to the
force of the sound.   The cause of the increase of
sound in a speaking trumpet is well known.
  The air enclosed in a given space does not con-
sonate  with every sound;  and  although several
sounds or murmurs may consonate therein, it will be
found that they  do not do so with  equal force and
clearness. Consonating bodies only respond to those
tones which they themselves are able to produce, or to
vibrations forming some aliquot part of such tones.1
  1 Die Naturlehre, hach ihrem gegenw'artigen Zustande, von
Baumgartner und Ettingshausen. 
76        AUSCULTATION OF THE VOICE.
   The following conclusions respecting the conso-
 nance of the thoracic voice, may be drawn from a
 consideration of these physical data; the air con-
 tained in the trachea and bronchial tubes  conso-
 nates with the voice, in so far as the walls confining
 it, have, in respect of  their power of reflecting
 sound, a similar or analogous condition to the Avails
 of the larynx, of the mouth, and of the nasal cavi-
 ties.  In the trachea, the walls of which are formed
 of cartilaginous rings, the consonance of the voice
 is nearly as  forcible as  the voice itself, heard in
 the larynx;  and it can be little  less so in the right
 and left bronchi.
  As  the bronchial tubes pass into the parenchyma
 of the lungs, their cartilaginous rings  gradually
 disappear, the cartilaginous structure existing at
 last only as irregular thin plates, lying in a fibrous
 tissue; the  finer divisions of the bronchial tubes
 are merely thin membranous canals.  The conso-
 nance of the voice is consequently much feebler in
 the bronchial tubes, which run into the parenchyma
 of the lungs, than in the trachea, and, in fact, be-
comes weaker in proportion as the amount of car-
tilaginous structure diminishes.
  The conditions requisite for  the production of
increased consonance of the voice in the bronchial
tubes, which run into the parenchyma of the lungs,
are these: either, the walls  of  the  tubes must be
cartilaginous, or, if membranous, the  membrane
must be very dense, or the tissue of the lung around
the tubes must be deprived of air: in any of these
cases, the walls of the bronchial tubes will reflect 
AUSCULTATION OF THE VOICE.         77
sound more strongly, than in their normal condi-
dition.  Of course the communication between the
air in  the  tubes, and the air in the larynx, must
remain uninterrupted.
  It frequently happens, when musical vibrations—
original or communicated—are excited in air in a
confined space, that the walls themselves which
surround the air also vibrate in unison, and the
more readily, the less rigid and unyielding they
are.  An organ-pipe vibrates when the air within
it sounds, and so  does a speaking-trumpet.  The
trachea vibrates with every sound, and  its vibra-
tions are perceptible, even  through several inches
of firm fleshy layers.  The walls of the bronchial
tubes, running into the parenchyma of the lungs,
likewise  vibrate,  when the  voice  consonates in
them, just as the walls of the larynx do: the vibra-
tions thus  excited may extend to the walls of the
thorax, and even pass  through several  inches of
thick  fleshy parts, or of fluid, and be heard at the
thorax as consonating sounds of the bronchial tubes.
  Diseased Conditions of the Respiratory Organs,
which, in accordance with  the preceding explana-
tions, will produce an increase in Strength or Clear-
ness of the Thoracic Voice.
  Among these may be classed:
  1. All those diseases by which the parenchyma
of the lungs is deprived of  air, and rendered firm,
dense,  and  solid.—The walls of a bronchial tube,
surrounded by such an abnormal parenchyma, re-
flect sound  as well, or even  better, than the wall of
the trachea.  And the reflection of the sound, and
                      7* 
78        AUSCULTATION OF THE VOICE.
the force  of its  consonance, is greater or less, in
proportion to the density of the parenchyma.
  The diseases which render the lung-parenchyma
solid, are: pneumonia, tubercular infiltration,  or
pulmonary apoplexy—apoplexia pulmonum.   In
these diseases, no increase of the thoracic voice will
occur, unless the air has been wholly expelled—or
apparently so—from the air-cells, by the infiltrated
matters; and the solidified portion of lung  be  of
such a size as to  contain at least one of the larger
bronchial tubes, having air in it, and communicating
freely  with the  larynx.  The  more  extensively
the lung is solidified, the more marked is the in-
crease  of the strength of the thoracic voice.
  Pneumonia in its first stage, inflammation con-
fined to a few lobules of the lung,—lobular hepa-
tization,—oedema of  the lungs, or limited effusion
of blood into the lung-parenchyma, produce very
slight, or  no increase whatever, in the strength of
the thoracic voice; neither do  solitary tubercles,
however numerous, provided the intervening pa-
renchyma remains pervious to  air.  Effusion  of
blood into the lung-parenchyma—Laennec's pulmo-
nary apoplexy—being of rare occurrence, and ge-
nerally very limited in extent, seldom gives rise to
increase of the thoracic voice.  Its increase is very
frequently observed in the course of extensive he-
patizations and tubercular infiltrations of the lungs.
It is also produced by the condensation of the lung,
which  remains after an  unresolved hepatization,
just as in hepatization itself.  I have never  found
the lung substance completely deprived of air, in 
       ABNORMAL CONDITION OF THE LUNGS.     79

oedema of the lungs, unless the lung was, at the
same time, subjected to external pressure.1

II.  ABNORMAL CONDITION OF THE LUNGS,  IN WHICH
       THE PARENCHYMA IS DEPRIVED OF AIR
                 BY COMPRESSION.
  The walls of a  bronchial tube surrounded by
parenchyma, which is compressed and deprived of
air, reflect sound as forcibly as the soft parts of the
mouth; but compression of the lung will  not give
rise to the thoracic voice, unless the compressed por-
tion be large enough to contain a  bronchial tube,
which, from its size and cartilaginous  character,
cannot undergo complete compression; the simply
membranous bronchial tubes may be entirely ob-
literated.
  The lung-substance can be compressed by fluid or
solid exudations, or by gas present in the pleura, by
tumours, by enlargement of the heart, by pericar-
dial effusions, aortic aneurisms,  enlargement of
the  abdominal viscera, curvatures of  the spine,
or other deformities of the  thorax.   Of all  these
causes, those which  most  generally, and indeed
almost exclusively, produce increased thoracic voice
are pleuritic effusions, and pneumothorax; com-
  1 According to Dr. C. J. B. Williams, Raciborsky, and some
other authors, bronchophony may be produced by congestion of
the pulmonary vessels.  Now this congestion exists, in a high
degree, when the mitral orifice of the heart is contracted; con-
sequently, such contraction should always give rise to broncho-
phony.  Congestion of the pulmonary vessels  does not cause
bronchophony and, most assuredly does not alter the resonance
of the voice. 
80
ABNORMAL CONDITION
plete compression of large portions of the lung has
very rarely been found dependent upon other causes.
  It is certainly  true, that,  in  curvatures of the
spine, we sometimes find a lobe, or even an entire
lung,  subjected to pressure; but  nevertheless, so
long as the lung is healthy it always  contains air>
except in some of its smaller divisions.  It rarely
happens, when the abdomen is extensively enlarged,
the diaphragm  forced upwards, and  the thoracic
cavity diminished, that more  than  the edges of the
compressed lower lobes of the lung are completely
deprived of air; the upper part of these lobes almost
invariably retains some portions of it.
  Moreover, we scarcely ever find any considerable
amount of lung-substance deprived of air by pres-
sure, even in cases of enormous enlargement of the
heart, or very extensive pericardial  effusions, or
large  aneurisms.  When the thorax  contracts, in
consequence of the absorption of pleuritic effusion,
the lung, although much reduced in volume, always
contains air, provided its parenchyma be not in-
durated.
  The question  may naturally be asked:  what
amount of fluid, or gas, is requisite to produce such
compression of the lungs as will  give rise to the
thoracic voice ?   Generally speaking, we cannot an-
swer this question; for it may happen that the lobe
of a lung is completely deprived of air, though not
reduced to more  than three-fourths of its natural
size; and again, it may be reduced to a third, and
even less,  and still contain air.  The cause of the
difference is  obviously this,  that in the one case, 
OF THE LUNGS.
81
the parenchyma is loose, and contains but a small
amount of fluid; and in the other, it is dense, and
contains  much  fluid: from this circumstance, and
from  differences in the capacity of the thorax, we
find that at one time half  a pound of fluid is suffi-
cient, while at another, several pounds are requisite,
for the production of the increased thoracic voice.
  If the lung be not adherent to the thoracic walls,
fluids when  present, always collect in the  lowest
parts  of the pleura, thereby compressing the under
portions  of  the  lung, and very frequently  giving
rise to increased thoracic  voice: the lower  lobe of
the lung, thus  deprived of air, sinks beneath the
fluid, by reason of its increased specific gravity; the
bronchial tubes passing into it are reduced in size,
but not  obliterated, nor  distorted, and the air in
them communicates with the air in the other bron-
chial tubes, provided the communication is not pre-
vented by the presence of mucus, etc.   Compression
of its parenchyma does not so readily give rise to an
increase in the thoracic voice in the upper, as in the
lower parts of the  lung: this is particularly true of
the upper and anterior parts of the organ, where the
bronchial tubes are more readily obliterated by com-
pression, in consequence of the curved course which
they  follow.  It happens occasionally, when the
quantity of fluid is so considerable as to compress
the whole lung, that the  increased thoracic voice
is heard as  well marked over the anterior  surface
of the thorax, as beneath the scapulae.   We  cannot
 accurately determine the  distance a bronchial tube,
in which consonance occurs, may be from the sur- 
82    THICKENING OF THE BRONCHIAL TUBES.

face of the thorax, when its consonating sounds are
heard there; but no doubt the distance may be con-
siderable.  Increase  of voice is occasionally met
with, in cases where the amount of effusion is so
great as to produce enlargement of the thorax.
  The increase of the voice is seldom  produced, if
the fluid is prevented from accumulating in the
lower part of the thorax, and is confined to  some
particular spot by adhesions between the pulmo-
nary and costal pleura.  I have never observed it,
in cases where  partial effusions existed, about the
upper parts of  the lung:  such  effusions, however,
around the lower lobe of the lung—when the fluid
is present in  such  quantity as  to cover more than
the half of its surface, and so as in part, or altogether,
to deprive it of air—occasionally give rise  to in-
crease in the  thoracic voice.

III.  THICKENING AND ENLARGEMENT  (HYPERTROPHY)
      OF THE CARTILAGES OF THE BRONCHIAL
           TUBES WITHIN THE  LUNGS.
  The chief reason why the thoracic voice is gene-
rally louder in old than in young persons, is, that
in the former, the bronchial cartilages are increased
in size and density. Disease may render them larger
and denser than natural, both in the  old and the
young;  but such degeneration of the cartilages
(which is always accompanied by an increased, and
generally purulent, secretion from the bronchial
mucous membrane) is not of common occurrence,
and rarely proceeds so far  as  to  produce an in-
crease of the thoracic voice. 
      THICKENING OF THE BRONCHIAL TUBES.     83

  Cavities in the substance of the lungs, and en-
largements of  the  bronchial tubes—(a bronchial
tube may be uniformly enlarged through the whole
length of it, or  its enlargement may be partial, and
of a sacculated  form)—do not produce increase of
the thoracic voice, unless their walls  reflect sound,
and are infiltrated, thickened, and deprived of air,
through a depth of at least several lines.  A cavity
or enlarged bronchial tube, surrounded by paren-
chyma containing air, never gives rise  to increase
of the thoracic voice.

   Experiments in support of the considerations  of-
fered above, respecting the causes of the variations
which occur in the strength and clearness of the
 Thoracic Voice.
   We may experiment by directing  the voice into
a wooden tube, fixed after death into the trachea of
a person whose lung is hepatized, infiltrated with
tubercle, or contains cavities: for this purpose, the
lungs may be either left in the thorax, or removed
entire, with the trachea and the larynx: it very sel-
dom happens, however, that we hear  the voice over
the diseased parts the same as during life.  In these
experiments, the voice generally appears clearer in
the healthy, than in the diseased parts of the lungs;
and when they are taken out of the  body, we find
that the strength of the voice, in the normal portion
of the lung, resembles pretty closely the strength
of the voice, as observed during life, at those parts
 of the thorax beneath which the abnormal lung was
 situated.   The results obtained are not more satis-
 factory,  if, instead of speaking into  the larynx 
84    THICKENING OF THE BRONCHIAL TUBES.

through a tube, we produce a sound analogous to the
human voice, by blowing into the larynx through
the narrowed glottis. These facts may be explained
by the circumstance that, after death, fluid is almost
invariably present in the bronchial tubes, the com-
munication between the deeper bronchial tubes, or
between cavities and the larynx, being generally
either partially or  completely interrupted by  the
presence of mucus, blood, serum, etc.  For this rea-
son, we are not able to obtain satisfactory results
from experiments with the lungs; and it is very dif-
ficult and tedious, generally indeed impracticable,
to withdraw the fluid from the bronchial tubes.
  But there are other methods, by which the nature
of the modifications of the thoracic voice, as they
occur in the healthy and diseased conditions of the
lungs, can be  more readily determined.  The coats
of the small intestines may be considered, in respect
of their power of reflecting sound, to have an analo-
gous character to the membranous parts of the bron-
chial tubes; and the liver, and the substance of the
heart, to resemble in a similar respect  hepatized
lung.
  Now, if a person  speaks  through a stethoscope
placed upon one end of a portion of intestine, mode-
rately filled with air, the voice will be heard con-
sonating in the air of the intestine, through a stetho-
scope placed upon the other end; .but the force of
the  consonance will diminish,  if its coats be  much
distended.  If, instead of placing the stethoscope
immediately  upon  the intestine, the auscultation
be performed through the medium of a portion  of
liver, of lung, or of  intestine filled with water,  the 
       THICKENING OF THE BRONCHIAL TUBES.    85

consonance will cease, or be very indistinctly heard,
even though the medium employed  be not more
than half an inch thick, and merely large enough
to close the mouth of the stethoscope.
  Again, let a canal be bored along the substance
of a liver, but not so as to perforate it, and then a
person speak into the canal through a tube,  so
placed over its opening as to close it accurately;
it will be found that the  voice can be heard along
the whole length of the canal, and to a certain dis-
tance on either side of it, considerably louder than
if the person spoke through the open  air; and the
voice will still be  heard  along the course of the
artificial canal, although  the auscultation be per-
formed through the medium of hepatic or pulmo-
nary tissue several inches thick, or through bone or
cartilage;  it  becomes weaker,  however,  as the
thickness of the medium  is increased, and at last
altogether  ceases.
  If the liver be submerged in water, and care taken
to prevent the entrance of the water into the artifi-
cial opening, the voice may be heard, even through
a layer of one or two inches of water.
  This experiment is more readily performed with
the heart than the liver.  For  this  purpose, the
left ventricle is emptied  of  blood, the left auricle
closed, and the aortic valves destroyed; if the voice
of a person is now directed into a tube fixed in the
aorta, it  will  be heard consonating in its cavity,
through a stethoscope placed  over the left ventricle;
the  auscultation may  be practised  at pleasnre,
       8 
86    THICKENING OF THE BRONCHIAL TUBES.
 through the medium of lung or liver-substance, as
 well as under water.
   The same phenomena are also observed, when the
 larynx,  together  with the trachea and  the  two
 bronchi (which last must be closed,) are taken out
 of the body, and a person speaks through a tube
 fixed  in the larynx.
   Again, let a portion of intestine,  filled with air,
 be fixed under water, and two stethoscopes placed
 upon it, at a moderate distance from  each other
 (care being taken  that no water passes into them,
 which is easily managed,) and then let a person
 speak  into one of them, while the ear of the  ob-
 server is applied to the other, and it will be found
 that the consonance of the voice in the intestine is
 much  louder  than when the  experiment is per-
 formed out of water;  and  that the force of  the
 consonance is immediatedly diminished, if a portion
 of the  intestine be  allowed to project  above  the
 surface of the water.
  These experiments seem to me to indicate pretty
clearly the relation in which the increased thoracic
voice stands to the different conditions of the lungs.
If the consonance of the voice in the intestine, when
this is not placed under water, be so feeble as to be-
come inaudible through a medium of lung, liver or
fluid, half an inch to an inch in thickness, it seems
probable that the voice in the  membranous  bron-
chial tubes will likewise be so feeble, as to become
either very indistinct, or altogether inaudible, over
the thorax.  And again, justas the voice consonates
forcibly along the  artificial canal formed in the
"V:,s,**i>. 
        THE TIMBRE OF THE THORACIC VOICE.      87

 liver, in the ventricle of the heart, and in the tra-
 chea, so will it consonate forcibly in the bronchial
 tubes  of a  hepatized lung, or in the  cavity of a
 lung infiltrated with tubercle, and  appear louder
 at the thorax, than the voice which passes through
 the open air into the ear of the observer.  I have
 not been able to determine, by experiments on the
 dead body, why the thoracic voice is at  one time
 strong and clear; at another, strong and less clear;
 and, in certain cases, clear and not strong.

        THE TIMBRE OF THE THORACIC VOICE.
   The voices of individuals, and the sounds of mu-
 sical instruments, differ, not only in strength, clear-
 ness, and pitch, but (and particularly) in that quality
 also for which there is no common distinctive ex-
 pression, but which is known as the tone, the cha-
 racter, or timbre of the voice.
   The timbre of the thoracic, always differs from
 the timbre of the oral voice, and has seldom any
 resemblance to that which is  heard through the
 stethoscope, when placed upon the larynx.
   The thoracic has not the roundness of  the  oral
 voice; it is generally of a tremulous character, and
 from this circumstance, a strong thoracic voice par-
 takes of the timbre of the speaking-trumpet; a weak
 voice, of the timbre of a child's trumpet.  The tre-
 mor of a weak voice is at times hardly perceptible,
 and its timbre then resembles that  of the nasal
voice: in other cases, the tremor is as strong as that
produced by speaking against a paper, placed close
over the teeth of a comb.  The tremor is not well
marked, except when the thoracic voice  is clear, 
 88     THE TIMBRE OF THE THORACIC VOICE.

 and its consonance increased; it is hardly to be de-
 tected, if the voice be indistinct.
  It frequently happens that merely a whispering
 is heard  in the thorax.  The thoracic voice is also
 at times  observed to take somewhat of the charac-
 ter  of the amphoric echo, or metallic ringing sound,
 in cases of pneumothorax, and where large cavities
 are present in the lungs.
  The modifications in the timbre of the voice
 (which admit of several degrees,) may form various
 combinations with one another.   Thus the timbre
 of the speaking trumpet, as well as that of the nasal
 voice, and of the child's trumpet, may  be accom-
 panied by an amphoric echo, or metallic sound; and
 a peculiar tremulous tone be heard associated with
 the  nasal voice.  The timbre, and the strength and
 clearness of the thoracic voice, do not remain con-
 stantly the same in the same individual; one word
 may have the timbre  of  the speaking trumpet,
 another that of the  nasal  voice, or of the child's
 trumpet,  and so on.
  It may be asked, where  does this tremor of the
thoracic voice  arise?  The fact of the laryngeal
voice having the  timbre of the speaking-trumpet,
but not possessing the roundness of the  oral voice,
makes it  probable that  the voice becomes  tremu-
lous, not  in the air of the bronchial tubes, but in
 its  passage  through the lung-substance and  the
 thoracic  walls.  It  has not been yet  explained,
 either by clinical or post-mortem observations, why
 the  tremor is at  one time weak, and at another
very strong; and why it occasionally seems to form,
as it were, a second voice.  This much, however, 
ARTICULATION OF THE VOICE.         89
is certain,  that  the  most marked tremor of the
voice may accompany all those abnormal conditions
of the lungs which give rise to increased resonance
of the voice; it is therefore  not peculiar  to any
particular condition.
  The fact that, in a given  space, only certain
sounds consonate, enables us to explain the circum-
stance of the  thoracic voice being, in some rare
cases, replaced  by a whispering.
  The whispering represents the articulated expi-
ratory murmur;  and  when the respiratory murmur
of the larynx consonates in the lungs, we hear a
whispering, instead of a thoracic voice.
  The causes  of the amphoric echo and metallic
tinkling, will be discussed hereafter.
      THE PITCH OF THE CONSONATING VOICE.
  The pitch of the thoracic, seems occasionally dif-
ferent from the  pitch of the  oral voice;  but close
attention shows  us that a difference in  the pitch of
the consonating voice, is only to  be  heard accom-
panying the amphoric echo.  We do not find that
the pitch of the  nasal voice, and the timbre of the
speaking-trumpet, differ from that of the oral voice.
I doubt whether Laennec, under the  term "voix
plus aigiie," understood a more acute  voice (eine
hohere Stimme,) as it is rendered by Meissner, in
his  translation of Laennec's second edition.1
  THE ARTICULATION OF THE CONSONATING VOICE.
  The articulation of the voice is never heard dis-
tinctly in the thorax; the voice sounds as  though
  1 Laennec's Treatise, etc., translated by Meissner, pt. i. p. 56.
                      8* 
90          laennec's pectoriloquy
the individual were speaking without  moving the
tongue; but, though indistinct, it is nevertheless
heard  in different  degrees  of  clearness; a very
strong voice appears less articulate than a weak
one; and the articulation is  often more marked in
whispering than in speaking.  The nasal voice, and
the tracheal voice, are much less capable  of being
articulated.

    laennec's division of the thoracic voice.
  Laennec  distinguished:—
  1. The resonance of the voice in healthy lung-
tissue, and in the smaller bronchial tubes.
  2. The resonance of the voice in the larger bron-
chial tubes, lying at the roots of the lungs, in their
normal condition—Bronchophony.
  3. The resonance of the voice in  the bronchial
tubes, when the  lung-tissue  is dense and consoli-
dated—Accidental Bronchophony.
  4. The resonance of the voice in the cavity exist-
ing in the thorax, and containing air—Pectoriloquy.
  5. The tremulous—bleating—resonance caused
by fluid in the pleura—iEgophony.
  I differ from Laennec, in his views respecting
pectoriloquy, accidental bronchophony, and aego-
phony; my reasons  for so doing will appear from
the following detailed considerations of these phe-
nomena.

   laennec's pectoriloquy and bronchophony.
  Laennec, with  the view of more accurately de-
fining what he meant by pectoriloquy,  broncho-
phony, Ac,  expresses himself thus:—"The voice 
and bronchophony.
91
passes wholly through  the  stethoscope; the voice
passes  only in part through the stethoscope;  the
voice does not enter the stethoscope:" but it is ma-
nifest that whenever the voice is heard through the
stethoscope, it must have passed through it.  The
distinction which Laennec wished to draw seems to
have been this:  that in one case the voice merely
reaches the ear, but that, in  the other, it at the same
time produces a  concussion in the ear.   The voice
is said to pass wholly through the stethoscope when
it is heard, and its vibrations felt, as if it had been
directed  at once into the ear.
  The only definition of pectoriloquy which can be
gathered from Laennec's works is this, that it is the
resonance of the voice in cavities; there does  not
appear to be any  peculiarity in the voice itself which
renders it characteristic of pectoriloquy.  Laennec
divides pectoriloquy into the perfect, the imperfect,
and the doubtful.  " It is perfect when it cannot be
confounded with bronchophony, by reason  of the
distinct passage of the voice through  the  stetho-
scope, of the circumscribed  nature of the phenome-
non, and of the concurrent signs  offered by  the
cough, the rales, and the respiration.  It is imper-
fect when any of these signs are wanting, and parti-
cularly when there is no distinct passage of the voice
through the stethoscope.   It is doubtful when the
resonance is very feeble, and in such case only to be
distinguished from bronchophony by the signs ob-
served at the spot where it occurs, as well as by the
general symptoms and progress of the disease."
  Bronchophony is thus defined:—"The voice rare- 
92          laennec's pectoriloquy
ly traverses the stethoscope; its timbre has some re-
semblance to that of the speaking-trumpet; its re-
sonance is diffused, and evidently extends to a dis-
tance. If any uncertainty still remains, itis removed
by the cough, and by the sonorous inspiration which
precedes and follows it:  these phenomena  seem to
take place in lengthened tubes, and not in circum-
scribed spaces, and  have no cavernous character."
  What, according to  these descriptions of pecto-
riloquy and bronchophony, are the signs by which
they are distinguished ?
  The perfect passage of the voice through the ste-
thoscope occurs only in perfect pectoriloquy; but
even then, according to Laennec, pectoriloquy can-
not be distinguished from bronchophony, except by
taking into consideration the part where the pheno-
menon is observed, the extent of surface over which
it is heard, and also the signs offered at the same
time by the cough, the rales, and  the respiration.
The timbre of bronchophony is likened to that of
the speaking-trumpet, but nothing is said of the
timbre of pectoriloquy; we must therefore conclude
that, in  Laennec's opinion, no difference exists  be-
tween them; had any difference existed, there could
then have been no necessity for taking into consi-
deration the situation  and extent of the resonance,
the nature of  the cough, the  respiration, &c, in
order to discriminate between the two sounds.
  It seems, therefore,  that Laennec points out no
distinctive sign between the voice, which  he calls
pectoriloquy, and that known as bronchophony; that
the same voice is at one time called  by him pecto- 
and bronchophony.
93
riloquy, and at another bronchophony, according
as it is heard in different situations, and over dif-
ferent extents of surface, and  is accompanied by
particular signs, derivable from the respiration, the
rales, and the disturbance of the general functions.
But  surely when a voice, heard in different situa-
tions, is everywhere identically the same, it ought
to have but one name applied to it.
  The real question at issue is this,—how  are we
to ascertain, from the nature of the voice, whether
the resonance heard  proceeds  from a  cavity, or
from a bronchial tube ?  It is not answered, simply
by calling  the resonance  of the voice in cavities
pectoriloquy, and that in the bronchial tubes bron-
chophony, without pointing out any essential dif-
ference between the two.
  Neither have Laennec's followers, nor other phy-
sicians who have attempted the task, been more
successful  than himself in defining the distinction.
On the contrary, most writers adduce cases in which
Laennec's pectoriloquy had been heard,  and yet no
pulmonary cavities existed.  This division  of the
voice into pectoriloquy,  and bronchophony,  how-
ever, holds its ground in France, where pectorilo-
quy is still considered as characteristic of the pre-
sence of a cavity.
  We are  not able to decide with certainty by ex-
periments on the dead body, whether the voice re-
sounds in cavities,  after  the same manner as in
bronchial  tubes; but the reverse of this seems very
improbable. We hear the voice along the course of
a canal perforated in a liver,—as described above— 
94
laennec's ^gophony.
just the same as we do in the experiments with the
heart,and consequently as the resonance in a cavity.
  If we call to mind the conditions described above
as necessary for the production of the increased
thoracic voice, we shall find that there is no definite
sign, adapted to each particular case,  which will
enable us to distinguish between the resonance of
the voice in cavities, and in bronchial tubes. If the
size  of the air-containing space were alone to be
taken into consideration, a  distinction  might per-
haps be observed; but we have shown that the force
of the consonating voice is determined  by  the size
of the air-containing space, its form, the nature of
its walls, and its mode of communication with the
air in the larynx; moreover, we have seen  that the
consonating voice is modified, by the distance of its
point of origin from the thoracic walls, and by the
nature of the  medium  through which it passes,
whether lung-parenchyma, or some abnormal body.
  For these reasons, I consider it certain that the
perfect or imperfect passage of the voice through the
stethoscope, does not enable us to decide upon the
presence or absence of a cavity in the lungs;  and,
consequently, that attempts to draw a distinction
between pectoriloquy and bronchophony are use-
less, and can only be productive of error.

             laennec's ^gophony.
   Physicians have paid even more attention to the
subject of aegophony, than to that of pectoriloquy
and  bronchophony.
   "Simple aegophony," says Laennec, "consists of
a particular resonance of the voice, accompanying 
laennec's aegophony.            95
or following the articulation of words.   A voice,
sharper and harsher than that of the patient, seems
to vibrate on the surface of the lungs, resembling
its echo, rather  than  the  voice itself; it seldom
passes into  the  stethoscope, and very rarely tra-
verses it completely.  It possesses one constant cha-
racter, from which I have named it, that  of trem-
bling and hesitating, like  the bleating of a goat;
in its timbre, also, according to  the description we
have given, it resembles the voice of that animal.
  "iEgophony, heard in the neighbourhood  of a
large bronchial  tube, and in particular about the
roots of the lungs, is often found mixed up with a
more or less well-marked bronchophony.
   "The combination of these two phenomena pre-
sents numerous varieties of sound of which we may
form  a tolerably correct idea,  by calling  to mind
the effects produced:  by the transmission of the
voice through a metallic speaking-trumpet, or a split
reed; by a counter placed between the teeth and
lips of  a person while speaking; and by the nasal
quivering of the voice of showmen imitating punchi-
nello.
   "The last comparison is often very perfect, par-
ticularly in persons possessing a deep voice.   We
frequently find that simple  aegophony is present
about the lower part of the external border of the
scapula, in persons who present a combination of
the two phenomena at the root  of the lung.
   " The bleating which constitutes aegophony, seems
chiefly to belong to the articulation of the words,
although the oral voice of the patient in no degree
partakes of it; sometimes, however, it is quite dis- 
96           laennec's aegophony.
  tinct, and we hear both the resonant voice and the
  bleating silvery echo separately, though at the same
  instant; so that the last would appear to arise at a
  point either further from, or nearer to, the ear of
  the observer, than the  resonant voice.  At times,
  when the patient speaks slowly, and in broken
  words, the bleating is heard immediately  after the
  voice, and not with it, so as to appear like an im-
  perfect echo at the end of the words.  These two
  last varieties of the  phenomenon in question, ap-
  pear to me to occur only when the effusion is not
  very considerable.
   " To hear the bleating distinctly, the stethoscope
 should be firmly applied to the thorax, and the ear
 laid lightly upon it;  if the latter be pressed  hard
 upon the instrument, the bleating will be much di-
 minished in force, and the voice take more of the
 character of bronchophony.
  ^ "^Egophonyis not confined to a  distinct  spot,
 like pectoriloquy, but is spread over a considerable
 extent of surface; it may generally be recognised
 at the same moment over the whole space between
 the inner border of the scapula and the vertebral
 column, around the lower angle of the scapula, and
 through  a zone from one to  three fingers broad,
 extending along the ribs, from the middle of the
 scapula towards the nipple.
  "In a few rare cases of pleurisy, I have, in the
 first period of the disease, heard aegophony over
the whole of the affected side; and in  two of them
I ascertained after death that the phenomenon was
caused by partial adhesions of the  lung to the cos-
tal pleura, preventing the lung from being  pushed 
laennec's ^gophony.
97
back towards the mediastinum, and thus causing it
to be everywhere surrounded by a thin layer of
serum.
  " Moreover, a harsh, somewhat bleating, or reedy
bronchophony (a timbre file) is not sufficient to cha-
racterize the combination of aegophony with bron-
chophony, since, as we have said, aegophony is not
to be considered as a distinct and certain sign, ex-
cept when it reveals itself as a bleating, weak, and
silvery resonance, situated  at the  surface of the
lung."
   iEgophony, according to Laennec, exists only
when fluid  is present in the thorax, being gene-
rally observed in cases of pleurisy andhydrothorax,
where the quantity of fluid in the pleura is small.
He has himself noticed aegophony in cases where
the pleura did not contain more than three or four
ounces of fluid; and he found that the sound always
disappeared when the effusion became considerable,
and especially if sufficiently abundant to cause en-
largement of the thorax.
   According to Laennec's views, aegophony is the
natural resonance of  the voice in the branches of
the bronchial tubes, which are compressed and flat-
tened by fluid in the  pleura: the resonance tra-
versing a thin tremulous layer of fluid, and  be-
coming audible in consequence of the lung-paren-
chyma being compressed and denser than natural,
and thus made a better conductor of sound.
   In support of his opinion, Laennec offers the fol-
lowing considerations:—
   " iEgophony is most  constantly heard in those
       9 
98
LAENNEC'S jEGOPHONY.
parts,—viz. the neighbourhood of the lower angle
of the scapula, and the space between the inner
border of the scapula  and the vertebral column,
where the bronchial tubes are largest and most nu-
merous, and where the layer of fluid effused into
the pleura is thinnest  when the patient  is in the
sitting or recumbent position.
  " If the patient be placed upon his abdomen, or
lie upon the opposite side to that in which the  effu-
sion is present, the aegophony is no longer heard
in its ordinary situation, but becomes more distinct
in some other part; it ceases to be heard altogether,
if the effusion be so considerable as to compress the
bronchial  tubes as well as the pulmonary tissue.
But it reappears as the effusion diminishes, in  con-
sequence of  the  bronchial tubes, through their
greater  elasticity, regaining  their  normal state
sooner than the lung-parenchyma."
  Laennec endeavoured to show, by direct experi-
ment, the influence which the  intervention of fluid
has in the production of the bleating sound which
is characteristic of aegophony.   For this purpose,
he placed a bladder, half filled with water, on the
interscapular region of a young man, in whom there
naturally existed at this part a very clear broncho-
phony.  The voice passing through this fluid, ap-
peared to him, and to  several other  persons  who
assisted at the experiment, to be rendered sharper,
and somewhat tremulous, though not as distinctly
so as in aegophony, produced by pleuritic effusion.
A similar experiment  over the  larynx produced
similar results.
  " The bassoon and oboe, it is well known,  owe 
laennec's ^gophony.          99
their bleating tone to the thin and flattened form
of their mouth-piece, which yields to the slightest
pressure of the lips, and is made to vibrate by the
passage  of the  breath.  Now, when the lung is
forced back towards the vertebral column by pleu-
ritic effusion, the bronchial tubes must become com-
pressed and flattened, somewhat after the manner
of the mouth-piece of  these instruments; and thus
the bronchial system of  tubes becomes a kind of
wind instrument, which terminates in a number of
mouth-pieces, and in which the voice is resonant
and tremulous.  The lung-parenchyma being com-
pressed and condensed, and thereby rendered abet-
ter conductor of sound, and the  intervening fluid
(a still better conductor,) both assist in causing the
voice to reach the ear.
   " But the flattening of the bronchial tubes cannot
be looked upon as the sole cause of aegophony.  The
extent of surface over which it is heard, and the zone
of surface along which it courses, as we follow it
from the under part of the scapula towards the mam-
ma, seems to  me to prove, that a thin layer of fluid,
which is made  to vibrate by the voice, assists much,
if it be not absolutely indispensable, in the produc-
tion of aegophony;  and we may remark, moreover,
that if simple compression of the bronchial tubes
sufficed to produce aegophony, it would be constantly
present in cases of contraction of the thorax, con-
sequent upon the absorption of extensive pleuritic
 effusions.
   iEgophony, according to Laennec, is not produced
by solid exudations in the pleura, by pneumonia,
 by tubercular infiltrations, or by pulmonary cavities. 
100
laennec's ^egophony.
   A combination of aegophony with bronchophony,
 necessarily occurs in pleuro-pneumonia, one of the
 sounds in turn predominating over the other.  Pec-
 toriloquy may assume  the  tremulous character of
 aegophony, but it is only in very rare cases that it
 does so—in those, for example, where the cavity
 has a flattened form and its walls a certain degree
 of solidity.   Lastly, aegophony, bronchophony, and
 pectoriloquy, may all be present together in pleuro-
 pneumonia, associated with abscess of the lung.
   According to the preceding account, Laennec's
 simple aegophony is a sound of so peculiar a charac-
 ter, as to be always readily  distinguishable from
 bronchophony and pectoriloquy. But, on the other
 hand, the modification of the voice described by
 him as arising out of the combination of aegophony
 with bronchophony, can in no  way be distinguished
 from what he considered as simple  bronchophony,
 having somewhat of a bleating character.  How,
 for example, are we to distinguish the sharp, some-
 what bleating, and reedy bronchophony—a timbre
file—(which does not represent any combination of
 aegophony with bronchophony) from the resonance
 of the voice, as heard in a metallic  speaking-trum-
 pet or in a split reed, or from the voice of  punchi-
 nello, which last modifications  of it are represented
 as illustrating the combinations of bronchophony
 with aegophony.
  Whether the union of bronchophony with sego-
 phony has really the signification ascribed to it°by
 Laennec, whether, indeed, it be a sign of  pleuro-
 pneumonia, but not heard in pneumonia unaccom- 
LAENNEC'S iEGOPHONY.           101
panied by pleuritic effusion, are questions which
Laennec himself  seems to have answered in the
negative; otherwise there could have been no neces-
sity for admitting the existence of a variety of bron-
chophony, possessed of a bleating character, yet not
segophonic.
  If, in accordance with Laennec's views, we admit
that a combination of bronchophony with aegophony
may exist without pleuritic effusion, it docs not
seem very improbable that simple aegophony may
also exist without it.
  It is remarkable that, while Laennec was teaching
that aegophony could not exist without the presence
of fluid in the pleura, many of his most distinguished
followers should assert that they had observed the
phenomenon in simple pneumonia.  This, Laennec
always attributed to their confounding aegophony
with bronchophony. But what Laennec calls simple
aegophony,  cannot  be readily confounded  with
simple bronchophony; and in every case in which
the mistake is supposed to have occurred, there
must at all events have been a combination  of aego-
phony with  bronchophony; from which it follows
that this combination may exist independent of
pleuritic effusion.
  But as a considerable number of cases have been
observed, in which there was simple aegophony with-
out pleuritic effusion, it seems improbable that any
such mistake really did occur; and consequently we
cannot, despite of the great authority of Laennec,
consider aegophony as a certain sign of the exist-
ence of pleuritic effusion.
                       9* 
 102          LAENNEC'S iEGOPHONY.

   Dr. C. J. B. Williams is, as far as I  know, the
 only writer on  auscultation who entirely  adopts
 Laennec's views on aegophony.
   Dr. Reynaud, a pupil of Laennec, tells us that
 aegophony  may be  converted into bronchophony,
 when the patient, in whom it is heard in the erect
 position between the scapulae, is made to lie upon
 his abdomen, or incline well forwards.  The bron-
 chophony thus produced is weak when the lung is
 healthy, but loud when it is hepatized.   In the latter
 case, the moment the aegophony ceases,  bronchial
 breathing and crepitating rales appear.   From this
 Dr. Reynaud concludes,  that aegophony is merely a
 remote bronchophony, that is, bronchophony heard
 through a layer of fluid  more or less  thick.
   This theory  has been  favourably  received in
 France, and Meriadec Laennec remarks,  that Rey-
 naud's experiments give us a sure means of inva-
 riably distinguishing aegophony proper from bron-
 chophony, or rather, of distinguishing pleuritic effu-
 sion, either in a healthy or a hepatized  condition
 of the lungs, from hepatization of the lungs with-
 out pleuritic effusion.
  I have already spoken of Laennec's aegophony,
 under the name of the tremulous voice, in the chap-
 ter on the timbre of the consonating voice.  I must
 here repeat, that I have myself met with the simple
 aegophony of Laennec, both when fluid existed in
 the pleura,  and when no  trace of it could  be found
 there; also in pneumonia and in tubercular infiltra-
tions, with  or without cavities;  I have  also fre-
quently found fluid in the pleura, when  the con-
sonating thoracic voice had presented neither a tre- 
             LAENNEC'S AEGOPHONY.          103

mulous nor a bleating character; and I have ob-
served that in pleuritic effusions, as well as in pneu-
monia without such effusion, single words or sylla-
bles offered the tremulous bleating character of the
voice, whilst other words were entirely free from it.
  When a bladder filled with water is placed over
the larynx of a person speaking, the voice sounds
just the same as through a piece of liver of the same
thickness as the depth of water in the bladder.  If
the experiments which have been already frequently
referred to—as performed with portions of intestine
filled with air, or with a  perforated liver placed
under water—are repeated, it will be found that
the consonating voice in the intestine is not heard
either bleating or tremulous through the water.
I have  frequently noticed  the  tremulous sound
accidentally produced in experiments with livers,
etc., both in and out of water, but  I have never
been  able to produce it arbitrarily.
  I cannot therefore, in accordance with my own
experience, admit Laennec's aegophony to be a sign
characteristic of pleuritic  effusion;  indeed this
sound has been heard, both  by myself and others,
over the interscapular region in women and chil-
dren, whose lungs were perfectly healthy.
  If it be true that  aegophony may exist indepen-
dently  of pleuritic  effusion, it naturally follows
that Laennec's idea of the sound being occasioned
by the vibrations of a thin layer of fluid, cannot at
all  events be true in every case.
  Without pretending to call in question the cor-
rectness of Dr. Reynaud's statements respecting the 
104          LAENNEC'S 2EGOPHONY.
 conversion  of aegophony into bronchophony by
 change of the patient's  position, I would wish to
 make the following remarks thereon: Dr. Reynaud
 supposes that, when the patient is in an upright
 position, the compressed or hepatized lung is sepa-
 rated from the posterior walls of the thorax by a
 layer of fluid; but that if the patient be made to
 lie upon his abdomen, or lean well forward,  the
 lung approaches the posterior walls, and the fluid
 gravitates towards the  fore  part of the thorax.
 Now, it is well known that hepatized or compressed
 lung has a  greater specific gravity than pleuritic
 fluids; but, according to Reynaud's views, the lung
 must rise in the fluid, if it approach the back of
 the thorax when the patient lies upon his abdomen.
 My own belief is, that the compressed or hepatized
 lung of the patient lying on his back, has a decided
 tendency to  gravitate towards the posterior part of
 the thorax, and that it would slightly recede from
 that position if he assumed an upright posture, and
 still more so, if he leaned forward or lay upon his
 abdomen. I have frequently repeated Reynaud's ex-
 periments, but have never obtained similar results.
  It has occurred to me, that his observations must
 have been made upon patients in whom the pleu-
 ritic fluid existed in a sacculated form, and conse-
 quently was  incapable of change of position.  Pa-
 tients suffering from pleuritic effusions not of a sac-
 culated kind, could not endure, for more than a few
 seconds, the position of body necessary for carrying
 out Dr. Reynaud's experiments,-that  is,  if the
effusion were present in quantity sufficient to pro-
duce increased thoracic voice. 
laennec's jcgophony.          105
  1 do not believe that flattening of the bronchial
tubes has anything to do with the production of the
tremulous resonance,  as Laennec supposed.  My
own opinion is, that a tremulous sound can only be
produced by the impact of one solid body upon an-
other, or upon  some fluid or aeriform body, and
that mere vibrations of the  air cannot give rise to
it.  Musical instruments, the tones of which have
a tremulous character, are  either tongued instru-
ments, in which the tongue as it is called imparts
impulses to  the air, or instruments in which the
tongue is replaced by  some  other contrivance.
  If a disk of wood, metal, or ivory, be so placed
in the mouth as to lie between the lips and the teeth,
and  to obstruct the passage of the air out of the
mouth, it will be found that every sound excited in
the larynx takes a bleating character, of  uniform
pitch, caused by the impact of the disk on the teeth,
and bearing a most perfect resemblance to Laen-
nec's aegophony.  To  the same  cause, namely, im-
pact of one solid  body upon another, we must at-
tribute the tremulous  sound produced by speaking
upon paper placed over the teeth of a comb.
  If a person speaks into the hollow end of a ste-
thoscope, taking care that his lips completely close
the opening, but at the same time rest lightly upon
it, it will be found that nearly every tone which is-
sues from his larynx is accompanied by a tremulous
sound, of uniform pitch, which arises either between
the lips, or between the lips and the  stethoscope.
  A consideration of all these circumstances, leads
me  to the conclusion  that Laennec's aegophony is 
106
LAENNEC'S iEGOPHONY.
produced by  the impact  of one solid body  upon
another, or upon a fluid or aeriform  body.   Such
impact, however,  can only occur when the  voice
consonates in some air-containing space within the
thorax; for, as we have already shown, vibrations
are not communicated from the larynx to the pa-
renchyma of  the lungs along the walls of the tra-
chea and the  bronchial tubes.  It is therefore pro-
bable that in  most cases the walls of the bronchial
tube, within which the air consonates, react by im-
pact on the air contained within them, and so give
rise to the tremulous sound.  It is possible, how-
ever,  that it  may be occasionally  produced by a
portion of mucus, etc., partially closing the mouth
of the bronchial tube, imitating the thin tongue in
the mouth-piece of tongued instruments.
  But whatever be the way in which  aegophony is
produced, it is certain that the presence of  three
or four ounces of fluid in the pleura alone can never
produce it.
  Provided aegophony does not exist in the normal
state of the thoracic organs—and we have seen that
it does so occasionally, in women and  thin children
—it will  not  be produced, unless the fluid in the
pleura be sufficient to completely deprive of its air
by compression a portion of lung, large enough to
contain a cartilaginous bronchial tube.
  Dr. Raciborsky gives the following explanation of
aegophony:—" If the quantity of pleuritic effusion
be not sufficient fully to compress the layers of air-
cells, but only to force the pleura inwards upon them,
so as to cause the pleura and compressed air-cells to 
              laennec's .egophony.           107

form, as it were, a more or less tense membrane
about the extremities of the air-passages, a very
peculiar character will be given to the resonance of
the voice: it becomes broken and quivering, like the
voice of punchinello, or like the notes of a reed-pipe.
It has been compared to the bleating of a goat, and
in consequence received the name of aegophony." •
   I  am  convinced that aegophony cannot arise in
this way, because increased strength and clearness
of the thoracic voice is only possible, when a consi-
derable portion of lung is entirely deprived of air*
and, moreover, I consider the idea of the pleura
being pressed inwards on the air-cells, and rendered
tense by a small quantity of fluid, to be erroneous.
The lung-cells do not resist compression; they are
expanded by the pressure of the atmosphere as the
thorax dilates, and they likewise contract, whenever
pressed upon by any body occupying the cavity of
the thorax.  The more the lung is distended, the
more will the pulmonary pleura be stretched, and
consequently pressed  inwards on the walls of the
air-cells.  When the air-cells are diminished in size,
the pleura falls into  folds; and  we cannot rightly
speak of its exerting any strong pressure  against
the lung-substance, until the  whole of the  air is
forced out of the air-cells.1
  1 Fournet, Recherches Cliniques  sur VAuscultation, says:—
" Dependant l'egophonie existe, on ne saurait en douter; et dans
un certain nombre de cas, ce caractere coincide avec un  epan-
chement pleurgtique, et sert a le faire reconnaitre.  Mais on
pent e-tablir en principe gene-rale,  qu'elle ne  peut donner au
diagnostic un caractere de certitude, qu'autant qu'elle est borate 
108      DIVISION OF THE THORACIC VOICE.
   THE AUTHOR'S DIVISION OF THE THORACIC VOICE.
  I believe I have shown that Laennec's pectoriloquy
and bronchophony represent one and the same phe-
nomenon; and that his aegophony is a sound which
 a l'un des cotes de la poitrine;  qu'elle est bien nettement carac-
 terisi-e; qu'elle ne coincide point avec  le caractere cheVrotant
 de la voix ausculte'e a distance; qu'elle  n'est point sujette,
 dans ses dcgres, aux nemes variations que  le malade  peut im-
 printer a, savoix: qu'elle suit les displacements que le liquide
 peut e"prouver dans les changements de position, auxquels  on
 soumet le malade.  Ce dernier caractere est le meilleur  dont
 on puisse se  servir,  pour distinguer la bronchophonie d'avec
 l'egophonie; en effet le siege  de la  bronchophonie reste meme
 quelles que soient les attitudes diverses que prenne le malade.
 Enfin l'dgophonie n'a de veritable valeur comme signe d'epanche-
 ment pleur^tique, qu'autant qu'elle coincide avec d'autres  phe-
 nomena, soit locaux, soit ge'ne'raux, qui  de  leur cot6 autorisent
 la pens6e d'un <5panchement dans la plevre."
   In  the  Ejcaminateur Medicate, 15th  September, 1842, there is
 an essay by Roger, in which mention  is made of my Treatise on
 Auscultation and Percussion.  After describing my views  con-
 cerning the cause of the increased thoracic  voice, he goes on to
 say:—"Le docteur Skoda n'adment que deux modifications de
 la resonnance de la voix, ce sont la bronchophonie, qui  est forte
 ou faible,  et un bourdonnement indistinct, qui n'a pas pour le
 diagnostic de valeur precise.  II ne voit  pas la n<5cessite' d'ad-
 mettre, ni la pectoriloquie, ni  l'egophonie de Laennec;  ou du
 moins, si  elles  existent, comme varie'te's  de la bronchophonie,
 elles ne lui semblent pas meriter une  denomination spdciale.
 Cette  reTorme  est  certainement commode, en ce qu'elle simpli-
fierait l'Stude de l'auscultation; mais  elle prive le diagnostic de
ressources pr^cieuses, et si, en effet, il est de cas nombreux de
cavemes pulmonaires, et d'epanchements pleure"tiques oh man-
quent la voix caverneuse, et l'egophonie; si, d'autre part,  cer-
taines modifications, meme normales de la voix, peuvent parfois
simuler ces deux varices du retentissement vocal, dans d'autres 
LOUD BRONCHOPHONY.           109
is occasionally heard accompanying the consonating
voice, and which has no necessary connexion with
the presence of  fluid in the  pleura, nor, as a sign,
any especial value.
  I distinguish the  following modifications of the
thoracic voice:—
  1. The voice accompanied by a concussion in the
ear, completely traverses  the  stethoscope—loud
bronchophony, which may be either clear or dull.
  2. The voice unaccompanied by concussion in the
ear, passes incompletely through the stethoscope—
weak bronchophony.
  3. An indistinct  humming (Summen,) with or
without a barely appreciable concussion in the ear.
  4. Amphoric resonance, and the metallic echo of
the voice.  Of these, I shall speak apart hereafter.

                 LOUD BRONCHOPHONY.
  Loud Clear  Bronchophony.—In this  case, the
thoracic voice may be either as loud as, or louder,
or somewhat weaker, than the laryngeal voice; the
articulation being at the same time distinguishable.
It indicates the  presence of a considerable amount
circonstances, les phenomenes morbides sont si tranche's, qu'ils
ont une valeur s6m6iotique tres-grande, surtout si on fait atten-
tion a la region du thorax ou ils sont produits: une egophonie
marquee est un signe a peu pres certain d'epanchement  pleure-
tique, de meme que  la voix caverneuse, percue au sommet de la
poitrine, annonce neuf fois sur dix une excavation tuberculeuse,
et la variete que nous avons appeiee voix caverneuse eteinte (v.
Barth. et Roger, loc. cit. p. 185) est une signe presque infaillible
de caverne tuberculeuse."
  These arguments seem to me to be rather in favour of, than
opposed to, my views on pectoriloquy and aegophony.
        10 
110
LOUD BRONCHOPHONY.
of consolidated lung-substance beneath the part of
the thoracic walls where it is heard.   The consoli-
dated lung may be  either immediately in contact
with the walls, or separated from them by a layer
of lung-tissue containing  air, or by solid or  fluid
pleuritic exudations, provided such  intervening
media are of no considerable thickness.  Mere fluid
in the thorax does not produce loud clear broncho-
phony, except in the upper half of the interscapular
region.
  When loud clear bronchophony  is heard  over
other parts of the thorax, we may infer the existence
of one of the following abnormal states:—advanced
pneumonia or pleuro-pneumonia; hepatization, with
or without moderate pleuritic effusion; tubercular
infiltration;  pulmonary apoplexy of considerable
extent;  thickening of the bronchial tubes, with com-
plete atrophy of the lung-tissue; or a high degree
of pulmonary oedema, with co-existing pleuritic ef-
fusion, by which the cedeinatous lung has been  com-
pletely deprived of its air.   Of these different  mor-
bid conditions, hepatization and tubercular infiltra-
tion of the lungs are those which most frequently
produce loud clear bronchophony; pulmonary apo-
plexy is rarely sufficiently  extensive to produce
it.  Thickening of the bronchial tubes, with  atro-
phy of the lung-tissue, is a somewhat more frequent
cause, but still a rare one in comparison with pneu-
monia and tubercular infiltration.
  In cases of pulmonary oedema, when the whole
of the air is  forced out of considerable portions of
the lung by co-existing pleuritic effusions, or by any 
WEAK BRONCHOPHONY.
Ill
other cause, we  hear weak,  not  loud,  broncho-
phony.
  The mere existence of loud  clear bronchophony
does not enable us to decide, whether or not cavities
or enlarged bronchial tubes are present in a lung
which is hepatized, or which has become indurated
consequent to hepatization, or  which is infiltrated
with tubercular matter.  But, as we know that ab-
scesses  are  very  rare  in  pneumonia, and, on  the
other hand, that vomicae are rarely absent in tuber-
cular infiltrations, we shall not often err if, in tu-
bercular diseases, we prognosticate the presence of
cavities at  those  parts where  the voice is heard
loudest; and never infer the existence of an abscess
in  pneumonia from the  thoracic  voice, however
loud it may be heard.
   Loud Dull Bronchophony.—The voice produces a
concussion in the ear, but the articulation, and con-
sequently the words spoken, are not recognisable.
   Loud dull bronchophony is occasionally met with
between the upper halves of the scapulae of old per-
sons, in the normal condition of their lungs, but in
no other region.  When heard over any other part
of the thorax, it has the same signification as loud
clear bronchophony.

                WEAK BRONCHOPHONY.
   The  term weak bronchophony is not used to de-
signate mere humming, but a clear and  audible
voice, which produces little or no concussion in the
ear;  the articulation of the words uttered being
generally distinctly heard.   Weak bronchophony
indicates the presence of extensive pleuritic effu- 
112
WEAK BRONCHOPHONY.
sion and hydrothorax, in  addition to the diseased
conditions referred to under loud bronchophony.
   Assisted by the  percussion signs, we can  some-
times determine upon which of these two causes
bronchophony depends; if it depend upon pleuritic
effusion, we find complete dulness of percussion
over at least the half of one lobe of a lung, for it
is necessary that the fluid should be present in such
quantity, as to deprive a portion of lung,  large
enough to contain a cartilaginous bronchial tube,
of air by compression.   But if we find, at the part
where the weak bronchophony is heard, that the
percussion-sound is not completely dull, or not dull
over so large a surface as just referred to, we may
safely conclude that the bronchophony is not caused
solely by fluid in the pleura, but in part  by con-
solidated lung-parenchyma.
  If, together  with weak bronchophony, there is a
completely dull percussion-sound over a still larger
extent of surface, we cannot determine, without the
aid of other signs, whether the bronchophony is a
consequence of pleuritic effusion, or of hepatization
of the  lung.   It has been  said, that the doubt can
be removed by changing the position of the patient.
I have frequently examined patients, suffering both
from acute and chronic effusions, in different posi-
tions, but have  never observed any sign which
could serve to solve the question.
  When I am unable, either by percussion or by the
character of the thoracic voice, to decide whether the
phenomenon observed  proceeds from pleuritic ef-
fusion  or hepatization of  the lung, I (if possible) 
WEAK BRONCHOPHONY.
113
call to aid other auscultatory signs that may be at
my command, and,  in  particular,  endeavour  to
ascertain the position of the neighbouring organs.
  If,  for  example,  the  effusion is considerable
(which it must necessarily be if the dulness of the
percussion-sound be extensive,)  the neighbouring
organs are pressed out of their natural  position;
but when the lung is hepatized, or infiltrated with
tubercular matter—without pleuritic effusion —
they almost invariably retain their normal position.
If the impulse of the heart is felt at the scrobiculus
cordis, and the percussion sound  is completely dull
over the region of  the heart and the left side, we
may be sure that a  considerable amount of fluid is
present in the left pleura.
   Loud as well as weak bronchophony passes imper-
ceptibly into indistinct humming, which is either
accompanied or  not with concussion in the ear; no
distinct line of demarkation can be drawn between
these three degrees of the resonant voice; the ex-
treme varieties  are readily recognised, but the in-
termediate pass imperceptibly one into the other.
   No conclusion can therefore be drawn from the
resonance of the voice alone, except when it pre-
sents itself as undoubted bronchophony.   If the
voice be not sufficiently loud or clear to allow of
positive conclusions, we may yet obtain some tole-
rably safe results, by comparing it at different parts
of the thorax, especially at corresponding parts of
the two sides.   But it is  always well to take into
consideration every sign which  auscultation and
                      10* 
114
WEAK BRONCHOPHONY.
 percussion can afford us, before we come to any de-
 cided conclusion.
   This precaution is particularly necessary in the
 investigation of the interscapular and subclavicu-
 lar regions.
   We are not able  to draw any conclusions from
 bronchophony, when heard in the interscapular re-
 gion, as it is often observed there in the  normal
 condition of the respiratory organs.  In the healthy
 state of the lungs, the thoracic voice is nowhere
 heard so loud and clear as over the larynx; such
 strength and clearness, therefore, of the consonating
 voice, even though heard  in the interscapular re-
 gion, indicates the presence of a hepatized lung, or
 extensive pleuritic effusion.  If we hear the tho-
 racic voice as a clear whispering, i. e. as an articu-
 lated expiratory murmur, we may be certain that
 there exists some diseased condition of the respi-
 ratory organs.1
  The other varieties of weak bronchophony heard
in the interscapular  and subclavicular regions, of
themselves yield no results.  A comparison of the
sounds  heard at corresponding parts of the two
sides of the thorax must be made, and  every other
sign which percussion and auscultation can afford,
called in to aid the diagnosis.
  1 Laennec considered the clear whispering as a variety of bron-
chophony, and Barth and Roger looked upon it in the same light-
and so also did Fournet.  The clear whispering, unaccompanied
by amphoric resonance or metallic tinkling, is as little a sign of
the existence of a cavity, as any other vocal sound.  It has the
same  signification as weak bronchophony.  I have no doubt
that every one will recognise in the clear whispering, the phe-
nomenon described by  Fournet, vol. i., p. 159. 
RESPIEATORY MURMURS.          115
INDISTINCT HUMMING, WITH OR WITHOUT A BARELY PERCEPTIBLE
               CONCUSSION IN THE EAR.
  No distinct  signification can be attached to the
presence of this humming, nor to a complete absence
of all resonance.   Such humming is observed, not
only in the normal  state of the lungs, but may be
met with in any of  their diseased conditions;  and
the reason of this is, that bronchophony does not
depend upon one, but upon many different states of
the lungs.   A lung may be extensively hepatized,
without producing bronchophony, in consequence
of the bronchial tubes of the hepatized part being
filled with mucus, and not containing air.1

  II. MURMURS CAUSED BY THE MOTION  OP THE  AIR
               DURING RESPIRATION.
   These may be  generally classed under the head
of  respiratory murmurs, of rales, and of  whistling
(Pfeifen,) and sonorous  sounds (Schnurren.)   The
pure respiratory murmur is heard when the air, in
its passage through  the lungs, meets with no ob-
struction,  either from the presence of fluids in the
bronchial  tubes,  or from any peculiarity of their
construction.  The rales, and whistling, and sono-
rous sounds, are caused by the presence of fluid in
  i Dr. Hourmann states that if the auscultator himself speak
while examining a patient, he will hear pectoriloquy over cavi-
ties; bronchophony in hepatization of the lungs; and aegophony
in pleuritic effusion.  The experiment may be readily repeated.
It will be found that bronchophony is invariably heard, whether
the lung be healthy or diseased.  So-called autophony is, there-
fore, valueless as a sign of disease. 
116
RESPIRATORY MURMURS.
the air-passages, by thickening of the bronchial
mucous  membrane, and by any partial narrowing
or compression of the bronchial tubes.

   The Respiratory Murmur.—We know that the air
produces a murmur in the mouth and nose during
respiration;  by placing the stethoscope  over the
larynx and trachea we shall also hear murmurs ac-
companying  the respiratory movements; we are
therefore fully justified in concluding that murmurs
also take place  during respiration throughout the
whole extent of the air-passages of the lungs.
   The murmur most readily heard over the thorax,
would naturally be that which arises from the parts
of the lung immediately beneath the surface;  and as
only the air-cells and finer bronchial tubes exist near
the surface of the lung, it would follow that the mur-
mur  heard arises from those parts in particular.
But every murmur is propagated to a distance, in
proportion to its intensity; and, consequently, those
murmurs also which originate in the remoter—the
central—parts of the lung, in the large bronchial
tubes, and even in the trachea and  larynx, may be
heard over every part of the thorax, in addition to
the murmur of the air-cells and finer bronchial tubes.
   Now  if these  facts  be  correct, the  respiratory
murmur as heard at any particular part of the thorax
will not enable us to judge of the condition  of the
lung beneath it, unless we have some .means  of dis-
tinguishing between a near and a remote murmur—
between that of the air-cells, and of the larger bron-
chial tubes, of the trachea, and of the larynx.  This 
RESPIRATORY MURMURS.
117
at first sight does not appear very difficult, for we
are well accustomed  to  judge of the distance of
sounds.  Our  judgment may, indeed, be tolerably
correct so long as the sounds pass through no other
medium than the air, and their direction is not dis-
turbed; but by auscultation it is far from easy to
determine the distance and source of a sound.
   By experience we obtain positive proof that a re-
mote respiratory murmur can be heard over any part
of the thorax;1 thus, for example, we frequently re-
mark a very loud respiratory murmur at parts of the
thorax, beneath which there is a considerable portion
of hepatized lung, that is, lung into which no air can
enter.  Here, then, the question meets us, How are
we to distinguish between a near and a  remote re-
spiratory murmur—between the murmur of the air-
cells and finer bronchial tubes, and  the murmur of
the large bronchial tubes, of the trachea, and of the
larynx?
   To answer this  question it is necessary first to
isolate these  sounds, analyze them  apart, and fix
the  distinctive characters which belong to each in-
dividually; secondly, to ascertain the alterations
which they undergo by propagation to a distance;
and thirdly, to point out those cases in which the
laryngeal, the tracheal, or the bronchial murmurs,
  1 There is no doubt about the fact, although Dr. Phillip asserts
the contrary.
  Fournet, in the first volume of his work, p. 359, points out
the changes which  the respiratory murmurs undergo, when
heard at a distance from their point of origin. 
118
RESPIRATORY MURMURS.
become consonant in the bronchial tubes, or in ca-
vities;  and moreover to show how the non-conso-
nating tracheal murmurs, etc., may be distinguished
from the consonating.
  The respiratory murmur of the larynx and trachea
may during life be heard isolated; and we may also
isolate the murmur proper to a bronchus, by sepa-
rating the tube from the trachea and the lungs, and
then forcing a stream of air through it.  The re-
spiratory murmur of the air-cells and finer bronchial
tubes cannot be imitated in the dead body, in con-
sequence of fluid being constantly present in the air
passages  after death,  so that  rales  are produced
whenever air is forced into them: the only way by
which we can obtain a knowledge of the nature of
this murmur is by a comparison of it as heard in
different individuals.
  Now we know that, as a rule, the respiratory mur-
mur in children is much more distinct and loud than
in grown-up people, though there appears no differ-
ence in the intensity of their  laryngeal murmur.
There are also many circumstances which may in-
crease the respiratory murmur in grown-up persons,
and render it puerile, the laryngeal murmur remain-
ing unaltered.   We may therefore conclude that
the murmur as heard in infants, presents us with the
most perfect  characters proper to the  respiratory
murmur of the air-cells and finer bronchial tubes.
  The next question is, What signs have  we  by
which to distinguish between the respiratory mur-
murs of the larynx, the trachea, the large bronchi,
the air-cells, and the finer bronchial tubes? 
RESPIRATORY MURMURS.
119
  Determination of the Differences in the Respira-
tory Murmurs.—The different respiratory murmurs
may be  imitated, either by  drawing  air into,  or
forcing it out of the mouth.   In attempting to imi-
tate them, it will be found that we always place
the lips and tongue in  the  position which is re-
quisite for the conversion of  an unarticulated into
an articulated laryngeal sound; in short, that every
murmur is  produced by the  union of a consonant
and a vowel, the sound not being  formed in the
larynx, but in the mouth alone.   That position of
the mouth which is necessary for the pronunciation
of any particular consonant and vowel, always-gives
rise to the same murmur.  Hence we can distinguish
sufficiently well between the different respiratory
murmurs, inasmuch as  they are  capable of being
imitated by the mouth,  and  as the position of the
lips and the tongue requisite for the production of
 any .murmur, can be determined by the pronuncia-
 tion of a consonant and a vowel.1
   The alterations which take place in the murmurs,
 through change of the vowels, are analogous to those
 which take place in the pitch of the laryngeal sounds,
  1 I am well aware, that no one can obtain a just idea of aus-
cultation, without practising it; but he who will give himself
the trouble to analyze the sounds separately, will fix them with
greater facility in his memory, and attain to a nearer knowledge
of their peculiarities.
  The respiratory murmurs are capable of very close imitation
by the mouth; and the student, by frequently attempting to imi-
tate them, will soon be convinced of the correctness of the above
statement; and he will also  find, that  a clear idea of the dis-
tinctions  drawn by me is far from useless. 
120         RESPIRATORY MURMURS.
particularly of the musical sounds. I shall not, there-
fore, trouble myself by speaking of the pitch of the
different murmurs, but shall consider this deter-
mined by the vowel which is requisite for the pro-
duction of the murmur.   The letter e produces the
highest pitch in a murmur, the letter u the lowest.

  Character of the  respiratory murmurs of the la-
rynx, the trachea, and the large bronchi.—In attempt-
ing to imitate these murmurs, we find that in each
case we retain the same consonant, and that what-
ever difference arises, depends upon a change of the
vowel employed.  The consonant which answers to
these murmurs is ch guttural, or it falls between h
and  ch.  The laryngeal, tracheal, and  bronchial
murmurs, may be imitated by forcing air against the
hard palate; this is done  involuntarily in  hard
breathing.   The pitch of the murmur depends upon
the width of the opening  through which the  air
passes, that is, the ch appears in combination with
different vowels.  As a rule, the laryngeal murmur
is higher than the respiratory murmur of the lungs.

  Character of the respiratory murmur of  the air-
cells and finer bronchial tubes.—This murmur may
be imitated by narrowing the opening of the mouth,
and then drawing in the air.  The consonant of this
murmur is v or 6.  This character, however, refers
only to  the murmur of inspiration; that  of expira-
tion in the normal state of the respiratory organs,
causes little or no  sound in the air-cells and finer
bronchial tubes; whatever sound is heard differs
from the  murmur of inspiration,  and  resembles 
RESPIRATORY MURMURS.
121
rather a gentle  aspiration (Hauchen) or blowing
(Blasen.)  It can only be imitated  by the mouth
during expiration; the consonant which represents
it falls between f and h.
  Changes which the respiratory murmurs undergo
when propagated to  a distance.—The respiratory
murmurs present  the above characters only when
they are heard near their origin; at a distance from
it, their proper characters may be lost, even though
the murmur itself be of considerable strength.  All
murmurs and sounds lose more or less of their es-
sential character by propagation to a distance. The
rolling of a  carriage is readily distinguished from
the clatter of a mill, and the roaring of a waterfall
from the howling of a storm, when the sounds are
produced in our immediate neighbourhood; but
when they reach us from a distance, their character
becomes  so similar, that we can no longer ascribe
its particular cause to any of them.
  The nature of the laryngeal respiratory murmur,
as heard over the thorax through the healthy paren-
chyma of the lungs, may be ascertained in the fol-
lowing manner:—A healthy person being made to
hold his breath, the observer auscultates his thorax,
whilst an assistant blows into a tube, inserted as far
down as conveniently may be the  throat of the per-
son auscultated, thus exciting a loud murmur there.
The murmur thus caused by the air driven through
the tube  resembles the laryngeal respiratory mur-
mur; and in consequence of its loudness and prox-
imity to the larynx, traverses the parenchyma of the
lungs as perfectly as the natural laryngeal murmur.
       11 
122
RESPIRATORY MURMURS.
  During the experiment a murmur may be heard,
especially in the  interscapular region, which does
not resemble the ordinary laryngeal murmur; it is
deep and hard of imitation by the mouth, and there-
fore its consonant is difficult to determine.  The
pronunciation of the consonant/during expiration
gives us the best idea of it.
  It happens occasionally, when pleuritic effusion
has so thoroughly compressed a lung as  to prevent
all entrance of air into it, that a  respiratory mur-
mur is  still heard  over the  affected side, particu-
larly in the space between the scapula and the spine,
and  beneath the clavicles;  such  murmur must of
necessity have its origin in the trachea or one of the
large bronchial tubes, and hence we have means of
judging what changes the tracheal murmur under-
goes by its passage through a considerable amount
of liquid.  It becomes deep, and  no longer re-
sembles the ordinary tracheal murmur; if any one
attempt to imitate it by the  mouth, he will find it
best represented by the consonant f pronounced
during expiration.
  We can judge of the character of the respiratory
murmur of the air-cells and finer bronchial tubes,
by auscultating over those parts of the thorax be-
neath which we have ascertained by percussion that
there is no lung present, but which are not so far
from the lung as to prevent our hearing the murmur.
In this way we shall find, that by distance the mur-
mur loses  its sipping  character, and  is converted
into something between an  aspiration and a blow-
ing very difficult of imitation, and also  best repre- 
RESPIRATORY MURMURS.
123
sented by the consonant/ pronounced during ex-
piration.
  In certain perfectly healthy individuals, the in-
spiratory  murmur is scarcely audible,  or, at all
events, has not the characters which are here given
as proper  to it, although in these cases  the air as-
suredly enters into the air-cells of the lungs: it re-
sembles rather a remote murmur of the air-cells or
of the trachea, but has nothing of a sipping (Schlur-
fen) or gasping (Keucheh) character, and cannot
therefore  be safely referred to either the one or
the other  of these sounds.

  Conditions under which an increase by  consonance
of the laryngeal, tracheal, and bronchial murmurs
takes place within the lungs;  and the difference be-
tween the  consonating and non-consonating  tracheal
murmurs as heard over the thorax.—If it be true, that
the thoracic voice is increased by consonance in
certain altered conditions of the respiratory organs,
there can be no doubt that the laryngeal, tracheal,
and bronchial  respiratory murmurs may  likewise
be increased by consonance within the thorax, and
be heard louder and clearer than natural  over the
surface of the thorax.   It is evident, that the con-
ditions necessary to produce consonance of the re-
spiratory  murmurs, are the same as those required
for the voice; I shall not; therefore, repeat  them here.
  The distinction between the consonating and the
non-consonating respiratory murmurs, or murmurs
merely conducted from a distance (as heard over the
thorax,) becomes evident, if we consider the differ-
ence between the consonating and non-consonating 
124         VESICULAR RESPIRATION.
voice.  If the conditions necessary for consonance
are present, the voice is  heard as such over the
thorax, otherwise it is recognised only as a hum-
ming.  In like manner, the consonating laryngeal
murmur is heard as a  laryngeal murmur over the
thorax, except in cases of large excavations or of
pneumothorax, where  the  amphoric resonance or
metallic tinkling is associated with the murmur:
the non-consonating laryngeal murmur has the cha-
racters already described.

    LAENNEC'S  DIVISION OF THE RESPIRATORY
                  MURMURS.
  1. Pulmonary—Vesicular—Respiratory Murmur.
  2. Bronchial Respiration.
  3. Cavernous Respiration.
  4. Blowing Respiration, and Masked Respiration
(souffle voile.)

          LAENNEC'S VESICULAR RESPIRATION.
  This he  describes  as a weak but  very distinct
murmur, audible during inspiration and expiration,
indicating the entrance of air into the pulmonary
tissue, and  its consequent distention.  The laryn-
geal, the tracheal, and bronchial murmurs, he tells
us, are audible only in the interscapular space and
behind the sternum, and even there almost wholly
masked by the vesicular  murmur.  He draws no
distinction between the inspiratory and expiratory
murmurs, and appears to set down every thoracic
murmur which is not bronchial, cavernous, blowing,
or amphoric, as vesicular.
  I believe that this view is incorrect, for the rea- 
VESICULAR RESPIRATION.          125
sons I have given above, and consequently that the
signification attached  by Laennec to his vesicular
murmur, cannot be true in all cases.
  "When the respiration," says Laennec, "is dis-
tinctly heard of pretty equal strength  over every
part of  the  thorax, we  may be  sure that neither
pleuritic effusion nor engorgementof the pulmonary
tissue has taken place; but, on the contrary, when
we find  the inspiration deficient at  a certain part,
we may safely conclude that the subjacent lung is
impermeable to air; this sign is as characteristic,
and as  readily distinguished, as the existence  or
absence of the proper percussion-sound of the part
(as ascertained by the method of Auenbrugger,) and
supplies precisely the same indications.  Absence
of sound is  always  associated with absence of re-
spiration, excepting in some few cases, in which a
comparison of the results obtained by auscultation
and percussion will afford signs which are perfectly
pathognomonic.
  " Auscultation, as we shall see, has the advantage
of indicating the different  degrees of pulmonary
congestion with greater certainty than percussion;
it has the disadvantage of occupying more time, but
its practice  requires  less care  and attention than
percussion;  it is  available in every case, and even
serviceable  in those which yield no results to the
method of Auenbrugger."
  Now I am convinced, that the respiratory mur-
mur may be heard of equal strength and clearness
over the whole of the thorax, even when consider-
able portions of the lung are distended  and con-
                      11* 
126     BRONCHIAL RESPIRATORY MURMUR.
gested, and that it may be strong at one part, and
weak and indistinct at another, when there exists no
abnormal affection of the lungs which is appreciable.
I therefore dissent from  the opinion, that auscul-
tation is a surer indication than percussion of the
different degrees of pulmonary congestion; I hold it
essential, in every case, to take  into consideration
the percussion signs and the general  symptoms, as
well as the indications obtainable by auscultation.

      LAENNEC'S BRONCHIAL RESPIRATORY MURMUR.
  By this murmur, Laennec understood the sound
produced during respiration by motion of the air in
the larynx, the trachea, the large bronchial tubes
at the root of the lung, and in the smaller bronchial
tubes.  In the healthy condition of the respiratory
organs,  however,  it  is not heard  in the smaller
bronchial tubes, being mixed up with the vesicular
murmur.  Hence  the bronchial murmur is audible
only in the neighbourhood of the larynx, and occa-
sionally over the surface of the neck; in certain (and
particularly so in  thin) persons, the murmur heard
behind the sternum and in the interscapular region,
partakes of the character of the bronchial murmur,
but is hard to be  distinguished,  being commingled
with the vesicular murmur.
  Should the pulmonary tissue have become hard-
ened or condensed from any cause, as from pleuritic
effusion, peripneumonia,  or pulmonary  apoplexy,
and the respiratory murmur be notably diminished,
or have entirely  disappeared, we  then often dis-
tinctly hear the bronchial respiration, not only in
the larger bronchial tubes, but also in the smaller 
        BRONCHIAL RESPIRATORY MURMUR.      127

branches.  This phenomenon Laennec explains in the
following  manner:—"The entrance of air into the
air-cells is prevented by the congestion and con-
densation  of the pulmonary tissue, and hence bron-
chial respiration alone takes place, and it is heard
so much the louder and more readily, in consequence
of the sound-conducting power of the tissue being
increased  by its condensation.
  The bronchial respiration in such abnormal states
of the  lung, is heard with most distinctness about
the root and apex of the lung; and the reason  of
this is, that at the root  the bronchial tubes are
widest, and at the apex most subject to dilatation.
  I do not consider Laennec's opinion of the cause
of the  bronchial  respiration correct.  The bron-
chial respiration  is often heard remarkably  loud
in cases where the  lung-tissue is compressed,  or
completely hepatized, so that no air can enter into
it; but an increased current of air would of neces-
sity be required to produce the bronchial murmur,
if Laennec's views were correct.  Now, during in-
spiration,  the air rushes into the lung with greater
force and  rapidity, the greater the power of expan-
sion of that organ; and is more  forcibly driven out
again during expiration, the more firmly the  lung
contracts,  or is compressed.  The less any part of
a lung expands during inspiration, and contracts
during expiration, the less will be the current  of
air  flowing into  or out of the bronchial  tubes;
when the  lung-tissue is completely compressed  or
hepatized, the current will be almost nil.f  As no
change of volume takes place in a hepatized lung
during respiration, we can hardly speak of any cur- 
128         CAVERNOUS RESPIRATION.
rent of air  flowing into or out of it.  The slight
contraction which the bronchial tubes possibly un-
dergo during expiration from pressure of the tho-
racic walls, and the equally slight expansion during
inspiration,  may certainly permit the entrance  of
air into them, but  can cause no current capable of
producing the loud bronchial murmurs frequently
heard over the thorax.1
   For  similar reasons, I cannot adopt Andral's ex-
planation of bronchial respiration.  It is  as fol-
lows: "When there is any obstruction to the en-
trance  of air into the air-cells, the pressure of the
air upon the bronchial tubes is increased, and, con-
sequently, a louder murmur is  produced  within
them."  My belief is, that the bronchial respiration
must be explained  by the laws of consonance.
When, for instance, the walls of any large pulmo-
nary cavity, or of the bronchial  tubes, which run
into the parenchyma of the lungs, are solid enough
to reflect sound, the respiratory murmur of the la-
rynx, of the trachea, and of the two bronchi, will
consonate in the air contained within them.

          LAENNEC'S CAVERNOUS RESPIRATION.
   "By the term cavernous respiration," says Laen-
nec, " I  understand   the  murmur  which  occurs
during inspiration and expiration in a cavity formed
in a pulmonary tissue, either through softening of
tubercular matter, or through gangrene, or through
  1 Fournet and Barth and Roger, all give the same explanation
of the bronchial murmur as Laennec does; but they state, in
addition, that the thickened pulmonary tissue  consonates and
strengthens the sound. 
CAYERNOUS RESPIRATION.          129
abscess  consequent on pneumonia.  This kind of
respiratory murmur has the same character as the
bronchial respiration, but the air seems to penetrate
into a larger cavity than that of a bronchial tube.
If any doubt as to its nature arise, it  may readily
be removed by observation of the resonance of the
voice, and of the cough.
  It is not possible from such a description to draw
any distinction between bronchial and cavernous
breathing.  Daily experience teaches us that va-
rious kinds of murmurs are produced by air, when
it enters into a wide and confined space ; of such,
those to which Laennec gave the name of amphoric
echo, and metallic tinkling, can alone be considered
as characteristic of a cavity.  This, however, does
not appear to have been Laennec's idea, for he
speaks of the amphoric echo as heard during respi-
ration, and of its signification, under another head
altogether.
  If Laennec had been able to  observe any con-
stant distinctive sign between cavernous and bron-
chial respiration, he would doubtlessly have endea-
voured to give  an idea of it by comparison with
some well-known  murmur, and not have proposed
that as a sign of cavernous breathing, which cannot
possibly be a sign.
  The statement made by Laennec, viz., that air is
heard entering into a cavity larger than that of a
bronchial tube, furnishes us with no characteristic
sign, for what the peculiarity  of the murmur  is
which indicates the entrance of air into the larger
space, is not defined. 
130         CAVERNOUS RESPIRATION.
  A cavity in a lung does not always yield the same
murmur: the murmur varies according  to the size
of the cavity, the number and diameter of the bron-
chial tubes which open into it, and the condition of
its walls.  The murmur is also more or less dis-
tinct, according  as the cavity is more or less dis-
tant from the walls of the thorax.   Some cavities
in the lungs have such firm and hardened walls,
that any diminution or enlargement of them during
respiration must be very slight, and in some cases
impossible;  consequently, no air passes into them
during inspiration, nor out during expiration; yet,
if they contain air, and communicate with the bron-
chial tubes, a very loud murmur is generally pro-
duced within them during respiration: this murmur
is evidently an  effect of consonance.  The air in
the cavity vibrates in unison with the air contained
in the nearest bronchial tube which communicates
with it, and in which a murmur is produced by the
current of air during respiration: the murmur thus
excited in a cavity by consonance is bronchial, ex-
cepting when the cavity is of sufficient magnitude
to give rise to amphoric echo or metallic tinkling.
   Some cavities, though their walls are solid, are
capable of being compressed, and consequently ad-
mit air during inspiration, and expel it during ex-
piration.  According to the laws of consonance, we
ought in such cavities to hear  both the respiratory
murmur of  the nearest or even of distant bronchial
 tubes, and that also which is caused by the current
 of air flowing into and out of  the cavity, provided
 the change in its capacity be sufficiently great.  The 
BLOWING RESPIRATION.
131
murmur, however, produced by consonance, is al-
ways either bronchial or amphoric; and that excited
by the passage of the air into and out of the cavity,
must, owing to the solidity of its walls, have the
same  character, provided it be not  accidentally
converted into a hissing, whistling, or  sonorous
sound, in  consequence of the narrowness  of the
mouth of the bronchial tube which opens into the
cavity.
  Little or no consonance  occurs in cavities, the
walls of which are merely membranous, and imme-
diately surrounded by air-containing lung-tissue ;
neither are bronchial breathing, amphoric echo, nor
metallic tinkling, produced within them.  The air
streaming in and out (provided the communication
be sufficiently free) causes a feeble murmur, not re-
sembling the vesicular murmur, but something be-
tween an aspiration and a blowing; when the com-
munication is narrow, whistling, hissing, and sono-
rous sounds arise.  If the  cavity is large, and the
opening into it narrow,  and particularly if there
are several such cavities, we hear, in cases of dys-
pnoea, a loud  hissing during inspiration, followed
by one or more clicks at the end of inspiration,—a
sotmd resembling that produced by suddenly stretch-
ing a slip of paper, and which is known under the
name of craquement, dry crepitant rale.

    laennec's blowing respiration (respiration sovfflante.)
   When the  respiratory murmur produces  in the
ear of the observer a sensation as of air being drawn
from his ear during inspiration, and blown into it
during expiration, it  gives us a representation of 
132
BLOWING RESPIRATION.
Laennec's blowing-respiration:  this  blowing,  ac-
cording to him, accompanies bronchial and cavern-
ous breathing only, and  occurs in those  cases in
which the bronchial tubes or the cavity lie very
near to the thoracic walls.  The  vesicular respi-
ration may produce a similar illusion, when the in-
spiratory and expiratory murmurs  are sufficiently
strong.  The bronchial murmur does not become
blowing, unless its intensity is increased.
  But the intensity of the respiratory murmur does
not depend solely upon the distance of the bron-
chial tubes, or the  cavity in which  the  murmur
arises from the thoracic walls; it depends also upon
the rapidity and  extent of the  respiratory move-
ments, and upon the force of the consonance. The
blowing bronchial respiration does not invariably in-
dicate the presence of a cavity, or of a bronchial tube
lying immediately subjacent to the thoracic walls.
  Laennec  speaks of another modification of  the
blowing respiration, as the masked blowing (souffle
voile,) in the following terms: "It seems as though
every vibration of the voice, the cough, and the re-
spiration, puts in motion a kind of moveable veil,
placed between  the cavity and  the ear of the  ob-
server.  The phenomenon is observed—1. In tuber-
cular cavities, the walls of which are at some points
very thin, and at the same time soft and flexible,
having no attachment, or but a very slight one, to
the walls of the thorax; 2. In cases where the walls
of peripneumonic abscesses are in a state of unequal
inflammatory induration, being still at some points
in the stage of congestion; 3. The phenomenon is 
BLOWING RESPIRATION.
133
still more frequently observed in cases where bron-
chophony, produced by pneumonia in some of the
large bronchial trunks, is present, the affected bron-
chus being in some parts of its course  surrounded
by healthy pulmonary tissue, or tissue but slightly
congested, which is placed between the bronchus
and the ear of the observer; 4. Dilatation of the bron-
chial tubes and pleurisy are sometimes attended by
the  same phenomenon,  under  analogous circum-
stances,—that is, when the oavity in which the re-
sonance of the respiration,  of the voice, or of the
cough takes place, has its walls much less dense in
some parts than in others.
   "This phenomenon must not be confounded with
the  large  bubbling mucous rale which sometimes
attends it; the difference is readily recognised by
any one accustomed to auscultation."
   It is impossible to understand exactly the nature
 of the murmur, to which Laennec applies the term
 souffle voile, for in his description of it, he does not
 give us the means of comparing it with any known
 murmur.  In works on auscultation which have
 appeared  since Laennec's time, the  souffle voile
 is scarcely referred to.   I have never  myself met
 with any  murmur which is  constantly associated
 with the conditions described by Laennec as requi-
 site for the production of the souffle voile, and which
 is observable in no other case.  I believe that Laen-
 nec, by souffle voile, intended to represent the phe-
 nomenon which is observed when the respiratory
 murmur is indistinct at the commencement of in-
 spiration, but  suddenly becomes bronchial,  and
        12 
134   DIVISION OF THE RESPIRATORY MURMURS.

even bronchial blowing, as the inspiration advances;
the expiratory murmur, on the other hand, being
loud at its commencement,  and indistinct at its
conclusion.
  Such a modification of the bronchial breathing
indicates nothing more than  this: that at the com-
mencement of inspiration and at the end of expira-
tion, the communication  of the  bronchial tube, or
the cavity whence the bronchial breathing proceeds,
with the other bronchial tubes, is either partially
or completely interrupted, and is  restored again
during inspiration.


   THE  AUTHOR'S DIVISION OF THE  RESPIRATORY
                   MURMURS.
  I consider Laennec's bronchial and  cavernous re-
spiration to be one and the same murmur; his blow-
ing bronchial to be  a loud bronchial  murmur; and
his souffle voile to be an unimportant modification
of the bronchial respiration.  I am also convinced
that there are  respiratory murmurs  audible over
the thorax, which  cannot be classed either under
the head of bronchial or of vesicular murmurs.
   The  following is my division of the  respiratory
murmurs:—
   1.  The pulmonary respiratory murmur, or vesi-
cular breathing of Andral.
   2.  Bronchial breathing.
   3.  Amphoric echo and metallic tinkling heard
during breathing: of these I shall speak hereafter. 
VESICULAR BREATHING.
135
   4.  Indeterminate (unbestimmte) respiratory mur-
murs.1
                  VESICULAR BREATHING.
   By vesicular breathing, I understand that mur-
mur only which is heard during inspiration; it re-
sembles the sound made by sucking in air through
the  lips.  I do not apply  the term to any inspira-
  1 Dr. Phillip, following  Fournet,  says:—"Metallic tinkling,
amphoric echo, the  cavernous, the  bronchial, the  blowing, the
resonant  respiratory, and the clear respiratory murmur—all
come under the same type, the metallic.   In many diseases—as
in phthisis—we see them passing through every shade, one into
the other.  There is no change in the nature, the essence of the
murmur, but  merely a  gradual conversion of one variety into
another.
   But what is the essence of the murmur?  I can scarcely be-
lieve that any one will, upon reflection, repeat this indefinite de-
scription of Fournet.  What  do we  gain by being told that me-
tallic tinkling, cavernous  and bronchial  breathing, etc., are not
distinct murmurs,  but merely degrees  of the same  murmur ?
The question  still remains: What are the conditions indicated
by these  different murmurs,  or these different degrees of the
same murmur?  In  this  respect, amphoric  echo  and metallic
tinkling must be separated from all the varieties  of bronchial
breathing.  If the gradual passage of one murmur into another
justified  us in classing them under one head, then we may say
that all murmurs must be classed together, for all pass gradually
one into  the other.
   But Fournet,  notwithstanding his assertion of similitude of
type between these murmurs, could not  bring  himself to place
the  cavernous and  the bronchial breathing  in the  same class.
He says:—"Ce  n'est pas que, lors de l'absence des caracteres
caverneux et amphoriques, on doive conclure nScessairement &
la non-existence  de cavernes; car, il arrive quelquefois que, dans
certaines dispositions, anatomiques des  parties malades, le ca-
ractere bronchique au deuxieme, ou trousieme degre\ qui se passe
adns une partie rapproch^e, de 1'oreille, obscurcit, ou meme 
136
VESICULAR BREATH INC.
tory murmur which does  not distinctly offer  this
character, even though it be the inspiratory mur-
mur of a perfectly healthy individual.   I am con-
vinced that a respiratory murmur of the character
here given, can only be produced by the passage of
the air into the air-cells of the lungs.  The expira-
tory murmur has no relation whatever to vesicular
breathing; it may be weak or strong, or altogether
absent, without in any way affecting the vesicular
breathing.
   I explain the sound of the vesicular breating as
Laennec does, attributing it to the friction of the
air against the walls  of the finer bronchial tubes
and the air-cells, the contractile power of which it
has to overcome.  The reason why the inspiratory
murmur of the air-cells is much louder than the ex-
piratory is, that the air, when it enters into them,
meets  with  resistance  from their contractility, but
does not meet with any in its passage out of them.
It is otherwise, however, with the large bronchial
tubes, and particularly with the trachea and larynx:
here the air, during inspiration, meets with no op-
position—it  has, indeed, rather a tendency  to ex-
pansion; but during inspiration, being forced from
a  larger—the air-cells—into a smaller space, it is
compressed; and hence the expiratory  murmur of
efface tout-a-fait le caractere caverneux a un faible degree qui
se produit dans les parties centrales du poumon."—Recherches
cliniques sur VAuscultation, pt. ii. p. 519.
  Barth and Roger entirely follow Laennec, in regard to the sig-
nifications of the respiratory murmurs.  I believe that I differ
somewhat from the generally received opinion, in representing
the bronchial and cavernous respiration as identical. 
VESICULAR BREATHING.          137
the larynx, the trachea, and the large bronchi, is,
as a rule, louder than the inspiratory.
  This  fact of itself almost suffices to disprove
Beau's theory of the cause of vesicular breathing:
his explanation is this:—the sound produced by the
impulse of the air against the soft palate, and the
neighbouring parts, is propagated along the whole
length of the columns of air contained in the tubes.
I believe I have already shown that the respiratory
murmur of the soft palate, the larynx, the trachea,
and the large  bronchi, is never heard as vesicular
breathing  over  the  thorax when the lungs  are
healthy; in certain diseased cpnditions  of these or-
gans it is sometimes heard as bronchial breathing.
Beau appears, in his explanation of the respiratory
murmur, to have  been  guided by observation of
the bronchial  breathing heard over the thorax.
   The presence of the vesicular murmur at any
part of the thorax, indicates the entrance of air
into the air-cells of that part of the lung which lies
beneath the spot auscultated.  Its existence, there-
fore,  excludes those  abnormal conditions which
prevent the passage of air into the air-cells; such,
for example, as their compression by exudations,
or tumours in the pleura, by enlargement of the
heart, and other diseases; infiltration of the  lung
tissue by plastic  or tubercular matters, by blood,
serum, etc., atrophy of  the  air-cells, and the obli-
teration of the bronchial tubes by mucus and blood,
or by swelling of  the mucous membranes.
   Solitary tubercles, however abundant, do  not
necessarily interfere with the vesicular respiration,
                      12* 
138
VESICULAR BREATIIINC
nor does inflammation confined to a few lobules—
lobular hepatization;—the vesicular murmur is, in
fact,  frequently observed  in  the course of these
diseased conditions of the lungs.
   The  greater  the opposition  produced  by  con-
tractility to the entrance of air into  the air-cells,
and  the more rapid  and  complete the inspiratory
movements', the louder will the vesicular breathing
be.   The force of the vesicular respiration is also
modified  by the different  conditions of the lining
membrane of the air-cells  and the finer  bronchial
tubes; it always becomes  louder when of a coarse
character—the coarseness indicates a slight degree
of swelling of the mucous membrane of the  finer
bronchial tubes, and the air-cells.1
   Vesicular breathing may pass gradually into the
indeterminate respiratory murmur, and harsh vesi-
cular breathing into hissing, whistling  and sono-
rous  sounds.
  The tone of the vesicular is almost always deeper
  1 Fournet treats of the qualities of respiratory murmurs under
the following heads: 1, their essential character;  2, their cha-
racter of hardness and softness; 3, their character of dryness
and moistness; 4, their timbre;  5, pitch; 6, intensity; 7,  dura-
tion ;  and 8, rhythm.  I believe that the timbre of the murmur
is its essential character. Fournet himself says:—"Le caractere
propre de la grande classe des alterations de timbre consiste dans
cette impression auditive, que Ton a rendue par le nom de me"-
tallique;" that is, the  metallic  timbre forms the essential cha-
racter of a certain class of sounds.  The character of hardness
is better interpreted by the term of harshness; the healthy vesi-
cular murmur is gentle and soft, quite unlike the coarse vesicular
murmur.  The term moist is not applicable to the respiratory
murmur; we cannot speak of a moist or dry respiration, the idea
of moistness can be attached only to  rales. 
VESICULAR BREATHING.         I39
than that of the laryngeal respiratory murmur.
It is sometimes inordinately acute, particularly in
the upper parts of the lungs, in old people, and in
cases of pulmonary oedema, and when solitary tu-
bercles are thickly scattered through the tissue of,
the lungs ; in some rare cases it is even more acute
than the laryngeal murmur.  An acute vesicular
murmur of this character is nearly allied to a hiss-
ing sound.  The vesicular breathing may be  un-
attended by an expiratory murmur; when the lat-
ter is  present, it varies considerably in strength,
and is occasionally much louder than  the  inspira-
tory.  The  presence of  an expiratory  murmur
always indicates  the  existence in  the bronchial
tubes of some obstruction to the egress of the air
from the lungs.   The impediment is, in most cases,
caused by a swelling of the  lining membrane of
the  bronchial tubes.  The expiratory murmur is,
with very few exceptions,  of a deeper tone than
the inspiratory;  and the depth is in the ratio of the
distance of  the  bronchial tube, in which it arises,
from the surface of the lung.  It approaches the
pitch  of the vesicular inspiration in those cases
only, where the current of air meets with  obstruc-
tion in the finest bronchial tubes.   Fournet has
carefully investigated  the relation of the  expira-
tory to  the inspiratory murmur, and he has ex-
pressed  their strength and duration by figures, in
order more accurately to define their relative de-
grees.
   The normal inspiratory murmur, that is, vesicu-
lar breathing, may be expressed by the number 10,
and normal expiration by 2; in other words, the 
140          VESICULAR BREATHING.
 strength and duration of the latter  are only one-
 fifth of those of the former.
   Under abnormal circumstances, inspiration may
 fall from  10 to 0; the expiratory murmur either
 sinking in  a like proportion,  or remaining  un-
 changed, or rising even as high as 20.  The inten-
 sity  of the  inspiratory may  also increase, whilst
 that of the expiratory murmur  either remains un-
 altered, or is also increased.  Lastly, the intensity
 alone of both the inspiratory and the expiratory
 murmur, may be  either increased or diminished,
 the duration either  remaining unaltered, or in-
 creasing or diminishing in different proportions.
 Their  duration may also differ from the normal
 standard, without the intensity undergoing any al-
 teration.
  Fournet considers that increased intensity of the
 expiratory, attended by diminution in that of the
inspiratory murmur, is a very important diagnostic
sign; the higher degrees of such abnormal  changes
being observable  in  cases of emphysema  and  tu-
bercle  of the lungs:  such variations  in the inten-
sity of the murmurs also occur, but in a less marked
degree, in cases of induration  of the  lung from
other causes, in acute catarrh, and in pleurisy, ac-
companied by moderate effusion.  I am, neverthe-
less, still of opinion  that an increased expiratory
murmur—provided it has not a  bronchial,  nor any
other character than that proper to  it—indicates
nothing more than this; that the air, in passing out
of the  lungs, meets with some obstruction in the
bronchial tubes.
  In some rare cases, the acute  development of 
VESICULAR BREATHING.
141
solitary tubercles produces no alteration whatever
in the  respiratory murmur;  most generally, how-
ever, it is attended by signs of catarrh.  The slow
formation of tubercle in isolated spots, either pro-
duces no signs at all, or, if any, those of catarrh
or of pleurisy.
   A marked prolongation of the respiratory, accom-
panied by a shortened inspiratory murmur, is not
observed in chronic development of tubercle, unless
the tubercular mass be considerable, or cavities be
also present in the lungs.  Whenever there is ex-
tensive condensation of  the  lung-tissue,  from any
other cause, the prolonged expiratory and shortened
inspiratory murmurs also co-exist.  In such cases,
however, the strength of the expiratory murmur is
frequently  produced by consonance;  and it often
happens, that an indistinct expiratory murmur is con-
verted by a deep inspiration  into bronchial breath-
ing, and thus is frequently associated Avith broncho-
phony.  The intensity of such an expiratory mur-
mur occasionally indicates its approaching conver-
sion into a sonorous sound, or of its having already
assumed the character of a weak sonorous sound.
   The murmurs attending emphysema of the lungs
vary much, according to the extent of the disease,
and the amount of catarrh accompanying it.  The
expiratory murmur is very slight, when  the bron-
chial tubes contain no mucus, and are  not swollen;
but it becomes full and  prolonged, if their mucous
membrane be thickened, or the bronchial tubes in
any way narrowed,  as  by contraction:  generally
speaking, the  murmur ceases to be a respiratory
murmur, properly so called, but is converted into a 
142         BRONCHIAL RESPIRATION.
sonorous, a whistling, or hissing sound,—in short,
emphysema of the lungs yields the same ausculta-
tory signs as catarrh.

              BRONCHIAL RESPIRATION.
  A respiratory murmur cannot be called bronchial,
unless it has a character of a laryngeal or tracheal
murmur, differing from the latter only in respect of
its pitch.  Bronchial breathing may be imitated by
blowing into a tube; to imitate it  with the mouth,
the tongue must be so placed as to form the con-
sonant ch—guttural—and the air then drawn in and
forced out.   The bronchial respiration heard over
the thorax  may be  higher, stronger, deeper, or
weaker  than the laryngeal murmur, or it may be
of the same strength and pitch; the reason of its
thus varying in character is, that the bronchial re-
spiration is not always a consonating laryngeal re-
spiratory murmur, but frequently proceeds from
the lower  part of the trachea, or  from one of the
bronchial trunks, or even from one of the large bron-
chial branches.   The different degrees of strength
and pitch  of the bronchial respiration heard over
the thorax, afford no special indication, inasmuch
as such modifications are not produced by one, but
by several causes.
  The different degrees of strength  and pitch of
the respiratory murmur of the larynx, the trachea,
and the  bronchi—which depend in part upon the
rapidity and extent  of the respiratory movements,
and in part upon the condition of  the lining mem-
brane of the air-passages, and the more or less per-
fect consonance of the murmur within the diseased 
BRONCHIAL RESPIRATION.          143
lung (which takes place  after the manner I have
described)—produce changes in the strength and
pitch of the bronchial  respiration heard over the
thorax.
  The bronchial respiration is generally  heard
louder  over the thorax  during  expiration, than
during inspiration, in consequence of the tracheal,
the laryngeal, and  bronchial expiratory murmurs
being for the most part louder than the inspiratory;
but there are exceptions to this, for the inspiratory
murmur may be  the louder, or exist alone;1  or the
expiratory only  may be heard;  or the inspiration
may commence  with an  indistinct vesicular, and
then pass into a  bronchial murmur.
  These modifications are all accidental;  they are
caused  for the  most   part by the interruption
(through the presence of mucus, blood, etc.) of the
communication between  the bronchial  tubes, and
may vary from minute to minute.2
  Bronchial respiration offers the same indications
as weak bronchophony, and I therefore refer the
reader to what has  been  already said  under  that
head:3 it does not however occur, like weak bron-
  1 "Jamais je n'ai vu le caractere  bronchique normale  ou
morbide, exister pendant l'inspiration seulement," says Fournet,
p. 58.
  2 Barth and Roger, p. 83, observe:—"Du reste, le ph^nomene
—la respiration bronchique—est continu, permanent,  et n'est
point sujet a des intermittences."  I must entirely deny this
assertion.  The bronchial  respiration appears and disappears,
and is replaced by other murmurs.
  * Barth and  Roger, p. 88, assert, that bronchial respiration
very rarely occurs, in cases where effusion exists alone, without
thickening of the lung-parenchyma; it occurs, they say, first, 
144    INDETERMINATE RESPIRATORY MURMURS.
chophony, in the normal  state of the respiratory
organs.   It  may be heard occasionally, in healthy
persons, about the  upper  dorsal vertebrae, and, in
cases of great dyspnoea, between the  scapulas, and
sometimes over  every part of the thorax, without
there being any change of ^structure  in the corre-
sponding portion of lung-tissue.  This anomaly may
be explained by the circumstance, that when the
respiratory murmur of the large bronchial tubes is
loud at its origin, it may become audible  as bron-
chial respiration over  the thorax, without  being
strengthened by consonance.
  Bronchial breathing may pass gradually into the
indeterminate respiratory murmur, into  amphoric
echo and metallic tinkling, and into  consonating,
whistling, hissing,  and sonorous sounds.
    indeterminate (unbestimmte)  RESPIRATORY murmur.
  Under this title  I include such respiratory mur-
murs as have neither the character of vesicular nor

occasionally at the  commencement  of an attack of pleurisy,
when  the quantity  of  effusion  is small, and  the  respiration
strong; and secondly,  in cases where the  effusion is  spread
equally over the lung, in consequence of its being partially
attached to the walls  of the thorax. Except in these cases,
bronchial respiration invariably indicates condensation  of the
lung-tissue.
  There  is no doubt   that bronchial respiration is most fre-
quently heard in cases  of hepatization and tubercular infiltra-
tions of the lung;  but it is also heard when effusion alone
exists, not indeed under the circumstances stated by Barth and
Roger, but in every case where the conditions necessary for the
production of consonance present themselves.   Equally incor-
rect is the statement, that the bronchial respiration caused by
effusion, is distinguishable from that caused by hepatization of
the lung. 
      INDETERMINATE RESPIRATORY MURMURS.   145

of bronchial  respiration, are not attended by am-
phoric echo nor  metallic tinkling, nor are repre-
sented by any of the other murmurs  hereafter to
be described, which accompany  respiration; viz.,
whistling, hissing, and sonorous sounds, or pleural
friction sounds.
  The respiratory murmur of the air-cells is some-
times so little marked, as to be in no way distin-
guishable from the  murmur which proceeds from
the deeper bronchial tubes, or even from the larynx,
and which is propagated, unaided by consonance,
through the parenchyma of the lungs, to the thora-
cic walls.  A weak  and remote  rale  may also  be
heard over the thorax, as an ill-defined respiratory
murmur of the air-cells.  No distinct indication can
in any particular case be drawn  from such a mur-
mur, as several causes may concur in producing  it.
We cannot ascribe  it with any certainty either to
the entrance  of air into the air-cells, or to fhe pas-
sage of air through the  larger bronchial tubes,  or
to a weak and remote rale, though we may be cer-
tain that it depends upon some one or other of these
causes, or upon some combination of them.
  Moreover,  the  murmur  of  the larger bronchial
tubes may, without either consonating or partaking
of the character of the bronchial respiration,  be
heard so distinctly over the thorax, as at once to
satisfy the observer  that it is not formed in the air-
cells ; but in such a case we cannot tell whether the
air does or does not enter  into the  air-cells,  for
either alternative is possible; and hence, from a
murmur of this kind, no conclusion can be drawn
       13 
 146   INDETERMINATE RESPIRATORY MURMURS.

 as to the state of the pulmonary parenchyma: nei-
 ther does the expiratory murmur, provided it be
 not bronchial, nor amphoric, afford us any indica-
 tion of the condition of the lung.
   All respiratory murmurs which give us no infor-
 mation as to the state of  the parenchyma  of  the
 lungs, I call indeterminate respiratory murmurs—
 any subdivision of them appears to me useless.
   A loud  indeterminate respiratory murmur indi-
 cates that obstruction exists to the passage of the
 air in some of the bronchial tubes; its strength and
 pitch enable us to judge tolerably well of the size
 of the tubes.  The indeterminate respiratory mur-
 mur passes gradually into whistling,  hissing, and
 sonorous  sounds.
   I have not troubled myself to describe accurately
 the characters of the respiratory murmurs; for I do
 not consider that there is any great difficulty in dis-
 tinguishing a murmur, provided  it be not  one  of
 those sounds which characterize the transition  of
 one murmur into another.   The more delicate and
 practised  the ear of the observer, the more readily
 will he judge rightly of these transition-murmurs:
 it is, however, much the safer plan to regard  all
 respiratory murmurs which are not distinct in cha-
 racter, as  indeterminate murmurs, and to draw no
 conclusion from them without due consideration
 of all the  other indications obtainable by percus-
 sion, etc.   With  such precautions, an observer,
 though  but moderately practised in auscultation'
 wdl rarely fail in his object.1

  1 Fournet, vol. i., p. 82, gives th7^owing~description^f a
peculiar  respiratory murmur.—"On apprecie  trfcs bien par 
THE RALES.
147
                        RALES.
          Causes of the Rales, and their Varieties.
   The rales heard during  respiration are, for the
most part, caused by the passage of air through li-
quids, such as mucus, blood, serum, etc., which are
accidentally pressed in  the bronchial tubes, or in
pulmonary cavities.  A  kind  of rale may also be
produced by solid  bodies—as,  for example, by a
fold of mucous membrane—when they partially ob-
struct the air, and are made to vibrate.   A pecu-
liar rale  is  also produced when  a current of air
passes into a lung which is distensible, but has lost
its contractile power.
   The respiratory  murmurs may  be either  com-
l'auscultation, a la sensation recue par l'oreille, si l'air pe"netre
bien avant dans le tissu pulmonaire, et a quel degre' se fait l'ex-
pansion de ce tissu.  Si un 6panchement pleur6tique considerable
comprime le poumon, on sent, en quelque sorte que Fair, apres
avoir pdn<3tre" un peu dans l'arbre bronchique, ne peut pas aller
plus loin; on sent qu'alors il lutte un instant contre 1'obstacle qui
s'oppose a, la dilatation des v6sicules, et que, ne pouvant p6n6trer
dans celle-ci, il fait exe'cuter au tissu pulmonaire comprint, une
sorte de dilatation en masse  qui s'accompagne d'un petit  bruit
tout particulier.  II n'est pas de mot, qui  puisse rendre exacte-
ment cette sensation; il faut 1'avoir eprouve"e;  mais  il importe
beaucoup d'en marquer le degre, afin de savoir oh l'on en est de
la marche de la maladie," etc.
  The  statement that the air struggles for an instant  against an
obstacle, and  then, because the air-cells will not allow of expan-
sion, dilates the  lung-substance in mass, hardly needs refuta-
tion.   Air enters only where a vacuum is formed, and does not
struggle against obstacles, except when a vacuum exists beyond
them.   I  am unacquainted with the murmur  described  by
Fournet; it is impossible to follow a statement so mixed up with
hypothesis. 
148               THE RALES.
pletely masked by the rales, or heard in concert
with them.
  Rales resemble the bubbling of boiling water or
of fat, the breaking of bubbles  on the surface of
fermenting fluids, the fine crackling of the little
bubbles which rise to the surface of water begin-
ning to boil, or of roasting fat, the crackling of
salt  on  hot coals, the cracking  of dry wood, the
creaking of frozen snow, or of leather, etc.:  they
may be associated with the amphoric echo, and me-
tallic tinkling.   Hence rales vary much in charac-
ter; but, with very few exceptions, they indicate the
presence of liquids in the  bronchial  tubes, or in
cavities.
  Most  of the  rales take the character of sounds
produced by the breaking of bubbles in a liquid;
some, however, resemble the creaking  of leather,
etc.; the first sort have been called moist, the latter
dry rales; but no distinctive line can be drawn be-
tween them; they pass gradually one into the other.
It may be asked, if we are able, by  the character of
the rale, to ascertain the nature and quantity of the
fluid which occasions it, whether the fluid is present
in the air-cells, in the larger or smaller bronchial
tubes, or in cavities, and what is  the condition of
the lung-parenchyma?  These questions cannot be
answered until  all the varieties of sounds which
these rales present, and their causes, are determined.
   The sounds caused by the breaking of bubbles
in a fluid vary with the size of the bubbles; moist
rales are formed by large, small, or very fine bub-
blings.   In the  creaking of leather and of snow,
and in the cracking of wood, the intervals of the 
MOIST AND DRY RALES.
149
sounds vary in duration; and  thus  the dry rales
have been called  large, small, fine-bubbling  rales,
to indicate the extent of the intervals between the
cracklings which form them.
  Rales, whether  dry or  moist, and whatever the
size of the  bubbles  producing them, may be loud
or weak, clear or dull, scanty or  abundant; they
may also vary in pitch, and  have  an amphoric or
metallic echo.

             MOIST  AND DRY RALES.
  It is probable that the moist or dry character of
a rale, depends upon the consistence of the liquid
in the bronchial  tubes or the cavities where it oc-
curs: solid  bodies, however, can only produce rales
after the manner described above: when we speak
of dry rales, we mean no more than that, in all pro-
bability, the fluid which  occasions them is more
tenacious than that which causes moist rales.

             SIZE OF THE BUBBLES.
  The larger bronchial tubes and cavities can alone
produce  large bubbles; small bubbles, however,
may occur both in the smaller and the larger bron-
chial tubes, and in cavities: the size of the bubbles
in the larger bronchial  tubes  and in cavities, de-
pends upon the quantity and quality of the  fluid in
them, and upon the rapidity of the current of air
passing through  it;  but  although  the sound of
small, and even of very fine bubbles, may be heard
in the larger bronchial tubes  and in cavities, yet
large bubbles are always intermingled with them:
                      13* 
150        AMOUNT OF RALES PRESENT.

the rales are never equal.  A fine and equal bub-
bling rale can take place only in the smallest bron-
chial tubes and in the air-cells; it indicates, there-
fore, the presence of some fluid—mucus, blood, or
serum—in those tubes and air-cells, and by demon-
strating  the entrance of air into the air-cells, it
precludes the existence of every diseased condition
of the respiratory organs, which would render the
entrance of air into the air-cells impossible.  It
has, in relation to the lung parenchyma, the same
signification as vesicular breathing.

           AMOUNT  OF RALES PRESENT.
  This depends upon  the quantity  of fluid, and
whether  it be present  in one or  in several bron-
chial tubes, and upon the force of the respiration.
If the rales are scanty, consisting of single  bub-
blings, and the vesicular or  bronchial respiratory
murmur at the same time audible, then we may be
certain that little fluid is present in the air-pas-
sages, provided cavities, the fluid contents of which
are not disturbed by the stream of air, do not exist
in the lungs.   Abundant rales, unaccompanied by
a respiratory murmur,  or  heard in  combination
with an  indeterminate  respiratory  murmur, indi-
cate, for the most part, that the bronchial tubes are
extensively filled with mucus, blood, serum, etc.
We may observe here, that rales may be heard
either both during  inspiration and expiration, or
during inspiration or expiration only.  Such differ-
ence is quite accidental; the fine equal bubbling
rale is the only rale audible  for any length of time 
STRENGTH OF THE RALES.
151
during inspiration only, and continuing after the
patient coughs.

            STRENGTH OF  THE RALES.
  Rales are at times so loud that they may be heard
passing through the mouth of the patient, and also
through the walls of the thorax, without the ear or
stethoscope  being brought in contact with them;
at other times they are so feeble, that as careful
attention is required for their observation as for
that of a weak respiratory murmur.  The differ-
ence in the strength of rales depends chiefly upon
the extent and rapidity of the respiratory move-
ments.
  The  death-rattle  may  be  classed among  the
loudest of rales; it is audible through the mouth,
and is produced for the most part in the larynx,
the trachea,  and the two bronchial trunks;  but
rales occur at the same time in the bronchial tubes.
Rales  arising in a superficial pulmonary cavity,
may be sometimes heard through the walls of the
thorax, without the ear being brought in contact
with it, and this, too, when the respiration is neither
rapid  nor strong: in such cases, the rales are also
generally heard through the mouth of the patient,
although  not produced in the larynx and trachea.
Loud  rales,  arising in  the larynx or the trachea,
may be heard over the whole thorax, and so pre-
clude  the  observation of  any other auscultatory
sign which the respiration might offer.  Ausculta-
tion of the heart and arterial  trunks within the
thorax, may also be rendered impossible by the
presence of rales. 
152        CLEARNESS OF THE RALES.
      CLEARNESS  OR DISTINCTNESS OF  RALES.
  It is often very difficult to determine the exact
spot, where rales which are heard over the thorax
arise;  thoracic sounds  pass through other media
besides the air, and they do not always travel in a
straight direction; we must therefore endeavour to
judge of their points of origin by considering  their
clearness and distinctness, whenever this is possible.
  A remote rale is not so clear as a rale arising in
the neighbourhood of the spot where it is observed;
but a loud and distant rale may be clearer than a
near and  feeble  one; again, rales  arising in  the
larynx, the trachea, or either of  the bronchi, may
consonate within the thorax, just as  the voice or
the respiratory murmur consonates in the diseased
states of the lung-tissue already referred to, and thus
becomes distinctly audible  throughout the thorax.
  Fine, equal bubbling rales, if clear, must of ne-
cessity arise immediately beneath the spot where
they are observed; consequently the air-cells at the
part must be permeable to air, and the lung  con-
tain no cavities, or, at least, none of any magnitude.
  Unequal or large bubbling rales  may arise in
cavities which lie near the  surface of the lung, or,
when dyspnoea is present, they may proceed  from
distant cavities, or  enlarged bronchial tubes, or
they may  be consonating sounds  produced in  the
trachea, even though the respiration be feeble.
  It is not possible to define the distance from the
thoracic walls at which a dull rale  arises; it  may
proceed from the larynx, the trachea, the bronchial
tubes, the air-cells, or cavities. 
PITCH OF THE RALES,           153
              PITCH OF THE RALES.
  I determine the pitch of  a rale in the same way
as that of a respiratory murmur; that is, by ascer-
taining  the vowel which is used when we attempt
to imitate either it or an equal pitched respiratory
murmur by the mouth.
  The pitch of a rale generally corresponds to that
of the respiratory murmur, which is either replaced
by or accompanies it; the laryngeal and tracheal
rales and respiratory murmurs are, as a rule, more
acute than the vesicular rales and murmur.   But
there are exceptions to this in the case of the re-
spiratory murmurs,  and still greater in the case of
the rales, in consequence of their pitch being  so
much affected by the quality of the fluid which pro-
duces them.  However high or low pitched a bron-
chial rale may be, it always loses  by transmission,
and more or less in  proportion to its  original fee-
bleness, and to the remoteness of its source from
the walls of the thorax;  exception being made of the
case in which its intensity is  increased by conso-
nance.
  Acute rales in  the larger bronchial tubes, when
consonant, appear acute also over the thorax; did
they  reach the walls  by  mere conduction,  they
would become deeper.  The larger or unequal bub-
bling rales, therefore,  are only heard  as  acute
sounds over the thorax when the conditions neces-
sary for consonance are present, or when they arise
in cavities near the surface of the lung; in this last
case, however, as  a general  rule, acute rales are not
heard unless the walls of the cavity reflect the sounds. 
154     laennec's division of the rales.

  The acute large, or  unequal bubbling thoracic
rales, indicate the same condition of the lung-tis-
sue as bronchophony and bronchial respiration; it
is, for the most part, a sign of hepatization, or tu-
bercular infiltration  of the lung, being more fre-
quently present in these affections than in pleuritic
effusion; but for  greater accuracy of diagnosis, it
is always well to  take into account the sounds eli-
cited by percussion, and the general symptoms re-
ferred to in the remarks on bronchophony.
  A deep and dull rale indicates the presence of
mucus, blood, serum, etc., in the bronchial tubes, or
in cavities, but affords no information respecting
the condition of  the  lung-tissue.  A deep, clear,
large-bubbling rale, reaches  the surface from dis-
tant parts by consonance, or it arises immediately
beneath the surface of the lung, either in superficial
cavities, or in enlarged bronchial tubesj by the aid
of percussion, we may generally decide whether the
rale is consonating or not.

          laennec's  division of the rales.
  Laennec included, under the  denomination of
rales, the sonorous and sibilant sounds.   He pro-
poses five divisions:—
  1. Moist crepitating rale,  or "crepitation—"le
rale crepitant humide ou  crepitation."
  2.  Mucous rale or gurgling—"le rale muqueux,
ou gargouillement."
  3. Dry sonorous rale, or snoring—" le rale sec
sonore, ou ronflement."
  4.  Dry sibilant, or whistling rale—"le rale sibi-
lant sec, ou sifflement." 
MOIST CREPITATING RALES.
155
  5. Dry  crepitant rale with  large bubbles, or
crackling—"le rale crepitant sec a  grosse bulles,
ou craquement."
  Under the term rales, I myself include only such
sounds as  resemble the breaking of bubbles in wa-
ter, or the crackling (Prasseln) as of burning wood,
and shall  therefore  speak separately of Laennec's
dry sonorous, and dry sibilant rales.

          LAENNEC'S MOIST CREPITATING RALE.
  This rale, according to Laennec, is one of the most
important of auscultatory signs, and I shall there-
fore describe it in his own words. " The moist cre-
pitating rale evidently arises in the pulmonary tis-
sue ; it may be likened to the sound produced by
gently heating salt in a  pan or by  the inflation of
a dry bladder, or, still better, to the sound produced
by the  pressure between the fingers of a healthy
lung distended by  air, but  it is somewhat louder
than this; and, in addition, it has  a well-marked
character of fluidity.  On  hearing it, we at once
recognise the presence in the air-cells of a fluid of
the consistency of water, by which the entrance of
the air into them is not prevented; the bubbles form-
ing the rale appear extremely small.  This  rale,
which  is one of the most important, is readily re-
cognised; and any one who has once heard it, can
scarcely fail  to know it again;  it is a sign pathog-
nomonic of pneumonia in its first stage, and ceases
to be heard when the lung becomes hepatized, re-
appearing, however, during the resolution of the
hepatization; it may  be  also  observed in pulmo- 
156         MOIST CREPITATING RALES.
nary cedema, and occasionally in haemoptysis; but
in the last two cases the bubbles formed by the dis-
placement of the air, seem  somewhat larger  and
more  moist  than those  producing the crepitating
rale of pneumonia: to this variety of rale I have
given the name of sub-crepitant rale—" rale sous-
crepitant."
   Attempts have since been made to distinguish be-
tween  the  crepitating  and  sub-crepitating rales.
Dance considered that they differed in this: that the
crepitating rale was audible only duringinspiration,
and did not disappear after expectoration; the  sub-
crepitating rale being heard during both inspiration
and expiration, and disappearing after expectora-
tion.
   It is quite true, that the crepitating rale of Laen-
nec is occasionally observed during inspiration only,
and is not removed, by expectoration; but this does
not characterize it as a sign pathognomonic of pneu-
monia.  Andral,  Cruveilhier, Chomel, etc., have
brought forward numerous facts, which prove that
Laennec's crepitating rale cannot be regarded as
such a sign;  and that, in fact, no distinctive line can
be drawn between crepitating, sub-crepitating, and
mucous rales. Laennec's opinion, however, of the
great value, as a sign, of the crepitating rale, still
prevails; and most writers are careful to make a
marked distinction between  this and every other
rale.
   For myself, I consider Laennec's crepitation, viz.,
the fine, equal-bubbling rale, denotes the presence
of fluid in the finer bronchial tubes  and in the air-
cells, and the entrance of air into the latter; but that 
MUCOUS RALES.
157
it does not inform us by what particular disease the
fluid is produced; this must be learnt from  other
phenomena.  Moreover, I have not only not  found
this crepitation constantly present in pneumonia, but
if we are to follow Laennec's description of it very
closely, I must say that I have not often observed it.

               Laennec's Mucous Rale.
  Under this title are comprised the mucous rale
proper, rdle muqueux, or as Andral calls it, rale bron-
chique  humide,—and the cavernous rale—rale ca-
verneux.   Laennec distinguishes the mucous rale
from the crepitating by the greater and unequal size
of the bubbles which compose it; and the cavernous
from the mucous rale  by the bubbles of the former
being more abundant  and louder than those of the
latter;  and by the circumstance of its being heard
in a circumscribed space, where also the cavernous
cough and respiration, as well as pectoriloquy, are
generally present.
  It will be seen at once from this description  of the
cavernous rale, that it is in no respect a more accu-
rate sign of the existence of a cavity than pectorilo-
quy, or cavernous respiration.   The size and abun-
dance of the bubbles depend upon the quantity and
the quality of the fluid in the bronchial tubes, or in
the cavities, and upon the force of the respiration.
The limitation of the rale to a confined space is a
very uncertain sign.  If cavities occupied the whole
of one lung, how could we recognise the cavernous
character of the rale as described by Laennec? and
how are those abundant rales which sometimes arise
       14 
158          DRY CREPITATING RALES.
in large, single, and superficial bronchial tubes, to
be distinguished from Laennec's cavernous rales?
  I am convinced that no difference can be recog-
nised between bronchial and cavernous rales except
in cases where the latter  are associated with am-
phoric echo, or metallic tinkling.  Cavernous, just
as bronchial rales, are produced by bubbles, large
and small, moist and dry, abundant and scanty, clear
and dull, high and deep toned, and may consonate,
like the bronchial.  Cavities in the lungs, and bron-
chial  tubes equally, may remain for a  long time
filled with  fluid, without producing any rales; rales
only arise  in cavities, when these can expand and
contract during respiration, and when the passage
of air into and out of them is not wholly obstructed.

   Laennec's Dry Crepitating Rale with Large Bubbles—
                   Craquement.1
  This rale, according to  Laennec, resembles the
sound produced by inflating a pig's bladder, and is
a sign pathognomonic of vesicular and interlobular
emphysema of the lungs: it is observed only in those
cases where the air-cells of a portion of the lung
are considerably  enlarged, to  the size of  a pea,
perhaps, or a bean, and communicate with the bron-
chial tubes: in no other case of pulmonary emphy-
sema is it present.   It may arise, moreover, in en-
  1 No one, since Laennec, appears to have heard this rale, and
it is for the most part excluded from the list of auscultatory phe-
nomena.  I cannot agree with the general opinion on this point,
for I consider that such a rale really exists.  However, he who
has not heard it, or has not been able to discriminate it, has not
lost much. 
fournet's division of rales.        159
larged and sacculated bronchial tubes, and  in ca-
vities of the lungs which have membranous walls,
and communicate with the bronchial tubes through
moderate-sized openings.
  Laennec's craquement has been attributed to a
tearing up of the pulmonary tissue; but I do not
consider that we have any knowledge whatever of
the sound produced by rupture  of the air-cells.
My own belief is,  that  the craquement is caused
by distention, during inspiration, of the  walls of
the air-cells, the bronchial tubes, and cavities, when
these walls have lost their contractility, and simply
collapse during expiration.
  Such collapse, or, more properly speaking, com-
pression of the air-cells, enlarged bronchial tubes,
and cavities, is only possible when the still contrac-
tile portionof the lung—on account of some obstruc-
tion of its bronchial tubes, or of the large extent of
tissue rendered non-contractile in consequence of the
adhesion of the lung to the  costal pleura, etc.—is
insufficient, when inflated by inspiration, to distend
the cavity of the thorax;  the non-contractile por-
tion must therefore become altered in volume during
the respiratory movements.

        fournet's division of the rales.1
  His chief distinctions are drawn from the seat of
origin of the rales:—
  1 Barth and Roger follow Laennec's division of the rales:
they, however, call the mucous rale—rale sous-crepitant.   Ac-
cording to Professor Chomel, certain special characters belong
to the cavernous rale, by which an observer may decide whether
it is  produced in a pulmonary cavity, or in a circumscribed 
 160        fournet's division of rales.

   1. Intra-vesicular rales.
   2. Extra-vesicular rales.
   3. Bronchial rales.
   4. Tracheal rales.
   5. Laryngeal rales.
   6. Bucco-pharyngeal rales.
   Of the vesicular rales—rales intra-vesiculaires—
 he offers the following varieties.
   1. Rale humide a bulles continues de la conges-
 tion sanguine.
   2. Rale sous-crepitant de l'cedeme pulmonaire.
   3. Rale sous-crepitant, du catarre  pulmonaire
 aigu capillaire.
   4. Rale sous-crepitant, ou crepitant de retour de
 la pneumonie.
   5.  Rale crepitant primitif de la pneumonie.
   These rales are classed according to their degree
 of dryness or moisture;  number  one representing
 the moistest, and  number five the driest variety of
vesicular rales.
pleuritic cavity, communicating with bronchial tubes.  "A ca-
vernous rale is limited and fixed, and is generally situated in
the upper part of the thorax; its force diminishes in every di-
rection, as we follow it from the centre of the cavity;  but in the
case of pleuritic effusions, a large bubbling gurgling is produced
towards the  base of the lung, and is propagated upwards, ac-
cording to the direction which  the bubbles  take, in  passing
through the  fluid."
  One cannot help asking, What  becomes of the air-bubbles
which pass through the fluid during each inspiration ?
  I shall refer to  this hypothesis of the rising of air-bubbles,
when I speak of metallic tinkling.  In my opinion, Chomel has
interpreted his facts wrongly, no such distinctions as those de-
Bcribed by him really existing. 
fournet's division of rales.       161
  Under the term extra vesicular rales are included:
  1. Le rale ou bruit de froissement pulmonaire.
  2. Le rale de craquement sec.
  3. Le rale de craquement humide.
  4. Le  rale cavernuleux  ou muqueux a timbre
clair.
  5. Le rale  caverneux humide ou de  gargouille-
ment, et le rale caverneux sec.
  The first two rales arise external to the air-cells,
and  are  produced by friction  of  the  lung-tissue
against hardened parts; the last two arise in cavi-
ties.  The third variety is heard just about the pe-
riod when the hardened parts begin to soften down.
  The bubbling rales in the bronchial tubes are:
  1. Le rale  de gargouillement dans les cas  de di-
latation considerable des bronches.
  2. Le rale muqueux a grosses bulles.
  3. Le rale muqueux a bulles moyennes.
  4. Le rale muqueux a petites bulles.
  The fine, bubbling  rales of the  bronchial  tubes
are heard both during inspiration and expiration;
the vesicular rales during inspiration only.
  What is meant by tracheal and  laryngeal  rales,
is sufficiently indicated by their names.
  The bucco-pharyngeal rale implies a fine crepita-
tion, which is heard when the ear is  brought near
to the mouth of a patient whose air-passages con-
tain some kind of fluid.
  The mucous rale with large bubbles, Fournet  ob-
served during inspiration, in two cases of purulent
infiltration of the lung; and he  makes the  remark,
that further experience may perhaps prove such a
                      14* 
162       fournet's division of rales.

rale to be a sign of the passage of pneumonia from
its second to its third stage.
  I have  no remark to make upon the vesicular
rale of Fournet, further than what I have already
said when speaking of Laennec's crepitating rale.
I do not deny  that the varieties of rales described
by Fournet really exist; I believe that many more
might be added to them; but I affirm, and my opinion
is that of many other auscultators, that there is no
one distinct rale peculiar to congestion of the lungs
with blood, or to pneumonia, or to cedema, or to
catarrh, etc.: the classification of rales according to
the nature or  the stages  of disease, is, in  my opi-
nion, erroneous.
  Of the bruit de froissement pulmonaire, Fournet
says; "The general character of this bruit is, that
it produces in  the ear a peculiar sensation of  rub-
bing, by which it may be always readily recognised.
The observer  fancies that he both sees and hears
the pulmonary tissue forcibly struggling against
some impediment to its expansion."
  " The bruit appears in different forms and degrees.
When most perfect, it resembles the bruit de cuir
neuf, and differs from the new leather friction-sound
of pericarditis  solely in being of more acute timbre:
when less perfectly marked, it appears as a plain-
tive, moaning  sound, and presents various intona-
tions, according to the state of the patient and the
force and  rapidity of the  respiration: lastly, in its
third and  most feeble form, which is the least fre-
quently met with, it  reminds the  observer  simply
of the gentle, rapid, and  dry sound which is ob-
tained by blowing upon very fine  and dry paper." 
fournet's division of rales.       163
  Several varieties of murmurs are included under
the denomination of froissement, all of which have
this character in common, that they give to the per-
son observing them the impression that he can see
the lung-tissue  struggling,  with force  and  noise,
against some obstacle to its  distention.  I have
never yet met with such a  struggling  sound, and
shall abstain from offering any opinion upon it until
its existence shall have been clearly demonstrated.
According to Fournet, it is scarcely ever observed,
except in the first stage of phthisis, particularly
during the acute development of miliary tubercles.
He looks  upon it as an important sign of phthisis
in its first period.  I shall mention the phenomena
which I have myself observed in cases of miliary
tubercular disease, in the chapter on  tuberculosis.
   Craquement is a dry rale, and indicates the pre-
sence of fluid, probably of a tenacious character, in
some of the bronchial tubes, or in a cavity.  This
dry alternates with moist rales, etc., not only  in
tuberculosis, but in all conditions of the lungs where
there is fluid in the bronchial tubes.   It is confined
to a circumscribed space, and this is one of its most
striking characters, especially in phthisis: its signi-
fication, when  present in this disease, is the same
as that of moist rales, and I  therefore see no reason
why it should be treated as a special symptom, and
separated from other rales.
   The  rale of small  cavities—rale  cavernuleux a
timbre  clair—is that to which I give the name of
consonating: although it is  very frequently  ob-
served in certain stages of phthisis, as pointed out
by Hirtz  and Fournet, it has not the signification 
164     the author's division of rales.

attached to it by these  observers.  It is not cha-
racteristic of small cavities, but of tubercular, or
pneumonic infiltration of the lung-tissue.
  Respecting the moist  and dry cavernous rales, as
well as the  blowing rale of the bronchial tubes, I
must refer the reader to the chapter on Laennec's
mucous rale.  I consider that the distinction which
has been drawn between the  fine  bubbling bron-
chial rale, and the vesicular rale, viz., that the first
is heard during both inspiration and expiration, and
the latter only during inspiration, is arbitrary, and
not supported either by observation or by theory.
  In conclusion, I must observe that I am convinced
there are no rales which specially indicate the pass-
age of  pneumonia  from its second into its third
stage; for this particular period of the disease may
be attended by a great  variety of  rales, or it may
terminate without giving rise to any rales whatever.

         THE AUTHOR'S DIVISION OF RALES.
  I divide the rales as I do the voice and the  res-
piration, so far only as the division has a practical
value.   I class them as  follows:
  1. Vesicular rale.
  2. Consonating rftle.
  3. Dry, crepitating rale, with large bubbles, or
craquement: this rale has been already described.
  4. Indeterminate rales.
  5. Rales accompanied by amphoric resonance and
metallic tinkling; of these I shall say more hereafter.
                 VESICULAR RALE.
  By this term, I understand (in accordance with
Andral and Laennec) the rale which takes its origin 
CONSONATING RALES.
165
in the finer bronchial tubes, and in the air-cells: we
know that the rale arises there, from the fact of
its bubbles being small, and  of equal size: it indi-
cates the presence of mucus, blood, or serum,  etc.,
in the finer  bronchial  tubes and in the air-cells,
and  the entrance of air into the latter; precluding
the existence of any of those abnormal conditions
which prevent its entrance.  The rale, unless  it is
very distinctly heard, does not  enable us to draw
any  conclusions as to the condition of the portion
of the lung nearest to the surface of the thorax.
                 CONSONATING RALE.
   This rale is clear and high, is formed by une-
qual bubbles, and accompanied by resonance, which
has  neither an amphoric nor a metallic character.
A high and clear rale (as already shown) cannot be
produced within the thorax, unless the conditions
necessary for the production of consonance are  pre-
sent.  Hence  the consonating rale is of  the same
significance as bronchial breathing and broncho-
phony;  generally speaking, it  indicates the pre-
sence either of pneumonia, or of tubercular infil-
tration, being seldom observed in pleuritic effusion.

               INDETERMINATE RALES.
  Under this head, I comprise all those rales which
are neither vesicular nor consonating,  and are not
accompanied  by amphoric resonance  or metallic
tinkling: they offer no special indications respect-
ing the condition of the lung-tissue. What may be
learnt by their aid, of the quantity and quality of
the fluids contained in the air-passages, as well as 
166
SONOROUS SOUNDS.
concerning the situation of such fluids, has been
already considered, when we spoke of the different
varieties of rales.

       SONOROUS, WHISTLING, AND HISSING SOUNDS.
  Laennec, as we have already observed, included
these sounds among the rales.  A great variety of
sounds are produced by  the  passage  of the  air
through the air-tubes, when certain  parts of them
have become  narrowed from any  cause.   These
sounds are generally known to us under the names
of snoring, whistling,  hissing, etc. (Schnurren,
Pfeifen,  Zischen, etc.)  Their intensity, and  the
force with which they strike upon the ear,  enable
us to judge, but only approximatively, of the size
of the bronchial tubes in which they are produced.
The  sonorous sounds are most commonly produced
in the  larger bronchial tubes;  the whistling  in
bronchial tubes of a less diameter, and the hissing
in the finest portions of the air-passages; but there
are numerous exceptions to these rules.  The proxi-
mity of the point of origin of a sonorous, or whist-
ling  sound, cannot  be judged of by the distinctness
with which it is heard.  These sounds may  be fre-
quently observed  of  equal  strength over  a con-
siderable portion,  or even over  the whole  of  the
thorax; and the observer may sometimes hear them
without bringing his ear in contact with  the thorax,
and even at a considerable distance  from it.
  Snoring, whistling, and hissing  sounds may arise,
when the lung-tissue is normal, or under any of its
abnormal states; they therefore afford no informa-
tion  as to its condition,  except when they are con- 
AMPHORIC ECHO, ETC           167
sonant.  They consonate, in fact, just like the voice,
the respiration, and the rales.  Any one well ac-
quainted with the bronchial breathing, will have
little difficulty in deciding when these sounds are
consonant, and  when they are not so: when conso-
nant, they are accompanied by a resonance resem-
bling that of the bronchial voice, and  offer the
same indications  as to the condition of the lung-
tissue, as bronchial breathing, bronchophony, etc.
The sonorous, whistling, and perhaps also the hiss-
ing sounds, may also be attended by amphoric echo
and metallic tinkling.  The sonorous sound some-
times passes into dry crepitation.

   III.  AMPHORIC  ECHO AND METALLIC TINKLING.
     (Bourdonnement amphorique et tintement metallique.)
   These  phenomena may be imitated by a person
speaking and directing his voice into a jug: when
he does  so,  a peculiar humming is heard, in addi-
tion to the voice: this humming is Laennec's am-
phoric buzzing.   The  strength of the voice is  at
the same time generally increased, and very re-
markably so, when of a certain pitch.  The hum-
ming which accompanies  the voice is not always of
the same pitch as the voice; it may retain its pitch,
 though that of the voice  be altered.
   Besides this humming,  there is also occasionally
 heard a metallic after-tone (JYachklang,) resembling
 the flageolet-tone of a guitar string.  This tone,
 when it accompanies the voice, exactly represents
 Laennec's metallic tinkling. It may be often heard,
 as  a  kind of metallic  echo, in rooms, particularly 
168
AMPHORIC ECHO
if arched, when a person is speaking rather loud,
and  at  a particular pitch of the voice.  Any one
may convince himself, by  the production of the
metallic echo in a room, and by directing his voice
into a vessel, that amphoric echo and metallic tink-
ling are phenomena which arise under similar con-
ditions, and that metallic tinkling bears the same
relation to amphoric resonance, as does a high to a
deep flageolet tone of a guitar string.
  Amphoric echo and metallic  tinkling cannot be
produced in narrow tubes;  and therefore do not
arise within the thorax, unless there is some large
cavity present, the walls  of which are capable of
reflecting sound.  This statement is  fully corro-
borated by clinical  observation, these  phenomena
being only met with in cases of pneumothorax, and
where large pulmonary cavities exist.
  Laennec believes  that these sounds were not
produced, unless both fluid and air were present in
the cavity: I do not myself consider that the pre-
sence of fluid  is  necessary.  The two phenomena
are equally well produced in a pitcher, whether it
contain fluid or is perfectly empty; and assuredly
the presence of fluid is not  requisite to excite the
metallic echo in a room.  If a person speak into a
stethoscope placed on a stomach filled with air, both
metallic tinkling and amphoric echo will be heard
sounding within the stomach, and this, whether the
stomach be partly filled with, or contain not a drop
of fluid.
  Laennec believed, moreover, that these pheno-
mena could not be produced by the voice, unless a
communication existed between the pulmonary or 
AND METALLIC TINKLING.          169
pleuritic cavity and some bronchial  tube; but it
very rarely happens that in pneumothorax the com-
munication between the air in the pleura and that
in the bronchial tubes remains  free; and yet we
seldom meet with a case of pneumothorax in which
these sounds are not  present.   In the experiment
with the stomach just referred to, metallic tinkling
is produced, though no communication exists be-
tween the air in the stomach  and the  air in the
stethoscope: from  this experiment  also we may
learn how the  air in the pleura is made to vibrate
by the voice  in the larynx; if, for  instance, the
voice consonates  in a  bronchial tube, which is se-
parated from  the air in the pleural cavity merely
by a thin layer of pulmonary substance, its sound
will pass into  the air of the cavity with sufficient
force to excite therein consonant vibrations.
   Pulmonary cavities,  if tolerably large, always
communicate with the bronchial tubes.  I am not
able to state what is the smallest size of a pulmonary
or a pleural cavity, that admits of the production
within it of amphoric echo and metallic tinkling.1
  1 In a treatise  by Kolisko (Ost Jahrbuch, Okt, 1844) on am-
phoric echo and metallic tinkling heard in cavities within the
thorax,  my opinions—viz., that  these sounds may arise when
there is no communication  existing  between the  air  in the
pleura and  the air in the trachea, and that they may be excited
by sounds  originally produced  in a neighbouring bronchial
tube, or by sounds which  have  been strengthened by conso-
nance—are confirmed;  and  a case is related, where a single
tubercular cavity, of the size of a pigeon's  egg, and lined with
false membrane,  gave  rise  to a distinct metallic tinkling.
Kolisko's explanation of the phenomena may be seen in his
treatise.
       15 
170             AMPHORIC ECHO
  If amphoric echo and metallic tinkling are heard
during respiration  in  pneumothorax,—where, as
before mentioned, the air in the pleura rarely com-
municates with the  air in the bronchial  tubes,—
the laryngeal or the tracheal respiratory murmur
must have become  consonant in a bronchial tube,
which is separated from the pleural cavity by merely
a thin layer of lung-substance.
  Amphoric  echo and  metallic tinkling  are pro-
duced in pulmonary cavities by the drawing in and
forcing out of the air; the  transition of the ampho-
ric echo into the metallic tinkling is best observed
during respiration. The respiratory murmur may in
one case resemble a deep humming, like that caused
by blowing  into a jug;  in another, or even in the
same case, at some other  period, it  may resemble
the deep whistling which is produced  by  drawing
in or forcing out air from the mouth when its cavity
is enlarged and the opening of the lips narrowed;
this sound being heard alone or combined with the
humming.   The deep whistling, which evidently
represents a tone (Klang) may be  replaced by a
more acute and also by the essentially metallic tone,
viz., that which  resembles the flageolet-tone of a
guitar-string, and which may continue  during the
entire  act of inspiration and expiration.
  Metallic tinkling is more frequently excited in
pneumothorax, and in large cavities, by rales, than
by the voice, or the respiratory murmur: the rales
can take this metallic character,  although no com-
munication exists between the pneumothorax and
the bronchial tubes, and although no fluid be pre-
sent with the air in the pulmonary or pleural cavity. 
AND METALLIC TINKLING.         171
  Dr. Dance has offered the following explanation
of the mode of origin of the metallic tinkling (as
may be seen in Raciborsky's manual of auscultation
and percussion:) " When the level of the fluid con-
tained in the pleural cavity is higher than the open-
ing through which the air enters it, the air, at each
inspiration, is drawn into the cavity, and, in conse-
quence of its specific gravity, rises in bubbles to
the surface of the fluid, where the bubbles break,
and so produce metallic tinkling.
   In this explanation, we are not told what becomes
of the air which rises above the level of the fluid:
it is evident that, like the  air in a healthy lung, it
must be either taken up, other gaseous bodies being
separated in its place, or it must be very gradually
absorbed, or  must  remain unabsorbed.   Under
any of these conditions, it is difficult to understand
how the metallic tinkling can continue audible after
a few inspirations, or even after one single inspira-
tion;  for, in fact, the cavity takes in at each inspira-
tion as much air  as it can contain; and if the level
of the fluid be higher than the opening into it, the
air cannot be forced out of  it during expiration.
The cavity, during expiration, remains either com-
pletely distended, and consequently cannot admit
more air at a subsequent inspiration; or it is com-
pressed, and then a portion of its contents must be
forced into the mouth of the opening leading into
it, from whence  it is drawn  back again  into the
cavity at the next inspiration.   According to this
explanation of Dr. Dance, the phenomenon of me-
tallic tinkling should be very rarely observed, and
only at considerable intervals, and  more particu- 
172
AMPHORIC ECHO
larly during inspiration  after coughing: how it
should ever arise, during expiration, is perfectly
incomprehensible.
   Dr. Beau, who admits  Dr. Dance's theory, ex-
plains it thus: " In most cases," he says, " the cavity
is surrounded  by condensed parenchyma, and its
capacity does not diminish during expiration; con-
sequently the  air which is forced out of the other
parts of the lungs, either during expiration, or by
coughing, speaking, or expectorating, presses from
the trachea into the gaping bronchial  tubes, and
then acts just as though it had been inspired."
   Dr. Beau does not tell us whether air, under
these circumstances, enters into the cavity during
inspiration, but we are bound to believe that it does,
inasmuch as metallic tinkling is heard during inspi-
ration: it would appear, therefore, according to his
explanation, that cavities surrounded by condensed
tissue receive air both during inspiration and expi-
ration, and yet cannot force any of it out again!
   My own opinion is, that metallic tinkling—in ad-
dition to its being heard as a resonance of the voice,
of the breathing, and  of  whistling  sounds—may
present itself  in large cavities, as  the  resonance
of a rale, situated in a distant, but communicating
bronchial  tube, or as a resonance of a rale which
has its origin at the mouth of the  opening into
the cavity, or when many cavities communicate to-
gether, at the opening of communication between
them—where, in fact, the air may pass in and out
during respiration,  without being obstructed by
fluid—or as the resonance of a rale produced  in 
AND METALLIC TINKLING.           173
cavities, through violent concussion of their fluid
contents, by coughing, etc.
   The metallic tinkling  of pneumothorax is pro-
duced in a similar way; but as the air contained in
the  pleura very rarely communicates with that in
the bronchial tubes, the metallic tinkling  of pneu-
mothorax is more commonly produced as a loud, or
as a consonating rale, arising in a large and neigh-
bouring bronchial tube, or by succussion of the fluid
in the thorax, during coughing, etc.1
  1 If the pulmonary pleura be destroyed or torn at a part of
its surface, where it is not adherent to the thoracic walls, and
an opening for the entrance of air from the neighbouring parts
of the lungs into the pleura thereby established, it will be found
that the air enters into the pleural cavity, both during inspira-
tion and expiration, so long as the contractile power of the lung
remains: when its contractility ceases, air enters into the cavity
during  inspiration only, and  continues to do so until the cavity
is capable of no further distention.  No air can escape from the
cavity during expiration, for the opening at  the surface of the
lung, through which the air enters into the cavity during inspira-
tion, is closed by the  pressure of the air within the cavity upon
the surface of the lung  during  expiration: an exception must
be made  of the  case where a canal, with resistant walls, leads
from the cavity into  the  trachea—a case, however,  which  is
rarely ever met with.
  In pneumothorax produced by the bursting of a pulmonary
cavity,  or abscess into the pleura, the communication between
the air  in the cavity and the air in the trachea is completely de-
stroyed after a few inspirations; however small the opening may
be,  the pleura becomes very rapidly filled with air.
  The communication is, in some rare cases, restored by ulcera-
tion of the compressed lung, when the ulceration has perforated
or laid  bare an incompressible bronchial  tube, or even the tra-
chea, or when a single-mouthed fistulous opening  into a large
                          15* 
174       RESPIRATORY MURMURS, RALES,

  A drop of fluid, or a solid body falling acciden-
tally to the bottom of a pleural cavity filled with
air, would undoubtedly give rise to metallic tink-
ling: but such a cause of the phenomenon must be
exceedingly rare.
  When  metallic tinkling presents itself as the re-
sonance of a whistling sound, it resembles the most
beautiful  tone  of a guitar-string, when a  bow is
drawn across it.

IV. THE SIMULTANEOUS  EXISTENCE OF THE RESPIRA-
   TORY MURMURS, RALES, AND SONOROUS SOUNDS.
  It often happens that several distinct sounds are
heard  simultaneously, during respiration: thus,
rales, and whistling and sonorous sounds, and the
proper respiratory murmur, may be all recognised
by the ear at the  same time.   But these murmurs,
rales, etc. are not met with mixed together promis-
cuously.
  The non-consonating rales, and the non-conso-
nating sonorous, whistling, and hissing sounds may
be heard in company with  the vesicular respiratory
murmur, provided they are neither so loud nor so
extensively  distributed through the  lungs, as to
obscure the murmur.  The vesicular murmur is
never  associated  with metallic tinkling, and  am-
phoric resonance.  Bronchial respiration and con-
sonating rales  are sometimes heard in company
with it, when the deeper parts of the lung are in the
condition necessary for the production of  conso-
bronchial tube, or into the trachea, has been formed in a lung
consolidated by infiltration. 
AND SONOROUS SOUNDS.          175
nance, whilst its surface contains air; but such an
abnormal  state of the lungs seldom occurs, except
in those particular cases of pneumonia where the
inflammation travels from one part of the organ to
another, attacking each in succession.   In cases of
violent  dyspnoea, however,  where the breathing is
loud, it not unfrequently happens that the vesicular
and the bronchial  murmurs are heard together,
particularly over the dorsal region, independently
of any consonance.
  The non-consonating respiratory murmurs of the
larger bronchial trunks, which I place among the
indeterminate murmurs, are more frequently than
bronchial breathing heard in company with the ve-
sicular murmur.  Consonating and non-consonating
rales, sonorous, whistling, and hissing sounds, of
every variety, as well as the indeterminate respira-
tory murmurs, may be associated with the bronchial
respiration.
   Bronchial respiration may also be conjoined with
 amphoric resonance and metallic tinkling, without
 being masked by these sounds.
   The  indeterminate respiratory murmurs may be
 attended by rales, and sonorous, whistling, and hiss-
 ing sounds of every kind; and the same is true of
 amphoric resonance and metallic tinkling.
   The  simultaneous existence of several murmurs
 renders the accurate discrimination of any particu-
 lar one very difficult: it is only after long expe-
 rience that the ear is able to distinguish between
 such sounds,  so as  to isolate any one of them from
 the rest, and thus  examine each in turn. 
176    RESPIRATORY MURMURS, RALES, ETC.
  The concurrence  of two murmurs, in which the
distinction is not readily determined even when they "
arise separately, occasions the utmost difficulty in
diagnosis: the combination of vesicular and bron-
chial  respiration is an instance:  the two sounds
blend together into one, and the nicest observation
is barely sufficient to discriminate the one from the
other.
  If, in such a case, the expiratory murmur  gives
no sure indication respecting the condition of the
lung,  that is, if it be not  distinctly bronchial, the
respiratory murmur must be considered as indeter-
minate, and the diagnosis established by some other
means.  A murmur resembling that produced by
the combination of the vesicular and the bronchial
respiration, may arise through other causes besides
those  which occasion the simultaneous  occurrence
of the vesicular and bronchial respiration.
  It is difficult to determine the clearness and pitch
of a rale, when it is associated with a whistling or
a hissing sound; nor can we draw conclusions from
the clearness and pitch of whistling  sounds in the
same  manner as we can from  those of the rales un-
der similar circumstances.   If we wish to ascertain
the clearness and pitch of  a rale which is combined
with whistling  or  hissing  sounds, we must detach
it entirely from them; and if this cannot be done,
the rale must be set down as incapable of yielding
information respecting the condition of the  lung.
If the observer attributes the pitch of the whistling
sound to  the rale, he will mistake many murmurs
for consonating, which are, in reality, not so. 
AUSCULTATION OF THE COUGH.       177
        V. AUSCULTATION OF THE COUGH.
  The cough does not afford us any signs different
from those which have been already described; but
it may render them  all more distinct, as, for in-
stance, by removing the accumulation of fluids, etc.
which frequently takes place in the bronchial tubes,
and obstructs the passage of the sounds. Coughing
produces in the larynx its known  peculiar sound,
or a lesser degree of the sound which is  peculiar
to expiration, or it excites different kinds of rales.
In the bronchial tubes, or in pulmonary cavities,
the cough gives rise  either to the ordinary expira-
tory murmur alone, or  to this murmur, and, in ad-
dition, to rales, and whistling and sonorous sounds.
The sound peculiar to coughing, and the  other
sounds excited by it in the larynx and the air-pas-
sages, are heard over the thorax in varying degrees
of strength and clearness, according to the laws of
consonance and conduction of  sound which have
been already referred to.  Thus the coughing may
be heard as a bronchophonie sound, or as an indis-
tinct humming, and the respiratory murmur caused
by the cough, as a bronchial or indeterminate re-
spiratory murmur, and the rales as consonating or
indeterminate. In cases of pneumothorax, and where
large pulmonary cavities are present, the cough may
excite metallic  tinkling and amphoric resonance.
After coughing, the patient generally inspires more
 deeply than ordinarily, and thereby renders the in-
 spiratory murmur more distinct.
   Laennec made a distinction between the tubular
 and cavernous  cough, and the dull  cough-sound
 which is heard in the normal condition of the lungs. 
178     FRICTION SOUNDS OF THE PLEURA.
On this point, I have only to repeat what has been
already said respecting his division of the thoracic
voice.

VI. FRICTION SOUNDS PRODUCED BY THE ROUGHENED
     SURFACES OF THE PLEURA DURING THE RESPIRA-
     TORY MOVEMENTS.
  The contraction of the  diaphragm causes the ca-
vity of the thorax to enlarge downwards during in-
spiration, the lung, by the pressure of the air, being
made to occupy the augmented space, and therefore
to descend a little.  When the.contraction of the
diaphragm ceases, the lung contracts and ascends,
regaining its former volume.  The relaxed  dia-
phragm follows the movement of the lungs upwards,
the atmospheric pressure preventing the existence
of any vacuum in the thorax, or of any interval be-
tween the diaphragm and the lung—provided no
gaseous or fluid matters  intervene.   The upward
movement of the  diaphragm is  frequently pro-
moted by the  elasticity of the abdominal viscera,
and contraction of the abdominal muscles.
   This ascent and descent of the lung occasions a
rubbing between the pleural surfaces, which is in-
creased by the upward movement of the fore  part
of the thorax during inspiration, and its downward
movement during  expiration, the lung moving  in
the contrary direction.
   Diminished distensibility in one part of a lung
causes increased movements in other parts of it, and
consequently greater friction of the pleural surfaces.
If, for example, a portion of lung does not expand,
the parts around are pressed in towards it at each 
PLEURAL FRICTION SOUNDS.        179
inspiration, and fill the space which normally would
have been occupied by the non-expanding portion
of lung; at each expiration, the parts return back to
their former position.
   This contact of its surfaces produces no friction-
sound, so long as the pleura remains smooth  and
moist; but  the sound manifests  itself whenever,
through any cause, the surfaces have become rough-
ened: it generally accompanies both inspiration and
expiration,  being at one time most distinct during
inspiration, at another during expiration: it may be
heard during inspiration only,  or the reverse.  It
 resembles the creaking of leather, appears at inter-
vals, and is only distinguishable from a dry rale by
producing a feeling of friction and momentary con-
tact (Anstreifen.)  In most cases, it is recognisable
 by the finger as well as by the  ear, and the patient
 generally experiences  the sensation of something
 rubbing within his thorax.  Laennec has given to
 this friction sound' the name of frottement ascendant
 et descendant: it is, in fact, almost always produced
 by the vertical motion of the lungs, but it may be
 occasionally produced  by a horizontal movement,
 when any such impediment to the distention of the
 lungs exists as to cause a portion of these organs to
 take the horizontal direction during inspiration.
   Laennec imagined that the friction-sound was in
 most cases  produced by superficial interlobular em-
 physema, i. e., by the air vesicles immediately be-
 neath the pleura.   He also supposed that it would
 manifest itself when any cartilaginous, bony, tuber-
 cular, or scirrhous  tumours projected above the
 surface of the lung. 
180        PLEURAL FRICTION SOUNDS.
  Dr. Reynaud showed that the friction-sound was
generally caused by roughened pleural surfaces, and
his views have since  been fully confirmed.  The
sound is  most commonly caused by pleurisy.  It is
sometimes heard at the commencement of this dis-
ease, when lymph has beendeposited on the surfaces
of the pleura, and the contact of the surfaces is not
prevented by serous effusion: at this period of the
disease, however, the lymph has not always sufficient
consistency to produce the sound. It is much more
frequently heard, and more distinctly marked, at a
later period of the disease, when absorption of the
serous effusion has taken  place, and the surfaces,
covered by a firm plastic exudation, have once more
come in contact.   In this latter case, the friction-
sound continues, until either the lung has formed
attachments to the thoracic walls, or  the rubbing
surfaces have become  perfectly smooth.
  Tumours of the nature above referred to,—bony,
cartilaginous, tubercular, etc.—do not produce fric-
tion sounds, if their surfaces are smooth;  neither
does interlobular emphysema.
  There  is no doubt that a friction sound  may be
produced by the  rubbing of one lobe of a  lung
against another; but it would  be difficult to dis-
tinguish such a sound from a dry rale. The friction-
sound varies both in the length of its intervals, and
in its strength.   Differences in its strength, which
depend chiefly on the extent and the rapidity of the
respiratory movements, render the sound more or
less distinct.  The friction  sound may be limited in
extent or heard over many inches of surface. 
181
               CHAPTER IV.

AUSCULTATORY PHENOMENA PRESENTED BY THE OR-
             GANS OF CIRCULATION.

  These consist chiefly of the sounds and murmurs
which attend the heart's movements, and are audi-
ble in the prsecordial region, and in several of the
arteries.  By auscultation, however, we not only
hear, but we also feel the beat of the heart against
the walls of the thorax, and occasionally also the
pulsation of the arteries; such impulse of the heart
and arteries must consequently be reckoned among
auscultatory phenomena, in so far as it is  made
sensible to us by auscultation.  Auscultation, again,
takes note of the rhythm of the heart's movements.

          I. THE IMPULSE OF THE HEART.
   Cause of the Heart's Impulse.—-By impulse of the
heart is understood  its beat against  the walls  of
the thorax, which is observed nearly synchronously
with the pulsation of the carotid arteries, and ge-
nerally about the  cartilages of the fifth or sixth
true ribs on the left side.
   Corrigan, Stokes, Rigeaux, and Burdach, believed
that the impulse of the heart occurred during the
diastole of the ventricles, not during their systole,
an opinion now generally admitted to be erroneous:
it does not  require refutation.  The same remark
        16 
182          IMPULSE OF THE HEART.
may be applied to the explanation of the impulse,
by a supposed lengthening of the ventricles during
their systole, or by a stretching of the aortic arch.
  We may also pass over Dr. Hope's views,.as they
have never been seriously entertained by later ob-
servers.1
  Bouillaud and Filhos2 explain the impulse in the
following manner: "The muscular fibresof the heart
have their fixed point at the tendinous rings around
its base, and run from thence in a spiral direction
towards its apex; now these fibres become shortened
during  the ventricular systole, and  consequently,
the apex, like the moveable end of a lever, is tilted
upwards and towards the  walls  of the  thorax.
Filhos affirms, that the impulse is produced solely
by the contraction of the left ventricle, the muscu-
lar fibres of the right not being  spiral, and  there-
fore incapable of other movements  than those of
contraction and dilatation.
  The last opinion is completely refuted by clini-
cal observation; for, in cases of hypertrophy, with
dilatation of the right ventricle, the impulse is often
very strong, when the left ventricle is of its normal
size, or even atrophied.  I have never been able to
convince myself that the apex of the heart is raised
towards the thoracic walls during the ventricular
systole, in  consequence of the arrangement of its
muscular fibres, but I am far from denying its pos-
sibility.  This  much however is certain, that the

  1 Dr. James Hope, Diseases of the Heart and Arteries.
  a Traite clinique  des Maladies du Cocur, par J. Bouillaud.
Paris, 1835. 
IMPULSE OF THE HEART.
183
simple raising of the heart's apex towards the tho-
racic walls does not explain all  the phenomena
which accompany the impulse.
  When the heart acts vigorously in thin  indivi-
duals, we may observe, from the projection of the
intercostal spaces, that it moves downwards  during
the systole, and returns to its former position  during
the diastole.  The beat of the heart is sometimes
felt at the scrobiculus cordis, and an elevation of
the parts  there, observed during each ventricular
systole, which disappears during the diastole.
  Dr. Gutbrod * gives the  following explanation of
the cause  of the heart's impulse:—" It is  a well-
known physical law, that when a fluid escapes from
a vessel, the equality of pressure produced  by the
fluid on the walls of  the vessel is lost, for there is
no pressure at the opening whence the fluid escapes:
but at that part of the vessel which is opposite to
the opening, the pressure is still exerted.  This
pressure it is which set Segner's wheel in motion,
and produces the recoil of fire-arms, etc.  By con-
traction of the ventricles, the pressure which  the
blood exerts upon the walls of the heart, opposite
to the opening whence the stream escapes,  causes
a movement of the heart in a direction contrary to
that of the stream of blood, and by this movement
  1 I do not know when this theory was first brought forward
by Gutbrod, but it is certain, that a precisely similar explanation
of the cause of the heart's motion, and identical illustrations of
it, were published by Dr. Alderson, as long ago as the year 1825,
in the eighteenth volume of the Quarterly Journal of Science,
Literature, and the Arts. (Transl.) 
184
IMPULSE OF THE HEART.
the impulse of the heart  against the walls of the
thorax is  produced.  The heart is driven in a di-
rection contrary to that of the arteries, with a force
proportionate to the  quantity and the velocity of
the current of the blood.
  Many objections have been made to this expla-
nation. Valentin, in his Repertorium for 1841, made
the following statement:—"When an opening is
made into the apex of a frog's heart, no diminution
nor other change is observed in its  impulse;  but
some change ought to follow, on the supposition
of the impulse being caused by the counter-pressure
of the  blood."  To this I replied, that there was
no evidence whatever that the impulse of the frog's
heart was produced by the counter-pressure of the
blood; for the frog's heart has no downward move-
ment.  Now, if the counter-pressure of the blood
has no influence on  the impulse of the frog's heart,
the cause  of this must lie, either in the slowness of
its contractions, or in the small amount of its blood.
To answer this objection, Valentin cut off the apex
of the heart in a rabbit, and fixed a glass  tube into
the opening, to prevent its closure; and still he ob-
served no change in the heart's impulse.  I am far
from saying that Valentin's observations  are erro-
neous;  but I am not  at all inclined to pass over?
without consideration, the experiments which have
determined the fact  of the  descent  of the  heart,
under certain circumstances, during  each systole.
Among the theoretical considerations by which Va-
lentin seeks to prove the inapplicability  of  Dr.
Gutbrod's explanation, the last conclusion is, in my 
IMPULSE OF THE HEART.
185
opinion, incorrect.  Vide Valentin's Lehrbuch der
Physiologie, B. i. p. 426.
  Dr. Messerschmid makes the  following remarks
upon Gutbrod's theory, in Froriep's Notizen (Janner.
1840, No. cclxvi. p. 29:)—"The expression,/^*
no counter-pressure, is  founded on an erroneous
supposition.  In fire-arms, and at the mouths of the
openings of Segner's wheel, there is t!ie pressure of
the atmospheric air, and at the openings of the heart,
that produced by the columns of blood in the arte-
ries; hence this explanation of the heart's impulse
rests on an error, and the ordinary explanation of the
movements of Segner's wheel is unsatisfactory."
  Any one who will carefully examine the  above-
mentioned  physical law, will learn that the expres-
sion, "finds no counter-pressure," does not refer to
the  medium  surrounding Segner's wheel, but that
the  question in  debate is, concerning the pressure
and  counter-pressure of the  fluid upon the walls of
the vessel containing it.
  The pressure of the columns of water on Segner's
wheel is not destroyed, and consequently its motion
not lost, in vacuo. All  that we have  therefore to
decide is, whether the surrounding air has any, and,
if any, what influence upon its movements.  Dr.
Messerschmid says:—"Has  anyone attempted  to
set Segner's wheel in motion by water,  in a very
perfect vacuum ?  I doubt whether it has ever been
done.  But, independently of this, it is certain that
the  backward revolution of this  machine is not
caused by the one-sided pressure of the water solely,
for the surrounding air has also a considerable share
                      16* 
186          IMPULSE OF THE HEART.
in producing it.   The air presses uninterruptedly
against the jets of water  from the openings of the
horizontal tubes, and through these jets the counter-
pressure is propagated inwards to those parts of the
walls of the tubes which are opposite to their open-
ings.  And hence, in consequence of the well-known
arrangement of this machine,  the counter-pressure
of the  external air becomes the chief cause of its
backward movement."
  It does not  appear very clear why the counter-
pressure of the air should be supposed to  play a
subordinate, though considerable, part in the move-
ment at first, and afterwards become its principal
cause;  nor is it very intelligible, why the assumed
counter-pressure should limit its influence merely
to that part of the walls of the tube which is op-
posite to  the point at which the fluid escapes.   To
carry the argument out logically, this counter-pres-
sure ought to force the vertical column of water up-
wards,  and at last cause it to flow out over the upper
opening!   How comes it that the air resists the
stream of water, and presses it back, whilst the
vertical pipe offers no  resistance to the backward
movement?
  It is indeed surprising, how any one, on mature
reflection, can believe that the resistance offered by
the air to the flowing water, is capable of operating
backwards through the stream of water.  All that
really takes place as regards the air is, that a por-
tion of it is displaced by the water; the barometri-
cal  pressure of the air has nothing to do with the
phenomenon.
  Neither does the pressure of air in any way assist 
IMPULSE OF THE HEART.          187
in the recoil of fire-arms; here, also, there is merely
a displacement of a certain quantity of air.  If the
air in and around the mouth of fire-arms opposed
the forward movement of the expanding gases, any
tendency to a backward  movement that might be
thus produced in them, would of necessity be com-
pensated by the resistance of the air  behind  the
fire-arms; for there is no reason why the air in front
of the fire-arms should be displaced with greater
difficulty than the air behind them.  The cause of
the recoil of the fire-arms depends altogether upon
the pressure exercised by the expanding gases upon
the closed  end of the fire-arms, which pressure is
not  compensated by any  counter-pressure  of the
gases at the opposite end  (where the mouth is.)
  It is true that nothing like the expansion of gases
takes place in the heart, nor is there in its conditions
the  slightest similarity to those which obtain in
Segner's wheel; but there is, nevertheless, no reason
why the recoil of the heart may not be produced
on the same principle as the recoil of fire-arms, and
the movements of Segner's wheel.  During  the
ventricular systole, the blood  presses upon every
part of the heart's  surface with a force equal to
that by which it is itself compressed; the pressure
of the compressed blood on that part of the heart's
walls which is opposite  to the  arterial openings,
 produces a movement in a direction  contrary to
 these openings;  the  compressed blood exerts no
 pressure there, in consequence of the walls of the
 cavity being deficient.
   The resistance which the blood contained in the 
188          IMPULSE OF THE HEART.
arteries offers to the flow of blood from the heart,
has nothing to do with the physical laws referred to
by Dr. Gutbrod and myself; it is  not because I do
not think this resistance really exists, that I have
not mentioned it. The movement of the heart down-
wards can  only take place, according to  the laws
referred to, when all resistance is overcome, that is
to say, when, for our purpose, it no longer exists.
It is only the surplus of the expulsive power of the
heart over  the resistance of the blood in  the arte-
ries, which is taken into account in this explanation.
  Professor Von Kiwisch says, in vol. ix. of the
Prager Vierteljahrschrift,]). 501:—" Still less tena-
ble (than Gendrin's theory) is Gutbrod and Skoda's
explanation of the  cause of the heart's impulse: ac-
cording to  their view, the general pressure of the
blood contained in the ventricles of the  heart, is
removed by the escape of the blood through the
single opening, and is made to bear, in an especial
manner, upon that  part of the walls of the heart
which lies opposite to the opening, and thus forces
the  heart downwards.   The same  physical law
which moves Segner's wheel, and  causes the recoil
of discharged fire-arms, is the law in action here."
  " The incorrectness of the  above  explanation is
rendered manifest by the fact that, in the heart, the
motor power does not cease to act even during the
systole, when the  influence of the  blood flowing
from the auricles is removed by the closure of the
auriculo-ventricular valves.  We must also remem-
ber that, in this comparison, an  apparatus is cited,
which is formed of rigid materials, and a good con- 
IMPULSE OF THE HEART.          189
ductor of the impulse, whilst the heart and large
vessels  are formed  of elastic  tissues, which have
little conducting power; moreover, the walls of such
apparatus, when exposed  to pressure,  remain un-
changed, whilst the walls of the heart shorten and
contract."—I consider  that the objections here
stated by Kiwisch, have been already answered.
   It sounds  strange, to  hear any one  say that he
rejects all explanation of the heart's  impulse by
physical laws. Is it possible to explain the impulse
otherwise than by the laws of physics? or are there
certain physical laws, to which the heart is not sub-
jected?  The only question for us to  answer is this,
whether the pressure is  really powerful enough to
produce a movement of the heart  in a direction
downwards and forwards.  A gun does not recoil,
if only a small quantity of powder be exploded in
it; and Segner's wheel does not move, if the friction
be great, and the column of water small.   Now, ob-
servation  shows us, that in many cases the heart,
during its systole, evidently moves downwards with
great rapidity, and is forced against the walls of the
thorax.1   In my opinion, this fact is only capable of
explanation by the  above-mentioned physical  law.
  1 On the 8th of March, 1846, I examined a child, a few
days old, in whom the sternum was wanting, and whose thorax,
in consequence, presented in front a cleft, narrow above and
broad below, and  closed in merely  by the integuments.  At
each inspiration, the skin was forced backwards towards the
vertebrae, and the anterior ends of the ribs thereby bent some-
what inwards;  during expiration, the skin was  pressed  out-
wards, in the form of a bladder.  It was readily ascertained 
190            IMPULSE OF THE HEART.
   In every case in which blood is forced out of the
ventricles, it must  be  considered as a  cause co-
operating in the production  of impulse.
   I have never asserted that this was the only cause
by palpation, that the heart  lay in a vertical direction,  that
during each systole it  moved downwards and forwards, and at
each diastole upwards and backwards.  At each systole, in fact,
the impulse of the heart could  be felt immediately  above  the
insertion of the  diaphragm, and, at each  diastole, on a level
with the second  rib, provided  the finger was pressed deeply
enough  towards  the vertebrae at that  point.   The impulse of
the diastole was  as  strong  as that of the systole.  When two
fingers were so placed, that the lower  one  could  feel the  sys-
tolic,  and the upper one the diastolic  impulse, it  appeared as
though  the  heart glided about an inch downwards at each
systole.   When the skin was moderately stretched  between  the
fingers,  the outline of the heart was seen as well marked  du-
ring the systole,  as during the diastole; from which  it may be
concluded, that the impulse felt at the points indicated, is not
caused by any enlargement or lengthening of the heart, but by
a sliding movement.   When the integuments were not touched,
the outline of the  heart, during its systole, could be seen through
the puffed-out integuments to form, at each expiration, an eleva-
tion passing from above downwards; whilst, during the diastole,
a depression of the inflated skin was observed,  passing from be-
low upwards.
  When the integuments were pressed backwards  towards  the
vertebras during  inspiration, the contour of the heart became
as distinct  during the  systole as during the diastole.   When
the child was placed upon its back, the movement of the heart
downwards was  in  a  direction closely corresponding to  the
centre of the cleft; when laid upon its side, the movement was
somewhat diverted towards that side on which it lay.   I do not
think it  is necessary  that I should enter into any explanation of
this case, for I should only have to repeat what has been already
said. 
IMPULSE OF THE HEART
191
of the heart's impulse.  The double and triple im-
pulse, associated with a single beat of the pulse, and
with simultaneous contraction of both ventricles;
weakness of the pulse, conjoined with strong im-
pulse of the heart, when the condition of all its
valves is normal; the slow heaving of the thoracic
walls, unattended by concussion, and  other exten-
sive disturbances of the heart, occurring during its
systole—are not explicable by this  law.
   Bouillaud relates  cases, in which a double and
even a triple beat of the heart was observed with
each arterial pulse.  He ascribed  the second and
third beat, not to a repetition of the systolic impulse,
but to a diastolic impulse.   It sometimes happens,
when the heart is forced over to the  right side by
extensive effusion in the left pleura, that, at each
systole, an impulse is felt at that part  of the thorax
which corresponds to the  situation of the heart's
apex; and that a second impulse, or rather a heaving
of the thoracic walls, is also  observed during the
diastole, about an inch and a half above that part.
The same phenomenon is also occasionally observed
in cases of great hypertrophy, with  dilatation of
both ventricles: at each systole, the  part of the tho-
rax which corresponds to the heart's apex is raised,
and the  part over the middle of the heart falls in
somewhat, whilst, during the  diastole, the reverse
of these  movements  is observed.
   When the heart occupies a low position, in conse-
quence of the ascending aorta being lengthened, the
elevation of the thoracic walls, during the diastole,
becomes very marked.  The opinion of Gendrin, that 
192
IMPULSE OF THE HEART.
an impulse—particularly when of a heaving charac-
ter—felt beneath the third rib during the ventricular
diastole, is a sign of the heart being placed low, is
quite correct.   In many cases of hypertrophy with
dilatation of both ventricles, the systole causes an
impulse, but the diastole produces no heaving of the
walls; a concussion, however, is felt, not excited by
the impulse of the heart against the walls of the
thorax, apparently synchronous with the retreat of
the heart towards the vertebrae.  This phenomenon
is evidently the same as that described by Laennec
under the name of impulse of the auricles.
   I have never observed a distinct impulse, i. e. such
a one as takes place during the ventricular systole,
associated with the heart's  diastole.   In the  cases
which I have  seen, where there was a double  or
triple impulse of the heart accompanying each pulse
the impulse was always produced during the ven-
tricular systole.
   The double or triple impulse was caused in one of
the following ways: either through a double or triple
contraction of the right ventricle, united with  a
single contraction of the left; or by the two ventricles
contracting alternately; or, in consequence of blood
not being thrown into the aorta at each systole, its
supply from the lungs failing, or the bicuspid valves
being defective.   Deficiency of the bicuspid valves,
associated with single contractions of the heart, may
be recognsied by systolic murmurs heard in the left
ventricle, and a faulty pulse; when the  tricuspid
valves are defective, a strong pulsation is observable
in the  veins of the neck, and a weakness  of  the
 sounds in the pulmonary artery. 
IMPULSE OF THE HEART.
193
  I have never observed an impulse caused by con-
traction of the auricle.  Bouillaud relates a case,
where the left auricle was  supposed  to have pro-
duced an impulse; but it is not at all clear that the
impulse was so produced.   His grounds for  the
opinion were, that he could not explain the pheno-
menon observed in any other way.  (Traite  des
Malad. du Cceur, Paris,  1835, t. i. p.  149.)
  There are other causes, besides  the above-men-
tioned, which assist in the production  of the heart's
impulse.
  The lengthening of the arterial columns of blood,
which occurs at each systole, must be particularly
noticed.  The blood contained in the arteries is not
instantaneously driven onwards at each ventricular
systole, so as to afford sufficient room for  the addi-
tional quantity entering into them; but the arteries
themselves  enlarge in length and breadth, or, in
other words, the arterial columns, at each systole,
become thicker and longer: the lateral enlargement
of the arteries is small, but their elongation con-
siderable.
  The aorta and pulmonary artery, being free and
unattached to some distance from their origin in the
heart, allow of a lengthening of the blood column
downwards; and the heart will consequently  be
forced in that direction.
  Dr. Messerschmid undoubtedly takes this view of
the matter, but he gives no other explanation of it
than  this, that the resistance  of the blood in the
arteries is  communicated backwards to the heart,
through the blood contained in the heart, and thus
       17 
194         IMPULSE OF THE HEART.

forces it downwards.  The same explanation is also
given by Gendrin, Lemons sur les Maladies du Cceur,
p. 37.
  We occasionally observe cases, where the heart's
movement is  slow, and where it descends as much
as one or two inches lower during the systole, than
during the diastole.  Such a movement is inexpli-
cable, except upon the supposition of the aorta being
lengthened downwards; according to my own expe-
rience, indeed,  such extensive movements of the
heart only occur when the ascending aorta is longer
than natural, but not widened.
  A third cause of the heart's impulse, which I re-
ferred to, in  the first edition of this work, is the
change of the heart's form caused by its contraction.
When the heart is much enlarged, the thoracic walls
are sometimes extensively raised during its systole,
and sink suddenly back during its diastole;  and if
the movements of the heart are slow, the heaving up
of the thoracic  walls may take place  without  pro-
ducing any concussion.  When the heart is enor-
mously enlarged, I  believe  that it may raise the
walls of the thorax, in consequence of its anteropos-
terior diameter becoming greater during the systole,
than the space between the fore part of the thorax
and the vertebral column; from which also it must
be admitted, that the heaving of the thoracic walls,
when no sign is present to demonstrate a simulta-
neous and equal pressure on the vertebral column,
is only explicable by Dr.  Gutbrod's theory.
  Lastly, it must not be forgotten, that the heart by
becoming rigid  from contraction during its systole, 
IMPULSE OF THE HEART.          195
takes a different form and direction from those it
held in its relaxed state;  and that  such change of
form and position may aid in producing its impulse,
even though the idea of a lever-like elevation of its
apex against the thoracic walls, be hardly explica-
ble by the arrangement of its muscular fibres.
  Dr. Kiirschner—Arch, fur Anatomie, etc.,  Von
Johann Mailer, 1841, vol.  i. p. 103—offers the fol-
lowing explanation  of the heart's impulse, as de-
duced from vivisections and post-mortem researches:
—" The apex  of the heart, during its diastole, is
forced downwards by the flow of the venous blood,
and the aorta  and pulmonary artery consequently
put upon the stretch.  During the systole, the ven-
tricles are freed from the pressure of the venous
blood  by  the  closure of the auriculo-ventricular
valves, the extended arteries are shortened, and the
apex of the heart raised. The reason of this raising
of the apex being so forcible as to  produce a sen-
sible blow on the walls of the thorax, is, that  the
blood  is driven in that direction by the powerful
contraction  of  the muscular fibres, the heart itself
acquiring great firmness and consistency."
  I have not repeated Dr. Kiirschner's experiments,
and therefore  am  not able to say anything about
them.   This much, however, is very clear, that Dr.
Kiirschner, in  his  explanation, has not troubled
himself much about the laAvs of mechanics.
  If it be  correct, that the stream of venous blood
presses the apex of the heart towards the vertebral
column during the diastole,  the pressure must con-
tinue during the heart's systole, notwithstanding the 
196          IMPULSE OF THE HEART.
closure  of  the valves, for the pressure could not
cease, unless the valves were of themselves sufficient
to resist the influx of the venous blood  from the
auricles into the ventricles: but they possess no such
power of resistance, and consequently the pressure
of the venous blood on the ventricles, both during
the diastole and the systole, will be alike in force
and in direction.
  According to Dr. Heine, the heart is thrown for-
wards by the contraction of the papillary muscles.
The motion of the heart forwards and to the left is
thus accounted  for: the broad extremities of the
mitral and  tricuspid valves are fixed to segments of
the fibro-cartilaginous aortic ring, in an oblique,
not a  perpendicular direction, and when suddenly
stretched, throw the heart forwards; whilst the ar-
teries, being attached laterally and  superiorly, do
not yield to the  movement, but bend forward to-
wards the base of the heart.
  But, according to Dr. Heine's own showing, such
an effect could not be produced, except upon the
hypothesis  that the contraction of the heart  com-
mences at the  points of insertion of the papillary
muscles, so  as to afford these a firm point of support
for their action; such contraction of the heart being
followed by contraction of the papillary muscles, by
which the heart, still undiminished in size, is thrown
forward; then comes the heart's systole, and the ex-
pulsion  of the blood.
  I must say, that this explanation of the forward
movement of the heart by the mode of insertion of
the papillary muscles, and their contractions, is not 
IMPULSE OF THE HEART.          197
very intelligible to me:  if such an explanation is
admitted, the heart's impulse  can  no longer be
looked upon as a concomitant circumstance, but
must be regarded as the very object of its action—
an idea to which I must refuse to give my assent.
The object  of  the contraction  of the heart is  to
drive the blood onwards; and, in my opinion, we
have good right to take this fact as a postulate.  In
explaining the cause of the heart's impulse, we must
proceed by the process of demonstration; we have
no a priori facts to aid us.
  I might add, that, according to experience, the
force of the heart's impulse bears no relation in de-
gree to the development of  the papillary muscles.
Dr. Heine  has not taken into consideration the
slowly-developed impulse of the heart.  The expla-
nation of the movement of the heart downwards, as
a consequence of the contraction of the papillary
muscles,  can scarcely  be entertained as serious.
  Professor  von Kiwisch gives the following ex-
planation of the cause of the impulse: " The heart
cannot recede from the diaphragm and the thoracic
walls, unless some body—either gaseous or liquid
—or  a portion of lung, intervene between the two.
Now  it is  evident, that at  those parts where the
pericardium  is  attached to the thoracic walls and to
the diaphragm, no lung can intervene; so long there-
fore as the pericardium contains neither liquid nor
gaseous  bodies, the  thoracic walls  and the dia-
phragm form the fixed points of the heart;  the other
parts around the heart are yielding, and follow its
movements;  the heart, consequently, during its
                      17* 
198          IMPULSE OF THE HEART.

diastole, will be lengthened,and take a direction up-
wards and backwards.   The ribs  alone  form the
rigid portion of the thoracic walls, the intercostal
spaces being more or less yielding; when therefore
a contraction of the heart as it lies in contact with
the walls takes place, the ribs, being  the most un-
yielding parts, form the fixed points against which
the organ is firmly pressed, and from which it can-
not recede.
  "In this fixed position, the heart, during each
systole,  swells  out, becomes firmer,  and takes a
more globular form; its movement forward, thence
resulting, is restrained  by the ribs, but manifests
itself through the yielding intercostal spaces;  and
thus it is, and by no other means, that the pheno-
menon in question of the heart's impulse is produced.
Accordingly,  when we place a finger in the proper
intercostal  space, we do not feel what is wrongly
called the  beat (Anprallen) of the heart's  apex
against the thoracic walls, but we experience a sen-
sation as though the heart's walls were hardening
and swelling, being themselves  fixed and  at rest;
much the same sensation, in fact, as is experienced
when the hand is passed through the abdomen and
placed upon the contracting ventricles of the heart,
the diaphragm intervening, or when the thorax is
opened  and the hand  laid immediately upon the
heart."
  The following remarks may perhaps serve to ex-
plain this theory of Kiwisch.
  The heart cannot recede from the walls of the
thorax and the diaphragm unless some foreign body
intervene, because the formation of a vacuum is pre- 
IMPULSE OF THE HEART.         199
vented by the pressure of the atmosphere; this pres-
sure acts upon the position of the heart only through
the medium of the lungs; and the heart cannot re-
cede from the thoracic walls and the diaphragm, un-
less the lungs are distended with air.  The lungs
possess elasticity and organic contractility, by which
a continual opposition is offered to their distention
by the air; their contractile power is the  measure
of the force, by which the soft parts of the thorax
are drawn inwards.  When the abdomen is opened,
the diaphragm is found to be arched upwards, and
the intercostal spaces—provided the individual ex-
amined be not unusually fat—are  seen to be  fur-
rowed externally, and elevated within the thorax.
This drawing-in of the intercostal spaces is not con-
fined  to those parts of the thoracic walls beneath
which the lungs lie; the pressure of necessity acts
upon every part of the thoracic walls, and equally
well, therefore, whether through the heart, through
pleuritic effusions, or through an infiltrated portion
of lung.  The pressure is constant, but it is increased
by inspiration.   Since the heart is retained in con-
tact with the thoracic walls and  the  diaphragm,
solely by the distended  lungs, and since  the con-
tractility of the lungs produces a constant drawing-
in of the soft parts of the thoracic walls, it follows,
that whatever form the heart may take, it can never
cause  a  projection of the intercostal spaces, or of
the diaphragm, in a direction outwards or down-
wards; if no other influence affected the heart's po-
sition, a slight drawing-in of the intercostal spaces,
and the diaphragm, would be  more likely to  hap-
pen at each systole. 
200          IMPULSE OF THE HEART.
  The theory of Professor von Kiwisch presup-
poses that the lung  both contracts inwardly, and
presses outwardly. If the explanation above given
does not make the matter clear to any one, let him
recollect, that at times the impulse of the heart
not only forces forward the intercostal spaces, but
also raises the sternum and the ribs; a fact which
has been quite overlooked by Kiwisch.

    THE FORCE AND EXTENT OF  THE HEART'S IMPULSE.
  A consideration of the causes which produce the
heart's impulse  enables us, in  some cases, to pre-
mise certain facts respecting its force and extent.
  The different causes referred  to in the preceding
account are not  always found associated  together
in the production of the heart's impulse; one only
may be in operation, or there may be several; the
force  of the impulse  is necessarily connected with
the rapidity and completeness of the contractions,
and with the size of  the organ itself.
  If, for the moment, we admit that the pressure
of the blood on the walls of the ventricles, and the
lengthening of the arterial columns, are  the only
causes of  the heart's impulse, it follows that  this
impulse will be stronger, in  proportion to the quan-
tity of  blood and the  velocity with which it is
forced from the heart into the arteries.  An hyper-
trophied and  dilated ventricle is  therefore pecu-
liarly well fitted for the production of a strong im-
pulse.   In simple hypertrophy, without dilatation,
as well as in dilatation of the ventricles, without the
thinning of their walls, the  impulse is weaker than
in hypertrophy with dilatation, but stronger than in 
IMPULSE OF THE HEART.         201
the normal condition of the heart; on the other
hand, when its cavities  are dilated, and its walls
thin, it is weaker  than  in the last case, because a
simply dilated ventricle cannot completely expel
the blood within it.   An hypertrophied  and con-
tracted ventricle  produces  a diminished impulse.
The more contracted the ventricle, the weaker is
the impulse.
  But we must not conclude, that in hypertrophy
with dilatation the impulse is always stronger than
in hypertrophy without dilatation; for rapidity and
completeness in the heart's contractions are indis-
pensably required for the production of a strong
impulse, and these, as experience teaches us, de-
pend upon other causes than merely the thickness
of the heart's walls.
  An hypertrophied heart, when excited, may pro-
duce strong concussion of the thorax;  and yet, at
another time  beat so calmly that  its impulse is
almost imperceptible.
  If the hypertrophy and dilatation is confined to
the left ventricle,  and the right ventricle is either
of normal size, or smaller than natural, the left ven-
tricle will be  unable to throw its full quantity of
blood into the aorta, on account of  its receiving a
deficient supply from the  right ventricle, which
does not  contract more frequently than  the left.
Hence,  no distinct and constant increase  of  the
heart's impulse will attend  hypertrophy  and dila-
tation  confined to the left ventricle, provided  the
aortic valves are not defective; for when they are,
a portion of the  blood which is driven into  the
aorta during the systole, regurgitates into the ven- 
202          IMPULSE OF THE HEART.
tricle during the diastole:  from time to time, how-
ever, a beat more violent than ordinary will be
observed.  The same is true of hypertrophy and
dilatation of the  right ventricle, accompanied by
normal or  diminished  size, with thinning  of  the
walls of  the left  ventricle, provided there be no
defect of the tricuspid valves; the greater the dis-
proportion in  size between the two cavities,  the
less will be the force of the impulse.
  The force of the impulse is also affected  by  the
size of the arterial  opening, and the  quantity of
blood contained in the ventricle.  If the arterial
opening  be narrow, and  the ventricle  large,  the
impulse of the  heart is less than it would be if the
ventricle and arterial opening were both enlarged;
when the arterial opening is narrow, the impulse
is prolonged,  if the contraction of the ventricle
bo complete.  If  the disproportion  between  the
size of the arterial opening and the ventricle be
considerable, the heart cannot contract thoroughly,
its impulse is shortened, and may be scarcely per-
ceptible,  although the organ be hypertrophied  and
dilated.
  But it  has been shown  that  the impulse of  the
heart may be  caused by mere change of its form,
independent of any expulsion of blood from its ven-
tricles; consequently, what has been here said re-
specting  the effect which the condition of the arte-
rial openings  and the ventricles has upon the im-
pulse, must be taken in a modified sense.  Change
of form does  not produce any  increased impulse,
unless the heart be much  enlarged and  its action
violent. 
IMPULSE OF THE HEART.         203
  The heart's movements may be considerable, and
yet produce no concussion in the walls of the tho-
rax; and  the more distensible the aorta and pul-
monary artery  are, the greater is the  movement
produced  by the ventricular systole.  The greatest
displacement of the heart  occurs (as we have  al-
ready said) when the ascending aorta is lengthened
without being widened.  As a general rule, length-
ening of the aorta is only observed in old persons.
Little or no lengthening of the aorta takes  place,
when blood is forced into it during the ventricular
systole, provided it be not widened.  In such case,
there is either  very slight, or no downward move-
ment of the heart at all.  A rapid contraction of
the organ is not  absolutely indispensable to  the
lengthening of the aorta;  but the lengthening is
always  greater, the greater the quantity of blood
driven  out of the ventricle.

THE DIRECTION IN WHICH THE HEART MOVES DURING ITS SYSTOLE,
        AND THE PART WHERE THE IMPULSE IS FELT.
   Both the ventricles must contract synchronously,
for we find that, with very rare exceptions, one beat
of the  pulse takes place at every impulse  of  the
heart; if this were not the case, a double impulse of
the heart would accompany a single pulse.  It is not
a very easy matter to determine the direction which
the heart takes during the contraction of its ventri-
cles; the contraction of the right ventricle forces it
in a direction different to that which the  left ven-
tricle would give it; their simultaneous contraction
consequently produces a movement in the diagonal
of the forces.  When the heart is in its normal posi- 
204          IMPULSE OF THE HEART.
tion, its impulse may be felt between the cartilages
of the fifth and sixth ribs of the left side; if it lie in
a vertical position behind the sternum, it is forced
downwards at each systole, and consequently strikes
against the  lower part of the sternum, or at  the
scrobiculus cordis; in the latter case, the parts  are
seen to rise during the systole, and to return to their
former state during the diastole.
  When the position of the heart is horizontal, from
right to left, its impulse will be felt in the intercostal
spaces of the lower true ribs on the left side.
  Its vertical position is not observed, except in
cases of extensive pleuritic effusions, or in pneumo-
thorax of the left side, or of vesicular  emphysema
affecting the lower part of the left lung, or the whole
of the left lung, or  both the right and left  lungs
together.
  The horizontal position is given to the heart, either
from the diaphragm being forced upwards on the left
side by abdominal effusions, or by gaseous distention
of the bowels; or through enlargement of the  left
lobe of the liver; or through extensive pleuritic effu-
sions, or pneumothorax of the right side, by which
the right lobe of the liver is depressed and forced
towards the left, the left lobe being thereby driven
upwards.  This position of the heart may be also
produced by its own enlargement (the diaphragm
retaining its normal condition,) by lengthening of
the ascending aorta, or by large aneurisms on the
right side of the ascending aorta; the further the
apex of the heart is pressed towards the left, the
more extensive must  the  abnormal conditions be
which cause the pressure. 
IMPULSE OF THE HEART.
205
  Laennec,  and other writers after him, tell us,
that when the  left ventricle is hypertrophied, the
impulse of the heart is felt in the left side, but
when the right ventricle is  hypertrophied, behind
the sternum.  This  statement is by no means cor-
rect.   If the heart occupies the vertical position,
its impulse is felt behind the sternum, whether its
right or its left ventricle be hypertrophied; but if
it be  placed horizontally, the impulse is felt in the
left side, even though the right ventricle be hyper-
trophied. When the heart is considerably enlarged,
its impulse may be felt behind the  sternum, at the
pit of the stomach, and in the left  side.

   DIFFERENT DEGREES OF FORCE IN THE HEART'S IMPULSE.
   Three several degrees may be noted in the force
of the heart's impulse, each, however, passing gra-
dually into the other.
   1.  An impulse which does not raise the thoracic
walls, nor shake  the head of the  auscultator;  or
which is imperceptible.  The heart  producing such
an impulse may be perfectly normal, or it may  be
more or less hypertrophied and dilated, or dilated
only; the hypertrophy  and dilatation may be con-
fined to  one ventricle, the opposite state of things
obtaining  in  the  other: the impulse, lastly, is  af-
fected by the various degrees of pericardial effu-
sions.  From all which  it  results,  that a weak  or
imperceptible impulse is in itself a very indefinite
sign.
   2.  An impulse which does not raise up the tho-
racic walls, but imparts a strong concussion to the
       18 
 206          IMPULSE OF THE HEART.

 head of the auscultator.  Such an impulse indicates
 hypertrophy of one or both  sides of the heart, its
 cavities either remaining  of normal capacity, or
 being slightly dilated; or  it may be the result of
 increased action in a healthy heart.  We can only
 determine upon which of these causes it depends,
 by ascertaining the size of  the heart.  If the heart
 be of normal size, its walls are not hypertrophied,
 and the strong impulse  is  the  result of  increased
 action:  but if it be enlarged, and communicate a
 concussion to the head of the observer, there can
 be no doubt that its walls are hypertrophied.
   3. An impulse which  raises the thoracic walls
 during the heart's systole, the walls sinking again
 during  its diastole.  The head of the auscultator
 necessarily follows these movements.  The heav-
 ing of the thoracic Avails takes place  either sud-
 denly, producing a concussion, or the movement is
 gradual, and unaccompanied by concussion;  in the
 latter case, the heaving may be scarcely remarked
 by the auscultator, but the collapse, from its sud-
 denness, becomes the  more  striking.   In  conse-
 quence of a concussion being communicated  to the
 head when the heart sinks back, it is not impossible
 that a person little versed in auscultation  might
 confound the sinking back with  the impulse, and
 thus mistake the diastole for  the systole.
   An impulse strong enough  to raise the thoracic
walls  and the head of the auscultator, requires for
its production  hypertrophy and dilatation of both
ventricles. Hypertrophy and dilatation of the left
ventricle only, will not produce  such an impulse,
unless there be  considerable defect of the  aortic 
IMPULSE OF THE HEART.         207
valves co-existing: the same remark will apply to
the impulse which raises the thoracic walls without
imparting concussion to the head of the observer.
A slow contraction of the heart is the consequence,
either of a narrowing of its orifices, or of the area
of its cavities preponderating over the thickness
of their walls, or  of a general  deficiency of the
blood, etc.
   The second, as well  as  the  third degree of im-
pulse, does not preclude  the  idea of pericardial
effusion, or of union between the free and attached
pericardial surfaces.   It is only when the effusion
is considerable  in relation to the hypertrophy of
the heart,  that the increased impulse is lost; when
the heart is attached to the free pericardium, and
the layers of matters forming the union are thick,
the  thoracic walls may be raised  by an impulse
similar to  that produced by an hypertrophied and
dilated heart: the simply hypertrophied heart never
produces a concussion.
   The impulse moreover  varies, both as to the ex-
tent of surface  and the parts over which it is felt.
These points can be much more readily determined
by palpation, than by auscultation.   The impulse
of a normal heart cannot  be felt in more than one,
or at most in two, of the intercostal spaces; if it be
perceptible in several, or through more than an
inch and a half of one, at the same moment, we may
conclude that the heart is  enlarged. The cause and
the  signification of the heart's impulse,  as felt at
 different parts of the thorax, and at the  pit of the
stomach, have been already pointed out. 
208       PULSATION OF THE ARTERIES.
      II. THE PULSATION OF THE ARTERIES.
  We shall only speak here of the pulsation  of
the aorta and pulmonary artery.  If the ascending
aorta, or its  arch, be  so enlarged, as to come  in
contact with  the thoracic walls, or if any tumour
be present in the anterior mediastinum, an impulse
will be observed, at each systole of the heart, over
those parts of the thorax which correspond to the
course of the aorta—an impulse as strong, or even
stronger, than that of the heart itself.
  But we cannot be certain that the impulse is pro-
duced by pulsation of the aorta, unless it is  accom-
panied by a  perceptible heaving of the thoracic
walls; for the concussion produced by the impulse
of the heart is often distributed over a considerable
extent of surface, particularly over the  sternum.
When we are thus in doubt as to the cause of the
beat felt at the upper part of the sternum,—whe-
ther it be produced by the pulsation of the aorta,
or by the heart's impulse,—we must carefully ex-
amine the parts, proceeding from above downwards
to the heart's apex, and compare the force of the per-
cussion as felt at different points; if it be stronger
towards  the  upper part of the sternum, than  at
any point nearer the heart's apex, then it is evident
that the beat is caused by pulsation of the aorta.
It is however advisable in all cases to aid the diao
nosis by  percussion.
  The pulsation of the pulmonary artery may be
observed over the thorax, if a consolidated portion
of lung, or any solid body, intervene between its 
SOUNDS OF THE HEART.          209
root, or one of its large branches, and the thoracic
walls.   Hepatization, or tubercular infiltration of
the upper lobe of the lung, are the most  frequent
causes of this phenomenon, which Laennec  attri-
buted to transmission of the heart's impulse.
   I have never felt the pulsations  of the descend-
ing thoracic aorta. The pulsations of the abdominal
aorta are readily felt  in  thin  persons, when  the
abdomen  is retracted; in such cases  there  is no
difficulty in discovering any existing enlargement
of this vessel.

III. THE SOUNDS AND MURMURS HEARD IN THE REGION
   OF THE HEART, AND OVER DIFFERENT ARTERIES,
   CONSEQUENT UPON THE HEART'S MOVEMENTS.
   The normal sounds of the heart are generally
indicated by the expression " tic-tac;" its abnormal
sounds being comprised under the terms of bellows,
sawing, rasping, filing murmurs, etc.   The tic-tac
may be stronger or weaker than natural, or altered
in its  timbre; we are therefore obliged  to  speak
 of over-strong, or over-weak, or too  ringing—
 and consequently abnormal—normal heart sounds.
 This tic-tac I call the sounds (Tone) of the  heart,
and speak of normal and abnormal sounds.  By
 murmurs (Gerausche) I understand the abnormal
 sounds of the heart indicated above, blowing, saw-
 ing, rasping, etc.
   Gendrin gave  the name  of bruit  de  choc, and
 bruit de percussion to  the tic-tac, to distinguish it
 from the blowing, sawing, etc., murmurs.  I believe
 that the term chosen by myself is preferable.
                       18* 
210          SOUNDS OF THE HEART.
           THE SOUNDS  OF THE HEART.
               CAUSE OF THE SOUNDS.
  Observers are by no means agreed as to the in-
terpretation of the origin of the two sounds which
are heard  over  the region of the heart, and  are
synchronous with its systole and diastole.  Laennec
attributed  the first prolonged sound to contraction
of the ventricles, and the  second to contraction of
the auricles, but did not enter into any particular
explanation of their mode of origin;  doubts were
afterwards thrown upon this opinion, through the
researches  of Haller, who showed that a short and
rapid contraction of  the  auricles preceded—wie
ein Vorshlag—the systole of the ventricles.
  Majendie attributed the first sound to  the  im-
pulse of the heart's apex, and  the second to the
impulse of  the anterior surface of the right ventri-
cle, against the walls  of the thorax.
  At each systole, some part of the heart, if not
in every case its apex, beats  against  the thoracic
walls, the impulse frequently giving rise to a ring-
ing metallic sound, which may be imitated by tap-
ping upon  the back of the hand laid flat over the
ear.   But  the beat of the heart against the tho-
racic walls is not the only cause of the first sound,
for the sound  may be quite distinct when the im-
pulse is scarcely perceptible, and on the other hand
it may be barely audible when the impulse is vio-
lent.   Moreover, it  is shown by vivisections, that
the sounds of  the heart continue, although the or-
gan be prevented from striking against the sternum, 
SOUNDS OF THE HEART.
211
or any other body.  The right ventricle again does
not strike against the thorax during the diastole,
at least in the normal state of things.
   Rouanet attributed the first sound to a stretch-
ing of the auriculo-ventricular valves, during  the
ventricular systole; and  the second to the disten-
tion of the semilunar valves, produced by the back-
ward  pressure of the blood in the arteries during
the heart's diastole.
   Rouanet considered his views supported by the
fact, that membranes and chords  produce a sound
when suddenly rendered tense; this fact he applied
to the valves of the heart, which are rapidly brought
into a state of tension during the alternate systole
and diastole of that organ; and he endeavoured ex-
perimentally to demonstrate the correctness  of his
theory. For this purpose he tied a glass tube four
feet long into the aorta above the semilunar valves,
and beneath the valves he fixed a short tube, having
a bladder filled with water attached to it; he then
compressed the bladder, so as to force the water into
the tube fixed above the  valves, and suddenly re-
laxed the pressure; at each descent of the fluid he
noticed a stroke or sound which bore a certain de-
gree of resemblance to the second sound of the heart.
   Professor Bouillaud concurred in Rouanet's the-
ory, giving the name of valvular sounds to the ordi-
nary heart sounds.  In addition to the arguments
used by Rouanet in support of his views, Bouillaud
brought forward this important one,  viz.: that the
sounds of the heart are but very little  affected by
change in its structure, so long as the valves duly 
212
SOUNDS OF THE HEART.
perform their functions; but that they undergo con-
stant and  remarkable changes, and  are converted
into sounds of a totally different character, when-
ever the valves were altered in structure.  He was
not, however, of opinion, that the  first sound de-
pended entirely upon the distention of the auricular
valves during the systole, but attributed it in part
to the sudden flapping back of the semilunar valves
against the walls of the arteries; nor did he consi-
der that the second sound was produced solely by
distention of the semilunar valves, but also in part
by the simultaneous stroke  of the auricular valves
against the walls of the heart, at the time the blood
rushes from the auricles into the ventricles.
  Dr. C. J. B. Williams at first concluded from the
results afforded by vivisections, that the first sound
was a muscular sound; but he subsequently attri-
buted it to the vibrations excited in the ventricular
walls and the auricular valves during the heart's
contractions; the second sound he explained by the
impulse of the blood against the semilunar valves.
  The following are the conclusions drawn by the
Dublin Committee from their vivisections:—
  1. The sounds are not caused by contact  between
the ventricles and the sternum, but by movements
in the heart and its vessels.
  2. The distinctness of the sounds is increased by
contact of the ventricles with the sternum and an-
terior part of the thoracic walls.
  3. The first sound is connected with the systole
of the ventricles, and is of equal duration with it.
  4. The  cause of the first sound comes into action 
SOUNDS OF THE HEART.
213
and  ceases with the systole of the ventricles, and
is constantly in action during the continuance of
the systole.
  5. The first sound does  not  depend upon the
closing of the mitral and tricuspid valves, their act
of closure being  effected at the commencement of
the systole, and being of much shorter duration than
it.
  6. The first sound is  not  produced by friction
between the internal surfaces of the ventricles, for
friction can only take place when the ventricles are
empty, whereas the first sound commences with the
systole.
  7. The first sound is caused either by the sudden
rush of blood over the irregular internal surfaces of
the ventricle during its passage towards the arterial
openings, or by the muscular sound of the ventri-
cles, or probably it is the result of a combination
of these two causes.
  8. The second sound commences immediately on
cessation of the systole, and the integrity of the
semilunar valves is necessary for its continuance; it
seems to be caused by the sudden stoppage, through
the action of these valves, of those movements of
the blood which are occasioned by the elasticity of
the arterial trunks, and occur after each contraction
of the ventricles.
  The Committee close their report by observing
that,  notwithstanding  the  numerous researches
which had been made, the subject was not yet ex-
hausted,  and that  many doubtful points still re-
quired explanation.
  According to Gendrin, the contraction of the 
214         SOUNDS OF THE HEART.

ventricles produces undulations in the blood within
them,  which undulations converge  towards  the
heart's apex, and are communicated to its walls;
and hence the origin of the first sound.   It is loud-
est at the spot where the apex strikes the thoracic
walls, partly because the undulatory vibrations con-
verge towards  this point, and partly because  the
sound passes most readily from the apex  to  the
walls of the thorax, in consequence of the apex
coming in contact with the walls.
  At each  diastole the blood rushes into the ven-
tricles, first flowing down towards the heart's apex,
then upwards, striking at last against the walls of
the heart, about its base. This impulse gives rise to
the second sound, which consequently is heard loud-
est at the heart's base; the semilunar valves have no
part in its production, being already closed before
the ventricle is filled, and thus before the second
sound commences.  Neither do the auricular valves
assist in the formation of the first sound, for their
vibrations must be mixed up with the vibrations of
the blood; the first sound, moreover, is heard loud-
est towards the  heart's  apex, and not in the  neigh-
bourhood of the auricular valves; were it depend-
ent upon the tension of these valves, it ought to be
absent in cases where they are thickened or par-
tially destroyed, but it is  often heard  loudest in
such cases.   And so again, destruction of the semi-
lunar valves should put an end to the second sound,
if the sound depended upon them; but the sound is
always present,  though  masked by abnormal mur-
murs, which prevent its being recognised by  the
auscultator.  Any one may convince himself of  the 
SOUNDS OF THE HEART.
215
presence of the sounds, by listening for them, when
the ear is removed  to a little distance  from the
thorax.
  Cruveilhier considers that both sounds originate
about the roots of the aorta and pulmonary artery;
the first being caused by the flapping back of the
semilunar valves, the second by their closure.
  His views were formed from observations made
on an imperfectly formed infant.  The heart of the
child (which was in other respects well developed
and  full of life)  lay outside  the thorax, passing
through a round opening in the upper part of the
sternum.  It was uncovered by pericardium, and
completely bare, its  colour pale,  and surface dry.
Its position changed when the  child's posture was
altered: when the child was placed vertically the
heart sunk considerably, and its great vessels be-
came visible.  The axis of the heart was vertical.
Its action was not disturbed either by touching or by
gentle pressure, nor did the manipulation give rise
to pain.  Both its sounds were heard when the ear
was laid immediately on its surface, the first sound
much weaker than as ordinarily heard through the
thoracic walls.   Both sounds were loudest at the
base of the heart, and weakest  at its apex.  To as-
certain the cause of the first sound, Cruveilhier ex-
amined every part of the surface of the ventricles,
but could discover there neither vibration nor sound,
which  could be looked upon as other than the con-
sequence of conduction.  From this he concluded
that the auricular valves yield no sound, and that
the first sound is caused by the  flapping back of the 
216          SOUNDS OF THE HEART.
 semilunar valves, being heard loudest at the same
 spot as the second sound.  He considered his views
 supported by clinical observations; the sounds of
 the heart, according to him, being altered under
 every diseased condition of the semilunar valves,
 when  the  auricular valves are healthy.   The im-
 pulse of the heart against the thoracic walls assists
 in  the production of the first sound, and this is the
 reason why the first sound is loudest at the heart's
 apex.1

 THE AUTHOR'S VIEWS  RESPECTING THE CAUSE OF THE SOUNDS OF
                    THE HEART.
  The ventricles, the aorta, and pulmonary artery,
 severally contribute in  the production both of the
 first and of the second sound of the heart.
  The question,  as to  the origin of the heart's
 sounds, cannot, in my opinion, be solved by vivi-
 sections alone; observations must also be made upon
 individuals both  in health and in disease, and a
 careful comparison be instituted of facts observed
 during life, with  the results found after death.
  A person practised in  auscultation, with sufficient
 opportunities for investigation at his command, will
 find the'following statements correct: the sounds
 which  depend upon the movements of the heart
 differ in healthy individuals in their degree both of
strength and of clearness; in one person  they are
indistinct, or barely perceptible, in another remark-
ably clear, having even a ringing character; at one
time the sounds are scarcely audible in the region of
1 Gazette Medicate de Paris, 1841, No. 
SOUNDS OF THE HEART.
217
the heart, at another distinctly so over the whole an-
terior surface of the thorax, and even reach to the
back; again,in some persons they are particularly
clear at  those parts of the thoracic walls against
which  the heart beats, whilst  in  others they are
indistinctly heard there, but are very clear over the
pulmonary artery and aorta.
  By comparing the sounds heard over those parts
of the thorax against which the heart beats, with
the sounds heard above the base of the heart, where
the pulmonary artery and aorta lie, we frequently
observe that the first sound—the sound synchronous
with the  beat of the heart—is more prolonged over
the heart than the second sound, but that above the
base of the  heart the accent  falls on the second
sound.
  The sounds heard over the apex of  the heart—
and consequently over the left ventricle—also fre-
quently differ, in strength and clearness, from the
sounds heard at the same level, to the right and over
the  sternum—that is, over the right ventricle; I
have also occasionally observed a difference in their
pitch.
  The sounds heard above the base of  the heart—
about the middle of the sternum,  and  towards its
right border, beneath which parts  the aorta passes
—also occasionally differ in strength and clearness,
and in some  particular cases in pitch also, from the
sounds heard at the same level, but about an inch
to the left of the sternum.
   These  differences of  sound  are  much  more dis-
tinctly marked in individuals suffering from diseases
       19 
218
SOUNDS OF THE HEART.
of the heart  than in the healthy;  it will be well,
therefore, for observers to commence their investi-
gation of  them in persons suffering from  disease,
and afterwards study them in healthy subjects.
  Whoever has extensive opportunities for observa-
tion of diseases of the heart, will meet with cases
where neither the first nor the second sound can be
heard atthatpartof the thoracic walls against which
the apex of the heart beats—that  is, over the left
ventricle—but in their place he will find a single
or a double murmur, blowing, sawing, rasping, etc.;
while, at the  same time, to the right of this,—over
the right ventricle, and above the base of the heart,
i. e. over the  pulmonary artery and aorta—both
sounds are distinctly audible; the sounds, moreover,
heard at the three points indicated, generally differ
from each other in strength, clearness, etc.  In other
cases again, both sounds, which in  most cases differ
from each other, will be heard over the left ventricle,
the aorta, and the pulmonary artery, a  murmur,
synchronous  with the ventricular systole, being au-
dible over the right ventricle, but no sound.
   Still more  frequent are the cases  in which a single
 or double murmur, but no sound, is perceptible along
the course of the aorta, whilst over the right and
 left ventricles, and over the pulmonary artery, both
 sounds are distinctly audible.  A single or a double
 murmur may also be heard over the left ventricle
 and the aorta, the normal sounds still existing over
 the right ventricle and pulmonary artery; or  mur-
 murs  may be heard over the left and right ventri-
 cles,  or over the right ventricle and aorta, or over 
SOUNDS OF THE HEART.
219
the left and right ventricles and the aorta—whilst
at those parts where no murmur is heard, the sounds
are either distinct, or indistinct, or altogether in-
audible.
  If these remarks are correct, and I believe them
to be so, inasmuch as they are the results of a vast
number of observations made by myself and others,
it appears to me tolerably clear that the ventricles,
the pulmonary artery, and the aorta, severally assist
in producing the sounds of the heart.
   Variations in the sounds are generally associated
with changes in the condition of the valves of the
heart; we must, therefore, in our interpretation of
these sounds, take into consideration the state of the
valves during the heart's movements.  From obser-
vations made on the living, and compared with post-
mortem appearances, we are  forced  to the con-
clusion that variations in the sounds and murmurs
of the heart are generally associated with changes
in the condition of its valves; for when we observe
during life that the sounds are replaced by murmurs,
 as a rule, we find an abnormal state of the valves
 after death; they are thickened, or contracted, or
 covered by excrescences, or the opening they enclose
 is constricted, etc.  It  must, nevertheless, be  ad-
 mitted that we occasionally remark during life no
 change of sound, or only such as is consistent with
 the healthy condition of the valves, in cases where
 an abnormal state of the valves is found after death.
 From which it follows, that not every abnormal con-
 dition of the valves gives rise to well marked varia-
 tions in the sounds, but that certain'particular ab- 
220          SOUNDS OF THE HEART.
normal states are necessary for their production; or
else, that other circumstances, besides these abnor-
mal states of the valves, assist in producing them.
   By endeavouring to obtain a clear idea of the
manner in which  the  valves conduct themselves
during the movements of the heart, both in their nor-
mal and abnormal states, we may perhaps obtain an
insight into the conditions under which the valvular
sounds, and their changes and their conversion into
murmurs, are produced.  Such a survey of the pos-
sible conditions under which these changes may be
brought about, would afford us guidance in our in-
quiries, and thus, by aid of observations and direct
experiments, wc may be able to separate facts  from
mere conjectures.

  STATE OF TnE  MITRAL AND THE TRICUSPID VALVES  DURING
           THE MOVEMENTS OF THE HEART.
  Laennec asserted that the papillary muscles  were
so connected with the valves that their contraction
necessarily caused the valves to open; he must, there-
fore, have supposed that the papillary muscles do not
contract synchronously with the substance of the
heart, but during its diastole, i. e. when the blood
enters  into the ventricles.  Bouillaud, on the con-
trary, maintains that the valves  are closed by the
contraction of the papillary muscles.
  Now it will be found  that the valves do not close
however forcibly the papillary muscles and the ten-
dons attached to them are stretched in the direction
which they hold in the heart, and that whether the
force used be great or small, the valvular opening is
not diminished.  The closure of the valves is there- 
SOUNDS OF THE HEART.
221
fore not produced by shortening of the papillary
muscles during their contraction: neither do we ob-
serve that the blood meets with any obstruction in
flowing from the  auricles into the ventricles when
these muscles are relaxed; hence their functions do
not seem to be such as either Laennec or Bouillaud
attributed to them.  But since the contraction of
these muscles cannot close the valves, their closure
must necessarily  be effected by the pressure of the
blood against them.   The office of the tendons,
which pass from the muscles into the valves, is evi-
dently to prevent their eversion; for if the free bor-
ders  of the  mitral and  tricuspid valves were not
firmly held by the tendons which are inserted into
them, these valves, during the ventricular  systole,
would be driven by the stream of blood partly into
 the auricles and partly against the arterial openings,
 and anything like closure of them would be quite
 impossible.
   The tendons are affixed to the valves in a manner
 which is of the highest  importance to the correct
 performance of their functions; without such adjust-
 ment, indeed, the mitral and tricuspid valves could
 not prevent the reflux of the blood from the ventri-
 cles  into the auricles during the heart's systole.
    Several strong tendinous cords pass from each
 papillary muscle, towards the middle of that surface
 of the valve which is turned towards the ventricle,
 and are there inserted; some of them run on towards
 the base of the  valve, and are inserted near the
 point of union of  the valve with the walls of the
 heart.  Now from these strong tendinous cords,
                       19* 
222
SOUNDS OF THE HEART.
somewhere about their middle, and in part also from
the papillary muscles  themselves, smaller cords
arise, and are inserted somewhat nearer to the free
border of the valve.  Still finer cords again spring
from these last, and are inserted yet nearer to the
free border of the valve, and into the border itself.
No tendinous cord is attached to that surface  of
the valve which is turned towards the  auricle.
  If the papillary muscles be stretched in the same
direction as that which they take in the heart, it
will be  seen  that  merely the  stronger  tendinous
cords,—those which spring from the muscles them-
selves,—are rendered tense; the finer, which take
their origin from the stronger tendinous cords, and
are inserted nearer to the free border, or into the
border itself of the valve,  remain lax, however
strongly the muscles may contract.  Consequently,
the free border of the valve is never rendered tense,
by contraction of the papillary muscles, but  only
that portion of the valve included between its fixed
border and the part where the tendinous  cords
springing from the papillary muscles' are inserted;
the remainder of the valve,  the part included be-
tweenitsfreeborder and its middle, remains relaxed.
  When any  point of this relaxed surface  of the
valve is pressed in the direction of the auricle, so
that the tendinous cords inserted into it are made
tense, it will  be seen that a number of pouches are
thereby formed;  and if the same experiment  be
tried over the whole of the  valve, the ventricular
surface will lose its smoothness, and be thrown into
a series of folds, which commence at the free border 
SOUNDS OF THE HEART.
223
of the valve, and reach as far  as, or even farther
than, the middle of the valve;  these folds are evi-
dently formed by the peculiar insertion of the ten-
dinous cords.   Again, by blowing against the re-
laxed portion of the valve, in a direction towards
the auricle, the valve will be made to swell out like
a  sail, and  to  exhibit  the  folds around its free
border.   And the same thing happens, when water
is poured against it.*
   Now, since the blood during the ventricular sys-
tole, has  a tendency to flow back towards the au-
ricle, it must necessarily be caught in these pouches,
or semilunar-like swellings of the mitral and tricus-
pid  valves, and  thus cause the lax portions of the
valves—the portions unaffected by the contraction of
the papillary muscles_to project towards the auricle,
so far, at least, as the tendons inserted into them will
permit.  Through the formation of these projections
in the valves, the blood itself becomes the cause of
  * Dr.  Kiirschner imagined  that,  in my  experiments, the
border of the valve had not been completely unfolded, and that
false folds had thus been formed in it.  In their normal  state,
the tendinous cords—and particularly those of the mitral valves
—do not end as such, but spread out  into a kind of membrane,
and are  inserted into the valves in  such manner as to form
crescentic membranous folds.  Now, if blood or water be forced
between the  membranous folds formed  by the insertion of the
tendinous cords and the valve, a bladder-like  projection will be
observed on that surface of the valve which looks towards the
auricle:  it is to this projection that  I  apply the term pouch
(Tasche.)  These pouches are smaller in the  tricuspid, than in
the mitral valves, but they are always  present under normal cir-
cumstances. 
224          SOUNDS OF THE HEART.
the complete closure of the passage into the auricle,
i. e. when the valves are  held in  such a  position,
that no opening remains after these projections are
formed.  It is therefore evident, that the mode of
attachment, and the length of the tendinous cords of
the mitral and tricuspid valves, cannot be fortuitous.
  The area of the cavity of the ventricle at the com-
mencement, is different from its area at the end of
the systole; and the points of origin of the papillary
muscles approach continually nearer to the attached
borders of the mitral  and tricuspid valves, as the
systole progresses.  Now, the length of the ten-
dinous cords always  remaining  the  same, it  be-
comes evident, that for the perfect closure of  the
valves, the tendinous cords which  retain the valves
in their  proper position, must of necessity take
their  origin from the papillary muscles.
  If,  for  example, they arose immediately from the
walls of the heart, and were of due length for the
performance of their functions at the commencement
of the systole, they would necessarily be of too great
a length during its  progress; and on the other hand,
would impede the diastole, if their length was suffi-
cient  merely to retain the valves in their proper
position  towards the end of the  systole.  But as
the length of these cords is invariable, they must
necessarily have some muscular attachment; and the
object of the papillary muscles is evidently, by al-
ternate extension and contraction,  to retain  the
valves in their proper position.   During the pro-
gress of the systole, these muscles contract, the dis-
tance between their points of origin and the attach- 
SOUNDS OF THE HEART.
225
ment of the mitral and tricuspid valves continually
diminishing; in consequence of this contraction, the
tendinous cords arising from the muscles retain the
same degree of tension during the progress of sys-
tole, which they had at its commencement, and they
also retain it during the diastole, the papillary mus-
cles being lengthened when the heart expands.
  The correctness of the  views here offered of the
function of the papillary muscles, seems to me con-
firmed by the fact, that that division of the tricus-
pid valves, which lies against the heart's septum,
receives its tendinous cords either from very short
papillary muscles, or immediately from the walls of
the heart.  The points of  origin of these tendinous
cords approach but little, or not at all,  during the
systole, to  the points of attachment of the valve;
and recede as little during the diastole.  Now here,
a simple tendinous cord suffices for the proper re-
straint of the valve, because change in the length
of the cord is not required.*
  From what has been said it would appear, that
the movements of the mitral and  tricuspid valves
are as follows.  During the systole of  the ventri-
cles, the papillary muscles contract, and  prevent
the valves from being forced out of the ventricles,
and also restrain their movements in the direction
of the arterial openings.   At the same time, the
papillary muscles, and the tendinous cords arising
  * The use of the papillary muscles, as here given, has been
already pointed out by Professor Weber, in his edition of Hilde-
brandt's Anatomic. 
226
SOUNDS OF THE HEART.
from them, approach each other, and thus the surface
of the valves, into which they are inserted, is thrown
into folds, and the valvular opening diminished in
size.
  The remainder of the valvular opening is closed
by that portion of the valve which is not rendered
tense by the shortening of the papillary muscles.
The pressure of the blood, in fact, upon this portion
of the valve, bellies  it out like a sail; and opposite
points of the free borders of the valves, thus swollen,
come into contact and materially support each other;
partly in consequence of this support, but still more
through the attachment of the tendinous cords, the
eversion of  the free  borders of the valves is pre-
vented.  Since the finer cords, which run into the
free borders of the valves, spring from the larger ten-
dinous  cords, which have their origin from the pa-
pillary muscles, the pressure of the blood against the
distended portion of the valves causes all the ten-
dinous cords, arising from the muscles, in conse-
quence of the attachment of the finer cords to them,
to approach each other, and thus to take a curved
direction.
   At each diastole, the papillary muscles become
lengthened, and separate from each other, and the
blood, flowing from the auricles, would naturally
press the valves against the walls of the heart, and
also against the arterial openings, if they were not
retained in their proper position by the tendinous
cords.   These tendinous cords, arising from the pa-
pillary muscles, are not relaxed, even during the
diastole; for if they were, the valves could not, at
the commencement of the  ventricular  systole, be 
SOUNDS OF THE HEART.
227
brought into the position requisite for instantaneous
closure; and a great part of the blood would conse-
quently, at each contraction, flow back from the ven-
tricle into the auricle; the valves must indeed be
frequently drawn into their proper position, by the
contraction of the papillary muscles, in opposition
to the current of blood.1
  For the perfect performance of their functions,
the free borders of the mitral and tricuspid valves
must form the pouches above described, and the
tendinous cords and papillary muscles must be of
a length proportionate to the size of the ventricles.
If the valves do not possess their normal conforma-
tion,  they either permit a reflux of blood from the
ventricle into the auricle, during the systole—i.e.,
the valves are defective, or they present some ob-
stacle to the entrance of the blood into the ventri-
cle during the diastole.
  In  the first case, the abnormal condition is caused
by thickening or shortening of the free borders of
the valves, or by the union of their free borders with
  1 Dr. Kiirschner thinks that he has discovered certain muscu-
lar fibres, which pass from the auricle into the valves, and at-
tach themselves, either immediately or by tendinous cords, to
the points of insertion of the tendons of the papillary muscles;
not, however, to the larger tendinous cords—the tendons of the
first order—but to those of the second order, namely, such as
are inserted towards the free border of the valves.  The  object
of these muscles is, to increase the distance between the valvular
flaps and the tendons of the first order, during the contraction of
the auricle, and to bring them into such a relation to the margin of
the auricle, as to cause them, when pushed forward and distended,
to close the auricular  opening.  My own opinion is, that such
a contraction of the valves would serve no purpose whatever. 
228
SOUNDS OF THE HEART.
 the tendinous cords attached to the middle of the
 valves, so as to prevent the formation of the pouches;
 or  by shortening, lengthening, or rupture of the
 tendinous cords; or by excrescences, or deposition
 of blood-coagula, etc., upon the edges of the valves;
 or by union of the surfaces of the valves with the
 walls of the ventricle.
  In  the  second  case, the abnormal  condition is
 produced  by extensive deposition of foreign mat-
 ters, blood-coagula, or chalky concretions, etc., upon
 those surfaces of the valves which are turned to-
 wards the auricle; or by union of the tendinous cords
 among themselves, or with the free border of flie
 valves, by which their perfect contact is prevented.

           ACTION OF THE SEMILUNAR VALVES.
  The semilunar valves of the aorta and pulmonary
 artery are, as is well known, driven  against  the
 sides of their respective vessels by the blood which
is forced from the ventricles during  the  heart's
 systole, and expanded towards the ventricles, during
the diastole, by the backward pressure of the blood,
produced by the elasticity of the arteries.
  The aortic valves occasionally lose their flexibi-
lity, in consequence of the development of excre-
scences, chalky concretions, etc., upon  them, or of
their abnormal union with each other, and thus be-
come incapable of  being pressed back  against the
walls of the aorta, and obstruct the entrance of the
blood into  the aorta.  If the free borders of  the
valves are shortened or averted, or have foreign
bodies attached to them, or if they be in part torn
from their attachments, they are no longer in a con- 
SOUNDS OF THE HEART.
229
dition to prevent the reflux of the blood from the
aorta into the left ventricle,  during the heart's
diastole.
  We  may readily ascertain, after death, whether
the aortic valves duly performed their functions
during life, by pouring water into the aorta; if the
valves are healthy, the water does not flow back
into the left ventricle, its reflux being prevented by
closure of the aortic valves; but if the valves be de-
fective, the water passes into  the ventricle.
  We cannot, however; apply this test to the mitral
and tricuspid valves.  If the  apex of the left ven-
tricle  be opened, the aorta tied, and water then
poured into  the ventricle  through  the  artificial
opening, we shall find that the flow of the water
through the mitral valves is occasionally prevented;
but this does not invariably happen, and by repeti-
tion of the experiment, we shall soon discover that
no  conclusions  as to  the actual condition of the
valves can be drawn from it.   If, again, one of the
ventricles be  filled  with water,  and its  arterial
opening closed, and pressure be then applied to the
ventricle, the mitral or tricuspid valves (as the case
may be) will be distended, but will not  entirely
prevent the reflux of  blood, though in a perfectly
normal condition. And the  reason of this must
evidently be sought for in the fact, that we are not
able, after death, to imitate the contraction of the
papillary muscles, and the  general  contraction of
the heart's cavities. Whether, therefore, the mitral
or  tricuspid valves fully performed their functions
during life, or not, is a question which we can only
       20 
230          SOUNDS OF THE HEART.
 judge of, after death, from the conformation of the
 valves, of the tendinous cords, and of the papillary
 muscles, and from the changes which the defect of
 these valves is wont to produce in the auricles.

   EXPLANATION OF THE SOUNDS HEARD IN  THE VENTRICLES OF
                    THE HEAET.
   By comparison of clinical  observations with the
 facts revealed by post-mortem examinations, we find
 that a distinct first sound is very rarely heard over
 the left  ventricle, when the mitral  valves are inca-
 pable of preventing the reflux of the blood into the
 left auricle, during the heart's systole—i. e. when
 the mitral valves are defective.  In such case, a
 murmur, synchronous with the systole, is generally
 heard over those parts of the  thoracic walls against
 which the heart's apex beats; the first sound being
 distinctly audible over other parts of the precordial
 region.   The same is true of the  right ventricle,
 when the tricuspid valves are defective; no distinct
 first sound is then heard over the  right ventricle,
 but may  still be recognised over the left ventricle,
 the aorta, and the pulmonary artery; in the right
 ventricle, it is generally replaced by a murmur.
   The first sound in the ventricles, therefore, is
 for the most part produced by the sudden stoppage
 of the flow of blood towards the auricles, consequent
 upon the distention of the  mitral and tricuspid
valves, and thus, through the  impulse of the blood,
against these valves.  Every  blow creates a sound'
and the sound is duller, the more yielding  the na-
ture of the  body striking, or struck.  The state of
tension into which the valves  are suddenly thrown 
SOUNDS OF THE HEART.
231
by the pressure of the blood, undoubtedly contri-
butes to the production of the first sound, for cords
and membranes always yield a sound when sudden-
ly stretched, not solely in the air, as Gendrin and
others have supposed, but also in water.  The cir-
cumstance, moreover, that the first sound  is often
heard clear, with a clap, and at times even ringing,
tends evidently to  show, that the tension of  the
valves contributes to its formation.
   The first sound is also produced by the impulse of
the heart against the walls of the thorax.  A blow
struck with the finger, or with the apex of the heart
firmly compressed,  against the inner surface of the
thoracic walls, produces a chinking (klirrend) sound,
which differs in no particular from the ordinary first
sound of the heart.   If a part of the  walls of  the
heart be somewhat separated from the thoracic walls
during the ventricular diastole, but strike against
them during the systole; or even if the heart beat
against some other part of the thoracic walls during
its systole than that beneath which it lay during the
diastole, still, in either case, a chinking sound, or
one. exactly resembling the  ordinary first sound of
the heart, will be produced ; for the heart's substance
becomes firm during its systole.   If the heart beat
against that partofthe thoracic walls, beneath which
it lay during its diastole, the impulse will give rise
to either a very dull sound, or none at all.
   The muscular sound of the heart is always heard
as a dull and prolonged sound, never as a clap; for
no muscles ever yield a defined, clapping, or chink-
ing sound; according to the division of sounds which 
232          SOUNDS OF THE HEART.
I have adopted, this muscular sound cannot be pro-
perly classed among the sounds of the h<mrt, but
must be rather looked upon as an indistinct mur-
mur.   Whether the contractions of the heart be
really accompanied by such a murmur, I cannot say
from  observation  on the living; but  certainly
cases  are far from rare, in which  the  impulse of
the heart is violent, and therefore its contractions
strong, and in which nevertheless  no first sound
can be heard.
  The causes of the first sound here adduced are
not sufficient for  the  explanation  of every  case;
and  all attempts hitherto made to  explain the
different modifications of the first  sound  have
proved signally unsuccessful.
  The explanation of the causes of the second sound
of the ventricles presents  still greater difficulties
than that of the first sound; we cannot affirm that the
second sound is always formed in  the  ventricles,
when the condition of the heart is normal;  for it
seems probable, and sometimes indeed certain, that
the second sound heard over the heart arises in the
arteries, and, on account of its intensity, is propa-
gated to a distance.  But there are cases in which
we are forced to admit that the second sound arises
in the neighbourhood of the ventricles:  cases, for
instance, in which the second sound is barely au-
dible over the base of the heart, but very loud and
clear over its  apex.  A second sound of this de-
scription cannot be explained by  the impulse of
the heart against the thoracic walls, for there  is
no impulse during the ventricular  diastole. 
SOUNDS OF THE HEART.
233
  It is possible that the second sound may be oc-
casionally produced  by the impulse of the blood
against the walls of the ventricles during the dias-
tole;  such  an impulse undoubtedly takes place in
the left ventricle, when the aortic and mitral valves
are defective.  But only in one single case where
there was deficiency of the aortic valves, have I ob-
served the second sound to be louder at the heart's
apex than elsewhere; in this case indeed  it was re-
markably strong and ringing.  An increased second
sound at the apex of the heart, is more frequently
observed when the mitral valves are defective.
When the left auriculo-ventricular opening is con-
stricted, two muffled sounds, instead of a prolonged
murmur, are occasionally heard over the left ven-
tricle during the heart's diastole.
  Gendrin  availed  himself of this fact to support
his  theory  of the second sound of the heart:  he
considered  that the  double second sound was the
consequence of the two ventricles not being filled
synchronously: it appears to me much more proba-
ble, that these two sounds are merely divisions of
a single murmur, which has its origin at the con-
stricted opening.  In fact, this murmur of constric-
tion frequently becomes converted into two, or even
three separate sounds, when the movements of the
heart are weak.   Moreover, in many cases, the
murmur is distinctly heard at one spot, whilst over
the  parts around, two, or even three sounds—as
though they were louder periods (Momente) of the
same murmur—are audible.
                      20* 
234
SOUNDS OF THE HEART.
           SOUNDS IIEAED TX THE ARTERIES.
  In all the larger arteries, a sound may be occa-
sionally heard in company with the pulse, having
a tolerably close resemblance to an ordinary heart
sound.  I do'not suppose that any one can imagine,
that sounds heard over the crural or brachial ar-
turics can have had their origin in the heart, and
been  propagated from it; neither can the sounds
heard over the carotid and subclavian arteries be
considered as arising elsewhere than in the arteries
themselves, in cases where no sounds can be recog-
nised  in the region of the heart, or only such as are
weaker than those heard in the neck.  This last fact
may be frequently observed, and the only mode of
accounting for the phenomenon is, to ascribe it to
some especial conducting power in the parts which
the sound traverses.   It is an undoubted fact, that
the propagation of sound  through the thorax is af-
fected by changes in  the condition of its organs;
but we frequently meet with cases in which the
sounds are heard distinctly above or beneath the
clavicles, while they are indistinct in the region of
the heart, the lungs being in a perfectly normal con-
dition ; such cases are not explicable by the laws of
conduction of sound.  Bouillaud considers that the
arterial sounds differ from the heart's sounds, having
a resemblance to the sound produced by a fillip of
the finger. The arteries at a distance from the heart
most generally give rise to a simple toneless sound,
such as Bouillaud describes; whilst those  near the
heart—the carotid, the subclavian, the pulmonary
arteries, and the aorta—produce sounds for the most 
              SOUNDS OF THE HEART.          235

part as loud as those audible in the region of the
heart; on the other hand, the sounds heard in the
region of the  heart  are at times equally toneless.
  The sound heard over the arteries synchronously
with their pulsation, may be explained by the sud-
denly increased tension of their coats.  The second
sound is audible over the aorta and pulmonary ar-
tery, and also  generally along the carotid and sub-
clavian arteries.   In other arteries we rarely hear
any sound synchronous with the systole.
   The second sound, heard over the aorta and pul-
monary artery, is  evidently produced by the shock
arising  from  the  regurgitation of the blood upon
the semilunar valves, which takes  place  subse-
quent to the heart's  systole.  The  blood which
passes  into the arteries during the systole, is sub-
jected to compression  by their elasticity, and when
 the forcing power of the heart ceases, is of neces-
 sity driven back towards the  heart.
   The  reflux of the blood is suddenly arrested by
 the semilunar valves, and  the impulse which they
 receive in consequence,  is communicated  to the
 walls of the vessels; the  sound  resulting is not
 only audible over the aorta and pulmonary artery,
 but is frequently communicated along the carotid
 and subclavian arteries, and this, too, even in cases
 where the coats of the aorta  have lost  the condi-
 tions necessary for the production of sound.  The
 correctness of this explanation of the cause of the
 second sound, heard over the aorta and pulmonary
 artery, is placed beyond doubt  by physiological
 and pathological observations; the sound does not
 appear to have any other cause for its production. 
236
SOUNDS OF THE HEART.
  If its semilunar valves are defective, the second
sound is not heard over the aorta, but the sound is
replaced by a murmur.  The second  sound of the
pulmonary artery however remains distinctly audi-
ble.  When the pulmonary artery is abnormally
distended, which it always must be, when the pul-
monary circulation is obstructed, its second sound
becomes very loud, whilst the second aortic sound
is either weak or inaudible, or is replaced by a mur-
mur. The pulmonary artery, when thus distended,
presses with increased force upon the blood within
it, and consequently the backward stroke of the
columns of blood against its semilunar valves be-
comes more forcible.
  Dr. Rapp,—Zeitschrift fur  rationelle Medizin,
vol. viii.—insists upon it, that the first sound arises
only in the ventricles, the second only in the arte-
ries.  The first sound he considers, with Dr. Wil-
liams, to be a muscular sound; and the second, he
attributes to the impulse of blood against the aortic
and  pulmonary valves. The  explanation of the
first  sound, by  impulse of the blood against the
auricular valves, appears to him  inadmissible, for
the reason, that the valves are continually sur-
rounded by blood; neither does he believe in the
origin  of a first sound in  the arteries, and of a
second in the ventricles, inasmuch as the pheno-
mena are  otherwise fully capable of explanation.
Again, the interpretation of  the second sound,
heard over the ventricles, by a supposed  tension
of the tendinous cords of the auriculo-ventricular
valves, is opposed by the character of the murmurs 
SOUNDS OF THE HEART.
237
and sounds which are heard when the aortic valves
are defective, and also by the fact, that the diastole
does not follow instantaneously.  Lastly, the ex-
planation of the first sound in the arteries, by the
tension of their coats, is in contradiction with the
explanation of the first sound  in the ventricles,
by tension of the tendinous cords  of the auricular
valves; for the  tension of the arterial coats cannot
be less than that of the valvular cords, and conse-
quently the first sound in the arteries should be as
long and as loud as the first sound in the ventricles,
which is contradicted by experience.
   How far we are bound to admit the origin of the
first sound in the arteries, and of the second in the
ventricles, may be gathered from what we  have
already said: and on this score I have nothing fur-
ther to add.  I have already, in the second edition
of my book, abandoned the explanation of the se-
cond sound of the ventricles by tension of the ten-
dinous cords of the valves.  The sound of the arte-
ries during their diastole can hardly be otherwise
explained than by strong tension of their coats; it
is impossible to believe that the sound heard over
the brachial or crural arteries could have been pro-
pagated from the first ventricular sound.   Lastly,
if the origin of the first sound in  the ventricles is
not  to be explained by the  impulse of the blood
against  the auricular valves, because these valves
are  continually surrounded by blood,  then must
the second sound of the arteries have some other
cause than that to which it has been hitherto attri-
buted ; for the aortic and pulmonary valves are also
continually surrounded by blood. 
238          SOUNDS OF THE HEART.
   VARIATIONS IN THE CHARACTER OF THE HEART'S SOUNDS.
  The sounds of the heart and arteries vary in their
duration, strength, clearness, pureness, and pitch;
they may be well defined, resembling the tic-tac of
a watch, or prolonged, and murmuring.   When the
semilunar valves  are healthy,  the  second sound
of the aorta and pulmonary artery is well defined,
particularly if the  heart's action be  strong, and
closely resembles the flapping of a valve.  The more
defined, and consequently the more flapping, the
character of the first sound over the ventricles, and
the greater its resemblance to the  second sound
of the arteries, the more certainly may we conclude
that it is  produced by the impulse of the blood
against the valves; but when the first sound is dif-
fused over the ventricles, and ill-defined, it becomes
doubtful whether it is formed in this  manner; there
is, in fact, another cause which may  give rise to it.
Such a sound, viz., one that is prolonged and heard
over the ventricles, synchronously with the systole,
I call an indeterminate sound: it gives no indication
as to the condition of either the mitral or tricuspid
valves, and cannot be classed among the true sounds
or murmurs of the heart.
  The sound heard  with the systole over the ven-
tricles, is often composed of a flapping and of a dif-
fused and indeterminate sound.  The flapping first
sound of the heart is louder the greater the circum-
ference of the valves and the finer their  structure.
The first sound over the ventricles loses its ringing
character, when the free  borders of the mitral or
tricuspid valves are thickened;  it becomes shorter
than natural, resembling the sound produced by 
SOUNDS OF THE HEART.
239
striking together two hard, not-ringing (nicht-klin-
gende) bodies.   It may be very loud, and is fre-
quently of a remarkably high pitch.  The first sound
over the ventricles may commence with a deep and
end  with a high  tone,  producing the  sound  of
"twick" rather than of  "tic:" in  some  very rare
cases, it is of so fine and ringing a character, as al-
most  to resemble the sound caused by the sudden
tension of a silk thread.  It seems probable, that
in such cases the tendinous cords alone produce the
sound.
   There is another variety of the first sound over
the ventricles; the sound appears as though it were
divided, and formed of two, or even three sounds,
rapidly following upon each other, and blended to-
gether into a single one: the phenomenon appears
to result from the circumstance of the valves not ex-
panding instantaneously.  The ventricular systole
may also be accompanied by two distinctly different
sounds.  Gendrin considers this impossible, but Dr.
Williams (on the other hand,) in his Lectures  on
the diseases of the  Chest, admits the existence of a
double first sound, and explains it by a want of syn-
chronism in the contraction of the ventricles,  I be-
lieve that in many cases this explanation is correct.
   According to Augustus Baumgarten, the auricular
valves are not closed by the systole of the ventricles,
but by the contraction of the auricles preceding the
systole, by which a still further quantity of blood is
forced into the already distended ventricles, and
their walls thereby rendered tense.  Hamernjk has
somewhat modified this opinion: he considers that
the closing of the auricular  valves is not always 
240          SOUNDS OF THE HEART.
produced by the contraction of the auricles, but that
it is not unfrequently, the consequence of the pres-
sure to which the vena cava is subjected during ex-
piration, without any assistance from  the auricles.
On this hypothesis  Hamernjk explains  the first
sound in the ventricles, not by an impulse of the
blood against the auricular valves during the sys-
tole, but merely by their increased tension; and
the double first sound he attributes to a renewal of
the tension produced by an undulation of the blood
within the cavities of the heart.   The  closure of
the valves of the aorta, and of the pulmonary ar-
tery, according to Hamernjk, precedes the contrac-
tion of these vessels, and consequently the second
sound of the aorta  and pulmonary artery is not co-
incident with the closure of their valves, but results
from an increase of their  tension when  already
closed; the double  second sound is caused by a re-
petition of the increased tension consequent upon
an undulation of the arterial columns of blood. In
my opinion,  the reflux of the blood into the vena
cava, during the contraction of the right auricle,
would not be prevented if the state of things sug-
gested by Baumgarten really  existed;  if, under
normal circumstances, the right auricle contracted
in such wise as to  force blood into the ventricles,
pulsations of the veins of the neck would be in-
variably perceptible when the head was placed lower
than the thorax, and the veins thereby rendered
prominent.  Now,  as this is not the  case, I cannot
admit that the auricles normally contract so forci-
bly as to propel blood into the ventricles; I there- 
SOUNDS OF THE HEART.          241
fore consider that  Hamernjk's views  concerning
the origin of the first single and first double heart
sound, and of the second arterial sound, are  not
well founded.  I shall speak hereafter of his opi-
nions concerning the motion of the blood in  the
veins of the neck.
  The second sound over the ventricles has always
a flapping character, but it may be nevertheless
resonant, and somewhat prolonged; its continuity
may be also broken and interrupted.
  I have occasionally heard two  sounds over  the
ventricles, in the place of the proper second sound:
thus, instead of the ordinary "tic-tac" a "tic-tac-tac."
These two sounds  replacing the second sound, I
once observed in a phthisical lad, a few days before
his death; they continued audible till he died.  Post-
mortem examination did not bring to light any
abnormal  condition whatever of the heart.  Such
reduplication of the second sound is not explicable
by any of the theories hitherto offered, of the cause
of the second sound of the heart.  When these two
sounds are present, and the heart's movement slow,
and  the first sound, viz., that which corresponds
with  the ventricular  systole, loud, they resemble
the noise of a distant drumming.   The existence of
a double, and even triple second sound, in conjunc-
tion with constriction of the mitral orifice, has been
already mentioned, and an explanation of the phe-
nomenon been attempted.
  The first sound over the pulmonary  artery and
the aorta, has generally but little  of a clanging
character, (Klang,) and it has less, the thicker the
      21 
242          SOUNDS OF THE HEART.

coats of the arteries and the feebler the action of
the heart.
  The second  sound in the pulmonary artery and
aorta may also be broken;  the interruption seems
to arise from  the circumstance of the semilunar
valves not being all  distended at the same moment.
  In the ventricles the first sound is more prolonged
than the second; in the aorta and pulmonary artery
it is shorter, the accent falling on the second sound:
the latter of these facts may be  readily observed
when the sounds are loud.   Hence, the measure of
the sounds in the ventricles corresponds in  some
manner to a trochee ("";) and that of the sounds in
the aorta and pulmonary artery to  an  iambus,(" ".)
When the accent over the ventricles falls upon the
second sound, it is probable  that this sound is not
formed in the  ventricles, but arises at the aortic
and  pulmonary valves,  having been  propagated
thence by reason of its intensity.
  The first  and second sounds  are sometimes of
equal length over the ventricles, and over the arte-
ries, the accent falling upon neither the one nor
the other.
  The interval between the second sound and a
subsequent first sound is much longer than the in-
terval between the  first and second sounds.  The
latter interval is occasionally so short as to make
the second sound  over the ventricles appear like
the accentuated termination of the first sound, and
the first sound over the arteries as merely the com-
mencement (Vorschlag) of the second  sound. In
other cases, however, the interval between the first
and second sounds is nearly, or even quite as long, 
MURMURS OF THE HEART.
243
as that between the second sound and a subsequent
first sound; and  this is particularly remarkable
when the  movements of the heart are slow.  No
particular  signification  can be attached  to these
accidental conditions of the sounds.
  Laennec imagined that dilatation of the heart
and  thinning of its walls are indicated when the
first sound over the ventricles is clear, resembling
the second sound, and is audible over a considerable
extent of the thorax; an opposite condition of the
first sound, viz., when it is dull, weak, and scarcely
audible, he looked upon as a sign of hypertrophy
of the heart.  We may examine a multitude of cases
before we shall find one to corroborate such views.

           THE MURMURS OF THE HEART.
  The murmurs depending upon the heart's move-
ments arise either within the cavities of the heart,
or in the arteries or their coats, or within the pe-
ricardium.

    MURMURS ARISING WITHIN THE CAVITY OF THE HEART.
  These arc designated as bellows, grating, sawing,
filing, rasping, purring, whistling, and groaning
murmurs.  Laennec  believed  that  such  murmurs
had no connexion with  any structural changes  of
the heart, but were wholly the products of spasm;
and his opinion was long the prevailing one. More
extended  experience, however, has demonstrated
that in many cases organic  changes of the heart's
structure  are  associated with these murmurs, and
changes of such a nature as to render their causes
very explicable. 
244          MURMURS OF THE HEART.
  At the present time the general opinion is that
murmurs within the ventricles are caused by fric-
tion of the blood against the walls of the heart, or
against its valves.   I would add, that murmurs may
also be produced within the heart's cavities, by the
rapid flow of a small stream of blood against blood
that is quiescent,  or moving less rapidly, or in an
opposite  direction to it.  The  fact  of a murmur
being created, when a small stream of any fluid, as
water, blood, etc., is forced rapidly against a fluid at
rest, may be demonstrated by direct  experiment.
  The following are the organic changes of the heart
which give rise to murmurs within its cavities:—
  1.  Defect of the  mitral, the  tricuspid, and  the
aortic valves.
  2.  Constriction of the mitral orifice, or of the
mouth of the aorta.
  3.  Irregularities—such as excrescences; carti-
laginous, calcareous,  and bony  concretions;  and
blood-coagula—upon the endocardial membrane in
the neighbourhood of the arterial openings, or upon
the under surfaces  of the aortic and pulmonary
valves, or upon the  auricular surfaces of the  mitral
and tricuspid valves.   Excrescences, cartilaginous
and calcareous concretions, blood-coagula, etc., at-
tached to the lower half of the heart's ventricles,
do not create murmurs, because the current of blood
does not there possess the rapidity requisite  for
their production.
  Those murmurs which cannot be  directly attri-
buted to organic changes of the heart, undoubtedly
depend,  for the most part, upon  friction between 
MURMURS OF THE HEART.          245
the blood and the walls of the heart.  But how this
friction produces the murmurs, has yet to  be  ex-
plained.  A contraction of the heart, more forcible
or rapid than ordinary,  cannot of itself produce a
murmur; and, on the contrary, murmurs may exist
when the movements of the heart are slow.
  The opinion  that murmurs are caused by a par-
ticular condition of the blood, must be looked upon
as hypothetical, until it has been shown in what
that particular condition of the blood consists. It
is not true that a watery state of the blood is a cause
of murmurs in the heart; I have many times ab-
stracted very watery blood from patients in whom
no murmurs existed.   It is true that murmurs do oc-
casionally arise in the heart after great loss of blood,
and in anemia, but not  so constantly as to justify
us in considering the anasmic condition of the blood
as the only cause of the murmurs.
  Andral believes  that murmurs arise in the heart
in cases of general plethora: he explains their pre-
sence, by supposing that the cavities are  over-small,
relatively to the quantity of  blood which  should
pass through them in a  given time.   I  have never
observed a murmur  that was  thus  produced, and
cannot coincide with  Andral's views: the passage
of the blood through  the heart's cavities does  not
depend upon the blood, but upon the action of  the
heart.
  Cardiac murmurs, unassociated with appreciable
alteration of the heart's structure, are observed in
the course of many different diseases.   Chlorosis
may be particularly instanced;  but here, the mur-
                      21* 
246         MURMURS OF THE HEART.
murs are much more  frequently heard in the arte-
ries than in the heart.  The same remark  applies
to the faulty state of the blood produced by the
cachexia of cancer.
  A very loud blowing murmur has been sometimes
heard, during the systole of the heart, in cases of
acute  rheumatism, where no change of the  heart's
structure could be found after death.  During preg-
nancy, in puerperal diseases, at the onset of  typhus,
of small pox, and of severe inflammatory diseases,
and under many other circumstances, a systolic mur-
mur (either replacing the sound, or accompanying it)
is occasionally heard in the heart or in the arteries.
  Gendrin imagines that he can decide, from their
timbre, whether murmurs depend upon any rough-
nesses within the endocardium, or are independent
of any organic alterations of the heart; the latter
kind,  he tells us, resemble the sound of a bellows
kindling a fire.   I cannot admit this statement;  it
is vain to attempt to distinguish too particularly be-
tween the different kinds of murmurs; indeed, it mat-
ters little, as respects any conclusions which may be
deduced from our observations, whether the mur-
murs are of a blowing, sawing, or rasping character.
  We often  find a bellows murmur suddenly con-
verted into a sawing or rasping murmur, through
accidental increase of the heart's action. Murmurs
arising within the cavities of the heart, and the ar-
terial  murmurs, not only become louder when the
heart's action is increased, but they also acquire a
rougher, sharper, and more acute character; the
reverse of  this happens when the heart's action is 
MURMURS OF THE HEART.           247
weakened, the murmur becoming muffled and very
indistinct or disappearing altogether.
   The character  ascribed  to a  murmur  is often
very arbitrary:  if  several persons listen to  the
same murmur, one will probably describe  it as a
sawing, another as a filing, and a  third as a buzzing
murmur.   Of much greater  importance is it, that
we should know where the murmur arises, whether
in  the left or  the right ventricle, and  whether  it
corresponds with the systole, or with the diastole
of the heart;1  for by these  circumstances we judge
of  its signification.
  1 Gendrin has attempted to mark with greater accuracy the
sequence of the phenomena of the heart's action, in respect of
the time of their occurrence.  By Presystole, he represents the
moment of time which immediately precedes the  systole; the
moment immediately following the systole, he calls Perisystole:
in like manner, he describes a Prediastole, a Diastole and a Peri-
diastole.
  A murmur arising at the root of the aorta, during the ventri-
cular systole, is more perisystolic than a murmur arising in the
ventricles.  A prediastolic  murmur is heard, when the waves
of blood, in passing from the auricle into the ventricle, infringe
upon roughened surfaces: should  the roughness extend as far
as the free borders of the valves, the murmur is prolonged into
the second sound—Percussion diastolique—and ends with it, etc.
  I cannot believe that anything is gained by such  subdividing
of the systole and the diastole.   It is certainly true, that mur-
murs are more or less prolonged, that they immediately precede,
or arise at the same time with, or follow closely upon, the heart's
impulse; but if we recollect, that the  duration of the sound
does not depend wholly upon the continuation of the movement
which originally  occasioned it,  and that the  exact moment of
the  commencement of the  systole, and  of the diastole, is not
marked, either by the heart's  impulse, or by its  sounds, we
must consider the views of Gendrin, respecting the murmurs 
248           MURMURS OF THE HEART.
           MURMURS ARISING IN THE. ARTERIES.
   Every kind of murmur  which is heard within
the left ventricle, may also be heard  in the aorta.
Murmurs arise in the aorta when its internal mem-
brane is rendered uneven by  excrescences, or car-
tilaginous and chalky concretions, the vessel itself
either retaining its natural size, or being widened
or contracted. Murmurs are produced at the aortic
valves, when their under-surfaces are roughened;
when  foreign bodies occupy their free borders;
when they have become rigid, or so united to each
other  that the blood  flowing from  the ventricle
cannot force them back against the walls of the
aorta; or when they  are defective.
   Murmurs are frequently heard over  the subcla-
vian and carotid  arteries, not only when their in-
ternal membrane is roughened, but also when their
coats are perfectly healthy.1

which precede and follow the systole  and diastole, as hypothe-
tical.
  1 Hamernjk— Untersuchungen uber die Erscheinungen an Arterien
und Venen,  etc., I'rag. 1847—tells us, that no such  thing as
friction takes place between the  blood and the  walls of the
arteries, because there is  always a  layer of blood lying mo-
tionless in contact with the walls.   All arterial  sounds are pro-
duced by vibrations of the coats of the arteries, and it is there-
fore improper to speak of murmurs in arteries; for this reason,
Hamernjk calls them well-defined  and ill-defined arterial sounds
(Tone.)
  I have used the expression sound (Ton) as antithetical to mur-
mur (Gerdusch,) in order to avoid the repetition of the terms,
"normal, abnormal, limited," etc.   If  the adjectives "well-
defined and ill-defined" are employed, then, according to the
ordinary use of language, the expression murmur (Gerdusch^ 
MURMURS OF THE HEART.          249
  When both ventricles are hypertrophied and di-
lated, and more  particularly if the aortic valves
are at the same time defective, a loud, rough, saw-
ing, rasping, or groaning murmur is heard at each
ventricular systole (and consequently with the pul-
sation of the arteries) over the subclavian and the
carotid arteries,  but less frequently over  ^he ab-
dominal aorta, the crural, brachial, and radial ar-
teries.   When the aortic valves  are defective, a
murmur may be occasionally heard in  the  carotid
and subclavian arteries during the ventricular di-
astole: this phenomenon is most generally asso-
ciated with aneurisms of the aorta.
  A blowing systolic murmur is often heard over
the carotid  and  subclavian arteries of perfectly
healthy individuals, when their heart's action is in-
creased, and particularly if their cervical muscles
are at the same time put upon the stretch.1
  The smaller the artery, the more rarely the mur-
murs just described are observed in it.  Occasion-
ally, when the smaller arteries are  widened, we
hear  in them a continuous murmur, of a blowing,

Is more correct than  sound (Ton.)   The layer of blood at rest,
in contact with the  arterial walls, merely indicates  that the
current of* blood is slower there,  than in the middle of the
artery: this is the case in all tubes, and doubtless also in the
veins.
  * Bouillaud  tells us, that pressure with  the stethoscope on
every  moderate-sized  artery, produces a short, dull, blowing
murmur: this I have frequently, but not invariably, observed;
pressure, even against a  strongly pulsating abdominal aorta,
sometimes fails to produce  a blowing  murmur;  and, on the
other hand, in certain cases, the slightest pressure upon an ar-
tery, and even upon one as small as the radial, gives rise to it. 
250          MURMURS OF THE HEART.
humming, hissing, whistling character, resembling
the sounds produced by the air in a furnace, the
murmur becoming stronger and higher in the ratio
of the strength of the pulse; it is most frequently
observed  over  the  thyroid  arteries, in cases of
bronchocele; according to Professor von Kiwisch,
it is also heard over the epigastric arteries of preg-
nant women, or when the abdomen is distended by
ovarian or other  tumours.  We  are also told by
Kiwisch, that the so called placental  bruit  does
not arise in the vessels  of  the pregnant  uterus, in
the compressed arteries or veins  of the  pelvis, but
in the epigastric artery; and the proof  of  this is,
that the murmur disappears when the  epigastric
artery is compressed.1
   When a moderately-sized artery communicates
with a vein, we  generally observe at the point of
communication a very loud continuous murmur, the
strength of which increases at  each pulsation of
the artery, and which is audible to a greater or less
distance through the  surrounding parts.
   It is difficult to determine whether these arterial
murmurs are caused by friction of the blood  against
the walls  of the  arteries,  or by  vibrations of the
walls excited by their  distention: the  effect of a
more than ordinary amount of friction, even when
the arteries are healthy, must not be overlooked;
and there is no reason why we  should  not admit
that the arteries, through  distention of their coats

   1 Von Kiwisch, Beitrag zur Kenntniss  der Anatomischen Bes-
chaffenheit der Placenta, und Berichtigung  der Ansichten uler den
Sitz des sogennanten Placentargerausches, Prag. 1849. 
PERICARDIAL MURMURS.
251
during the systole, may produce a prolonged sound
or murmur, instead of a short-sound, the murmur
becoming continuous whenever  it lasts from one
pulse to another.
  In varicose aneurisms, the  murmur is probably
caused by the impulse of the stream of blood flowing
from the arteries, against the  blood in the veins.

         MURMURS ARISING IN THE PERICARDIUM.
  A murmur is produced by friction of the internal
surfaces of the pericardium, when rendered rough
by the deposition of plastic exudation, or of tuber-
cle, or of cartilaginous or chalky concretions: the
murmur accompanies the movements of the heart,1
and may be heard either during the systole or during
the diastole only, or both during the systole and
the diastole.
  Laennec was not aware of  the existence of this
murmur, nor did  he seem to pay any attention  to it,
even when Collin had shown that one of its varieties
—the new-leather sound—was a sign of pericarditis.
  Bouillaud describes three  varieties of friction-
sounds; viz., the rustling-sound, bruit de frblement;
the new leather-sound, bruit de cuir  neuf bruit de
tiraillement  et de craquement;  and the grating-
sound, bruit de rdclement.
  The first of these,—bruit defrolement,—according
to Bouillaud, bears a close resemblance to the fric-
  1 Gendrin will have it, that a pericardial murmur may be pro-
duced simply by increased action of the heart, especially in cases
of palpitation, without there being any roughness of the peri-
cardium.   This I have never observed myself. 
252
PERICARDIAL MURMURS.
tion-sound of the pleura, and may be imitated by the
crumpling of taffeta or parchment:  it may accom-
pany both the systole and diastole of the ventricles,
but is heard loudest during the systole, and if the
friction be considerable, becomes very like the rasp-
ing or sawing murmurs which  accompany certain
organic changes of the internal structure of the heart,
and is only to be distinguished from them by being of
a more superficial, diffused, and extended character.
  A softer kind of friction-sound is heard when the
opposed surfaces of the pericardium are dry and
somewhat adhesive, but not covered, or only very
partially, by false membranes, which is the case at
the commencement of pericarditis.  The superficial
rasping or sawing-sounds  indicate the formation
of thick and uneven false membranes.
  The  new-leather sound is much more rarely ob-
served than the rustling or rubbing-sound; indeed,
it is only met with in those cases where the false
membranes are thick, resistant, and elastic,  and
where perhaps they have formed partial adhesions,
which are continually being put upon the stretch by
the movements of the heart. The scratching-sound
must be attributed to the presence of bony, or chalky,
or fibro-cartilaginous concretions, or of points which,
during the heart's  movements, rub against each
other, or some part of the pericardium.
  There is no doubt that all these different friction-
sounds of the pericardium have a real existence, and
that many others might be added to them.  Accord-
ing to my own experience, indeed, there is no kind
of endocardial murmur, with the exception of the 
PERICARDIAL MURMURS.
253
whistling, which may not be imitated by a friction-
sound of the pericardium; and no pericardial mur-
mur which may not resemble an endocardial murmur.
  In my opinion friction-sounds of the pericardium
cannot be distinguished from internal  murmurs of
the heart, by being more superficial, more extended,
and more diffused than these.   A sound proceeding
from a solid body, when strong and clear, appears
to arise at its surface; but when of an opposite cha-
racter, to come from some distant part of it.  Thus,
murmurs arising within the heart, may appear quite
superficial, in consequence of their being inordi-
nately loud, clear, high, and hissing, and may be
audible over the whole region of the heart, and even
beyond it; on the other hand, the friction-sound of
the pericardium may be very weak and muffled, and
thus appear to arise remotely.  How are we  to
judge of the friction-sound which arises from  the
pericardium at the back of the heart.
   I know no sign by which the friction sounds of
the pericardium can be distinguished from the inter-
nal murmurs of the heart, excepting this, that the
internal murmurs correspond pretty exactly to the
rhythm and to  the  natural sounds of the heart,
whilst the pericardial friction-sounds seem to follow
upon the movements of the heart.  This distinctive
sign is only available when the murmur is somewhat
prolonged; if it be of short duration, we cannot de-
termine whether it is endocardial or pericardial.
   I do not believe that the pericardium can produce
a friction-sound, so  long as its surface is smooth or
uncovered by plastic exudation: at least, I have
       22 
254          PERICARDIAL MURMURS.
 never seen such a case.  The false membranes may
 be very thick, firm, uneven, and elastic, and may
 have formed adhesions, and still produce no other
 sound than a slight rubbing or rustling, having the
 character of a bellows-murmur.  Again, scarcely
 any friction-sound may be heard, in consequence of
 the  feebleness  of the movements of the heart, al-
 though  the pericardium be completely  covered by
 rough, thick, false  membranes, and the amount of
 serous effusion  small.  Hence the strength  of the
 friction-sound and its roughness depend upon  the
 force of the heart's movements, as well as upon the
 nature of the false  membrane.
   A friction-sound accompanying the movements of
 the heart, does  not invariably arise from the inner
 surface of the pericardium; it may depend also upon
 a roughened condition of that portion of the  pleura
 which covers the unattached parts of the pericar-
 dium.  The sound is produced by the rubbing of the
 pleura which covers this free portion of the pericar-
 dium, either against the thoracic walls, or against
 the surface of the lungs; being caused by the action
 of the heart, it coincides with its movements as com-
 pletely as though it had been produced  within the
pericardium.  The murmur thus arising external to
the  pericardium exactly resembles the  murmur
 arising within it.  I once thought, that a distinc-
 tion between them  might be found in the circum-
 stance of the external murmur being alternately
 increased and diminished in force during the respi-
 ration: but it appears that the internal pericardial
 murmur is likewise frequently affected in a similar
 way. 
VENOUS MURMURS.
255
        MURMURS ARISING IN THE JUGU1AR VEINS.
  In a great many young persons a continuous mur-
mur, which is apparently increased in strength at
each systole of  the heart, is audible in the hollow
between the heads of the sterno-cleido-mastoideus
muscles, particularly on the right side  of the neck;
this murmur was supposed to have had its origin in
the arteries of  the neck, until Dr. Ogier Ward, in
1837, and Hope and Aran after him, demonstrated
that it arose in the jugular veins.  Bouillaud called
this  sound bruit de  diable, in consequence of its
having a resemblance to the humming of a top (Top-
murmur, Nun's-murmur.)  Laennec pointed  out a
variety of it under  the name of musical arterial
bruit.  This bruit de diable,  heard  at  the  part
above referred  to, disappears when the current of
blood is interrupted  by pressure upon the internal
jugular vein; it also  disappears upon a deep inspi-
ration,  by which the blood is driven back into the
jugular veins;  and lastly, in every position of the
body where the head lies lower than the thorax, and
the flow of blood into the jugular veins  impeded.
The murmur is loudest in  the erect position and
during  inspiration, but is never heard when the ju-
gular veins are distended with blood.
   The increase of the murmur at each systole of the
heart, is only apparent, and is occasioned by the
sounds  and murmurs which proceed from the caro-
tid and subclavian arteries, and which are heard in
the neck  during the systole.   Deep expiration, as
well as a low position of the head, both  of which
cause the venous murmurs to disappear, have no ef- 
256
VENOUS MURMURS.
feet in arresting arterial murmurs; on the contrary,
such murmurs are not unfreqi*ently thereby pro-
duced, in cases where healthy sounds only are heard,
so long as the respiration is tranquil, and the head
erect.
  Although, from these facts, there appears to be
no doubt that the bruit de diable has its origin in
the jugular  veins, its mode of production is not
very clear.  Hamernjk explains the murmur in this
way:  the less the quantity of blood present in the
vena cava, the more rapid will be the flow of blood
through the jugular veins during inspiration, and
the smaller the current of blood. Now, the internal
jugular vein is so attached at its lower part, as of
necessity always to retain a certain width: the di-
minished  stream  of blood can  only fill this wide
space, by passing through it with an eddying move-
ment; this movement  is communicated to the walls
of the vein and the parts around, and is rendered
sensible to the touch by vibrations,  and to the ear
by murmurs.  It is well known, that  the bruit de
diable is only heard in the veins of the neck, and
more frequently on the right side than on  the left.
This fact, in Hamernjk's opinion, confirms his views;
for the conditions which, according to him,.are ne-
cessary for the production of the bruit, exist only
in the internal jugular veins, and in a much more
perfect manner in the right than in the left.  The
bruit has hitherto been considered a sign  both  of
anaemia and of spanaemia; Hamernjk looks upon it
as a sign of anaemia only.  I have for many years
looked upon it as a sign, neither of a watery con- 
MURMURS OF THE HEART, ETC.       257
dition of the blood, nor of deficiency of blood; for
it exists even in young and healthy individuals; in
such persons, the vena cava is never so distended
with blood as to cause its regurgitation into, and
swelling of, the jugular veins.  Moreover, the  ju-
gular veins are  shorter in young than in  old per-
sons, so that they may be stretched by certain  po-
sitions of the head; this  last circumstance may  ex-
plain the absence of the  bruit in old age, when  the
vena cava contains but little blood.
RULES  FOR THE DIAGNOSIS  AND DETERMINATION OF THE SOUNDS
  AND MURMURS OF THE HEART, THE  PERICARDIUM, THE AORTA,
  AND PULMONARY ARTERY.
   When an observer  auscultates the praecordial re-
 gion, and the points of the thorax which correspond
 to the course of the aorta and  pulmonary artery, he
 will everywhere hear, either the ordinary tic-tac,
 and no murmur synchronous with the heart's move-
 ments; or he will hear the tic-tac at certain points
 only, but still no murmur; or, again, he will  no-
 where hear the tic-tac, or only  at some special points,
 but in its place, at one, or several, or at every part,
 one or more murmurs.
   The sounds, as well as the murmurs, are  always
 loudest and most distinct at those parts of the thorax
 which are nearest to their  points of origin—ex-
 ception being made of those cases, in which the sound
 or murmur  is  either increased by resonance, or
 muffled by the accidental intervention of a bad  con-
 ductor of sound.  The heart's sounds and murmurs
 are increased by resonance in cases of pneumothorax,
 and when they arise  in the neighbourhood of empty
                        22* 
258        MURMURS OF THE HEART, ETC.

cavities; but they are rendered duller by the inter-
vention of lung, or of exudations, between the tho-
racic Avails and the heart.
  In accordance, therefore, with what has been here
stated, we ascribe to the left ventricle the origin of
all those sounds and murmurs which are heard most
distinctly at that part of the thoracic walls against
which  the  heart's apex strikes; and to the right
ventricle, those which are most clearly heard over
it—that  is,  over  the  lower part  of the  sternum.
Those sounds and murmurs, again, which are heard
loudest along the course of the ascending aorta, i. e.
a little to the right of the centre of the sternum, and
from thence upwards, arise in the aorta; the sounds
heard most distinctly along the course of the pulmo-
nary artery—somewhat to the left of the centre of
the sternum—are formed in the pulmonary artery.
It must not, however, be forgotten, that pericardial
murmurs may present  themselves at every part of
the thorax  here referred to.
  Of the position of these different parts, that of the
left ventricle of the heart is, in the greater number
of cases, the most readily and most certainly deter-
mined.   The point furthest to the left, where the
impulse of the heart can be felt—not the mere con-
cussion thereby produced, for this  may extend to
some  distance from the point of impulse—may be
taken as a  fixed point, for the determination of the
position of the other parts; this point will not fail
to represent the position of the left ventricle, except
in the case where there is very great dilatation of
the right, in conjunction with  diminution of the left
ventricle. 
MURMURS OF THE HEART, ETC.       259
  The ascending aorta always lies somewhat to the
right of the vertebral  column, consequently its
sounds and  murmurs must always be  sought for
over the middle, and somewhat to the right of the
sternum.  The base of the heart—and consequently
the aortic and pulmonary valves—are almost inva-
riably situated behind the middle of the sternum,
and are only found lower down, in cases of dilata-
tion and hypertrophy of the heart. The position of
the right ventricle is variable, and cannot be deter-
mined, unless that of the  left  ventricle and  aorta
has been previously ascertained; it yields no special
indication.  The same remark is true of the position
of the pulmonary artery.
   It is of great importance for us to be able to de-
termine, whether the murmurs heard arise in the
heart and arteries, or in the pericardium; for the
murmurswhich take their origin in the pericardium,
may be heard over the same parts as those which
arise in the heart and arteries.
   If the duration of the murmur be so short, or the
heart's movements so indistinct to the touch, or so
irregular, as to prevent our deciding the question by
the criteria above.given, still we frequently may, by
a comparison of all the signs present, diagnose with
pretty considerable accuracy, if not with actual cer-
tainty, the seat of origin of any particular murmur.
Thus, murmurs arising within the heart and arteries,
are occasioned by changes in the state of their in-
ternal membranes, and particularly of their valves;
which changes, by their influence on the circulation,
and through the  effects which  they produce in the 
260       MURMURS OF THE HEART, ETC.

heart, and the aorta, are generally rendered manifest
by other signs, as well as by murmurs.   On the
other hand, the exudations which give rise to peri-
cardial murmurs, are very often associated with
serous effusion, in such quantity that its presence
may be determined by percussion.
  When  we have decided that the pericardium is
the source of the murmur heard, we must next en-
deavour to ascertain, whether it arises on its internal
or external surface, i. e. whether the morbid condi-
tion occasioning it exists within or without the peri-
cardium.   As we have already said, the character of
the murmur itself does not aid our diagnosis; we must
therefore take into consideration the  percussion
signs, the position of the heart,  and the exact  part
where the murmur is heard.  If percussion indicates
the presence of effusion in the region of the heart,
and if the heart be not thereby displaced, we  may
conclude  that the effusion is in the pericardium; and
it then becomes very probable, that the murmur also
proceeds  from the internal surface of the membrane.
But if again we determine the existence of effusion
in the praecordial  region, and  at the same time find
the heart forced from its natural position, we then
conclude that the effusion is external to the pericar-
dium,—that is, in the pleura,—and the murmur,  in
all probability, arises upon the outer surface of the
pericardium.  If percussion do not indicate effusion,
and the murmur be heard loudest at the middle line
of the sternum, it arises within the pericardium; but
if it be heard loudest at the periphery of the sternum,
or beyond this, then it becomes very doubtful, whe- 
MURMURS OF THE HEART, ETC.       261
ther the morbid condition exists within or without
the pericardium.
  When we have determined that the murmur arises
within the heart or the arteries, and have also ascer-
tained at what points of the thorax it is heard loud-
est, it still remains for us to decide—that is, in case
the murmur is audible over a considerable extent of
surface—whether it has one or several sources.  To
ascertain this, we must make a comparative exami-
nation of the other signs present.  We have already
observed, that changes of the inner coverings of the
heart and aorta, and  particularly of their valves,
give rise to murmurs; such changes also  produce
disturbances in the general circulation, and disturb-
ances of the circulation bring forth a variety of phe-
nomena, and amongst others very frequently abnor-
mities in the form, the size, and the nutrition of the
heart, which again present their own especial indica-
tions: thus  we  are enabled  by one set of signs to
correct another, and by their comparison to arrive
at right conclusions.
   When we have satisfactorily determined the point
of origin of the sound or the murmur, it remains for
us to ascertain whether the sound or murmur be
synchronous with the heart's systole or diastole; this
may generally be at once decided from the rhythm
of the sounds or murmurs; for the interval between
the second sound or murmur and a subsequent first
sound or murmur, is, as a rule, longer than the inter-
val between the first and the second sound or mur-
mur.  A person, however, who is not much practised
in auscultation, will do well to feel for the heart's 
262       MURMURS OF THE HEART, ETC.

impulse with his fingers while listening with his ear.
The sound or murmur synchronous with the heart's
impulse, will be found  to correspond with the heart's
sj^stole—the first sound; the sound or murmur heard
subsequent to the heart's impulse, to be synchronous
with the beginning of the diastole—the second sound.
This combination of auscultation with palpation of
the heart's impulse, is  particularly necessary  in the
investigation of the sounds or murmurs of the aorta
and pulmonary artery.  Indeed it frequently hap-
pens that the irregularity of the heart's movements
is such, that even  the most skilful auscultators can-
not decide, from the rhythm of the sounds and mur-
murs, which is the first and which the second; he
must, in such cases, of necessity consult the heart's
impulse; and the  same remark is true when  only
one sound or one murmur is audible.

 SIGNIFICATION OF THE SOUNDS AND MURMURS HEARD OVER THE
     VENTRICLES, THE AORTA, AND PULMONARY ARTERY.
  In the left ventricle, during its systole, a sound
without murmur—first sound—indicates that the
mitral valves  duly perform  their office, and that
there is no  reflux of blood from the left ventricle
into the left auricle.
  A murmur only—first murmur—indicates either
imperfect  closure of the  mitral valves during the
systole, and friction of the blood against some rough-
ened  parts of  the valves  through the reflux of the
blood into the  left auricle; or, that a rapid current
of blood from the left ventricle is forced in an oppo-
site direction  to the blood flowing from the left 
MURMURS OF THE HEART, ETC.       263
auricle.  The murmur may also arise through fric-
tion of the blood against irregularities situated upon
the surface of the internal  membrane of the  left
ventricle, about the arterial opening, which do not
interfere with the closure of the mitral valves; or
it may be produced  by a combination of the  first
and second of these causes.
   When the closure of the mitral valves is not com-
plete, a portion of blood at each systole regurgi-
tates from the left ventricle into the left auricle,
causing distention of the left ventricle and of the
pulmonary veins and arteries, so that increased ef-
forts of the  right ventricle become  necessary, in
order  to force the blood onwards through the dis-
tended vessels; the pulmonary artery, thus strongly
dilated, presses with an exaggerated force upon
the blood within it,  and drives it more suddenly
and more forcibly backwards against the  semilunar
valves during the heart's diastole, whereby the se-
cond sound of the pulmonary artery is increased.
   We must not conclude, from the fact of a murmur
being heard  in the left ventricle during  the heart's
systole, that  the mitral valves are defective, unless
we at the same  time ascertain that there is an in-
crease in the intensity of the second sound of the
pulmonary artery: if the force of this sound be not
increased, the murmur then indicates that the sur-
 faces of the  valves, or the lining-membrane of the
ventricle, about  the  arterial openings, are  rough-
 ened.  It is at these parts that the stream of blood
 possesses such velocity,  that its friction  can create
 a murmur; roughness about the apex or the middle
 of the ventricle produces no murmur. 
 264       MURMURS OF THE HEART, ETC.

   An increase of the second sound of the pulmonary
 artery almost invariably accompanies defect of the
 mitral valves; I believe that it can only fail to  do
 so when the coats  of the pulmonary artery have
 lost their elasticity, and do not contract rapidly
 after distention.
   When the lining-membrane of the left ventricle
 is inflamed,—endocarditis,—a systolic-murmur will
 arise in that ventricle, provided there be any defect
 of the mitral valves, produced either by tumefaction
 of their free borders, by lengthening or shortening
 of their tendinous  cords, by excrescences  on  the
 valves or their tendons, or by deposition of fibrinous
 matters upon them,  or by any roughness of surface
 about  the ostium arteriosum.  Hence  a systolic
 murmur heard over the left ventricle, does  not in-
 dicate  endocarditis, unless when associated with
 such disturbance of the organic functions as usually
 attends endocarditis, and when the murmur did not
 exist previous to the functional disturbance.
  A sound associated with a murmur has the same
signification as a  murmur without a sound.  For
 example; the sound may result  from the  perfect
closure of the valves, and the murmur from the rough-
ness of the ventricular surface about the ostium arte-
 riosum : or the sound may arise from distention of
some of the pouches of the mitral valves which still
 retain  their normal  condition, whilst their perfect
closure is prevented by the abnormal condition of
the remaining portion of their borders, and  a mur-
mur thus produced;  or the sound  may proceed from
the heart's impulse, and the murmur from defect of
the mitral valves. 
          MURMURS OF THE HEART, ETC.       265

  Failure of both sound and murmur is a pheno-
menon of no value-as indicative of the condition of
the mitral valves.  When we meet with such a case,
we must endeavour to decide as to the closure of the
valves, by a careful consideration of all the other co-
existing phenomena. The sound may fail, although
the closure of the valves is perfect, and the reflux of
blood prevented, whenever those conditions which
render the sound dull are present in a high degree.
  The murmur may likewise fail, though  there is
deficiency of the mitral valves, and though the blood
in its reflux impinges  upon no  roughened surface
nor flows with any great velocity.   Failure of the
murmur with defect of the valves, is of rarer occur-
rence than failure of the sound in connexion with
their perfect closure.  If neither sound nor murmur
can be heard over the left ventricle during its sys-
tole, we must turn our attention to the state of the
second sound of the pulmonary artery, and ascertain
whether there is any diastolic murmur audible over
the left ventricle; if the second sound of the pul-
monary artery is increased in force, and the second
sound over the left ventricle replaced by a murmur,
it becomes more than  probable that the  closure of
the mitral valves is not perfect, the phenomena pre-
sent indicating contraction of the mitral valves,
which very rarely happens without their being also
defective.
  Although the second sound of the pulmonary
artery is increased, and both sound  and  murmur
absent in the left ventricle, during the heart's systole,
and the second sound in the left ventricle, either un-
       23 
266        MURMURS OF THE HEART, ETC.

accompanied by a murmur or inaudible, still we are
not justified in considering the  mitral valves de-
fective, unless we can show that no other cause is
present to account for hypertrophy of the right ven-
tricle, except that of the deficiency of the valves in
question.  The other more particular causes of hy-
pertrophy of the right ventricle are, curvatures of
the spine, extensive and long-standing thoracic effu-
sions without marasmus, etc.
  A sound (Schall) may be  sometimes heard in the
left ventricle during its systole, of such an indefinite
character, that it cannot be classed either as a sound
or a murmur.  For the determination of the condi-
tion of the mitral valves when such an indefinite
sound is heard, the  same rules must be applied as
are laid down in the case where  there is failure of
both sound and murmur.
  In the left ventricle during its diastole, a sound
unaccompanied by a murmur—second sound—indi-
cates that there is no constriction of the leftauriculo-
ventricular opening, and that the blood, in passing
from the  left auricle into  the left ventricle, does
not flow over any roughened surface.
  A murmur accompanied by a sound, or a murmur
alone, indicates either constriction of the mitral ori-
fice, with roughness of the narrowed surface of the
canal, or the presence of rough eminences upon the
auricular  surface of the mitral  valves, unaccom-
panied by  constriction of the opening. Constriction
of the mitral orifice causes the blood to accumulate
in the left auricle, and in the pulmonary veins and
arteries, producing hypertrophy with dilatation of 
MURMURS OF THE HEART, ETC.       267
the right ventricle, and an increased second sound
of the pulmonary artery, much more readily than
mere deficiency of the mitral values.  The increased
second sound is not observed when roughness alone
exists on the auricular surface of the valves, without
constriction of theauriculo- ventricular opening, pro-
vided it be not accidentally present through some
other cause.
   The more constricted the mitral orifice is, the
longer will be the time necessary for the flow of the
blood into the  ventricle, and the more prolonged
and louder the murmur.  It is in cases of this kind
especially, that vibrations are felt when  the hand
is laid upon the precordial region,—a phenomenon
likened by Laennec to the purring of a cat—fre-
missement cataire.
   These vibrations  are indeed  often visible,  and
the murmur then resembles the humming  (summen)
of a distant bell.   The murmur resulting  from con-
striction of the mitral orifice, may be so prolonged
as to be only momentarily  interrupted during the
systole, particularly if  the  heart's  movements be
rapid: an unpractised observer will find it difficult,
in such a case, to decide by the ear whether the
murmur occurs during  the systole or the diastole;
he will therefore do well to aid his judgment by
palpation, and by ascertaining the presence or not
of the "purring" during the diastole.
   Failure both of sound and murmur has no distinct
signification; particular regard must therefore be
paid  to the nature of the second sound of the pul-
monary artery, and  to the first sound  or murmur, 
268       MURMURS OF THE HEART, ETC.
and, above all, to the action of the  mitral valves
during the ventricular systole, if we wish to obtain
a satisfactory idea of their  condition during  the
diastole.  If the first sound  is audible in the  left
ventricle, unaccompanied  by a murmur, and  the
second sound of the pulmonary artery is not in-
creased, we  have no grounds for concluding that
the mitral valves are abnormal; but if a systolic
murmur be heard over the left ventricle, and  the
second sound of the pulmonary artery be increased,
then failure of the second sound in the left ventricle
must be attributed to defect of the mitral valve.
  The presence* of a systolic murmur  in  the  left
ventricle, with absence of sound and murmur during
the diastole, and increase  of the second sound of
the pulmonary artery, are signs which in most cases
indicate  defect of the mitral valves,  without con-
striction of the mitral orifice;  at the same time
they do not preclude the existence  of such con-
striction.  If the left auriculo-ventricular opening
be constricted (and this  condition is almost always
associated with defect of the mitral valves,) the dias-
tolic murmur is generally loud and prolonged, the
systolic being weak, and of short duration, or even
inaudible; but there are exceptions to this, for the
systolic murmur may be loud and prolonged, while
the diastolic is weak and short, or inaudible.  These
differences most  probably depend  upon the form
and direction of the constricted canal, and upon
the situation of its roughened surfaces.
  Lastly, when the movements of the  heart  are
rapid, the systolic may be  so  confounded with the 
          MURMURS OF THE HEART, ETC.       269

diastolic murmur, that only one prolonged murmur
is heard, commencing with the systole, continuing
through the first part of the diastole, and broken
only by the very short interval which corresponds
to the quiescent state of the ventricle.  This com-
bined double murmur is in no way distinguishable
from a prolonged  single murmur; and it is only
when the heart's movements are slow, that it  be-
comes resolved into two distinct murmurs.
   When there is an absence both of sound and mur-
mur over the left ventricle during the systole and
the diastole, we cannot affirm the existence of any
abnormal condition, such as defect or constriction
of the mitral valves, by which functional derange-
ment of the heart is produced, unless the  second
sound of the pulmonary artery is distinctly increased,
and its increase not attributable to any other cause.
   An indeterminate sound, which cannot be desig-
 nated either as a sound or a murmur, may be some-
 times heard in the left ventricle, during both the
 systole and diastole of the heart.   In such  case,
 we must draw the same conclusions as when neither
 sound nor murmur are audible.
   In the right ventricle, during the systole, a sound
 without a murmur—first sound—indicates perfect
 closure of the tricuspid valves, and, consequently,
 that there is no reflux of the blood from the right
 ventricle into  the right auricle  during the ventri-
 cular systole.
   A murmur  alone, or a  sound accompanied by a
 murmur, indicates either  imperfect closure of the
 tricuspid valves, with roughness of their free bor-
                       28* 
270        MURMURS OF THE HEART, ETC.

ders, or that they are roughened  spots upon the
conus arteriosus, the valves duly performing their
office;  this latter case, however,  rarely  happens.
When  the closure of the  valves is perfect, the sys-
tolic murmur heard, arises more frequently from
roughnesses upon  the tendinous cords, which are
inserted into the septum  of the ventricles near to
the conus arteriosus, than from roughness upon the
surface of the conus arteriosus itself.
  Defect of the tricuspid  valves gives rise to accu-
mulation of blood  in the  right auricle, vena cava,
etc.; hence results swelling of the veins of the neck,
which would  otherwise be retracted and shrunken,
so long, at least, as the head and neck are placed
higher than the thorax, the abdomen, and the lower
extremities.  The  blood driven back into the right
auricle, during  each systole of the  right ventricle,
causes  an accumulation of blood in  the venae cavae;
the jugular veins become full and  distended, and,
at each diastole, seem to  retract and collapse; this
phenomenon  represents the so-called pulsation of
the jugular veins;  there is'generally, however, no
pulsation perceptible to the touch. The undulations
of the blood may be felt when the distention  of the
veins is considerable, and particularly in the sub-
clavian vein,  when it projects above the clavicle.
  Deficiency of the tricuspid valves will therefore be
recognised by systolic murmur in the right ventri-
cle, with synchronous pulsation of the jugular veins.
Such a murmur, however,  unaccompanied by  pulsa-
tion or distention  of the veins, does not indicate
defect  of the tricuspid valves.  When the murmur 
          MURMURS OF THE HEART, ETC.       271

exists, and the cervical veins are distended, but do
not pulsate, the tricuspid valves may be defective;
but in such case, either the heart's action is feeble,
or the deficiency of the valves is very slight, so that
but little blood is driven backwards at each systole.
   I will here state my objections to Hamernjk's
opinions concerning the use of the valves in the
veins of the neck, and the movement of the blood
in the vena cavae.  The most essential part of what
here follows, I have taught ever since 1836.
   The object of the valves of the veins is not to aid
.the flow of blood towards the heart, or to lessen the
weight of the columns of blood, but solely to limit to
the larger veins the unavoidable reflux of the blood
produced by movement of the body, or by pressure
upon any single  parts, and thereby to prevent in-
jury of the capillary vessels.  Thus, for example,
rubbing the arm down and pressing it at the same
time, would  cause rupture of  the capillaries, but
 for the valves of the veins;  in fact but for them,
 any sudden  contraction of  large  muscles would
 scarcely fail to produce effusion of blood.
   The valves of the veins of the neck have no other
 object than this; most assuredly, they have not the
 function attributed to them by Hamernjk, viz.: to
 serve as fixed points for the columns of blood in the
 venae cavae, during ordinary expiration, so as to ren-
 der possible a forcing of blood into the right ven-
 tricle, by the movements of expiration.
   Healthy  lung-tissue  possesses  a  contractile
 power, which occasions the arching upwards of the
 diaphragm, and the  sinking-in of the intercostal 
272       MURMURS OF THE HEART, ETC.

spaces: and the power does not cease with inspira-
tion.  It may be shown, by experiments on animals
whose lungs are healthy, that when the thorax is
opened, the lung frequently contracts into less than
half the space it occupied  towards the end of  ex-
piration, when the thorax was uninjured. The con-
tinuance  of the contractile power of the human
lung during expiration, and to the end of expiration,
is proved by  the fact that, in healthy persons,  the
percussion-sound is as little tympanitic during ex-
piration as during inspiration; whilst the loss of con-
tractile power of the lung in disease, is rendered ma-
nifest by the presence of a tympanitic sound during
inspiration and expiration—a diminution of its con-
tractile power is shown by the presence of the tym-
panitic sound during expiration only.  Consequent-
ly the healthy lung exercises an influence over the
walls of the thorax and the contents of the thoracic
cavity, both during inspiration and expiration; and
this influence is greater during inspiration than
during expiration;  the difference, however,  can
hardly be considered  sufficient  to account for any
perceptible widening  or narrowing of the venae
cavae  during the  respiratory movements,  for  the
tension of the  intercostal spaces  does  not visibly
remit during tranquil expiration.
  When  the respiration is tranquil, no pressure is
exerted on the vena cava or on any of the thoracic
organs during  expiration, and consequently  the
blood in the vena cava is not pressed upon, nor the
valves of the veins of the neck called into action;
neither need we assume that the liver is displaced 
          MURMURS OF THE HEART, ETC.       273

in some most extraordinary and original manner, in
order to serve as a valve for the inferior vena cava.
  Pressure of the thoracic Avails upon the lungs, and
through the lungs upon the contents of the thorax,
takes place only during expiration, when the con-
tractile power of the lung is insufficient to  expel the
air it contains.   In such cases, the blood  is driven
back from the vena cava into the veins of the neck
and of the extremities; and, were it not for the pre-
sence of their valves, the vena cava would be com-
pletely emptied of blood whenever a certain degree
of pressure was exerted upon it by the lungs. There
is no necessity for a valve in the vena cava between
the thorax and the abdomen, because at  each forcible
expiration, the  organs  of the abdomen undergo the
same pressure as the lungs, and  the blood in the
inferior vena cava and in the hepatic veins, is as
much  pressed  upon as the blood in  the superior
vena cava.
   It is hardly necessary to refer to the fact that the
blood is not forced from the venae cavae into the auri-
cle or the ventricle of the heart, during either ordi-
nary or forced expiration.  The  contractile power
of the lungs, when  the expiration is  tranquil, and
the pressure of the thoracic walls, when  it is forci-
ble, acts with  exactly the same power  upon the
heart as upon the venae cavae.  It is not my inten-
 tion to pass in review the different theories of Ha-
 mernjk, which  result from his views concerning the
 influence of expiration upon the  circulation of the
 blood.  I will merely add a few remarks  on the
 venous pulse. 
 274       MURMURS OF THE HEART, ETC

   A reflux of the blood into the venae cavae during
 forcible expiration, is produced by the pressure of
 the walls of the thorax and abdomen, by contraction
 of the right auricle, and by contraction of the right
 ventricle when the tricuspid valves are defective.
   This reflux of the blood into the vena cava, be-
 comes manifest in the cervical veins, either when
 the blood is driven back  into them, or when  it is
 impeded in its onward movement; the first  case
 happens when the valves of the cervical veins are
 defective, the second, when they duly perform their
 office.  So long as the valves act, the veins have only
 to sustain the pressure of the blood behind, and are
 consequently but slightly distended; but if they do
 not close, they have to bear a share of the pressure
 which is  exerted upon the thoracic and abnormal
 organs during forcible expiration, and are conse-
 quently much distended.
  When expiration is performed by the contractile
 power of the lungs alone, either very slight or no
 undulation  whatever is observed in the cervical
 veins during  the respiratory movements; and this
 is true, even though their valves do not close.  The
 widening of the vena cava (although  very inconsi-
 derable) which takes place within the thorax durino-
 •   •   .                                      ^
 inspiration, in consequence of the increased pres-
 sure exerted upon the inferior vena cava  by the
 contraction of the abdominal muscles, is compensa-
 ted by its contraction within the thorax during ex-
 piration, consequent upon the enlargement of the
abdominal cavity and diminished pressure upon the
inferior vena  cava.  When the contractile  power 
          MURMURS OF THE HEART, ETC       275

of the lungs is of itself insufficient to expel the air,
the cervical veins, if their valves are defective, be-
come distended, the blood being forced back  from
the vena cava into them during expiration; if the
valves close, and the blood be retained in the vena
cava, the  cervical veins will also be distended as
suddenly, but not  as forcibly.
   During inspiration, the swelling of the cervical
veins  diminishes  or disappears.  This rising and
sinking of them during the respiratory movements,
does not represent what is called the venous pulse.
   Contraction of the right auricle, the  object of
which is to propel  the blood into the ventricle,
must also cause a reflux of blood in the vena cava;
and this reflux becomes visible in the cervical veins,
even  if her valves  close, whenever the blood in
 them  presses upon the blood in the vena cava, or
-the blood in the vena cava upon that in the cervical
 veins. In such cases, the impulse imparted to the
 valves by the reflux of the blood, is necessarily com-
 municated to the columns of blood above the valves;
 the undulations  thus  produced are synchronous
 with  the increase of the blood-columns, which oc-
 cur during the closure of the valves, and  is occa-
 sioned by the unceasing reflux of the blood.
    In  health, the vena cava is never completely filled
 with  blood, and consequently the blood in the cer-
 vical veins does  not press upon  that in the vena
 cava, so long as the head is higher than the  tho-
 rax; in such a position moderate reflux of the blood
 might occur, without manifesting itself in the cervi-
  caf veins; but if the head be placed lower than the 
276        MURMURS OF TI1E HEART, ETC

thorax, the cervical veins at once swell out,  be-
cause the blood in the vena cava now rests upon
that contained within the veins,  and every reflux
of blood from the vena cava  becomes manifest as
an undulation in the cervical veins.
  In healthy persons no  such undulatory  move-
ment of these veins is visible, even when they arc
considerably swollen and  the  head is placed low;
the reason of this  is, that, under normal circum-
stances, the right auricle does not contract so as to
communicate movement to the blood.  In  abnormal
states,  however, and particularly when much dis-
tended through obstruction to the  pulmonary cir-
culation, the  right auricle  contracts vigorously,
and its contractions produce  pulsation in  the cervi-
cal veins.  These contractions occur either  in the
course  of the ventricular diastole, or they somewhat
precede the ventricular systole: two, or even three
contractions, may be associated with a single systole.
  When the tricuspid valves are  defective, regur-
gitation of  blood into the vena cava takes place at
each ventricular systole;  the  undulation thereby
created reaches the blood in the cervical  veins,
even though their valves be closed, and produces
a pulsation there, provided the blood in the cervi-
cal veins rests upon the blood in  the vena cava.
  Experience teaches us, that contractions of the
right auricle may be synchronous with the ventri-
cular systole; pulsations therefore of the cervical
veins cannot be considered as indicative of defect of
the tricuspid valves, unless associated with a systolic
murmur of the right ventricle.   Pulsation of the 
MURMURS OF THE HEART, ETC.       277
cervical veins, caused by contraction  of the right
auricle, does not continue for  any length of time
synchronous with the ventricular systole;  several
venous pulsations may correspond to a single  sys-
tole ;  and an undulatory movement of the cervical
veins maybe produced solely by violent movements
of the heart, independent of any contractions of the
right auricle or defect of the tricuspid valves.
   The absence  of sound and murmur, or the  pre-
sence of a sound of such indefinite character, that it
cannot be classed either as a sound or murmur,  does
not offer any distinct indications.  We must, in such
cases, in order  to obtain some probable idea of the
condition of the tricuspid valves, proceed in the
manner recommended for ascertaining the condition
of the mitral valves, in the case where there is ab-
sence of sound and murmur  in the left ventricle
during its systole—with, this difference, that in the
one case  regard must be  had to the force of the
second sound of the pulmonary artery, and, in the
other, to the condition of the jugular veins.
   I have never observed a diastolic murmur over the
right ventricle.  Contraction of the right auriculo-
ventricular opening is of very rare occurrence.  The
signification of the second  sound in the right ven-
tricle, as well as its absence, may be gathered from
what has gone  before.
   A sound heard in the aorta during  the heart's
systole, unaccompanied by a murmur,—first sound,
—does not necessarily indicate that the aorta is
in a  perfectly  normal condition; it is heard  loud-
est during the  violent action of an enlarged heart,
       24 
278       MURMURS OF THE HEART, ETC.

when the coats of the aorta are  healthy, and its
width adapted to the size of the heart.  The sound
is dull when the coats of the aorta are thicker and
less  elastic than natural;  when the heart's action
is weak; and when the diameter of the aorta is
either too large or too small in comparison with the
size of the heart.
  A murmur alone, or a sound accompanied by a mur-
mur, indicates the presence of roughened  patches
upon the inner surface  of the aorta, or upon the
under surface of the semilunar valves.   But a mur-
mur of a dull character may arise in the aorta, inde-
pendent of such abnormal conditions.
  The absence of sound  and  murmur, or a sound of
such indeterminate character as not to be capable of
being classed either as a sound or murmur, is pro-
duced by an exaggeration  of the same causes that
give rise to dulness of the  first aortic sound.
  A sound heard in the aorta during the ventricular
diastole,  unaccompanied by a murmur,—second
sound,—indicates closure of the aortic valves.   It is
strong and loud, when the coats of the aorta and the
aortic valves are healthy, and the action of the heart
strong; but the sound becomes dull, when the aortic
valves and the coats of the aorta are thicker and less
elastic than natural, when the heart's action is weak,
and when the mitral valves are  defective, or the
mitral orifice constricted.  In some rare cases, the
second sound of  the aorta  has a ringing character
(Klang,) and then really becomes  a musical sound
(Ton.)   This ringing second sound is not heard, ex-
cept  in old people.   In one case, where it was very 
          MURMURS OF THE HEART, ETC.       279

marked, the ascending and transverse aorta, as well
as the large arteries given off from it, were found,
after death, converted into nearly solid canals by the
deposition of chalky concretions, the aortic valves
being healthy.
   A murmur without a sound, when it is prolonged,
and heard above the base of the heart, indicates de-
fect of the aortic valves, and the presence of rough-
nesses upon their free borders.  If the murmur is
short, and  only heard high up over the aorta, it is
caused by  the  presence of roughnesses upon the
inner surface of the aorta; we cannot, therefore, by
consideration of the murmur alone, decide whether
the closure of the aortic valves is complete.
   A murmur terminating in a sound—a murmur
bounded by a sound—depends upon the presence of
roughened patches upon the inner surface of the
aorta, when the closure of its valves is perfect.  The
columns of blood driven against the valves during
the diastole, produce a  murmur, through friction
against the roughened patches on the inner  surface
of the aorta; but the murmur continues only so long
as the current of blood is in motion, and therefore
ceases with the closure of the valves, which  closure
produces a sound.
   A murmur accompanied by a sound, the murmur
being of longer duration than the sound.  The aortic
valves, in such case, are distended by the blood, but
are incapable of performing their office; the blood
regurgitates into the left ventricle, and causes a pro-
longed  murmur.
   The  absence of  both sound and murmur, or a 
280       MURMURS OF THE HEART, ETC.
sound so dull that it cannot be characterized either
as a true sound or a murmur, has no distinct signifi-
cation.  When such indefinite signs are present, we
may perhaps arrive at some idea of the condition of
the aortic valves, by taking into consideration the
consequences of their deficiency.  When the aortic
valves are defective, the power by which the blood
is driven onwards by the arteries, acts backwards
upon the left ventricle  during its  diastole, causing
the heart to become dilated and hypertrophied. If,
therefore, we discover  signs of hypertrophy of the
left ventricle, and the signs of closure of the aortic
valves are doubtful, it is most probable that these
valves are not perfect; but if the size of the left ven-
tricle be normal, then we may be certain that the
closure  of the valves is complete, even though the
second  aortic sound  should be very indistinct, or
altogether absent.
   Hypertrophy with dilatation of the right ventricle,
caused by defect of the mitral valves, is occasionally
accompanied by a systolic murmur in the pulmonary
artery;  this murmur perhaps depends upon some
softening of  the inner  membrane of  the distended
artery.   If  any  communication exists between the
pulmonary artery and the aorta—either through the
canal of Botal, or by the opening of an aortic aneu-
rism into the pulmonary artery—aloud systolic mur-
mur will be heard in the pulmonary artery, which
sometimes becomes continuous, increasing, however,
in force during the systole.   In  the greater number
of cases, a murmur heard in the pulmonary artery
during  the  heart's systole, does not depend  upon 
          MURMURS OF THE HEART, ETC.       281

any structural change in the artery, but upon other
causes, hitherto unexplained.  I have  never ob-
served a murmur in the  pulmonary artery during
the heart's diastole.   Defect of the valves of the pul-
monary artery  is a very rare phenomenon.   The
sound is loud,  and  the *accent falls upon it when
the mitral valves are defective; when the left auri-
culo-ventricular opening is  constricted,  without
valvular deficiency; when the right ventricle is
hypertrophied and dilated, and the heart acts vigo-
rously.
   A double  systolic  sound may occur, both  in the
normal and abnormal  condition of the heart.  It
merely indicates irregular action of the heart—pro-
bably a want of synchronism in the contraction of
the ventricles.   Neither is a double second  sound
any proof of structural change of the heart.  It
arises either from non-synchronous dilatation of the
ventricles; or the two sounds are, as we before ob-
served, the  audible  periods (Momente) of a weak
murmur, attendant upon constriction of the  mitral
orifice, and defective aortic  valves; or the  redu-
plicated  second sound  (as well as the ordinary
second sound,)  is produced by the movements of the
heart.
   More than two murmurs, either accompanied or
not by sounds, are occasionally audible in the in-
terval between one systole and  another, in cases
where endocarditis and  pericarditis are both pre-
sent, or where  the valves are in an abnormal condi-
tion, and  the pericardium roughened: the fact may
be explained by the circumstance  of the pericardial
                      24* 
282
RHYTHM OF THE
not being exactly synchronous with the endocardial
murmurs.   Our endeavour must be to discriminate
and seize upon each murmur and each sound sepa-
rately : this is always possible, with the aid of the
above rules, provided the movements of the heart
are not very weak and rapid: the sound, or murmur,
once discriminated, there is no difficulty in deciding
upon its signification.
  We now and then meet with cases in which two
different murmurs are heard simultaneously at the
same  spot; such murmurs may  both arise in  the
same part, as, for instance, in the left ventricle; or
one of them may arise in the aorta, and the other
in the  left ventricle:  they must be judged  of as
in other cases.  The grand object is, to ascertain
whence the murmur proceeds, and whether it is
synchronous with the systole, or with the diastole
of the  heart.

   IV. THE RHYTHM OF  THE HEART'S MOVEMENTS.
  The deviations from the normal rhythm of the
heart's movements are manifold: the number of the
movements, in a given time, may be abnormally in-
creased or diminished: single movements may be
unequal in duration and in force: and the relation
of the length of the systole to that of the diastole
altered.  Several of these unnatural conditions of
the heart's rhythm may be mixed upxme with the
other, and their combination brought under another
class  of irregularities; or the  movements of the
heart may be such as to render their reduction into
any order impossible. 
HEART'S MOVEMENTS.
283
  We form our judgment of the heart's movements,
whether  normal or abnormal, from the nature of
its impulse and of its sounds and murmurs, and
from the  condition of the arterial pulse.  Now, the
opinion which an observer may give in any par-
ticular case respecting the character of these move-
ments, will depend very much upon the views which
he holds concerning the causes of the heart's impulse,
and of its sounds and murmurs.   Laennec, for in-
stance, tells us, that in certain cases of palpitation
of the  heart, two or more contractions of the auri-
cles may be observed accompanying a single con-
traction  of the ventricles: he believed that the se-
cond sound was produced by contraction of the au-
ricles.   Bouillaud, on the other hand, speaks of an
occasional  double or even triple ventricular dias-
tole, associated with a single systole.
   The impulse of the heart is a sure indication of
the ventricular systole; but we cannot decide with
certainty upon the nature of the heart's movements
by the aid of its sounds, for though we know  many,
we do not know all  the causes upon which these
sounds depend.
   Abnormal rhythm of the heart's movements very
 frequently depends upon structural change  in the
 heart  itself; but it is nevertheless certain that the
 most marked irregularity in the rhythm, both of its
 impulse  and sounds, may exist when its structure is
 apparently perfectly normal; on  the other hand,
 there  is scarcely a single organic alteration  of the
 heart  and its valves, which may not co-exist with 
284    RHYTHM OF THE HEART'S MOVEMENTS.

the most complete regularity in  the rhythm of its
movements; hecce the greatest irregularity of its
rhythm does not justify us in assuming the existence
of organic disease of the heart. 
285
                  PART  II.
DESCRIPTION OF THE PHENOMENA OBTAINABLE BY THE AID OF
           AUSCULTATION AND PERCUSSION,
  APPERTAINING TO SPECIAL CONDITIONS OF THE THORAX AND
                    ABDOMEN.

                 CHAPTER I.
NORMAL CONDITIONS OF THE THORACIC AND ABDOMINAL
                    ORGANS.
  The phenomena proper to special conditions of
the thoracic and abdominal organs, obtainable by
the aid of  auscultation  and percussion,  are to be
deduced from a consideration of the foregoing de-
scription of these  phenomena.  For  the more full
comprehension of  the subject in hand, I will here
give an account of the deductions which may be
thus arrived at.
  The percussion  sound and the resistance vary
much in the different regions of the thorax and ab-
domen, when the subjacent organs are in a normal
condition.  The percussion-sound also varies in dif-
ferent individuals over corresponding parts; and
the same is true of the phenomena of auscultation.

       PHENOMENA OBTAINED BY PERCUSSION.
   Variations of the  sound as heard in the different
regions of the thorax.   The right half of the ante- 
286
THE PHENOMENA
 rior surface of the thorax, between the sternum and
 right lateral region, and from the collar-bone down
 to  the  fifth  rib,  yields an equal, full, clear, non-
 tympanitic percussion sound, and very  little resist-
 ance.   From the sixth rib down to the lower border
 of the thorax, the sound (in consequence of the pre-
 sence of the liver) is almost completely  dull, resem-
 bling the percussion-sound of the  thigh, and the
 resistance felt is considerable.   Above, the dull
 liver-sound  passes  gradually into the  clear lung-
 sound, and at the lower border of the  thorax into
 the muffled or clear tympanitic sound of the intes-
 tines.   The upper half of the sternum yields, for
 the most part, as full and clear a sound as the neigh-
 bouring part of the right thorax; lower down, and
 particularly towards the left, the sound  over the
 sternum becomes duller, in consequence of the pre-
 sence of the  heart  behind it; the left lobe of the
 liver usually reaches as far as the ensiform cartilage.
  The surface of the thorax to the left  of the ster-
 num, and as far as the left lateral region, and from
 the clavicle down to the fourth rib, yields the same
 sound, and the same resistance, as the corresponding
 parts  on the right side.   The surface, from the
 fourth left rib to within an inch of the lower  border
 of the thorax, or even to the border, and from the
 sternum to the left lateral region, offers a muffled
 and less full sound, and an increased resistance.
  The diminution of the sound is most marked at
 that point where the heart comes in contact with
the  thoracic walls; it is also observed for the space
of half  an inch or more around  that point.  The 
OF AUSCULTATION.
287
sound, however, in the region of the heart is not
completely dull.   The  dulness  of the sound ob-
served beneath the heart, is partly caused by the
left lobe of the liver; an inch or more above the
lower border of the  thorax, we may generally re-
mark the stomach-sound,  either muffled, or very
clear and tympanitic; occasionally, it is accompanied
by a metallic resonance—Piorry's son humorique.
In the right lateral region, the percussion-sound is
clear, but not so full as under the clavicles; from
the axilla downwards, it gradually becomes emptier,
and towards the sixth rib is muffled, and from thence
to the border of the thorax completely dull.  In
the left lateral region, the sound is not so empty
as on the right  side.  From the sixth rib down-
wards, we have generally the tympanitic sound  of
the stomach,  muffled by the spleen, but becoming
perfectly clear at the border of  the  thorax.   Up-
wards, from the  sixth rib to the  axilla, percussion
produces either the  non-tympanitic  sound of the
lungs, which  is  at times  as  full as beneath the
clavicles, or a combination of the lung  and the
stomach-sound, and louder than that heard beneath
the clavicles.
  The percussion-sound is much  less distinct, and
the resistance greater, on the posterior, than on the
anterior part of the thorax.  The sound is dullest,
and the resistance greatest, over the scapulae.  Not
less dull is the sound over the vertebrae, unless the
percussion be very strong.  The interscapular space,
which may  be increased  by displacement of the
scapulae, offers a duller and emptier  sound, and a 
288
THE PHENOMENA
greater resistance, than the parts beneath the axilla;
the dulness increasing as we proceed upwards.  From
beneath the scapulae, down to the third or fourth
false rib, the percussion-sound is fuller than between
the scapulae—about the sixth or  seventh  true  rib,
even fuller than in the right axilla, though less clear.
   Variations of sound as observed in different indi-
viduals.—We find remarkable differences in the cha-
racter of the percussion-sound of the thorax in dif-
ferent persons, whose thoracic organs are healthy.
In one, a very gentle stroke produces a loud sound,
whilst in another, and at the corresponding part,
strong percussion is necessary to elicit even a mo-
derately clear sound. The percussion-sound is in-
comparably louder in persons who are spare  and
not muscular, and whose ribs are thin and yielding,
than in others of an opposite conformation.   It is
hardly necessary to  observe, that the percussion-
sound is altered by the female breast; whenever it is
possible, this organ must be pressed aside, and in
different directions, so as to enable us to obtain the
percussion-sounds proper to the parts beneath.
  The percussion-sound of the thorax is much louder
in children than in  grown-up persons, in conse-
quence of the thinness of their muscles, and the flex-
ibility of their ribs.  It is also frequently  louder in
old,  than  in middle-aged  individuals; a  fact ex-
plained by Raciborsky, after the theory of Hourmann
and  Dechambre, by a supposed rarefaction of the
lung parenchyma, and by increased rigidity of the
thoracic walls.  My own belief is, that this loud per-
cussion-sound in the aged, results from wasting and 
OF AUSCULTATION.
289
thinning of the muscles and ribs, and from the en-
largement of the thoracic cavity, caused by the sink-
ing of the diaphragm: for when the muscular tissue
of the aged is not wasted, it remains unaltered,
and becomes as loud in the young, when the ribs
and their attached muscles have become atrophied
and wasted by disease, as it is in the old.

             PERCUSSION OF THE ABDOMEN.
   In the normal condition of the abdominal organs,
 the percussion-sound of the abdomen varies, being
 at one time distinctly tympanitic and clear, at ano-
 ther indistinct, and scarcely at all tympanitic; this
 difference depends partly upon the varying amount
 of gases present in the intestines, and partly upon
 the pressure exerted upon the intestines by the ab-
 dominal walls: the less this pressure is, the clearer
 and more tympanitic will be the sound of the intes-
 tines when they contain air. The percussion-sound
 is not alike over every part of the abdomen; and
 it varies in proportion as the  intestines are more
 readily capable of being displaced.
    The loudest and clearest tympanitic sound is ge-
  nerally heard over the region of the stomach; it is
  at times  accompanied by a metallic  clang.  The
  right lateral gives, for the most part, a louder sound
  than the left lateral region; the left lumbar region
  yields  a completely dull sound, except when a por-
  tion of intestine happens to lie in the neighbour-
  hood, and so occasions a tympanitic sound.

         25 
290
THE PHENOMENA
           AUSCULTATORY PHENOMENA.
        AUSCULTATION OF THE RESPIRATORY ORGANS.
   When a person speaks, either no sound whatever
of his voice reaches the ear of the observer, through
the thoracic  walls, or merely a  dull, interrupted
humming is heard, from which not the faintest idea
of the words  spoken  can  be gathered.  The hum-
ming is much  louder in the  interscapular space
than elsewhere, and some of the words spoken may
be occasionally distinguished there, especially  at
the upper part of this space—bronchophony is heard
there.  The  bronchophony is loud, in proportion
to the depth of the voice; and distinct, in propor-
tion to its acuteness.
  A loud humming, indicating the passage of the
sound into  bronchophony, is not unfrequently ob-
served  immediately  beneath  the clavicles.  The
humming is not heard alike over  the other parts  of
the thorax: its force  diminishes as we recede from
the neighbourhood of the large bronchial  tubes.
Loud bronchophony is almost always audible above
the clavicles,  and  proceeds from the larynx.
  The inspiratory murmur is  either vesicular,  or
it is indeterminate, or scarcely audible.  The vesi-
cular  breathing of infants is very loud; in adults,
it is more distinct in those whose muscles are weak,
and whose  thoracic  movements  are  free.   When
the breathing is very loud, it  may be even heard
over those parts of the thorax beneath which there
is  no  lung  present;  as, for  instance, over  every
part of the cardiac region, and over a certain por-
tion of the liver, and of the stomach. 
OF AUSCULTATION.            291
  In individuals whose muscular structure is highly
developed, the respiratory murmur, under normal
conditions, is rarely loud enough to render its ve-
sicular character manifest; in such persons, scarcely
any, or only an indeterminate respiratory murmur, is
audible during  ordinary respiration; a deep, quick
inspiration, may occasionally produce the true vesi-
cular breathing, but this is not always the case.  The
loudest inspiratory murmur is heard during the deep
and rapid inspirations of a person speaking, or which
precede or follow coughing; but we now and then
meet with healthy persons, in whom the respiratory
murmur does not become distinct, even under such
conditions. In the aged, it is generally indistinct,
and more or less loud, in  proportion as the murmur
of the finer bronchial tubes and air-cells is more or
 less mixed up with that of the larger bronchial tubes.
 In old people, a peculiar modification of the respira-
 tory murmur  is occasionally  met with; it is very
 acute, and approachesin character to ahissing sound.
   When the lungs are normal, the inspiratory mur-
 mur is heard  every where  alike over the thorax;
 or it may be more distinct at some parts than at
 others, and perhaps inaudible at certain points. The
 vesicular murmur is purest  and  most distinct at
 those parts of the lung which are furthest from the
 large bronchial tubes: when very weak, it is heard
 loudest in the interscapular space, but generally
 only as an indeterminate respiratory murmur.
    When the lungs are normal, scarcely any murmur
 is heard during expiration; it is difficult to discover
 a trace of even a very short and weak  one; the in- 
292             THE PHENOMENA
terscapular space alone frequently produces an in-
determinate murmur during expiration.
  Bronchial respiration under normal conditions is
not heard except in the neighbourhood of the upper
dorsal vertebrae, and  not frequently  even there.
In cases of violent dyspnoea, however, it may be
heard during expiration over the whole of the back
and even over the anterior part of the thorax, the
lung being neither infiltrated nor compressed.

 AUSCULTATION OF THE HEART, OF THE ARTERIAL TRUNKS, AND
                  OF THE VEINS.
  The impulse of the heart is to be sought for about
the cartilages of the fifth or sixth ribs.   If there be
no excitement, either of the mind  or body, the  im-
pulse may be barely perceptible; on the other hand,
it may be so increased in a healthy heart, as to com-
municate a movement to the head of the ausculta-
tor; but in such case, it will be found that the shock
is not communicated to so large a surface as when
caused by enlargement of the heart.  A concussion
is occasionally observed  at each systole,  over  the
parts of the thorax which correspond to the course
of the aorta and pulmonary artery, particularly in
persons  in whom the anterior part of the thorax is
abnormally depressed towards  the bodies  of  the
vertebrae.
  The sounds in  the ventricles, as well as in  the
arteries, may be very clear and loud, or very weak
and barely audible; they may resemble each other
and differ from each other; at one  time the ventri-
cular sounds are the louder, at another, the arterial. 
OF AUSCULTATION.
293
The ventricular are generally to be distinguished
from the arterial sounds by this, that in the ven-
tricular the accent falls upon the first, and in the
arteries upon the second sound.  The first sound
may be very loud in one or both ventricles, and the
second weak or scarcely audible; whilst in the arte-
ries both sounds may be weak, or one of them weak
and the other strong: the sounds in the arteries may
also differ in respect of their strength.  Variations
may be observed in the  clearness, pitch, etc., of the
sounds, both in the ventricles and in the arteries.
   The second sound follows rapidly upon the first,
then  comes a pause, which is broken by a subse-
quent first sound.   In some rare cases, the interval
between the first and second sounds is somewhat
prolonged, and the pause succeeding the second
sound very short;  so that it becomes difficult, or
even impossible, to decide by the ear alone, which
is the first and which the second sound.
   Murmurs do not arise in the ventricles of a healthy
heart, but in weakly individuals, whose circulation
 is rapid, a blowing or hissing murmur accompanying
 each pulse is readily excited in the large arteries of
 the neck, particularly in the carotid.  This murmur
 is seldom audible in the aorta, though it may be dis-
 tinctly so in the cervical arteries: when heard in the
 aorta, it is always very dull and weak.
    In the hollow between the two heads of the sterno-
 cleido-mastoideus muscles, a bruit  de diable is fre-
 quently audible in young persons; it takes its origin
 in the internal jugular vein, and is observed much
 more frequently on the right than  on the  left side.
                       25* 
294
THE PHENOMENA
  The bruit is not heard in old persons, nor in young
persons when their cervical veins are distended, in
consequence of obstructed  pulmonary circulation.
It cannot, of itself, be considered a sign of chlorosis,
or of a spanaemic condition of the blood.

         AUSCULTATION OF THE GRAVID UTERUS.
  The auscultatory phenomena of the gravid uterus
were pointed out by Le Jumeau de Kergaradec. He
discovered the sounds of the foetal heart, and the so-
called placental murmur, already referred to. More
lately, Nagele has described a bellows-sound syn-
chronous with the pulsations of the foetal heart. The
sounds of the fcetal heart can be heard over the
uterus at the sixth month of pregnancy, and become
more distinct as the pregnancy advances.  They are
not generally audible over any considerable extent
of surface, but may  occasionally be heard  over the
greater part of the uterus; their presence  is a sure
sign of the foetus being alive.   No great skill in
auscultation is necessary to discover the sounds of
the fcetal heart, and to discriminate them from any
other accidental sounds; it shows great inexperience
for any one to affirm that the so-called foetal pulse
can be imitated by accidental murmurs.  It was once
thought that the position of the foetus could be di-
agnosed  from the sounds of its heart, but  this idea
appears  to be  now abandoned.  It is  possible, at
times, to discover the presence of twins by  the foetal
pulse, in those cases where the two hearts do not
pulsate with equal rapidity.
   We are not justified in concluding from a single 
OF AUSCULTATION.            295
examination, in which we fail to discover the pulsa-
tions of the fcetal heart, that pregnancy does  not
exist, or that the child is dead; but if, upon repeated
and carefully-made examinations, no foetal pulse can
be found, we are justified in concluding either that
the pregnancy is not far advanced, or that the child
is dead.
  Whether abnormal states of the foetal heart and
extra-uterine pregnancy can be discovered by  aus-
cultation, the future must  decide.
  The so-called placental bruit, the mode of origin
of which has been already referred to, is not nearly
so valuable a sign in the diagnosis of pregnancy,
as the sounds of the foetal  heart; for it  has  been
heard in cases of the enlargement  of the uterus
and ovaries, when pregnancy did not exist.   But
such cases are  rare, and hence the presence of this.^
murmur over  the uterus, always  makes the  exis-
 tence of pregnancy probable.
   The blowing murmur of Nagele,  which is  syn-
 chronous with the pulsations  of the foetal heart,
 must arise from some particular coiling-up of the
 umbilical cord. 
296
THE PHENOMENA
                CHAPTER II.
ABNORMAL CONDITIONS OF THE THORACIC AND ABDO-
                MINAL ORGANS.
      ABNORMAL POSITION OF THESE ORGANS.
  Percussion signs.—The organs of the thorax and
abdomen may be otherwise perfectly normal and
perform their functions normally, and yet give rise
to changes in the natural percussion sounds of these
cavities, in consequence of their position being ab-
normal.  Thus, the liver may be placed very high,
and render the percussion sound of the thorax dull
as far up as the right axilla; the tympanitic sound
of the intestines at the same time reaching an inch,
or even more, above the lower border of the thorax.
  When the stomach lies high in the  abdomen, and
contains  air, the percussion sound will be found
tympanitic over the whole precordial  region, as
far up as the fourth rib  on the left side.  The liver
and stomach may, on the other hand, occupy a low
position,  and thus produce considerable  changes in
the percussion sounds of the abdomen.  Again, the
liver may lie in the left, and the spleen in the  right
hypochondrium, and the heart in the right side of
the  thorax, etc. The  presence of any portion of
the intestines  in the cavity  of the pleura, may be
generally ascertained by  percussion.
  Auscultatory signs.—Abnormal  positions of the 
OF AUSCULTATION.
297
liver, stomach, etc., are not indicated by auscultation;
auscultation, however, assists us in diagnosing the
altered position of the heart.   When the liver lies
high up under the thoracic walls, the respiratory
murmur is not heard in the left lateral region so low
down as  usual; but it should  be remembered, that
the murmur is generally weak  in this part, when the
position of the liver is normal; and, moreover, that
it may be naturally weak, and  almost inaudible over
the whole of the thorax.  If the respiratory murmur
be particularly loud, it may'be heard to a consider-
able distance downwards even though the liver be
situated  high up under the thoracic walls.

ABNORMAL  CONFORMATION OF THE WALLS  OF THE
                    THORAX.
   Deviations from the natural form of the thorax
produce  changes  in the  percussion sound.  The
sound becomes louder than  usual, when the ribs
are flattened, and their power  of resistance conse-
 quently diminished; but by arching out of the ribs,
 resistance is increased, and  at those points where
 they are bent,  and form  projections outwards, the
 percussion sound is sensibly diminished.   We must
 take these facts into consideration, in judging of the
 variations in the percussion sound produced by the
 projections and depressions met with in deformities
 of the sternum, and  in abnormal curvatures of the
 ribs.
   The highest degree of abnormity in form of the
 thorax is produced by curvatures of the spine; not
 only are the ribs thereby unnaturally bent, but fre- 
298
THE PHENOMENA
quently one entire half of the thorax is considerably
diminished in size; or the upper half of one  side
is much enlarged, and the lower half much dimi-
nished, the reverse of this holding good in the other
half of the thorax. The abnormal form of the tho-
rax necessarily induces a change in the  position of
its contained organs.  In the contracted  part of
the thorax the lung is compressed, and in the ex-
panded part, more distended than natural.   The en-
larged liver reaches high up, and stretches far to
the left beneath the thoracic walls; the right side
of the heart is also enlarged, and generally occu-
pies a greater space than ordinary.
  Auscultatory signs.—That  portion of the lung,
which is compressed and diminished in size through
abnormal  form of the thorax, yields either a vesi-
cular or an indeterminate respiratory murmur, ac-
cording as it is slightly or much compressed.  The
distended portion of lung yields a vesicular murmur,
which is generally very clear, but sometimes indis-
tinct.  The murmur seldom remains clear when the
abnormal  form of the thorax  is very considerable,
for the compressed portion of lung generally pro-
duces hissing, whistling, or sonorous sounds. I have
never met with a case where  bronchial breathing,
or bronchophony, has arisen solely from pressure of
the lung consequent upon spinal curvature.   Cur-
vatures of the spine almost invariably occasion hy-
pertrophy and dilatation of the right ventricle,
and, consequently, an increase of the heart's sounds
over those parts of the thorax which correspond to
the right  ventricle; and  the  second sound of the 
OF AUSCULTATION.
299
pulmonary artery is always very loud, much louder
indeed than the second sound of the aorta.

   ABNORMAL CONDITIONS OF THE THORACIC AND
              ABDOMINAL ORGANS.
         I. DISEASES OF THE BRONCHIAL TUBES.
  Percussion signs.—Diseases of the bronchial tubes
produce no change in the percussion sound, so long
as the lung-parenchyma remains healthy.  In ca-
tarrhal inflammation of the bronchial  tubes, in
crt)up, in suffocative catarrh, in chronic  bronchor-
rhoea,  in bronchial hemorrhage, and  in enlarge-
ment of the tubes, the percussion sound remains the
samaas in the healthy lung.
  Auscultatory signs.—Catarrhal inflammation of
the lining-membrane of the bronchial tubes gives
rise to various auscultatory signs, which signs differ
according to the seat of the inflammation, whether
it be in the  finer or the larger bronchial tubes, or
in both sets of tubes at the same time:  according
also to the condition of the lining-membrane of the
tubes, whether it is merely swollen, or swollen and
covered with secretion.
   The slightest  degree of swelling of the lining-
membrane of the tubes renders the respiratory mur-
mur louder and coarser than natural;  thus, at the
beginning of an attack of catarrhal inflammation,
we often hear a very loud and coarse vesicular mur-
mur, seated  in the finer bronchial tubes;  when the
inflammation falls upon the larger bronchial tubes,
the vesicular murmur is frequently masked by a
coarse indeterminate murmur.   The coarse vesicu- 
300
THE PHENOMENA
lar and the indeterminate respiratory murmur pass
into the sibilant, whistling, and  sonorous  sounds.
If the breathing is not hurried, it sometimes happens
at the onset of the disease that no sounds whatever
are heard over many parts of the thorax.  When
secretion has taken place into the  finer bronchial
tubes and air-cells, fine bubbling rales and hissing
and whistling sounds arise; if it is not very tena-
cious, fine bubbling rales alone are heard.
   If, in addition to the hissing, whistling, and sono-
rous sounds, the respiratory murmur is present, we
may conclude that the secretion  is scanty; but ab-
sence of the murmur when the respiration is vigo-
rous, indicates the presence of a considerable amount
of secretion.  Secretions may be present in the air-
cells and finer bronchial tubes, either in large or
small quantity, without giving  rise to murmurs;
this cannot happen, however, when the quantity of
secretion  is  small, unless the respiratioif is at the
same time weak and languid.
   The secretion in the larger bronchial tubes pro-
duces, according to  its degree of tenacity, either
unequal-bubbling dull rales, or in addition to these,
whistling and sonorous sounds, or these latter only.
Besides these different rales, and whistling and
sonorous sounds, we may also recognise respira-
tory murmurs, either vesicular  or indeterminate.
When the fluid is secreted into the larynx or trachea,
the rales and sibilant and sonorous sounds thence
arising are sometimes heard over every part of the
thorax, the respiratory murmur, vesicular or inde-
terminate, either remaining audible or being com-
pletely masked by them. 
BRONCHITIS.
301
   The intensity of these different sounds, produced
 by inflammation of the lining membrane of the air-
 passages, depends chiefly upon the extent and  ra-
 pidity of the respiratory movements.  If the respi-
 ration be slow and vigorous, large bubbling rales
 are produced.
   Under normal circumstances expiration produces
 scarcely any murmur, but when the bronchial mem-
 brane is inflamed, a murmur becomes audible during
 expiration, presenting itself as  an indeterminate
 murmur, or as one of the different rales, or as a hiss-
 ing, whistling, or sonorous sound.  Expiration may
 even produce a louder murmur  than inspiration;
 and the sibilant and  sonorous sounds, when they
 proceed from one of the large bronchial tubes, may
 extend to a considerable distance from their origin,
 and, indeed, be heard over the whole of one side of
 the thorax; when formed in the trachea, they may
 be heard of nearly equal strength over every part of
 the thorax.   No change is produced in the thoracic
 voice by inflammation of the bronchial membrane.
   Chronic bronchial catarrh gives rise to the same
 auscultatory signs as acute catarrh.  The nature of
 these signs depends upon the degree of swelling of
.the  bronchial membrane, and upon  the quantity
 and tenacity of the secreted fluid.
   The same  is true of all diseases which produce
 thickening of the bronchial mucous membrane, or
 give rise to secretions into the air passages: such
 as whooping-cough, suffocative catarrh,  inflamma-
 tion of the  air-passages, with croupous or puru.
       26 
302
BRONCHITIS.
lent secretion, and hemorrhage from the bronchial
tubes or air-cells.
   The acute exanthemata, small-pox, measles, scar-
latina, etc., abdominal typhus, pneumonia, the rapid
development, and especially the softening of tuber-
cles, are almost invariably associated with bronchial
catarrh, that is, with swelling of the lining-mem-
brane of the bronchial tubes, and with increased
secretion; they offer the same auscultatory signs as
catarrh of the lungs.  These signs  are not so con-
stant in  pericarditis,  endocarditis, carditis, and
pleuritis; but they generally manifest themselves
in the progress of organic disease of the heart, or
of long-standing pericardial or pleuritic  effusions.
   Enlargement of a bronchial tube may take place
under  a double form; the  tube  may be equally
widened throughout its whole length, or for a por-
tion of its length;  or it  may be widened, so as to
form cavities of different sizes.  The first kind of
widening (so long as the lung-tissue surrounding
the tube contains air) does not offer any  ausculta-
tory signs, other than those attending bronchial
catarrh.   The second form of enlargement of the
bronchial tubes—the sacculated—when it pervades
an entire lobe of the lung, which is adherent to the
costal pleura, produces a peculiar auscultatory sign,
viz., the large-bubbling dry crepitant rale—craque-
ment;  if the bronchial cavities are large, and the
openings into them small, the  craquement is pre-
ceded by a very loud hissing sound.  The expira-
tion is either free from murmurs, or is accompanied
by hissing, whistling, and sonorous  sounds. If  a 
PNEUMONIA.
303
sacculated portion of the bronchus  approach the
surface of the lung, a pleural friction-sound is ge-
nerally added to the craquement.
  Enlargement and thickening—hypertrophy and
Ossification of the cartilages of the bronchial tubes, I
have never seen developed to such an extent as to
give rise to bronchial breathing,  unless complete
atrophy of the pulmonary substance  existed at the
same time. This abnormal condition of the bronchial
tubes, produces the same auscultatory phenomena
as catarrh, by which it is invariably accompanied.

  II. DISEASES OF THE PARENCHYMA OF THE LUNGS.
                   PNEUMONIA.
  Inflammation of the parenchyma of the lungs pro-
duces manifold changes, both in the percussion and
in the auscultatory signs of the thorax.  These
changes depend upon the altered conditions of the
inflamed tissue; upon the amount of the catarrhal
affection, which always attends inflammation of the
lungs, and upon the strength and the rapidity of
the respiratory movements.
   The different abnormal conditions of the lung
parenchyma, effected by the  inflammation, have no
special auscultatory or percussion signs belonging
to them.  Two grand distinctions,  however, may be
marked in the condition of the lung, viz., whether
it be permeable or impermeable to air.  The lung
is permeable in the first period of the inflammation,
and during its resolution; and  impermeable when
completely hepatized. 
304
PNEUMONIA.
SIGNS OF PNEUMONIA, WHEN THE LUNG-TISSUE IS PERMEABLE TO
  AIR, i. e., AT THE COMMENCEMENT OF PNEUMONIA AND DURING
  ITS RESOLUTION.
  Percussion signs.—The percussion sound remains
unaltered, however congested with blood the vessels
of the lung may be, so long as no exudation has
taken place into the lung parenchyma, and the con-
tractility of the lung not destroyed.  The truth of
this is demonstrated, not only by observation of pneu-
monia in its first stage, but also, and more strikingly
and conclusively, in cases of constriction of the mi-
tral orifice of the heart, where the  highest degree
of congestion of the pulmonary vessels takes place,
without producing any change in the normal per-
cussion sound of the lungs.
  An alteration of the percussion sound is first ob-
served when effusion has taken place into the pul-
monary tissue, or when the contractility of the lung
is increased or  diminished.   In the first case, the
change depends upon the relative proportion be-
tween the air in the lung-tissue and the amount of
the  infiltration, and is in no way connected either
with the  intensity of the inflammatory  process or
with its duration.  The parts of the thorax, beneath
which the infiltrated lung-tissue lies, and so long as
it contains  air, generally yield a somewhat tympa-
nitic sound, provided the thoracic walls are not very
rigid; the resistance offered to percussion being at
the same time increased.  The tympanitic sound is
seldom perfectly clear; it remains full up to a cer-
tain degree (which cannot be distinctly marked) of
the infiltration: when the sound becomes empty, we
may be sure that hepatization of the tissue is at hand. 
PNEUMONIA.
305
The empty sound is caused by diminution of the
contractility of the lung.
  The tympanitic character of the percussion sound
continues in some rare cases, even when it has  be-
come very empty; in others again, it soon disap-
pears, a dull, empty percussion sound alone remain-
ing.  From experiments which I have made on the
dead body, I believe it is scarcely possible to recog-
nise any changes in the percussion sound, or the re-
sistance, unless the  portion  of lung inflamed be at
least an inch thick, and equal in breadth to a plexi-
meter.
  The non-infiltrated pulmonary tissue surrounding
the infiltrated portion yields the normal percussion
sound;  if the latter be not  particularly clear  and
full, the percussion sound of the infiltrated portion
of lung may be clearer than it; in which case it
is only by comparison of the percussion sound at
several  points, and  particularly at corresponding
points of the two sides, that we can determine which
is the normal and which the abnormal sound.
  Nothing abnormal will be observed, either in the
percussion sound, or in the resistance, unless the in-
filtrated portion of lung-tissue lie immediately in con-
tact with the thoracic walls. Change in the sound
and the resistance, however, is  possible when the
whole of the inner part of  the lung-tissue is infil-
trated  and surrounded by  merely a thin layer of
normal tissue.
   Auscultatory signs.—-The different degrees of ca-
tarrhal affection which accompanies the inflamma-
tion, and of the force and the rapidity of the respi-
                      26* 
30G               PNEUMONIA.
ratory movements, produce changes only in the aus-
cultatory signs.
  When the vessels  of the lung are merely con-
gested with blood, and no infiltration of its tissue
nor secretion into its air passages has taken place,
the auscultatory signs are normal, or indicate merely
swelling of the bronchial membrane.
  Infiltration of the lung-tissue, associated with fluid
secretions in  the air passages, produces the same
signs as bronchial catarrh, so long as air can enter
into  the inflamed lung.  The nature of the rales
heard at the commencement of, or during the reso-
lution of pneumonia, depends upon the situation of
the secretion, whether it be present in the finer
bronchial tubes and air-cells alone, or in these and
the larger bronchial tubes also, or in  the larger
bronchial tubes  only;  it  depends, also, upon the
greater  or less tenacity of the fluid, and upon the
respiratory movements, whether  strong and rapid,
or weak and slow.  Hence  at the commencement,
and during the resolution of pneumonia, every kind
of rale and hissing, whistling, and sonorous sounds
may  be  heard,  except  only the  consonating; the
rales and sounds may  be also variously combined
together, and are not  necessarily confined to that
part  of the thorax beneath which the inflamed lung
lies,  but are  sometimes heard beyond it, and even
reach over the whole of the thorax.
   These different rales and sounds, may, as in simple
catarrh, completely mask the respiratory murmur,
whether indeterminate or vesicular; or the murmur
may be  heard together with them.   If the respira- 
PNEUMONIA.                307
tion be weak and slow, there may be an entire ab-
sence of every kind of sound.
  In some rare cases, infiltration of the lung-tissue
occurs, without secretion into the air passages; and,
in still rarer cases, there is no secretion into the air
passages during the resolution of pneumonia, when
the infiltrated matters arebeing absorbed.  In such
cases no rales whatever are heard, and the respira-
tion is either indeterminate or vesicular, or hissing,
whistling, and sonorous sounds present themselves,
and become very loud, if dyspnoea likewise exist; the
vesicular breathing especially may be even stronger
than that of children, and either coarser than natural,
or very acute, in which case it assumes a hissing cha-
racter.   When the respiration is slow and weak, it
sometimes happens that neither respiratory mur-
mur, nor rales, nor hissing, etc. sounds, are audible
over the inflamed lung.

 SIGNS OF PNEUMONIA, WHEN THE INFLAMED LUNG-TISSUE IS IMPER-
             MEABLE TO AIR--HEPATIZATION.
   Percussion signs.—The thoracic walls, beneath
 which the hepatized lung lies, yield a dull percussion
 sound,  and their  resistance is increased, provided
 the hepatized portion of lung have the thickness
 of about an inch, and an  extent greater than that
 of a pleximeter.  The more extensive the hepati-
 zation, the duller is  the sound and the greater the
 resistance.  We  must however recollect, that the
 flexibility of the thoracic walls varies in different
 persons,  and that therefore the degree of dulness
 and  resistance observed is  not to be taken as  an
 exact measure of the extent of the  hepatization. 
308
PNEUMONIA.
When the  percussion sound is empty, we may be
certain  that the hepatized part is of considerable
thickness; and if the sound is so dull as to resemble
the thigh percussion sound, over flexible parts of
the thorax, that the lung  beneath is  hepatized
through its entire thickness.
  The lung surrounding the hepatized part is either
infiltrated, though still permeable to air; or it is free
from infiltration, and normally distended: or it is ab-
normally distended and emphysematous.   Emphy-
sema  very frequently occurs around the borders of
inflamed lung.  The portions of lung remote from
the hepatization, may be emphysematous or normal;
or, in consequence of the inflammation, may be infil-
trated by fluids of a consistent  character, or merely
by serosity,—still, however, containing air.  These
are the circumstances upon which the variations in
the percussion sound of those parts of the thoracic
walls, beneath which the non-hepatized portion of
lung lies, depend.
  The emphysematous lung immediately surround-
ing the hepatization, generally yields  a tympanitic
sound; but the emphysematous portion of lung re-
mote from the hepatization, does not, as a rule, ren.
der the percussion sound tympanitic.  The infiltrated
parts  of the lung, which are still permeable to  air,
also frequently yield a tympanitic sound, where they
approach the thoracic walls; the healthy parts of the
lung give their natural sound.
  The normal percussion sound cannot be distinctly
characterized,  inasmuch as it varies considerably in
different individuals, and at different  parts of the
thorax in the same individual; it is necessary there- 
PNEUMONIA.
309
fore for us, in cases of hepatization of the lung, to
compare the percussion sound, as heard at different
parts of the thorax, especially at corresponding
points of the two sides, in order to discriminate the
abnormal from  the  normal sounds: without such
comparison, we can never with certainty set down
any sound as abnormal, except the completely dull
percussion sound, when it is heard at those parts of
the thorax which, in the healthy condition  of the
respiratory  organs, never yield such a sound.
   Auscultatory signs.—When the portion of lung
hepatized is extensive enough to contain within it
at least one of the larger bronchial tubes, and if the
tube contains air, and is not obstructed, either by
solid or fluid exudations or by blood coagula; and
if the communication between the air in the bron-
chial  tube and the air in the trachea be free, then
 the voice of the patient will consonate in the bron-
 chial  tube, and  be  heard, either as loud or weak
 bronchophony, over those parts of the thorax which
 are nearest to the tube.  The phenomena  attend-
 ing the respiration, vary according to the  nature
 of the rales, etc., which happen to be present, either
 in the larynx, the trachea,  or the bronchus, through
 which the  air must pass  before  it enters into the
 bronchial tube surrounded by the hepatized tissue;
 the respiratory murmur may alone be heard, or,
 in addition to  this, rales, and hissing, whistling,
 and sonorous sounds, or one of these rales or sounds
 only, or several of them combined together.
   These rales,  etc., may all, like the voice, conso-
 nate  in the bronchial tube, which is surrounded by
 the hepatized tissue, and be heard at the same parts 
310
PNEUMONIA.
of the thorax as the bronchophony, although they
take their origin at a distance.
  Thus, in hepatization of the lungs, and under the
conditions  indicated, we may have either simple
bronchial breathing, or, in addition to this, consona-
ting rales, or consonating hissing, etc., either singly
or variously combined together: the deeper and
the more accelerated  the respiration, the more dis-
tinct will the rades, etc., be.
  Consonance of the voice, of the respiratory mur-
mur, and of the different rales, and  of the hissing,
etc., sounds, arises from the same  cause, in each
case; but when bronchophony is present, it does not
necessarily follow that bronchial breathing, or that
high, clear, consonating rSles, etc., must be present
likewise; nor on the other hand, is bronchial breath-
ing, etc., necessarily associated with bronchophony.
The reason of this is, that  not every sound conso-
nates in the same space.   Thus  an  indeterminate
respiratory—but never a vesicular—murmur, some-
times accompanies  loud bronchophony, and so also
do rSles, or hissing and sonorous sounds;  on the
other hand, bronchial respiration, or consonating
r&les, or the hissing  and sonorous sounds, may be
very distinct, when bronchophony is not present.
Dull rales, etc., may also accompany bronchial res-
piration, and indeterminate respiratory  murmurs
be associated with  consonating rales.
  If the hepatized portion of lung be  not large
enough to contain one of the larger bronchial tubes;
or if it be large enough, but the tube be filled with
fluid or solid matters; or if the communication be-
tween the tube and  the trachea  be obstructed  by 
PNEUMONIA.
311
mucus, blood, etc., then consonance  cannot take
place: under such conditions, neither bronchophony,
nor bronchial breathing, nor high clear rales, nor
consonating whistling, hissing, and sonorous sounds,
will be heard over the hepatized lung; the patient's
voice will be inaudible, or recognisable only as a
dull muttering: the respiratory  murmur will be
either indistinct, or not heard at all; and  the hiss-
ing, whistling, or sonorous sounds present, not con-
sonating, nor the r&les high and clear.
  Obstructions to the free communication between
the bronchial tube and  the trachea, caused by the
presence of fluid or solid matters in the tube, may
be removed by coughing, or by expectoration; thus,
after coughing  or expectoration, bronchophony,
bronchial breathing, consonating  rales,  etc.,  fre-
quently manifest themselves, in cases where pre-
viously they had not been heard.
  The  auscultatory and percussion signs are the
same, whether the hepatization be red or gray, whe-
ther the lung be hard or soft, of firm or loose texture.
  I have frequently examined patients  suffering
from pneumonia, in whose lungs newly-formed ab-
scesses were  found  after death;  but I have never,
in any  single instance, recognised  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.
If the  abscess be accidentally emptied of its con-
tents, it will be rapidly filled again by the secretion,
unless  it be of long standing, and its walls have
become solid and their secreting power diminished.
  We may here observe, that there are no ausculta- 
312
PNEUMONIA.
tory nor percussion signs, by which we can discri-
minate  between inflamed lung, when it contains a
small quantity of air, and when  it contains no air
at all; in many cases, the auscultatory or percussion
signs, or both of these signs, indicate the existence
of hepatization,  although  air  still finds entrance
into the inflamed lung; and  it is not difficult  to
understand this, if we consider that consonance may
be produced when only one or  two large bronchial
tubes are surrounded by hepatized lung of several
lines in thickness, and that infiltration of a lung,
which is not entirely deprived of air, may render
the percussion-sound completely dull, at those parts
of the thorax where it is somewhat dull under nor-
mal circumstances.
  An impulse, synchronous with each beat of the
heart, is not unfrequently observed over the hepa-
tized portion of lung.   Laennec believed that this
was produced by propagation of the heart's im-
pulse;  but  there is no doubt  whatever, that the
impulse felt over a hepatized lung, or a lung in-
filtrated by tubercle, is caused by the pulsation of
the arteries passing into the lung.
  Auscultation does not always yield similar signs
at those parts of the thorax where the subjacent lung
is not hepatized; and the reason of this is, that the
non-hepatized portion of lung may be either normal
or affected  by infiltration  in various degrees; its
bronchial tubes  also may be healthy or inflame,
and contain secretion; or  the  respiration  may be
hurried and deep, or slow and imperfect; and  thus
at those parts of the thorax, beneath which hepa- 
PNEUMONIA.               313
tized lung does not lie, there may be heard either
a very loud or a weak vesicular murmur, or inde-
terminate respiration, or large- and small-bubbling
non-consonating raies, or  hissing, whistling,  and
sonorous sounds, etc.   The voice is never broncho-
phonie.

PHENOMENA ATTENDING THE INFLAMMATION, WHEN LIMITED TO A
               SMALL PORTION OF LUNG.
  Limited inflammation of the lungs—lobular pneu-
monia—does not occasion any change in the per-
cussion sound, whether it attack one or several differ-
ent parts; it is, however, almost invariably attended
by the auscultatory signs of catarrh, audible either
at single parts, or over the whole  of the  thorax.

PHENOMENA ATTENDING THE INDURATION WHICH OCCASIONALLY
  REMAINS SUBSEQUENT TO AN ATTACK OF PNEUMONIA;  THE CA-
  VITIES FORMED THEREIN ;  AND  THE WIDENINGS OF THE BRON-
  CHIAL TUBES.
  The auscultatory and percussion signs of indurated
lung, are the same as those of hepatization of the
lung; and what has been said of the circumstances
by which these signs are modified in hepatization,
holds good in the case of induration.  The presence
of empty cavities in the indurated part, renders the
percussion sound fuller and less dull; if the cavity
is of the size of a pleximeter, and situated near the
thoracic walls, it may produce an empty tympanitic
sound, which becomes clearer and fuller, as the size
of the cavity increases.  In some rare cases, percus-
sion produces the cracked-pot sound; the  cavity
must be very large to give rise to metallic tinkling.
       27 
314
PNEUMONIA.
   Either bronchophony, or an indistinct muttering,
or no trace of voice whatever, is heard over those
parts of the thorax which correspond to the ulcerated
portion of lung; the respiratory murmur is either
bronchial, or indeterminate, or altogether inaudi-
ble; and it is either clear, or mingled with every
kind of rale, or with whistling and sonorous sounds:
in very large cavities we may hear the metallic
tinkling, or the amphoric buzzing, as the resonance
of the voice,  of  the breathing, and  of  the  rales.
Dilatation of the  bronchial  tubes, in  the  consoli-
dated lung which remains after pneumonia, occurs
at least as frequently as  the formation of cavities
in it through ulceration.  Dilatation of the bron-
chial tubes offers the  same auscultatory signs as
induration of the lung  tissue.
  THE AUSCULTATORY SIGNS  OF PNEUMONIA, AS DESCRIBED BY
                   LAENNEC.
   Laennec's  account of the auscultatory  signs of
pneumonia is very different from the preceding.
According to him, crepitation is a sign pathogno-
monic of the first stage of pneumonia; it attends the
first onset of the inflammation, and is accompanied
by the respiratory murmur.  The extent of surface
over which it is heard, corresponds to that of the in-
flamed lung, and frequently is not greater than the
diameter of the  stethoscope.   Immediately in the
neighbourhood of the inflamed  lung, the rale be-
comes less distinct, and appears as though it came
from a distance, and at two or three inches from it
is  no longer audible.   As the disease advances
into the stage of hepatization, the crepitating rale 
PNEUMONIA.               315
becomes moister, the bubbles of unequal size, and
fewer in number; at the same time, the respiratory
murmur diminishes in force, and at length disap-
pears.   When  the hepatization is complete, the
crepitation ceases  altogether.
   Laennec believed that, by the aid of  the crepi-
tating rale, he could not only diagnose the more ex-
tended and superficial inflammations of the lungs,
but those also which are centrically situated, and of
very limited extent, even though the inflamed part
should not exceed the size of an almond.  Moreover.,
he imagined that he could determine whether or not
the inflammation was centrical, and of partial extent.
He asserts, that when the pneumonia is central and
not extensive, the  crepitation is of a deep character,
and heard over a limited space, and that at the same
time the respiratory murmur is clear and superficial,
often, indeed, even puerile; as the inflammation ap-
proaches the surface, th» respiratory murmur dimi-
nishes.  He was also able to distinguish the crepi-
tating rale, even amidst the noisy mucous rales of
 the dying, or of suffocative catarrh, and thereby to
 diagnose  the existence of a central and  circum-
 scribed pneumonia.1

   1 Laennec seems to  have very frequently observed the crepi-
 tating rale; I rarely meet with it.  The reason  of this differ-
 ence has  been accounted for, by supposing that when Laennec
 made his observations, pneumonia was of a different character
 to what it is now, being at present of a gastric  type, and not
 pure.  The division of pneumonia into pure, gastric,  bilious,
 etc.,—although of ancient date,—is altogether based upon the-
 ory.  As regards the anatomical conditions of the lungs in pneu-
 monia, they seem to be at the present time exactly such as de-
 scribed by Laennec. 
316
PNEUMONIA.
  Absence of the respiratory murmur and of crepi-
tation, and in many cases the appearance of bron-
chophony, are, according to Laennec, the ausculta-
tory signs of hepatization of the lung.  When'the
pneumonia is central, the bronchophony is either
very indistinct, or not heard at all; in fact, it never
becomes distinct, unless the inflammation approaches
the surface of the lung.   The bronchophony is al-
ways  accompanied by bronchial respiration  and
bronchial cough;  in central pneumonia, however,
deep  bronchial  respiration and  deep bronchial
cough are present, without bronchophony;  and the
reason of this is, that the surface of the lung  still
contains  air, or is  simply  congested, and conse-
quently is not a good conductor of sound.  If bron-
chial  rales accompany the bronchial respiration,
they will be rendered louder  by the hepatization,
and become audible over a greater space.   The
bronchophony at the roots^nd apices of the lungs
resembles pectoriloquy, and, in  observing it, we
often experience a  sensation, as though air were
blown into  the ear; the bronchophony being, in
such case, accompanied  by the souffle voile.
  So  long as the- inflammation is on the increase,
the crepitating  rale  continues to be heard in the
neighbourhood of the hepatized lung, or it appears
at some previously healthy parts, and thus becomes,
as it were, a kind of forerunner of the approaching
hepatization of those parts.
  The infiltration of the pulmonary tissue with pus,
produces no new sign, so long as the  pus remains 
PNEUMONIA.               317
concrete;* when it softens down, a more or less well-
marked mucous rale arises in the bronchial tubes,
accompanied by cavernous respiration and pecto-
riloquy.   If the abscess is situated near the surface
of the lungs, the auscultator will experience the sen-
sation as of air being blown into his ear (souffle dans
Voreille,) and should some part of its walls be soft-
ened and thin, the blowing becomes converted into
the souffle voile. Little skill, according to Laennec,
is requisite for distinguishing between the purely
bronchial, and  the cavernous respiration; this last
evidently appears as though it proceeded from a cir-
cumscribed  space of greater magnitude  than the
largest bronchial tube.   The intensity of the rales,
added to other signs, when the abscess is half filled
with fluid; the punchinello voice accompanying the
pectoriloquy; the limited extent of the disease,
which has been from the commencement of a partial
character, or has become so subsequently to the re-
solution of the  pneumonia in the other parts of the
lungs,—are all signs which, in the greater number
of cases, leave us no room for hesitation in diagnosis.
  The following, we read, are  the signs of the re-
solution of pneumonia: If the resolution commences
before the pneumonia has reached the stage of he-
patization, the crepitating  rale gradually dimi-
nishes, and the natural  respiratory or pulmonary
murmur becomes more distinct,  and is at last heard
free from every kind of rale.
  1 Fornet believes he has discovered a peculiar rale, which
attends the transition of red into gray hepatization. See p. 157.
                      27* 
318
PNEUMONIA.
  The resolution of pneumonia which has reached
the stage of hepatization, is announced by the return
of the crepitating rale; this is a most certain sign.
I have never, observes Laennec, known it fail in any
case of pneumonia which I have followed from day
to day;  I have given it the name of recurring cre-
pitating rale—rale crepitant de retour.  The murmur
of the  pulmonary distention becomes  gradually
mixed up with this rale, and is at last alone audible.
  The crepitating ra,le, moreover, announces the com-
mencing resolution of pneumonia which has arrived
at the stage of purulent infiltration; but in this case,
it is generally preceded by a mucous or sub-mucous
rale, indicating the softening down of a portion of
the purulent deposit.  The murmur of the pulmonary
expansion is  not associated with the rales at so  early
a period in this, as in the former case.  In the course
of a few days, sometimes in a few hours, the crepi-
tating rale becomes sub-crepitant, announcing the
presence of oedema, which generally attends the
resolution of pneumonia  in this stage.  The  same
thing happens when oedema supervenes, during the
resolution of pneumonia,  in the two other stages of
the disease.
  Dr. Stokes speaks of a stage of pneumonia, which
precedes the first stage of Laennec: he attributes the
lively red colour of the lungs to the congestion of
the finer arteries, and considers this to be the condi-
tion which always precedes the secretion—the crepi-
tating rale.  The rapid  production of hepatization,
not preceded by Laennec's signs of the first stage of
pneumonia, can, according to Dr. Stokes, only  occur 
PNEUMONIA.
319
secondarily  during typhus,  but never in sthenic
pneumonia.   The red hepatization is caused by ex-
cessive congestion of the parenchyma, and not by
deposit of lymph-exudation within  it; and hence
we may understand the reason of the rapid deve-
lopment and sudden disappearance of this morbid
condition  of the lungs.  The rare  occurrence of
abscess in pneumonia, he explains by the circum-
stance that  the disease, which  is seldom circum-
scribed, destroys life before the abscess has time
to form; he  does not, however, believe that pulmo-
nary abscess is so rare a phenomenon as  it is gene-
rally thought to be.  We learn from Rokitansky's
Pathological Anatomy, that the lively red colour
of the lungs is occasioned by anaemia, and has no-
thing whatever to  do with incipient inflammation.
I must reject the opinions of Dr. Stokes, respect-
ing the nature of  red hepatization,  and  of pulmo-
nary abscess.
  He gives us, as signs of his supposed first stage of
pneumonia, the sudden advent of puerile respiration
over  a circumscribed  spot, combined with fever
and disturbance of the respiratory  system.  It is
certainly true, that loud vesicular respiration oc-
casionally precedes the crepitating  rale; but this
is no reason  for setting up an especial first stage of
pneumonia, this symptom being even less constant
than crepitating rale.
  The signs of Dr. Stokes's second stage—Laen-
nec's first—are the presence of the crepitating rale,
and the gradual disappearance of the vesicular
breathing; but he  lays no especial value on  the
crepitating  rale, because it  is not constantly  pre- 
320
PNEUMONIA.
sent in pneumonia, nor, as a physical sign, indicates
anything more than the presence of secretion in the
air cells.  He has not met with cases in which the
completely dull percussion sound, and the bronchial
respiration have passed  into vesicular breathing,
without any intervention of the crepitating rale.
   He believes also, that the production of bronchial
respiration requires not merely condensation of the
lung,  but also a certain degree of distention of the
affected side of the thorax; and that when the entire
lung is condensed, the bronchial respiration ceases,
because the affected side of the thorax is immovea-
ble ; this, he considers, is  the reason why bronchial
respiration in pneumonia increases in force up to a
certain point, then decreases, and finally, when the
percussion sound is everywhere  dull, and the re-
sonance of the voice fails,  ceases altogether.  When
resolution of the inflammation commences,  even
though  it be  over a limited space, or when an ab-
scess forms, the bronchial respiration returns, and
again for a time increases in strength,
   I cannot admit  these  assertions  of Dr.  Stokes,
respecting bronchial  breathing:  it  would  not  be
difficult  to prove their untenable character  from
his own writing; nor can I agree with the state-
ment, that the conversion of red  hepatization into
purulent infiltration is indicated by the simultane-
ous appearance of bronchial respiration, and of a
peculiar sharp muco-crepitant r&le.
   It seems probable, that the kind of rale referred
to by Stokes, is what  I call consonating rale.  He
looks upon Laennec's signs of pulmonary  abscess 
PNEUMONIA.
321
as almost infallible, when due consideration is given
to the antecedent phenomena.   He explains the
tympanitic percussion sound  by the exhalation of
gases into the pleural cavity.
  Dr. J. C. B. Williams gives the following explana-
tion of the crepitating rale:  the lung-cells and finer
bronchial  tubes are compressed by the  distended
blood vessels in the first stage  of pneumonia, so
that the  air is unable to pass through them, and
the mucus, which lines them, in a continuous stream;
but passes in very minute bubbles, the bursting of
which constitutes the crepitation in question.   The
bronchophony of hepatized lung is much diminished
in force when heard through a stethoscope fitted
with a stopper, but  this is  not  the case with the
pectoriloquy of a cavity.   The tympanitic resonance
is sometimes  caused by the  stomach, when the left
lung is hepatized; near the sternum, we  may occa-
sionally have the  tubular resonance, or bottle note
of the large  air-tubes.  In other particulars, Dr.
Williams does not differ from Laennec.
  I have already  given my opinion of the value of
the auscultatory signs, which Laennec considered
as pathognomonic of pneumonia; I shall here merely
refer to the order in which  he places them.
  In the great majority of  cases, according to my
experience, the auscultatory signs of pneumonia
do  not follow in  the order assigned  to them by
Laennec.
  It frequently happens that the fine equal-bubbling
rale is not heard  at  the  commencement of pneu-
monia; we meet with the unequal bubbling rale— 
322
PNEUMONIA.
Laennec's mucous rale—or whistling and sonorous
sounds, much more often at this period.  In some
rarer cases, the disease at its onset is unaccompanied
by any rale at all; the inflamed parts yielding an
indeterminate, or vesicular, or very noisy respira-
tory murmur, which  passes at last into bronchial
respiration.
  So long as the  hepatization  continues, we may
have bronchial breathing unmingled with rales, or
combined with consonating or non-consonating hiss-
ing and  sonorous  sounds, or again  the breathing
may be indeterminate, and with  or without rales or
hissing sounds, etc.; or there may be no respiratory
murmur, nor any  rales whatever, audible.   The
consonating rales may be formed  of smallish bub-
bles, and when of a  dry character resemble crepi-
tation;  or the term crepitation might rather in
many instances be applied to the consonating rale.
It would be hard  to say, whether the rale which
is heard  previous to  the hepatization, or the conso-
nating rale attendant upon complete hepatization,
has been most frequently taken for Laennec's cre-
pitating rale.
  The period  of resolution of pneumonia does not
invariably commence with the  appearance  of the
crepitating r&le;  in most cases  it  is attended by a
great variety of rales, or by whistling and sonorous
sounds.  In some rare cases,  no rales whatever
appear during this stage of the inflammation; the
bronchial breathing being at first indeterminate,
and at last vesicular.
 '  The crepitating rale, or a rale  resembling it,  is
heard  during  the resolution of moderately severe 
GANGRENE OF THE LUNGS.         323
cases of pneumonia; it is also occasionally observed
in severer cases, at a more advanced period of the
resolution, when  the secretion has become scanty.
In the greater number of cases, the vesicular breath-
ing does not return immediately upon  the resolu-
tion of the disease; but  we generally find, after all
the functions are restored to their healthy condition,
and percussion no longer yields any abnormal sound,
that the respiration still remains indeterminate, or
that rales, or hissing, whistling, and sonorous sounds
continue.  Auscultation yields the same signs when
the resolution is incomplete.
   It follows  from the above, that the presence of
pneumonia cannot be determined by the ausculta-
tory signs alone, and that these are often very inde-
finite, and that bronchophony, bronchial breathing,
and other consonating sounds, as well as vesicular
breathing, and fine  equal-bubbling rales, are signs,
which of themselves do  not enable us to draw accu-
rate conclusions as to the  condition of the lung-paren-
chyma; in forming our diagnosis, we must also take
into consideration every other symptom attainable
by percussion, and by other means at our command.

              GANGRENE  OF THE LUNGS.
   Gangreneof the lungs may occur as a sequel to
inflammation of the lungs, or independently of pneu-
monia; in the latter case we find various abnormal
conditions of the  lungs; in the  former, percussion
and auscultation  give us the signs  of pneumonia;
in the last, of catarrh, or of that particular abnor-
mal condition which preceded the gangrene.
   Laennec asserts,  that the percussion and auscul- 
324          PULMONARY APOPLEXY.
tation signs of gangrene are much the same as the
signs of pulmonary  abscess, except that the cre-
pitating rale  is less frequently heard than in ordi-
nary inflammation of the lungs, which may be readily
accounted for by the fact, that an examination of the
thorax is rarely made in the first stage of the dis-
ease, on account of its insidious nature.  He has ob-
served, moreover, that the crepitating rale first
appears when destruction of the epithelial surface
has taken place, and therefore indicates the existence
of the inflammatory process by which it is separated.
Next arise cavernous rales, and when the cavity is
emptied of its contents, pectoriloquy: the pectori-
loquy is of a much clearer and louder character in
a gangrenous excavation, than in one formed by pul-
monary abscess; and presents nothing of that flap-
ping which appears to take place in the walls of pul-
monary abscesses, and indicates the destructive pro-
cess going on  within them; it is also very rarely ac-
companied by the souffle voile, so common in pulmo-
nary abscesses.  It is scarcely necessary for me to ob-
serve, that all these  assertions of Laennec are ar-
bitrary.

  laennec's fulmonary apoplexy. (Apoplexiepulmonaire.)
  I do not think this name has been aptly chosen,
for pulmonary apoplexy ought properly to  indicate
some anatomical change in the structure of the lungs;
whereas it has hitherto been used only to point out
a series of disturbances  of function, without any
regard to changes of organic structure.  The func-
tional disorders which occur in Laennec's pulmonary
apoplexy, have  no resemblance to the disturbances 
PULMONARY APOPLEXY.          325
in the brain, produced by cerebral apoplexy.  The
term signifies an effusion of blood into the paren-
chyma of the lungs, which is thereby rendered as
dense and as heavy, as though it were hepatized;
the part, on section, presents a granular appearance,
and a reddish-brown  colour, or a tint exactly re-
sembling that of the venous blood.1
   This abnormal condition of the lung-parenchyma
is rarely met with, and very few cases of haemop-
tysis depend upon it. * Effusion of blood  into the
parenchyma has been occasionally observed unat-
tended by haemoptysis; the infiltrated portions of
lung are  rarely of sufficient size to  produce  any
change in the percussion sound.
   The auscultation of pulmonary apoplexy presents
us with rales, or whistling  and sonorous sounds;
the infiltrated part of the lung is rarely of extent
sufficient to give rise to bronchophony, bronchial
breathing, etc.
   According to Laennec, auscultation offers us two
capital signs of haemorrhagic engorgement of the
pulmonary  tissue: viz., failure  of the respiration
over a moderate extent of the surface, and crepi-
tating rale  in the neighbourhood of the part where
the respiration is not heard, being  indicative of
slight haemorrhagic  infiltration; this crepitating
rale is only heard at  the commencement of the dis-
ease, and disappears afterwards.  These two signs
  i According to Bochdalet, the sanguineous effusion is pro-
duced by inflammation of the finest ramifications of the pulmo-
nary artery.
       28 
326
03DEMA OF THE LUNGS.
 enable  us  to distinguish between pulmonary apo-
 plexy and  haemorrhage from the bronchial tubes.
 I have very many times sought  for this crepitating
 rale in cases of haemoptysis, but have rarely found it.
 In some of the fatal cases in which crepitation had
 been observed  over several parts of  the  thorax
 shortly before death, no trace  of pulmonary apo-
 plexy was found.  It is possible, that the crepi-
 tating rale may  occasionally be  associated  with
 haemorrhagic infiltration, but,I have always hitherto
 observed some other kind of rale, or whistling or
 sonorous sounds.
  CEdenia of the lungs is very frequently observed
 after death; and  there can be no doubt, that it is
 not in every case produced during the last moments
 of life, although in the greater  number of cases it
 appears to be so.  When the air is not  completely
 forced out of the air-cells  by the oedema, which it
 very rarely is, the percussion sound  is normal, or
 somewhat more tympanitic than natural.  Auscul-
 tation produces different kinds of rales, and hissing,
 whistling,  and  sonorous sounds,  but  none  con-
 sonating.
  In some  few cases, where the post-mortem exa-
 mination proved oedema to have existed some time
 previous to death, I observed a distinctly vesicular,
 and even very loud, respiratory murmur a few hours
 before death, unaccompanied by  any rales, or whist-
ling or sonorous sounds: the vesicular murmur, how-
ever, was of an acute character, approaching to a
whistling.  I have never seen an oedematous lung
entirely deprived  of air, unless  it had been at the
same time subjected to pressure. 
EMPHYSEMA OF THE LUNGS.        327
  Laennec proposes two auscultatory signs, as di-
agnostic of oedema of the lungs; the respiration is
much less loud than what we should expect from the
violence and extent of the movements attending it;
at the same time, a gentle crepitation is heard, as
at the commencement of pneumonia, more akin to a
rale than to the natural respiratory murmur; this
crepitating, or sub-crepitating rale is not of so dry
a character as the rale which accompanies the first
stage of pneumonia; the bubbles seem larger, and
leave upon the ear a more distinct impression of
moisture.   Both these phenomena, mentioned by
Laennec, may occur  in  oedema  of the lungs, but
they are far from being characteristic of the disease.

              EMPHYSEMA of the lungs.
  Laennec divided emphysema of the lungs into the
vesicular and  interlobular form; in the vesicular,
the air-cells are enlarged without being ruptured;
in the interlobular, the air escapes from ruptured
air-cells, or bronchial tubes, into the cellular tissue
which unites them, and produces there air-bladders
of different sizes, either within  the lungs, or upon
their surface.   The formation of an air-bladder in
the parenchyma of the  lungs, through rupture of
an air-cell, or fine bronchial tube, can only be pro-
perly spoken  of, in my opinion,  when the air-blad-
der  does  not  communicate  with  the  air-cells, or
finer bronchial tubes, and consequently cannot ex-
pel the  air contained within it.
  An air-bladder, even of considerable size, which
communicates with a bronchial tube, may have been 
328         EMPHYSEMA OF THE LUNGS.

formed by a distended air-cell, its walls at the Bame
time becoming thicker.  It is improbable, that air
which has escaped into the cellular tissue of  the
lungs, through rupture of an air-cell or bronchial
tube, should again communicate with the bronchial
tubes.  Vesicular emphysema may extend through
both lungs, or through only one lung, or be confined
to a lobe, or to part of a lobe, or even to single cells.
In interlobular emphysema, the air-bladders may
be of the size of  millet seed, and  even as large or
larger than  a goose's egg.
   In  vesicular  emphysema, either the number of
air-cells is not diminished, or they are enlarged in
consequence of their number being lessened.  The
first case, viz. enlargement of the  air-cells without
diminution  of their number, cannot take place
throughout an entire lung, unless the thorax be  ab-
normally enlarged; and, on the other hand, abnor-
mal distention of the thorax always indicates em-
physema, provided the distention be not caused by
the presence of air, gas, fluid, or solid bodies in
the pleura or pericardium.  Abnormal enlargement
of the thoracic cavity takes place  through arching
of the thoracic walls, and particularly through  de-
pression of the diaphragm.   If we find, upon per-
cussion, that the  lungs extend downwards nearly
to the lower border of  the thorax, we  may be cer-
tain that vesicular emphysema exists;  and that it
extends over the whole of the lung, if the percus-
sion-sound be very full, and equally so over the
whole of one side of the thorax; if the  upper parts
of the lung yield a less full  percussion-sound, the
emphysema  is confined to the lower parts of the 
           EMPHYSEMA OF THE LUNGS.        329

lung.  Vesicular emphysema does not render the
percussion-sound tympanitic, unless the more fully
inflated portion of lung is bounded by another por-
tion of lung that is entirely deprived of air, which
not unfrequently happens in hepatization and tuber-
cular infiltration; or unless the emphysematous lung
has completely lost its contractile power.
  With the exception of these cases, emphysema of
the lungs does not give rise to the  tympanitic per-
cussion-sound, whether the thoracic cavity be en-
larged or  diminished, or of its natural size.  The
percussion-sound is either very full  and clear,  or
not more than naturally so, the difference depending
in part upon variations in the condition of the tho-
racic walls.   If the intercostal  spaces  are  much
stretched, in consequence of the distention of the
thorax, its walls exhibit greater resistance and resi-
liency, and are more elastic than in the normal state.
  Whether the vesicular emphysema is partial  or
general, the respiration may be vesicular or inde-
terminate, and free from every kind of rale, etc.;
this happens when the abnormally distended lung
has not lost its contractility, and when, consequently,
the emphysema is of recent origin, such as we find
it around hepatized  portions of the lung,  when
their bronchial tubes are free from catarrh.  But
this is not ordinarily the case,  for we generally
(and particularly  in  vesicular emphysema) meet
with a great variety of rales and whistling and so-
norous sounds produced by the catarrh,  which  is
almost invariably present.
  Interlobular emphysema—that  is, air-bladders
                     28* 
330       HYPERTROPHY OF THE LUNGS.
existing in the  parenchyma, or at the surface of
the lungs, and having no communication with the
bronchial tubes—does not produce any abnormal
percussion-sound; nor is there any  auscultatory
sign which is peculiar to these air-bladders. Those
within the lung can create no  murmur, for  they
cause no  friction, neither do those which are co-
vered  by the pleura, and lie at the surface of the
lung, except when this membrane is less smooth than
natural: the more elevated they are above the sur-
face  of the lung the more readily is this friction-
sound  produced.   When the  emphysema of the
lungs is not very far advanced, Laennec lays great
stress  upon the circumstance  of  the percussion-
sound being very clear, whilst the respiratory mur-
mur is very weak, or inaudible.  I have never ob-
served either the one or the other of these accidents
as a constant  phenomenon.

             hypertrophy of the lungs.
  The lung is said to be hypertrophied, when its
walls are thickened, but the air-cells themselves not
diminished in number.   The air-cells of an hyper-
trophied lung cannot contain as much air as a healthy
lung, unless the thoracic cavity be enlarged:  when
it is so, they  may contain as much, or even more.
The lung not collapsing, when the thorax is opened
after death, but  continuing to fill the cavity, or even
to protrude beyond it, is  no sign of its being hyper-
trophied; it only shows that there is  some impedi-
ment preventing the passage of the air out of the
lungs.   However hypertrophied a lung may  be, it 
             ATROPHY OF THE LUNGS.         331

collapses in the dead body, like a normal lung, if a
portion of its  air can escape from the air-cells.  The
lung has, in itself, no power of expansion, but its
contractility is continually in action; it is kept con-
stantly distended, and so  made to fill the thoracic
cavity by the pressure of the atmosphere.  An hy-
pertrophied lung cannot of itself enlarge  the tho-
racic cavity,  nor an atrophied lung  diminish  it.
The anatomical characters of hypertrophy of the
lung are: increase of density, and generally, also, of
firmness of parenchyma, the density not depending
upon its infiltration by  blood or  serum, etc., and
the lung still containing air. The percussion-sound
of hypertrophied, is the same as that of normal lung,
and differs only when the lung is much distended
by emphysema.   If the hypertrophy be unaccom-
panied by  bronchial catarrh, the  respiratory mur-
mur is always very loud  and vesicular.

               ATROPHY OF THE LUNGS.
   If the thoracic cavity  be of its normal size, an
 atrophied will contain a greater amount of air than
 a normal lung, the air-cells being larger than  na-
 tural.  There are many degrees  of atrophy of the
 lungs; in  the most extreme, the air-cells entirely
 disappear, and enlarged  and thickened bronchial
 tubes alone remain. The percussion-sound of atro-
 phied lung  is generally louder than natural; but
 this depends upon the  simultaneous wasting and
 increased  flexibility of   the thoracic walls. The
 auscultatory signs are those of catarrh. 
332                TUBERCLE.
              TUBERCLES of the lungs.
   Tubercular matter is developed in the lungs, as
in other organs, in two forms: viz., as isolated gra-
nules, or as a continuous mass infiltrated through
the  parenchyma.  The isolated tubercles  may be
so minute, as to escape the observation of an un-
practised eye; they may cause entire portions of the
lung to become impermeable to air, either through
their enlarging, and so coming in contact with each
other, or through the development of fresh tuber-
cles in the intervals between them.
   The percussion and auscultatory signs of tubercle
are various; and the reason of this is, that the soli-
tary tubercles are separated from each other by air-
containing tissue, whilst no air can enter into the
tissue infiltrated with  tubercular matter, or  filled
up by solitary tubercles, which are  enlarged and
come in contact with one another.  Certain special
phenomena are  occasionally observed to arise in
the cavities, produced by softening of the tubercu-
lar matter.  The quantity and quality of the se-
cretions  which are formed  in  the  bronchial tubes
and  cavities (and which are rarely absent in tuber-
cle of the lungs,) have also great influence on the
nature of the phenomena.   Whatever the signs ob-
served may be, we shall find that they are more or
less distinct,  in proportion to  the greater  or less
extent and rapidity of the respiratory movements.

               solitary tubercles.
  Percussion  signs.—Solitary  tubercles  do not of
themselves produce the slightest change  in the per- 
TUBERCLE.
333
cussion-sound of the lungs, even  though they be
scattered throughout these organs, and in very con-
siderable  quantity.  Any change  observed in the
percussion-sound, depends upon some altered con-
dition of the interstitial tissue, occurring in the lung
thus affected; the sound is tympanitic when the
tissue has lost its contractility; but the infiltration
of blood,  serum, etc., into the tissue, whereby the
air is expelled  from the lung, renders the sound
dull and empty: so long as the interstitial tissue re-
mains normal, the sound continues normal; but it
is less sonorous, if the tissue be more tense and hy-
pertrophied than natural.  The statement made by
Stokes, that soli tary tubercles, when very abundant,
produce a somewhat dull percussion-sound, is in-
correct; this may be shown on the dead body.
   Auscultatory Signs.—-The inspiratory murmur
may be distinctly, and even very  loudly vesicular,
or it may be indistinct, or altogether inaudible,
though unaccompanied  by rales, or whistling  or
sonorous  sounds.  Bales of every kind, as well as
whistling and  sonorous, etc.,  sounds,—non-conso-
nating,—may be mixed  with the vesicular or inde-
terminate inspiratory murmur; or rales or whistling
sounds alone be heard.   The expiratory murmur
may be altogether inaudible, or as loud and strong
as that of inspiration, and, like this, be associated
with rales and whistling and sonorous sounds.
   Swelling of, and secretion  from, the bronchial
mucous  membrane, soon make their  appearance,
when  any considerable  deposition of tubercle has
taken place in a lung; they may appear in the course 
334
TUBERCLE.
of a few days, when the tubercles are rapidly de-
veloped, but when these  are  of slower growth, a
longer period may elapse before they manifest their
presence.  In such cases, the inspiratory murmurls
either vesicular or indeterminate, and the expira-
tory almost inaudible; in other words, the respira-
tion may be normal.
  As the deposit of the tuberclar matter increases,
and in many cases even at its first deposition, swell-
ing of the bronchial mucous membrane, accompanied
or not by secretion, takes place; and then the same
auscultatory signs appear, as those described under
the head of catarrh.  The slow development of tu-
bercles almost invariably takes place in the upper
parts of the lungs, and hence, in such cases, we very
frequently find the auscultatory signs of catarrh per-
manent there, the respiratory murmur being else-
where healthy.  Rapidly developed tubercles, how-
ever, do not manifest themselves in the first instance
at the apices of the lungs, but are frequently scattered
equally throughout the whole of a lung, or of one
lobe. I may here remark, that there are no distinct
signs by which we can with certainty diagnose the
existence of acute miliary tubercles; we can  only
surmise their presence  with a greater or lesser de-
gree of probability.  Of this fact Laennec was well
aware.   Dr. Stokes offers the following  remarks
upon the diagnosis of miliary tubercles:—"If in a
case which exhibits the signs and symptoms of severe
bronchitis, or in which we observe a crepitating rale,
continuing without intermission, we*find incomplete
dulness over a considerable extent of the surface of 
TUBERCLE.
335
the thorax, unaccompanied by bronchial respiration;
and if the stethoscope shows that the lung is almost
everywhere permeable to air. and obstructed only at
certain places, or if the crepitation be too feeble
to account for the dull  percussion-sound, we may
diagnose  the acute inflammatory development of
tubercle."
   According to my experience, most cases of acute
tuberculosis  are unaccompanied by any of these
signs, and every one of them may be present, with-
out the disease being tubercular.

TUBERCLES  CONGREGATED TOGETHER IN MASSES, AND TUBERCU-
                 LAR INFILTRATION.
   Percussion signs.—-The conglomeration of tuber-
 cles takes place in  the upper parts of the lungs; at
 this point the tubercles are slowly developed, in-
 crease in size, and at last, by coming in contact
 with each other, form considerable masses.
   Tubercular infiltration  likewise appears in the
 form of a slow process of development, in the upper
 parts  of the lungs.  And hence it happens, that in
 by far the greater number of cases of tubercular
 disease of the lungs (when the disease is of  some
 standing,) the percussion-sound under one or both
 clavicles is duller  and  emptier than natural, or is
 completely dull; over the other parts of the thorax,
 the sound being normal,  or louder or duller than
 ordinary.  Generally speaking, when the sound be-
 neath the clavicles is duller than natural  in this
 disease, it is abnormally loud in the lateral regions
 of the thorax; the reason of which is, that the lower 
336
TUBERCLE.
part of the lung is more than usually distended, on
account of the respiration  being impeded above.
Acute tubercular infiltration takes place most com-
monly, but not always, in  the upper lobes of the
lungs.   It produces  the same changes in the per-
cussion-sound as hepatization.
  Auscultatory signs.— So  long  as the tubercular
mass and  the  tubercular infiltration are of such
limited  extent as not  to contain within  them,  at
least, one  large  bronchial tube,  they do not give
rise either to bronchophony, or to bronchial breath-
ing, or to any consonating sound.  Vesicular respi-
ration may continue audible beneath the clavicles,
even when tolerably large masses of tubercles are
present  in the upper lobes of the lungs, provided
there be sufficient healthy tissue to produce it, and
the bronchial mucous membrane be not swollen, nor
covered by secretion.  But this is not generally the
case, for we almost invariably observe an indeter-
minate inspiratory murmur, of different degrees  of
strength,  often indeed very strong, and in most
cases accompanied by  moist rales, or by hissing,
whistling, and sonorous sounds; the expiratory mur-
mur is nearly as  loud, or even louder, than the in-
spiratory,  and is likewise combined with different
kinds of rales, and whistling and hissing sounds.
  If the tubercular masses or infiltration be of such
extent as to embrace bronchial tubes, in which the
voice or the respiratory murmur can consonate, we
shall hear bronchophony and bronchial breathing
beneath the clavicles, provided the bronchial tubes
are not  filled by  any fluid or solid exudations; and 
TUBERCLE.
337
should there be any rales, or whistling or sonorous
sounds in the trachea, or in a large bronchial tube,
we shall also hear consonating rales, or whistling
and sonorous sounds.  But if the bronchial tubes in
question be  obliterated, neither bronchophony nor
bronchial breathing, nor any consonating rales, will
be audible; in their place, we shall have either in-
determinate respiratory murmurs, with or without
dull rales, or no murmur whatever.   It frequently
happens, in consequence  of the  bronchial tubes
being  at one  moment filled with mucus, and  at
another freed from it by coughing or expectoration,
that in the course of a few minutes, bronchophony
is heard  alternating with a very dull resonance of
the voice;   bronchial respiration with indistinct
breathing; and a  clear acute rale with a deep dull
rale, etc.: consonating and non-consonating sounds
may be also heard at the same time.
  Should the tubercular masses, or the tubercular
infiltration,  not be developed in the upper lobes of
the lungs, the respiration beneath the clavicles may
be perfectly normal; auscultatory signs of disease
being presented over those parts of the thorax which
correspond to  the affected portions of lung.
  The part  of the lung which is healthy, or which
contains only solitary tubercles, yields either a weak
or loud vesicular or indeterminate respiratory mur-
mur ; or every variety of rales and whistling and
sonorous sounds may be audible, according as the
bronchial tubes are or are not free  from catarrhal
affections.   There are  no auscultatory signs, pa-
thognomonic of tubercular disease of the lung; and
       29 
338
TUBERCLE.
there are none which will enable us to  determine
that no tubercle is present in a lung, or in any part
of it.

               TUBERCULAR CAVITIES.
  Cavities are produced by the softening down of
solitary tubercles, of conglomerated tubercles, and
of tubercular infiltration; they are met with of all
sizes, from a pin's head to a man's fist, and upwards.
Their walls consist either of tissue infiltrated with
tubercular matter, forming a more or less dense layer
around them (this layer being at times of such firm-
ness as to prevent any dilatation or contraction of
the cavity,) or merely of a membrane, which may be
so thin as to cause the cavity to appear like a mem-
branous sack, attached externally to the normal lung
tissue.  Tubercular cavities generally communicate
with the bronchial tubes, and are rarely free from
mucus, pus, etc.   On account of these differences in
their structure and contents, as well as from other
circhnistances,the percussion and auscultatory signs
Which cavities present are very varied.
  Percussion signs.—When the cavity is  formed  ,
within a portion of air-containing tissue, the percus-
sion-sound remains unchanged; and this is true, not
only of a small, but even of tolerably large-sized
cavities. The only sound which  cavities situated
within healthy tissue yield, is the cracked-pot sound,
but this happens only in rare cases, where the cavity
approaches the walls of the thorax, contains  air, and
is not smaller than a pleximeter; the sound, in such
case is more tympanitic than at other parts of the
thorax. 
TUBERCLE.                339
  Cavities containing air, even whendeeply situated
within a portion of lung infiltrated with tubercular
matter, will yield a tympanitic sound, if their size
be not less than that of a walnut.  Several smaller
cavities together, will produce the same effect.  The
more flexible the  walls of the thorax, the  more
readily will the tympanitic sound be produced; the
sound is clearer, the nearer the cavity approaches
the surface of the lung, and fuller, the  larger the
cavity.  The cracked-pot sound is most  readily
obtained  from cavities  which are large  and super-
ficial.  According to my  experience, a cavity will
not yield a metallic ringing sound, unless  it be of
the size of a fist; but it does not necessarily yield
such  a sound, though it be of that size.
   Auscultatory signs.—A dry  large-bubbling cre-
pitating rale is heard over large cavities, the walls
of which are yielding, and which dilate and contract
during inspiration and expiration, the lung  being
attached to the costal  pleura.   This rale is  most
readily produced when there are many cavities, of
the size of a pea or a bean, scattered through the
lobe; it is never heard  alone, but always in combi-
nation with other rales, or whistling and sonorous
sounds, in consequence of the secretion of mucus,
etc., which is invariably present in the affected por-
tion of lung.  Should the other rales be very loud,
 this dry large-bubbling crepitation will not be heard.
   When a few deep-seated cavities are present in
 a lung which is otherwise healthy, the vesicular
 breathing, interrupted  by a few bubbles of a muffled
 rale, may be heard over them; generally speaking, 
340
TUBERCLE.
 however, the murmur in such cases is not vesicular,
 but indeterminate. Cavities with membranous walls,
 situated in the midst of air-containing tissue,  even
 though of large size, never give rise to  broncho-
 phony, bronchial breathing, or consonating rales.
   Bronchophony, bronchial respiration, and conso-
 nating rales, and whistling and sonorous sounds,
 may take place in cavities, the walls of which  have
 a thickness of at least several lines; and if  their
 thickness  be considerable, the breathing  and the
 voice may be accompanied by metallic tinkling and
 amphoric resonance.   When the walls are thick and
 unyielding, there is neither increase nor diminution
 of the size of the cavity during inspiration or expi-
 ration; no air either enters into or passes out of
 them, and consequently no murmurs arise within
 them, those  that appear to proceed from them are
 consonating murmurs.  But murmurs may be pro-
 duced within the cavities, if their walls are flexible,
 and permit the entrance and exit of air during res-
 piration.   Rales and whistling sounds can  only
 arise in them, when the current of air is interrupt-
 ed by mucus, etc.   The movement which the se-
 cretion contained in the cavity undergoes during
inspiration, and  especially during  coughing, is at-
 tended by rales, or by whistling sounds, when air
 as well as fluid is present  in the cavity.
  We learn  from the above, that  percussion and
 auscultation  afford  very few  certain signs of the
presence of a cavity.  Experience, however, teaches
us, that tubercular masses and tubercular infiltra-
tions do not exist for any  length of time, without
producing cavities; we may, therefore, safely sup- 
TUBERCLE.
341
pose their presence, whenever the tubercular dis-
ease is of some standing.   Loud bronchial breath-
ing, loud large-bubbling rales, and bronchophony,
are frequently heard over cavities; but we as often,
and oftener indeed, meet with cavities which do
not reveal themselves to us by auscultatory signs,

           FOURNET'S SIGNS OF TUBERCULOSIS.
  Fournet divides the first stage of phthisis into
three periods.
  The first period ends with the formation of the
crude tubercle, and is characterized by the follow-
ing features.
  Altered conditions of the Inspiratory Murmur.—
This is increased in force from the normal standard
of ten to twelve, fifteen and eighteen.  Its increase
has a close relation to the progress of the tubercle.
It is, at the same time, generally shortened in its
duration, so as frequently to fall from ten to eight,
and  five.   Occasionally it does not  offer any re-
markable deviation from  the healthy standard,
either in respect of intensity or duration; and is
changed only, in having become of a drier, harsher,
and rougher character.  The dry, harsh, rough in-
spiration is constantly present at  the  commence-
ment of tuberculosis, and  gradually increases as
the disease advances, until  at  length it disappears
with the change of timbre, which takes place in
the murmur.
  Altered conditions of the Expiratory Murmur.—
The expiratory murmur is constantly increased in
intensity and duration, from the normal  standard
                      29* 
342
TUBERCLE.
of two, to eight, and upwards.  The increase of in-
tensity bears a pretty close  ratio to the develop-
ment of the tubercle.  The increased intensity and
duration of the expiratory murmur are constantly
present, unlike many other abnormal conditions of
the respiratory murmurs, which exist at one time,
but are  absent at another.  As a general  fact,
the intensity, as well as the duration of the mur-
mur is increased; the cases  are rare in which the
duration is alone affected.  The character of rough-
ness, harshness, and dryness is associated with the
expiratory, as well as the inspiratory murmur.
  Occasionally there appears a crackling of a pe-
culiar character—froissement pulmonaire.
  The resonance of the  voice, as well  as  of the
cough, is greater at that  part where  the tubercles
exist,  than elsewhere.
  In  the second period—which  is  an advanced
degree of the first—the timbre of the respiratory
murmur is altered, and the signs of the first period
are all exaggerated.  The lowest degree of change
in timbre—the clear timbre—is first perceptible in
the expiratory, and afterwards in the inspiratory
murmur, a further degree of change is next observed
in the expiratory, which now assumes the metallic
timbre, the resonant timbre, and the blowing cha-
racter, all of which, by degrees, at last attach them-
selves to the inspiratory murmur also.  The pecu-
liar crackling already referred to—froissement pul-
monaire—occasionally still persists; but more gene-
rally is replaced  by a dry crepitating rale—craque-
ment sec.  The percussion sound  becomes duller, 
TUBERCLE.
343
and the vibrations of the thoracic walls, if percep-
tible  while  the patient speaks, are diminished in
-force. Well-marked bronchophony is heard beneath
the clavicle on the affected side, and the heart's
sounds also are louder than natural at that point.
It must not however be forgotten, that the heart's
sounds are naturally louder beneath the left, than
beneath the right clavicle.
   The third  period  commences with  bronchial
breathing, and the conversion of the dry, into the
moist crackling—craquement humide.
   The bronchial breathing is first heard during
 expiration, and afterwards during inspiration.
   The second stage  of phthisis, is marked by the
 presence of moist rales having a clear timbre, as
 well  as by a more marked degree of bronchial respi-
 ration, or by  the passage of the bronchial into the
 cavernous breathing.
    In the third stage, cavernous rales, cavernous
 breathing,  and the cavernous voice, present them-
 selves, and as the cavity still further enlarges, am-
 phoric echo and metallic tinkling supervene.
    Fournet offers no auscultatory sign indicative of
 the  first stage  of development of tubercles, viz.,
 when they are yet barely visible to the unaided eye;
 still  he thinks that  he has ascertained their  pre-
 sence, when scattered in very small numbers, here
 and  there, through  healthy layers  of pulmonary
 tissue forming any continuous masses.
    The tubercles are more readily discovered when
 superficially, than when deeply seated in the lungs;
 and  Fournet believes that they can be distinguished 
344                TUBERCLE.

when massed  together in scanty groups, though
when much scattered, and in  very small numbers,
they escape observation.
  I must again repeat, that the alterations in the in-
tensity, the duration, the dryness, the softness, etc.,
of the respiratory murmur, here spoken of by Four-
net, as well as the froissement pulmonaire, and the
dry and moist crackling rales, stand in no direct rela-
tion with tubercle, and depend altogether upon the
catarrh, which invariably accompanies the develop-
ment of tubercle, or upon accidental pleuritic inflam-
mation, or upon altered contractility of the lung-
parenchyma.
  As regards the succession in which Fournet places
the auscultatory signs of tubercular disease of the
lungs, this much only is true, viz., that in every case
where the development of the tubercle is not very
rapid, the bronchial breathing and its associated
signs—those belonging to tubercular infiltration, or
circumscribed congregations of tubercle—are pre-
ceded by the signs of catarrh; viz., a rough, loud,
vesicular inspiratory murmur, or a  weak vesicular
or indeterminate inspiratory murmur; a loud, pro-
longed expiratory murmur,  dry and moist rales,
varying much in the size and number of the bubbles
which produce them, etc.
  The statements,  that the  inspiration  becomes
shorter, and the expiration more prolonged, in pro-
portion to the development of the  tubercles;  that
the dry crackling—craquement sec—is only heard
when the  tubercles are in a crude state; and that
the moist cr&ck\mg-craquement humide—indicates 
PLEURITIS.
345
softening of the tubercles, etc., are all completely
theoretical.
   Encephaloid  tumours;  cysts;  acephalo - cysts;
earthy, cartilaginous, and chalky concretions, when
present in the lungs, give rise to the same ausculta-
tory signs, as an equal extent of tubercular matter.

           III. DISEASES OF THE PLEURA.
                     PLEURITIS.
   Percussion signs.—The percussion sound is not
altered by mere thickening of the  pleura, nor by
layers (several lines deep,) of fluid or solid exuda-
tions upon it.1
   The exudation may be  even an inch in depth
without producing any marked alteration in the
sound; so much depends upon the condition of the
lung, which  lies behind  the exudation, and upon
the flexibility or resistancy of the thoracic walls.
When a lung  is contracted  or compressed into a
smaller volume than natural, and still contains air,
it  yields a more tympanitic, sometimes a distinctly
tympanitic, and not unfrequently a louder sound,
than a normally-distended lung. If completely de-
  1 Fournet says, vol. i. p. 318:—"It has been shown by post-
mortem examination, that a  recent false  membrane,  of the
thickness of one line, is sufficient to produce a distinct  altera-
tion in the percussion-sound;  and a diminution in the vocal
vibrations of the thoracic walls has also been observed  at the
same time, on a level with the parts covered by the false mem-
brane."
  The value of  this statement  may be readily tested by experi-
ment on the dead body.            » 
346               PLEURITIS.
prived of air  by compression, it  gives the thigh
percussion sound.  Percussion of a flexible part of
the thorax,  beneath which  exudation has taken
place, produces a tympanitic sound, provided  the
lung lying behind the exudation is not deprived of
its air.
  The amount of exudation which will cause  the
lung to yield a distinctly tympanitic sound is vari-
able, and  cannot  be accurately determined.  The
more air, and  the less solid and fluid  constituents
the organ contains when distended, and the greater
its contractility, the smaller will the volume be to
which the lung must be reduced, in order to produce
a tympanitic sound, and consequently the greater
the depth of the exudation;  whilst, on the other
hand, when the lung  is infiltrated by serum, etc.,
and the contractile power of its tissue  destroyed, a
small amount of exudation suffices to  bring about
this  change in the percussion  sound.   But  the
greater the depth of the exudation, the duller  the
percussion-sound  becomes, so that at  last we  are
not able to recognise  the tympanitic character of
the dull percussion-sound.   If the exudation takes
place beneath some unyielding part of the thoracic
walls, a less amount of it is  necessary to produce
the dull character of  the sound;  consequently at
such  part a completely dull  and empty percussion
sound does not necessarily indicate the. presence of
as large an amount of exudation, as it would if heard
over a yielding part of the thoracic walls.
  When the pulmonary and costal pleural surfaces
are not adherent, the fluid exudation naturally gra- 
PLEURITIS.
347
vitates towards the lower and back part of the tho-
rax, and collects there above the diaphragm; the por-
tion of lung immediately in contact with the fluid con-
tracts, or is more or less compressed, according to
the amount of the effusion.  If the portion of lung
thus compressed contains air, it will continue to rise
and float upon the surface of the fluid (being lighter
than this,) so long as the pressure of the lung above
does not hinder its upward movement; but further
elevation is prevented, when the upper part of the
lung has itself undergone some degree of compres-
sion, in consequence of the elevation of the lower
part, or when it has been rendered dense and heavy,
through infiltration of blood or serum into its tissue.
The portion of lung, however, once submerged be-
neath the fluid, is soon deprived of its air, and appa-
rently by compression;  its specific gravity is thereby
increased, and it now tends to sink towards the lower
part of the effusion, and does not again rise to the
surface, until, either through diminution of the ef-
fusion, or through increased capacity of the thorax,
the  resistance offered by the upper portions of the
lung to the entrance of the air, has become so great
as to cause the distention and elevation of the sub-
merged portion. By the increase of the effusion, the
whole of the lung may be at last compressed, so as
no longer to contain air.  In this  condition it is
pressed back towards that part of the  vertebral
column where the bronchial  tubes  and large ves-
sels enter into it; and  may be reduced  to even less
than half of its normal size, according  as it con-
tains more or less fluid or solid matters. 
348
PLEURITIS.
  A lung thus completely deprived of air, after it
has been for some time subjected to the pressure of
pleuritic effusion, may diminish, in consequence of
its  blood and serum being squeezed out of it, or
of its nutrition being interfered with. And hence
it may, and, indeed, frequently does happen, that
the fluid, which appeared for a time to fill completely
the pleuritic cavity, sinks to a lower level, although
its  quantity is in  no  way diminished;  the conse-
quence of this is, that air again enters into the upper
parts of the lung, and that the lung rises above the
surface of the fluid.  Similar results are produced by
increased capacity of thorax, either from distention
of the intercostal spaces, or from  greater  arching
of the ribs, or from depression of  the diaphragm.
  Partial attachments of  the pulmonary to the cos-
tal  pleura, at times prevent the descent of the fluid
to the lowest parts of the thorax.  Sacculated pleu-
ritic exudations occur in all parts of the thorax, be-
tween the lungs and the thoracic walls, between the
lungs and the diaphragm, between the lungs and the
pericardium, the  mediastinum, the vertebral co-
lumn and between the lobes of  the lung.
  The percussion-sound of the thorax may be per-
fectly normal, in cases where the pleuritis is attend-
ed with great  pain and febrile action; and it may
be strikingly abnormal, when the disease  is appa-
rently of very mild type.  In most cases of pleurisy,
though not in all, dulness of the percussion-sound
is observed in the first instance beneath the scapulae,
and then, as the effusion increases, over the lateral
region, and at length over the anterior part of the 
PLEURITIS.
349
thorax; it never, however, reaches as high before,
as it does behind.  The percussion-sound  may be
perfectly  tympanitic  over the upper half of the
affected side, and at the same time  perfectly dull
over the lower half; this happens when the lower
parts of the lung have been deprived of air by the
effusion, and the upper portion has merely under-
gone slight compression.1
   The affected side yields a completely dull sound
throughout, when the pleura is filled by the effusion;
after a time, however, the sound beneath the clavi-
cle, and also lower down, may become clearer, and
even distinctly tympanitic and full, and this without
any diminution in the amount of the effusion, but
in consequence of enlargement of the thoracic ca-
vity, or of diminution in size of the  lower portion
of the compressed lung.
   The adhesions between the lung  and the parts
around the effusion, which almost invariably take
place, prevent the displacement of the fluid by the
movements of the patient; and consequently, what-
ever be his position, the dull sound  is heard, as a
rule, over the same parts.  The statement that the
dull percussion-sound of pleurisy varies with the
position of the patient,  is in the majority of cases
incorrect.
   Auscultatory signs.—The thoracic voice is either

  1 Dr. C. J. B. Williams believes that, when the percussion-
sound beneath the clavicles is tympanitic, the upper part of
the lung is completely infiltrated or compressed.  There is no
difficulty whatever in coming to a  correct conclusion on  this
subject by the aid of a few experiments on the dead body.
       30 
350
PLEURITIS.
 not heard at all, or it is heard only as an indistinct
 humming, at those  parts of the thorax which  cor-
 respond to the situation of the effusion, so long as
 the lung is not completely deprived of air; the re-
 spiratory murmur being either vesicular or inde-
 terminate or altogether inaudible.  The same  aus-
 cultatory signs may be observed over those parts
 of the thorax  beneath which there is no effusion,
 provided there be no other  diseased  condition af-
 fecting the lungs there.   A friction-sound  is  pro-
 duced, when the pulmonary and costal surfaces are
 covered by plastic exudation, and  come  in contact
 with each other, during the respiratory movements;
 this friction-sound is  therefore a sign that, at the
 part where it occurs, there is no  serous  effusion
 present, and no adhesions of the pleural surfaces.
  The friction-sound is seldom heard at the com-
 mencement of an attack of pleurisy, probably be-
 cause the freshly-formed  plastic  matter is not of
 sufficient consistency to produce it;  it appears much
 more frequently at a  later period of the  disease,
 and particularly when absorption of  some portion
 of the serous  fluid  has taken  place, whereby  the
 lung is once more permitted to come in contact with
the thoracic walls.  The lung  is almost always co-
 vered by a layer of plastic exudation, and is  not
in the first instance united to the thoracic walls, so
 that  the friction-sound may be  generally produced
by a strong respiratory movement.
  The auscultatory signs  heard over  a  portion of
lung completely deprived of air by the effusion, are
either weak bronchophony, and bronchial respira-
tion, or one of these sounds alone; or the voice is 
PLEURITIS.
351
heard, but not increased in intensity, or it may be in-
audible, and the respiratory murmur indeterminate,
or likewise inaudible.  The bronchial breathing and
the weak bronchophony are in most cases heard be-
tween the lower angle of the scapula and the verte-
bras, and somewhat above and below this line. They
may also be  heard  over  every other part  of the
thorax.
  The bronchophony and bronchial respiration can-
not take place, if the large bronchial tubes, which
pass into the compressed portion of lung, are either
blocked up  by mucus, blood, serum, etc., or obli-
terated by pressure. The greater the amount of ex-
udation, the weaker will be the consonance of the
voice in the bronchial tubes, and the consonating re-
spiratory murmur; these signs indeed may become
perfectly indistinct, in consequence  of  the large
quantity of the effusion present.  Effusion,  which
compresses only the upper portion  of  the lung,
rarely gives rise to bronchial breathing and broncho-
phony, in consequence of the curved  course which
the bronchial tubes there take, and of their ready
obliteration by pressure.
  Such are the reasons, why bronchial breathing and
the loud clear voice are not heard in  every case of
effusion, where  a considerable portion of lung is
deprived of air; and why, instead of these symptoms,
we at times have merely an indeterminate, or no
respiratory murmur at all, and either a dull weak
humming when the patient speaks, or no sound what-
ever.   At those parts of the thorax, beneath which
there  lies a portion of lung which is but slightly
or not at all compressed, the voice is heard only as 
352
PLEURITIS.
a dull humming, the respiratory murmur being very
loud, or weak, or vesicular, or indeterminate, or
almost  inaudible;  the  last  condition  depending
chiefly upon whether the patient breathes  quickly
and deeply, or slowly.1
   Rales occur during pleuritis, if serum, blood, or
mucus, etc., happen to be present in the  bronchial
tubes; hissing, whistling, and sonorous sounds arise,
when the bronchial mucous membrane is swollen, or
covered by any plastic exudation, or tough mucus.
But rales  are much less  frequently present during
pleuritis, than in diseases of the parenchyma of the
lungs; and when the auscultatory and percussion
sounds are doubtful, we may look upon the existence
of a fine bubbling rale, as much more probably in-
dicative of pneumonia than of pleurisy.
   The rales heard during  pleurisy present every
variety, in respect of the size of the bubbles which
form them, of clearness and pitch; when  bronchial
breathing, or the conditions necessary for its pro-
duction, exist, the rales  may take the consonating
character, or be indistinctly audible.  Rales may be
heard, both at  those parts  of the thorax, beneath
which the effusion exists, and over every other part.
Whistling, hissing, and  sonorous sounds are less
  1 Great dyspnoea may, as we have already said, cause bron-
chial respiration to be audible, particularly during  expiration,
over the whole of the back, the lung being nowhere deprived of
its air.  Considerable dyspnoea generally attends the formation
of pleuritic effusions, and hence we have a bronchial expiratory
murmur over the back, before any dulness of percussion-sound
appears. 
PNEUMOTHORAX.
353
 often heard in pleurisy than the rales; they occur
 most frequently in that portion of the lung which
 is not compressed by the effusion, and render the
 vesicular respiration inaudible.

    SEROUS EFFUSIONS IN THE PLEURA, NOT OCCASIONED BY
              PLEURISY.--HYDROTHORAX.
   Percussion produces a dull sound, and the dul-
 ness changes its  site with change of the patient's
 position; in other words, the serous fluid, provided
 it be not fixed in any particular part by adhesions
 of the lung,—moves from  one part of the thorax to
 another, as the patient moves.   Similar changes
 of the percussion sound are produced  by effusions
 of blood, or pus,—Haeniothorax—Pyothorax—into
 the pleural cavity.
                  PNEUMOTHORAX.
  By this term, we understand the presence of aeri-
 form fluids in the cavity of  the pleura; they are
 rarely  ever found there alone, being generally at-
 tended  by fluid effusions.  Thus atmospheric air,
 when it finds its way into the pleura, in the human
 subject, almost invariably causes pleuritic exuda-
 tion.   It is probable, that the fluids,—such as the
 contents of tubercular  cavities, the sanies of gan-
 grene,  blood, etc.,—which generally pass with the
 air into the pleura, assist  in the production of the
 effusion.  Gases evolved in the pleura, must pro-
 ceed from the decomposition  of fluid contained
therein.  Secretion of  gas into  the pleura, seems
to me a highly improbable occurrence.
  Percussion signs.—The percussion sound of pneu-
                      30* 
354
PNEUMOTHORAX.
mothorax is, in most  cases, distinctly tympanitic;
but if the thoracic walls be much distended, it be-
comes little, or not at  all so.  The metallic ringing
is also  generally to be heard, but it is barely loud
enough to reach to a^istance; therefore to catch
the sound, it  is necessary to perform auscultation
and percussion at the same time.1
  The  liquid which is present with the air or  gas
in the pleura, occupies the lowest parts of the cavity,
and changes its position when that of the patient is
altered;  it must be of considerable amount to be
discovered by percussion in cases of pneumothorax.
The percussion sound is, in fact, tympanitic, even
below the level of the liquid, and remains unaltered,
if the  depth of the fluid be not great.   We may
reckon the quantity of fluid present in pneumotho-
rax as  double the amount indicated by percussion.
  Auscultatory signs.—Either amphoric resonance.
or metallic tinkling,  is associated with the voice;
and during the breathing we hear  the respiratory
murmur, and rales, and whistling and  sonorous
sounds, accompanied by metallic tinkling; or there
is neither metallic tinkling nor amphoric resonance
audible, but only an indeterminate respiratory mur-
mur,  muffled rales,  or whistling and  sonorous
sounds, or a dull resonance of the voice; or lastly,
it may be that  neither voice, nor respiratory mur-
mur, nor rales, etc., are audible.  These variations
  1 With the exception of this single case, the method of simul-
taneous auscultation and percussion—i. e. of auscultating the
percussion-sound—is of no service. 
PERICARDITIS.
355
in the auscultatory phenomena do not depend upon
the circumstance of the air in the pleura being at
one time in communication with the bronchial tubes,
and at another not so.  I have never yet met with
a case of recent pneumothorax, in which the com-
munication had become persistent; but, on the con-
trary, I have invariably found the  opening was
closed, partly by the compression of the lung, and
partly by the effusion.  In some very rare cases of
long-standing pneumothorax, an opening into the
compressed lung may be formed by ulceration, and
a communication thus established between the ex-
ternal air, and the air in  the pleura.  The varia-
tions in the auscultatory  signs depend  upon the
thickness of the  layer of pulmonary tissue, which
intervenes between the pleural  cavity, which con-
tains air, and the bronchial tube, where  the voice,
the respiratory murmurs, etc., consonate.

   TUBERCULAR AND ENCEPHALOID DISEASES OF THE PLEURA.
   These diseases do  not cause any marked altera-
tion in the percussion sound, unless they are of
considerable extent, nor does auscultation offer us
any sign characteristic of them.

        IV. DISEASES OF THE PERICARDIUM.
                  PERICARDITIS.
   Percussion signs.—The percussion-sound remains
normal, unless a large amount of effusion has taken
place into the pericardium.  It is impossible to de-
fine accurately what amount of effusion is requisite
to produce an appreciable change in the percussion- 
35(5
PERICARDITIS.
sound.  At one time, considerable dulness is pro-
duced by a few ounces of fluid, whilst at another,
even half-a-pound and upwards will not cause any
change in it.   The difference is caused by the po-
sition of the lungs, which  are pressed further for-
wards over the heart in some cases than in others.
  The heart  being specifically heavier than the
effusion, gravitates towards the lowest part of the
distended pericardium, so far at least as its attach-
ments will permit, the fluid occupying the upper
part; so that when this is not abundant, we find it
collected  around the base of  the heart, and the
origin of the  aorta and the pulmonary artery, the
remainder of the pericardium being occupied by
the heart.  There can be no exception to this, un-
less when, through partial or total relaxation, or
bulging out of the pericardium, this membrane fails
to be distended by its contents—the heart and the
effusion; or unless there be some attachment be-
tween the pericardium and the aorta, the pulmonary
artery, or the base of the heart.
  But if the effusion is considerable, it is not con-
fined to the base of the heart and  the origin of the
arteries.   When the patient lies upon his back, the
heart sinks in the  fluid  during the diastole, away
from the thoracic walls; and during the systole, it
is driven  forwards and  downwards, and  thus ap-
proaches them, whilst the fluid sinks towards the
back of the pericardium.   It appears from  this,
that when effusion takes place into the pericardium,
the dulness of percussion  is, in the first instance,
almost constantly observed about the roots of the 
PERICARDITIS.
357
aorta and pulmonary artery, or in other words, in
the long diameter of the heart; and that increased
dulness in the broad diameter coincides with  ex-
tensive effusion.   There are but few exceptions to
these rules.   If the pericardium contain as  much
as two  pounds of fluid, the percussion-sound  be-
comes completely dull from  the second  left costal
cartilage to the  lower border of the  thorax, and
from the right edge of the sternum to the middle
of the left lateral region:  and the resistance also
is as well marked as in cases of extensive pleuritic
effusions.
  Auscultatory signs.—At the commencement of
pericarditis, the action of the heart is  generally
increased, and, consequently, its impulse stronger,
and its sounds clearer than natural; but as the dis-
ease advances, the movements become weaker, often
indeed they are very weak, the impulse being either
not at all, or only very slightly perceptible, and the
sounds of the heart and arteries very faint or in-
audible.  This feebleness of the heart's movements,
however, may be associated as well with scanty as
with abundant effusion. When there is  much effu-
sion, and the patient lies upon his back, the heart
during  its diastole is separated from the thoracic
walls in consequence of the  anterior part of  the
pericardium being filled by the fluid, and must, if
it strike against the thoracic walls during its sys-
tole, move through a greater space  than it does
normally, when  it remains in  contact with them
during its diastole.
  As a rule, then, the heart's impulse  is weaker
than natural, when the pericardial effusion is exten- 
358
PERICARDITIS.
sive, and its sounds are less clear and strong; both
impulse and sounds may at times, also, be scarcely
perceptible, or not at all so, in consequence of  the
heart and arteries being separated from the thoracic
walls by the effusion. An hypertrophied heart may
produce a distinct impulse and loud sounds, although
surrounded by a considerable amount of effusion;
and it must not be forgotten, that the heart's  im-
pulse is frequently very weak, and even impercep-
tible, and  its  sounds muffled  or inaudible, when
there is no effusion in the pericardium.
   Thus the nature of the heart's impulse and sounds
does not enable us to decide with certainty, either
as to the presence or absence of pericardial effusion.
Friction-sounds are produced by the movements of
the heart, when the pericardial surfaces are covered
by firm plastic exudations, and come  in  contact
during its  movements: they present themselves
either as scraping, rubbing, scratching, and creaking
sounds, or as bellows, rasping, or sawing murmurs.
   The pericardial friction-sounds  are associated
with the movements of the  heart, but are  not  ex-
actly synchronous with its  sounds; and hence  we
have a means of distinguishing between exocardial
and endocardial murmurs.  There is no difference
whatever between the  friction-sounds which arise
within the pericardium, and those which arise  on
its external  surface, and are caused by friction of
the pericardium,  during the heart's movements,
against some portion of the  lung, whose  pleural
surface is covered by exudation.
  The friction-sound maybe heard at the commence- 
PERICARDITIS.
359
ment of pericarditis, as well as during its progress,
and it may continue long after  the inflammatory
condition of  the pericardium  has  subsided.   It
does  not occur  in every  case of pericarditis, nor
does  its intensity depend  upon the violence of the
inflammation; neither is it a sign, that the amount
of pericardial effusion is  small, for it may be pre-
sent when this is very abundant.   If the effusion
be  chiefly serous, or purulent, and  not plastic, no
friction murmur will be audible.

 EFFUSION IN THE PERICARDIUM,  NOT CAUSED BY PERICARDITIS.
  Dropsy of the pericardium—hydrops pericardii
— presents the same phenomena to auscultation and
percussion, as effusion consequent  on pericarditis;
and this is also true of effusions of blood into the
pericardium, at least so far as they have been matter
of observation.1

               PNEUMO-PERICARDIUM.
  I have never seen a case of pneumo-pericardium;
  1 Professor Schul had a patient under his charge in the hos-
pital, suffering from pneumothorax of the left side, produced
by violent  compression of the thorax between two carriages.
The movements of the heart were accompanied by a rule, which
closely resembled the gurgling of a cavity—a consonating rale;
and it was particularly marked during the ventricular diastole.
We were of opinion, that some blood had been effused into the
pericardium, and had rendered the pericardial surfaces  more
adhesive than natural, and that  the separation of the surfaces,
during  the movements of the heart, gave rise to  the rale in
question.  The patient was saved by puncture of  the thorax,
whereby exit was given to the confined air.   He recovered com-
pletely ; the pericardial murmur disappeared after a few  days. 
360
PERICARDITIS.
when it exists, the percussion-sound must be occa-
sionally tympanitic. Auscultation should yield some
special signs.  The development of gas in the peri-
cardium is scarcely  possible, except  through the
decomposition of fluid  contained  within it.  The
fluid  in such  case would be shaken by the move-
ments of the heart, and would give rise to a mur-
mur resembling that produced by fluid, when shaken
in a half empty bottle.1

   ADHESION BETWEEN THE SURFACES OF THE PERICARDIUM.
   I am not aware that percussion  and auscultation
afford us any signs diagnostic of  union of  the pe-
ricardial surfaces.   Dr. Hope tells us, that  in such
case,  a bellows murmur is heard accompanying the
first sound of the heart, and audible along the aorta,
and can scarcely fail to present  itself when the
heart beats strongly.   But the most characteristic
sign would seem to be, a sudden tumbling (polternd)
movement of the heart, readily discoverable by the
stethoscope, and  very distinct when  hypertrophy
and dilatation of the heart co-exist, in which case
the tumbling movement generally corresponds with
the systole and  diastole of  the ventricles.  The
  1 In Canstatt's Jahresbericht, 1844, p. 216, a case—related by
Brichtau, in the Archives Generates for March—is gjven, in
which gas was found in the pericardium, having been  evolved
from  a sanious effusion. Percussion  produced a  remarkably
resonant sound; at each systole of the heart, a sound was heard
resembling the  stroke of a mill wheel  on the surface of water.
Examination after death, showed that the pericardium was dis-
tended with gas, and that it contained, moreover, 250 grammes
of sanious effusion. 
DISEASES OF THE PERICARDIUM.        361
fact is, that neither of these signs has any relation
whatever to adhesion of the pericardial surfaces.
The bellows murmur arises within the heart or the
aorta,  through defect  of the valves,  or from the
presence of rough deposits on the lining membrane
of the ventricle or the  aorta; the tumbling motion
depends  on irregularity in  the  heart's  rhythm,
which may occur  in various abnormal conditions of
this organ, and, indeed, even  when it is apparently
in a perfectly healthy condition.1
  1  [In the Zeitschrift der K. K.  Gesellschaft der Aerzte zu Wien,
April, 1852, there is a paper by Skoda, on the phenomena which
indicate adhesions between the heart and pericardium.
  His diagnosis is based upon the signs which show that the
heart's apex is drawn upwards  and to the right, during the
Bystole, and is prevented from moving downwards and  to the
left.
  The heart's apex  gives no systolic beat: it is either not per-
ceptible, or seems to cause a shock during the diastole.
  During the systole, depressions become visible in the inter-
costal space  corresponding to  the apex, and frequently in one
or more  spaces above it, when, in addition to adhesion of the
heart and pericardium, there is likewise adhesion of the peri-
cardium to the costal pleura.
  Systolic  retraction of the left intercostal  spaces does  not,  of
itself, enable us to  diagnose  adherent pericardium; it must
likewise be shown that, simultaneously with the retraction, the
heart's apex is nowhere urged against the thoracic walls.
  The systolic retraction of the lower half of  the sternum, is a
certain sign of adhesion of the heart and pericardium,  and  of
their fixture to the vertebral column.
  The limits of  the dull  percussion-sound remain the  same,
during inspiration  and expiration.   See Edinburgh Monthly
Journal, July, 1852.   Transl.]
       31 
362
DISEASES OF THE
       TUBERCULAR DISEASE OF THE PERICARDIUM.
  This abnormal condition is rarely present in a
degree sufficient to produce any modification in the
percussion-sound. If the surfaces of the pericardi-
um are not adherent, the  tubercular disease is at-
tended by serous effusion, and that often in large
quantity.  Tubercles, as well  as firm plastic exu-
dation, may give rise to a friction-sound.
       ENOEPHALOID DISEASE OF THE PERICARDIUM.
  This disease may, in some  rare cases, be so ex-
tensive, as  to  produce a widely-spread  dull per-
cussion-sound.

V. ABNORMAL CONDITIONS OF THE SUBSTANCE OF THE
                    HEART.
   HYPERTROPHY WITH DILATATION OF BOTH VENTRICLES.
  The dulness of the percussion-sound is generally
greater than natural over the precordial  region,
when both ventricles are hypertrophied and dilated;
if  the diaphragm,  however, be placed low, the
thorax abnormally widened, and  the lung  emphy-
sematous, the  sound may remain normal,  though
somewhat deeper at the lower  border of the  thorax.
  The impulse of the heart is generally increased,
and often to such an extent, that the heaving of the
thoracic walls  at the  point where the heart comes
in  contact with them, is sensible both to  the eye
and to the touch; but this increase of impulse is not
constant, for it may be weak, and even impercep-
tible, although the heart be hypertrophied.  The
sounds of the  ventricles and  the arteries  may be
very loud, weak, muffled, or inaudible; or one or
more of them may be replaced by murmurs: these 
SUBSTANCE OF THE HEART.         363
differences depend upon the condition of the valves,
and of the lining membrane of the cavities of the
heart.

   HYPERTROPHY OF THE VENTRICLES, WITHOUT DILATATION.
  Auscultation and percussion yield the same phe-
nomena, in hypertrophy without, as in hypertrophy
with dilatation of the ventricles, the difference being
only in degree.  The impulse of the heart does not
impart a heaving motion to the thoracic walls, but
strikes upon  the ear of the  auscultator, like the
blow of a hammer.

   DILATATION OF THE VENTRICLES WITHOUT HYPERTROPHY.
  In this abnormal condition of the heart, the per-
cussion-sound is the same as in hypertrophy with
dilatation of the ventricles.   The impulse does not
shake  the head of the auscultator, and the heaving
of the thoracic walls  may be slight, or even im-
perceptible.   In pericarditis, and under all circum-
stances where the heart's action is much increased,
the impulse  of a simply dilated may become as
strong as that  of an  hypertrophied and  dilated
heart.  The  sounds or murmurs are, as  in hyper-
trophy with dilatation, either loud, or weak, or in-
audible: they may be heard only in the precordial
region, or reach over the whole of the thorax.  The
sounds may also be replaced by murmurs.

 HYPERTROPHY WITH DILATATION OF THE RIGHT VENTRICLE, THE
             LEFT VENTRICLE BEING NORMAL.
   The dulness of the  percussion-sound is here in-
 creased in the direction of the heart's breadth; but
 there  are exceptions, caused by particular confor- 
364
DISEASES OF THE
mations of the thorax, and especially by the position
of the lungs.  The impulse is either increased, or
differs but little from its normal strength.   As a
rule, we find the  second sound of  the pulmonary
artery increased, and louder than the second aortic
sound.  Increase of its first sound  is much less
frequently observed.  The sounds  over the right
ventricle are either normal or increased, or weaker
than natural; over the left ventricle they are either
normal or weakly, or either of them may be replaced
by a murmur.  The second sound  over the aorta
is not replaced by a murmur.

 HYPERTROPHY WITH DILATATION OF THE LEFT VENTRICLE, THE
           RIGHT VENTRICLE BEING NORMAL,
causes increased dulness of the percussion sound in
the direction of the heart's length, except when the
lungs are  abnormally distended.   The impulse is
either increased or normal; or may be very strong
at one  moment and weak at another: when the
hypertrophy and dilatation of the  left ventricle is
occasioned by defective aortic valves, the impulse
may be as strong as in hypertrophy with dilatation
of both ventricles.  The sounds of the ventricles
and of the  aorta  are either  normal or muffled, or
inaudible, or replaced by murmurs.

DIMINUTION OF THE CAPACITY OF THE RIGHT VENTRICLE, ITS WALLS
     BEING HYPERTROPHIED, OR ATROPHIED, OR NORMAL.
  When this abnormal condition of the right ven-
tricle is coincident with hypertrophy and dilatation
of the left ventricle, the percussion sound is much
the same, as in hypertrophy and dilatation of the 
SUBSTANCE OF THE HEART.        365
left, with a normal condition of the right ventricle.
The heart's impulse may be increased, if the aortic
valves are at the same time defective; otherwise
it is weaker than natural.  If the right ventricle
is diminished, and the left remains of normal size,
or is likewise diminished, the impulse is weak, and
may be even imperceptible.

DIMINUTION OF THE CAPACITY OF THE LEFT VENTRICLE WITH HY-
  PERTROPHY, ATROPHY, OR NORMAL  CONDITION OF ITS WALLS.
  If this state of the left ventricle is accompanied
by hypertrophy and dilatation of the right ventricle,
the dulness of the percussion-sound will be increased
in the direction of the transverse diameter of the
heart.   If  the tricuspid valves are  defective, the
impulse will  be somewhat increased, otherwise it
will be weaker, or imperceptible; and if the right
ventricle be  of normal size or diminished, the im-
pulse  will  also be  very feeble, or imperceptible.
The second sound in the aorta is never replaced by
a murmur.
  INFLAMMATION OF THE MUSCULAR SUBSTANCE  OF THE HEART.
  Neither auscultation nor percussion affords us any
signs characteristic of inflammation of the substance
of the heart.  The percussion-sound remains normal,
except when dilatation of the ventricles, or thick-
ening of their walls, have occurred, as consequences
of the inflammation; these, however,  are accidents
which can only happen when the inflammation has
been of some duration.
  The impulse of the heart is either increased, so
as to resemble that of an hypertrophied heart, or it
                      31* 
366
ENDOCARDITIS.
may be weaker than natural.   The sounds may be
loud, or feeble, or almost inaudible; murmurs do
not attend inflammation of the  heart's muscular
substance, unless endocarditis or pericarditis exist
at the same time.  The rhythm of the heart's action
is altered, the rapidity of its movements increased,
and its  impulses  of unequal force, being at one
moment strong and at another weak; its sounds, also,
are at one moment loud  and at another feeble, etc.
All these irregularities, however, occur during many
other abnormal conditions  of  the heart, and even
when the  heart  is apparently perfectly  healthy;
and they may be occasionally absent, or present only
in a very slight degree, when the substance of the
heart is inflamed.

SOFTENING, OR HARDENING OF THE  SUBSTANCE OF  THE HEART--
  CALCAREOUS CONCRETIONS WITHIN ITS SUBSTANCE—OSSIFICA-
  TION OF THE CORONARY ARTERIES.
  There are no signs characteristic of these morbid
conditions of the heart.

  VI. ABNORMAL CONDITIONS  OF THE ENDOCARDIUM.
                  ENDOCARDITIS.
  In endocarditis the percussion-sound is normal,
unless one or both ventricles have become dilated
and hypertrophied, in consequence of the defect of
the valves, etc., produced by the inflammation.  In-
crease of the heart's size may become perceptible
in the  course of a few days.   Its movements are
generally more vigorous and rapid than usual, and
at times irregular; hence the heart's impulse is in-
creased, etc. 
DEFECTS OF THE VALVES.         367
  The sounds may be everywhere normal, or they
may be louder, or duller than natural, or scarcely
audible;  or  again, sounds  may be heard at some,
and murmurs at other parts.  Where the current of
blood is not rapid, as at the lower half of the ven-
tricles, no murmur arises, even though the endo-
cardial membrane be inflamed and covered by  ex-
crescences;  but a rapid flow of blood over the in-
flamed endocardium creates a murmur which is
most distinctly audible at those parts of the thoracic
walls which lie nearest to the point of origin of  the
murmur.  Inflammation may render the valves in-
capable of effecting perfect closure—defective—or
produce constriction of the orifice at their base.  In
endocarditis, moreover, a systolic  murmur may be
audible either over  the left  or over the right ven-
tricle, or be confined to the aorta, or to the pul-
monary artery, the natural sounds being heard over
the other parts;  or the murmur  may be audible
over several parts at the same time.
  We rarely meet with a  diastolic murmur at  the
commencement of an attack of endocarditis;  such a
murmur, however, may arise in the aorta  in  the
course of a few  days, when the inflammation  has
rendered its valves incapable of preventing the re-
gurgitation of the blood into the ventricle.

              DEFECTS OF THE VALVES.
  Defective mitral  valves.— Here the  dulness of
the percussion sound is generally increased, in  the
direction of the heart's breadth, and this happens
because  hypertrophy  and dilatation of the right 
368          DEFECTS OF THE VALVES.

ventricle are the almost invariable sequels of de-
fective mitral valves.
  A systolic murmur is audible at that part of the
thorax where the heart's apex strikes, and occasion-
ally, also, to a greater or less extent, in its neigh-
bourhood; the second sound of the pulmonary artery
is increased, and the accent falls distinctly upon it.
Sometimes, and particularly when the heart's move-
ments are feeble, an indeterminate sound (Schall,)
which can neither be recognised as a true sound, nor
as a murmur, is heard during the systole over the
left ventricle.   During the diastole, either an inde-
terminate sound, or none at all, is heard over the
left ventricle; rarely do we meet with a tolerably
clear sound there.   If the deficiency of the mitral
valves  be considerable, the aortic sounds are weak,
and, as a rule, the heart's impulse is  increased.
  Constriction of the mitral orifice.—The  dulness
of the  percussion-sound is, as in the last case,  in-
creased; and hypertrophy of the heart occurs even
more rapidly.
  The  second sound in the left ventricle is replaced
by a murmur, which is often so prolonged, as to be
only momentarily interrupted during the heart's
systole.  The second sound of the pulmonary artery
is increased.   During the systole, either no sound
at all is heard in the left ventricle, or only an inde-
terminate sound; and again, a murmur may be audi-
ble there, because deficiency of the mitral valves is
generally associated with constriction of the mitral
orifice.  As a rule, the sounds of the aorta are weak,
and the heart's impulse increased, and perceptible
over a greater extent than natural. 
DEFECTS OF THE VALVES.
369
   Defective tricuspid valves.—Defect of the tricus-
pid valves occasions distention of the right auricle,
by which the dulness of the percussion-sound over
it is often strikingly increased.  A systolic murmur
also  appears in the right ventricle, the veins of the
neck being simultaneously distended, and a pulsa-
tion perceptible in them; when, however, the move-
ments of the heart are feeble, the ventricular mur-
mur may be converted into an indeterminate sound,
or be altogether inaudible.   During the diastole,
either an indeterminate sound, or  none at all, is
heard  over the right ventricle: a clear sound  is
rarely observed.
   Constriction of the right auriculo-ventricular ori-
fice.—This abnormal condition is exceedingly rare;
I have never yet observed it in the living.   There
are some  specimens of it in the pathological  mu-
seum here.
   Defective aortic valves.—The dulness of the per-
cussion-sound is almost constantly increased in the
direction of the heart's length, because defect of the
aortic valves invariably produces enlargement of the
left ventricle, which generally assumes the form  of
hypertrophy with dilatation. The increased dulness
of the percussion-sound, however, may be interfered
with by any considerable distention of the left lung.
The  heart's  impulse is also increased, and either a
heaving of the thoracic walls, or a stroke like that
of a hammer, against the head of the auscultator,
results.   The second sound of the aorta is replaced
by a prolonged  murmur, the intensity of which  is
greatest over the origin of the aorta.  This murmur 
370         DEFECTS OF THE VALVES.
is generally audible over a considerable extent of
surface, and if the defect of the valves be conside-
rable, the loud rushing of the refluent blood is heard
at the heart's apex; a murmur is thus produced in
the left ventricle instead of the second sound.
  During the systole, a murmur is generally heard
in the aorta, for whenever the aortic valves  are
defective, roughnesses are almost invariably found
to exist either upon the inner surface of the aorta
itself, or upon the under surface of its valves.  At
times, however, either a sound, or an indeterminate
sound, or no sound at all, is heard during the  sys-
tole.  The pulse of the  carotid and subclavian ar-
teries is accompanied by a loud rasping murmur.
A double murmur—bruit de va et vient,—is gene-
rally ascribed to deficiency of the aortic valves: it
is true,  that under these abnormal conditions we
very frequently meet with a murmur, accompanying
both the systole and diastole  of the heart; but the
systolic murmur is not dependent upon the defect
of the aortic valves: this condition produces merely
the diastolic murmur.   A diastolic  murmur, if it
have its appropriate signs, must be  considered as
indicative of a defective state of the aortic valves,
although there be no accompanying murmur, and a
sound be heard  during the heart's systole.
   Constriction of the aortic Opening, in consequence
of faulty aortic valves.—In this case hypertrophy
and dilatation of the left ventricle is also found,
though not to such an  extent as when the aortic
valves are defective.  Percussion gives the signs
of hypertrophy and dilatation of the left ventricle. 
       WIDENING OF THE ASCENDING AORTA.    371

The impulse of the heart is but little, or not at all
increased, provided  there is  no co-existing defi-
ciency of the aortic valves.
  The first aortic sound is replaced by a murmur,
which generally extends to a considerable distance,
and becomes indistinct only when the heart's action
is feeble; when this is feeble, and the aortic valves
are at the same time defective, the second aortic
sound is either very weak, or  very indistinct, or a
murmur is substituted for it.
  Deficiency of the valves of the pulmonary artery,
or constriction of its orifice in consequence of faulty
valves, I have never observed  in the living.  Such
abnormal conditions are still rarer than constriction
of the right auriculo-ventricular orifice.

VII. ABNORMAL CONDITIONS OF  THE AORTA AND PUL-
              MONARY ARTERY, ETC.
UNEVENNESS OF THE INTERNAL SURFACE OF THE ASCENDING POR-
                 TION OF THE AORTA.
  The percussion-sound remains unaltered.  A mur-
mur  is heard with the heart's  systole, and occa-
sionally during its diastole over the upper half of
the sternum.   The murmur ends in a sound, when
the aortic valves close perfectly, but continues as
a murmur, when they are defective.

           WIDENING OF THE ASCENDING AORTA.
  The widening may be of a  uniform, or of a sac-
culated  character; its existence cannot  be deter-
mined, unless the aorta comes in contact with the
anterior walls  of the thorax: in such case, the per-
cussion-sound will be found completely dull at that 
372    WIDENING OF THE DESCENDING AORTA.

portion of the upper part of the  sternum, behind
which  the aorta lies, and the resistance  also in-
creased.  Besides this, the auscultator will almost
invariably meet with an impulse during each systole
at the part referred to, as strong, or even stronger,
than that of the heart.  Little or no concussion is
felt over the thoracic walls, between the points
where  the impulse of the aorta, and that of the
heart, are observed.  In aneurism of the  aorta, a
murmur generally accompanies  both the systole
and diastole of the heart; but there are cases where
the murmur  is very indistinctly, or not at all heard,
or where both sounds and murmurs exist, or the
sounds only.  In cases where the thoracic aneu-
rism has formed an external tumour, we may con-
vince ourselves by actual contact, that both the first
and the second sounds may be produced in the
walls of the  aneurism.  A strong rasping  murmur
is generally heard in the  carotid and subclavian
arteries during the systole of the heart.

         CONSTRICTION OF THE ASCENDING AORTA.
   Enlargement of the left ventricle generally at-
tends this abnormal condition of the aorta, and even
the right ventricle seldom fails at last to participate
in the enlargement.  Sounds or murmurs are heard
in the aorta, accordingly as the inner surface of the
constricted aorta is normal or roughened, or as the
aortic valves are defective or not.

         WIDENING OF THE DESCENDING AORTA.
   A dull percussion-sound will not be observed over
the back of the thorax, unless the aneurismal sac 
PULMONARY ANEURISM.
373
be of considerable size.   In two cases, where the
aneurisms of the descending aorta were of very con-
siderable size, and produced a dull percussion-sound
in the back, no murmur was discovered by ausculta-
tion;  but nevertheless, there can be no doubt that
in aneurisms of this portion of the aorta, murmurs
synchronous with the arterial pulse may be heard;
such murmurs, however, do not of necessity indicate
the existence  of  aneurism,  but merely, that the
inner surface of the vessel is roughened.

          ANEURISM OF THE PULMONARY ARTERY.
  I have  never observed such  a condition of the
pulmonary artery but in one  single case:—The
patient, a strongly-built man, aged forty-three, came
into the hospital under my charge for oedema of the
feet and ascites.   According to his account, the
swelling of the feet first appeared towards the latter
end of November, 1841, after exposure to cold. He
remained two months in a provincial hospital and
entered the General Hospital of Vienna on the 28th
January, 1842. His face was the face characteristic
of cyanosis, the dyspnoea great, rales and sonorous
sounds were  heard over the whole  of the thorax,
and a blowing murmur with  the systole  over the
left ventricle of the heart; both sounds of this organ
were very indistinct at its base, and a weak blow-
ing murmur, which appeared to be propagated from
the left ventricle, was observed there during the
systole:  the  same phenomena  were noticed over
the right ventricle.
  Percussion  indicated  some enlargement  of the
       32 
374          PULMONARY ANEURISM.
heart,  but no condensation of the lung, and no
pleuritic effusion. The heart's impulse was scarcely
perceptible, the pulse very small  and normal in
number; the urine was reduced to a few ounces in
the day, of a blood-red colour, and  deposited an
abundant  red sediment, which on  examination
proved to be urate of ammonia.  His appetite was
tolerably good, and he was somewhat thirsty.  The
cedema of the feet and the ascites increased, serous
effusions into the pleura took  place, and the man
died on the 18th February, 1842.   No particular
change occurred in the other symptoms.
  On examination after death, the trunk of the pul-
monary artery was found distended to the  size of
a goose's egg.  The orifice of the artery at the ven-
tricle was scarcely at all enlarged, its valves healthy,
and  capable  of perfect closure.   Its  two chief
branches,  where they sprang from the aneurism,
were narrowed to the size  of  a crow's quill; the
right ventricle was hypertrophied and dilated; the
left ventricle, the aortic and tricuspid valves nor-
mal, the free borders of the mitral valves were par-
tially thickened, but it could not be said that they
were incapable of performing their functions during
life. The coats  of the aneurism showed the same
changes as are observed in aneurism of the aorta.
  I need scarcely say, that in this case auscultation
afforded us no signs of aneurism of the pulmonary
artery; the absence of all murmur may be readily
explained  by the remarkable narrowing of the two
chief branches of the artery.
  Uniform enlargement of the pulmonary artery is 
           ENLARGEMENT OF THE LIVER.       375

frequently observed, but I have never witnessed it
of extent sufficient to produce an alteration in the
percussion-sound.
  Widening of the vense cavae, or of the pulmo-
nary veins, never produces any change in the per-
cussion-sound.

   VIII. DISEASED CONDITIONS OF THE ABDOMINAL
                    ORGANS.
             ENLARGEMENT OF THE LIVER.
   Enlargement of the liver may depend upon hy-
pertrophy of its substance, or upon the development
within it of medullary cancer, melanosis, hydatids,
or abscess.  In each case, the percussion-sound is
the same.  An enlarged liver, if it be not depressed
into the abdomen, comes into contact with a greater
extent than natural of the thoracic walls, and, con-
sequently, increases the  extent of dulness of the
percussion-sound in every direction over the lower
half of the right side of the thorax.  The percussion-
sound in the  left hypochondrium may be rendered
duller than usual, or even completely dull, through
enlargement of the left lobe of the liver.  If the
liver be  depressed  into the abdomen,  the  sound
beneath the lower border of the  ribs on the right
side is perfectly dull; or the sound of the intestines
behind the liver is muffled as far as the liver reaches.
The degree of the resistance offered by the liver can
be ascertained  only through the abdominal walls.

               DIMINUTION OF THE LIVER.
   In consequence of diminution of the size of the
 liver, the percussion-sound may not be completely 
376       ENLARGEMENT OF THE SPLEEN.

dull over any part of the lower half of the  right
side of the thorax, but the natural non-tympanitic
sound of the lung will  be less clear immediately
above  the liver; over the shrunken liver itself,
where it comes in contact with the thoracic walls,
we recognise a muffled tympanitic sound arising
from the intestines beneath. The same may happen,
when the liver, without being diminished in size,
has lost somewhat in thickness: such a liver may be
even much larger than natural, it may reach high
up into the thorax, and  stretch far down into the
abdomen, and yet not yield a completely dull sound
at any part of its circumference, provided the in-
testines behind and beneath it contain air, and are
not rendered tense by pressure.  We are not able
by percussion to discover other abnormities of the
liver than those affecting its size and position.

            ENLARGEMENT OF THE SPLEEN.
  This is the only abnormal condition of the spleen
which can be determined by percussion.  Whatever
be the  cause of the enlargement, whether hyper-
trophy, medullary  cancer, hydatids, etc., the per-
cussion-sound remains the same. The spleen, when
much enlarged, renders the percussion-sound dull
at the lower half of the left lateral region.

ABNORMAL CONDITIONS OF THE STOMACH, THE INTESTINES, AND
                 THE PERITONEUM.
  When the intestines are much distended by air,
the percussion-sound is equally loud and drum-like
over nearly the whole of the abdomen, provided the 
     ABNORMAL CONDITIONS OF STOMACH, ETC   377

abdominal walls be not firmly contracted; the sound
is very rarely accompanied by a metallic resonance.
If the abdominal walls are also much distended by
the gaseous contents of the intestines, the percus-
sion-sound over the whole abdomen is everywhere
equally non-tympanitic, and less clear, than when
the abdominal walls are lax.
  Abdominal effusions, when not sacculated, always
occupy the lowest part of the abdomen, and change
their situation as the patient changes his position.
The intestines containing air float upon the surface
of the fluid, if permitted by the mesentery; but
should the length of the mesentery prevent their
doing so, then the air within them tends to collect
in those portions of the intestines which are upper-
most.   The moveable parts of  the intestines are
frequently pressed upwards in a coil towards the
stomach and the hypochondria.  The percussion-
sound of the abdomen, at the parts occupied by the
fluid, is as completely dull as the thigh percussion-
sound, provided there be no intestine containing
air  situated behind the fluid.   The  sound is not
altered by fluid intervening between the  folds of
the intestines, if it does not also separate them from
the abdominal walls.
  In all cases of extensive peritonitis, where the
intestines are much distended with air, and the
abdominal walls  tense,  the  percussion-sound  is
muffled, and less tympanitic than natural; and this
is the case, even though the exudation be of a plastic
character, and of inconsiderable thickness.
  When portions of the intestines  have become 
378       ENLARGEMENT OF THE KIDNEYS.

united together, or to the abdominal walls, they
generally contain a certain amount of air, and thus
the percussion-sound over the whole abdomen be-
comes as loud as when the intestines are free, but
it is less clear.
  The percussion-sound is also frequently muffled
in tubercular disease of the peritoneum; it is caused
by the gaseous distention of the intestines, without
which it is not observed.
  Encephaloid disease of the peritoneum does not
alter the percussion-sound, unless of very consider-
able extent: and this it rarely is, except when con-
nected with the omentum.
  Abnormal conditions of the muscular and mucous
coats of the stomach and intestines frequently pro-
duce changes  in the percussion-sound, by causing
accumulations of air or fluids in the stomach or in-
testines; changes may also arise from the develop-
ment of a large amount of secondary growths, as of
cancer in the stomach, or of tubercular degeneration
of a portion of the intestines.

                  THE PANCREAS.
  This organ does not give  rise to any  change in
the percussion-sound of the abdomen; the same  is
true of the mesenteric glands, even when much en-
larged, and of the ureters, however highly distended.

            ENLARGEMENT OF THE KIDNEYS.
  The character of the percussion-sound in the lum-
bar region is but little affected  by the size of the
kidneys; it may be completely dull when the kid-
neys are very small,, and tympanitic when they are 
     ANEURISM OF THE ABDOMINAL AORTA, ETC.  379

very large.  To succeed in the percussion of these
organs, the pleximeter must be firmly pressed to-
wards the kidney, until a completely dull sound is
produced, and the resistance of a solid  organ  felt.
When such manipulation has been repeated at seve-
ral spots, we may possibly arrive at some conclusions,
if the kidneys have attained to a considerable size.

  ANEURISM OF THE ABDOMINAL AORTA, COELIAC ARTERY, ETC.
  Where  the aneurism  comes in contact with the
abdominal walls,  the percussion-sound  is  either
completely dull, or it partakes of a muffled sound,
caused by the neighbouring portions of intestines.
If the aneurism does not reach the abdominal walls,
we must press the pleximeter down  upon it, to ob-
tain its percussion-sound.
  When the walls of the abdomen are wasted, the
pulsation of the abdominal aorta may generally be
felt through the stethoscope, or by the fingers, and
at the same time a distinct or a muffled  sound  may
be heard; more generally, however, bellows murmur
is heard, particularly when pressure is  made upon
the  stethoscope.  In aneurism of the  abdominal
aorta, and of the coeliac axis, pulsation  is felt  over
the  aneurism, as  well as along the aorta, and  a
murmur is generally heard  in the  aneurism, syn-
chronous with the arterial pulse; but the blood may
flow through the aneurism, without producing any-
thing beyond a very dull  and indistinct sound.

        ENLARGEMENT OF THE UTERUS AND OVARIES.
   The uterus, on  account of its deep  position in
the pelvis, and the ovaries, from the smallness of
their size, when normal, do not affect the percus- 
380        CALCULUS IN THE BLADDER.

sion sound.   When the pregnant uterus rises out
of the pelvis, or the ovaries are enlarged, the per-
cussion-sound over them is dull, wherever these
organs come in contact with the abdominal walls.

  DISTENTION OF THE BLADDER, AND ITS ENLARGEMENT FROM
              THICKENING OF ITS COATS.
  When the bladder is distended with urine, blood,
etc., the percussion sound above the pelvis is dull;
it is so also when the bladder is enlarged, through
thickening of its walls from hypertrophy, or from
any other abnormal  change.  In this  latter case,
however, the resistance felt is greater than when
the bladder  is distended by urine.

              CALCULUS IN THE BLADDER.
  The blow or the friction of a catheter upon  a
stone contained in the bladder, is heard much more
loud and distinct, through a stethoscope placed upon
the pubes, than through the air, even when the ear
of the observer is  brought very near to the pubic
region.  If the bladder contain no stone, the move-
ment of the cathether within it gives rise to an occa-
sional gurgle, or to a dull kind of murmur, which
has no resemblance whatever to the blow produced
by  the striking of the catheter  against a stone.
Auscultation must be  considered of some value
in the diagnosis of urinary calculi.  It  aids and
supports the sense of touch.
FINIS. 
 
 
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